06_境外及港澳台调查报告_part08.md

06_境外及港澳台调查报告 · 整合分片 part08

本片含 57 份报告。

FD06770 ｜ 2026_国际_CTIF_Report31_ERG.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2026 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

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International Association of Fire and Rescue Services Asociación Internacional de Servicios de Fuego y Rescate Internationale Vereinigung des Feuerwehr- und Rettungswesens

CTIF WWW.CTIF.ORG

Center for Fire Statistics

World Fire Statistics Estadísticas Mundiales de Bomberos Die Feuerwehrstatistik der Welt

Report / Informe / Bericht № 31

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All statistical data presented in this report were obtained from responses to the requests of the Fire Statistics Center of CTIF (CFS CTIF) and published previously in official statistical information of various countries. Data from past years have, in some cases, been updated with revised information. When comparing statistics of countries and cities, it is necessary to keep in mind that every country has its own rules for reporting fires, fire deaths, and fire injuries. These rules change from time to time. The authors are always grateful for suggestions to improve the Center for Fire Statistics' work.

Todos los datos estadísticos presentados en el informe se han obtenido a partir de las respuestas a las solicitudes del Centro de Estadísticas de Incendios del CTIF (CFS CTIF) y se han publicado anteriormente en la información estadística oficial de varios países. Los datos de años anteriores se han actualizado, en algunos casos, con información revisada. Al comparar las estadísticas de países y ciudades, es necesario tener en cuenta que cada país tiene sus propias normas para informar sobre los incendios, las muertes por incendio y los heridos por incendio. Estas normas cambian de vez en cuando. Los autores siempre agradecen las sugerencias para mejorar el trabajo del Centro de Estadísticas de Incendios.

Alle im Bericht vorgestellten statistischen Daten wurden den Fragebögen des Zentrums für Fire Statistics des CTIF (CFS CTIF) sowie den offiziell veröffentlichten statistischen Berichten verschiedener Staaten entnommen. Die Daten aus vergangenen Jahren wurden aufgrund neuerer Informationen aktualisiert. Beim Vergleich der statistischen Daten einzelner Staaten und verschiedener Jahre muss beachtet werden, dass in einzelnen Ländern spezifische Regeln für die Erfassung von Bränden, der Brandtoten- und Verletztenzahlen gelten, die sich ggf. auch über die Jahre hinweg verändert haben. Die Autoren sind wie immer für Hinweise, Kritik und Vorschläge zur Verbesserung der internationalen Feuerwehrstatistik dankbar.

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Content / Contenido / Inhalt

Introduction / Introducción / Einführung……..…………………………… 4 Brief comments

Countries of the World……………………………………………… 7

Cities of the World………………………………………………….. 9 Breves comentarios

Países del mundo …………..…………………..…………………… 12

Ciudades del mundo ………………………………….…………….. 13 Kurze Kommentare

Länder der Welt……………..……………………………………… 15

Städte der Welt ………………………………………….………….. 17 Acknowledgement / Conclusión / Zusammenfassung….............................. 19 Sources / Sources / Quellen…................................................................ 20 Table for filling / Cuadro para completar / Tabelle zum Ausfüllen ………. 21 Tables and Figures / Cuadros y Gráficos / Tabellen und Bilder…………. 23 Survey on Hospital fires …………………………………………… 70 EU FireStat II- Project ……………………………………………… 94 Bibliography 100

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Introduction

The CFS CTIF hereby publishes Report No. 31 containing information from countries and cities around the world on fire statistics for 2024, as well as the types of fire service calls, the number of fires, fire victims, and firefighter fatalities for 2020– 2024. Statistics for 2024 contain data from 40 countries, representing 1.5 bln. inhabitants, and 26 cities. The study includes the types of fire service calls, the numbers of fires, fire victims, and firefighter fatalities for 2020-2024, respectively, in 57, 75, 72, and 35 countries. The types of fire injuries for 2020-2024 were researched in 52 countries worldwide. In addition, data were collected on fire services in 66 countries worldwide. That is how the formation of world fire statistics continues. In this report, Table 1.1 presents aggregated data on fires worldwide from 1993 to 2024. The data for all years are constantly updated and supplemented as new sources of information become available. This indicates that more and more countries around the World are involved in the regular analysis and publication of national fire statistics. It is therefore expected that the 2024 data will also be replenished. Tables 1.2-1.6 show fire statistics for the year 2024. Tables 1.7-1.12 show the types of fire service calls, the numbers of fires, fire victims, and firefighter deaths for 2020-2024. Table 1.13 contains information on fire services in 66 countries from 2010 to 2024. Table 1.14 presents the ratio of women to men in the fire service. Table 1.15 provides information on the number of junior firefighters. Table 1.16 presents the distribution of fires by fire causes. Tables 2.1-2.5 present fire statistics in 26 cities around the World for the year 2024. Tables 2.6-2.8 show the calls, fires, and fire victims in 56 cities worldwide from 2020 to 2024. Finally, Table 2.9 contains information on fire services in 79 cities around the World.

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Introducción

El CFS CTIF publica por la presente el Informe nº 31 que contiene información de países y ciudades de todo el mundo sobre estadísticas de incendios para 2024, así como el tipo de llamadas de los servicios de bomberos, el número de incendios, las víctimas de incendios y las muertes de bomberos para 2020–2024. Las estadísticas de 2024 contienen datos de 40 países, que representan 1.500 millones de dólares. habitantes, y 26 ciudades. El estudio incluye el tipo de llamadas al servicio de bomberos, el número de incendios, las víctimas y las muertes de bomberos en 2020-2024, respectivamente, en 57, 75, 72 y 35 países. El tipo de lesiones por incendio para 2020-2024 se investigó en 52 países del mundo. Además, se recopilaron datos sobre los servicios de bomberos en 66 países de todo el mundo. Así es como continúa la formación de estadísticas mundiales de incendios. En este informe, la Tabla 1.1 contiene datos generales sobre la situación de los incendios en el mundo desde 1993 hasta 2024. Los datos de todos los años se actualizan y complementan constantemente a medida que se disponen de nuevas fuentes de información. Esto indica que cada vez más países del mundo participan en el análisis regular de estadísticas nacionales de incendios y su publicación. Por tanto, se espera que los datos de 2024 también se repongan en el futuro. Las tablas 1.2-1.6 muestran estadísticas de incendios para el año 2024. Las tablas 1.7-1.12 muestran el tipo de llamadas de los servicios de bomberos, el número de incendios, las víctimas y las muertes de bomberos en 2020-2024. La Tabla 1.13 contiene información sobre los servicios de bomberos en 66 países desde 2010 hasta 2024. La Tabla 1.14 presenta la proporción de mujeres a hombres en el servicio de bomberos. La Tabla 1.15 proporciona información sobre el número de bomberos juniores. La Tabla 1.16 presenta la distribución de los incendios por causas del incendio. Las Tablas 2.1-2.5 presentan estadísticas de incendios en 26 ciudades de todo el mundo para el año 2024. Las tablas 2.6-2.8 muestran las llamadas, incendios y víctimas de incendios en 56 ciudades del mundo entre 2020 y 2024. Finalmente, la Tabla 2.9 contiene información sobre los servicios de bomberos en 79 ciudades de todo el mundo.

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Einführung

Das CFS CTIF veröffentlicht hiermit Bericht Nr. 31, der Informationen aus Ländern und Städten weltweit zu Brandstatistiken für 2024 sowie zu den Arten von Feuerwehreinsätzen, der Anzahl der Brände, der Brandopfer und der Feuerwehrtodesfälle für 2020–2024 enthält. Die Statistiken für 2024 umfassen Daten aus 40 Ländern mit insgesamt 1,5 Milliarden Menschen. Einwohner und 26 Städte. Die Studie umfasst die Art der Feuerwehreinsätze sowie die Anzahl der Brände, der Brandopfer und der Todesfälle unter Feuerwehrleuten für die Jahre 2020–2024 in 57, 75, 72 und 35 Ländern. Die Art der Brandverletzungen in den Jahren 2020–2024 wurde in 52 Ländern weltweit untersucht. Darüber hinaus wurden Daten zu Feuerwehrdiensten in 66 Ländern weltweit erhoben. So setzt sich die Erstellung der weltweiten Feuerstatistiken fort. In diesem Bericht enthält Tabelle 1.1 verallgemeinerte Daten zur Lage der Brände weltweit von 1993 bis 2024. Die Daten für alle Jahre werden fortlaufend aktualisiert und ergänzt, sobald neue Informationsquellen verfügbar werden. Dies zeigt, dass immer mehr Länder weltweit an der regelmäßigen Analyse nationaler Brandstatistiken sowie an deren Veröffentlichung beteiligt sind. Daher wird erwartet, dass auch die Daten für 2024 künftig ergänzt werden. Die Tabellen 1.2–1.6 zeigen Brandstatistiken für das Jahr 2024. Die Tabellen 1.7–1.12 zeigen die Art der Feuerwehreinsätze sowie die Anzahl der Brände, der Brandopfer und der Todesfälle unter Feuerwehrleuten für 2020–2024. Tabelle 1.13 enthält Informationen über Feuerwehrdienste in 66 Ländern von 2010 bis 2024. Tabelle 1.14 zeigt das Verhältnis von Frauen zu Männern im Feuerwehrdienst. Tabelle 1.15 enthält Informationen zur Anzahl der jungen Feuerwehrleute. Tabelle 1.16 zeigt die Verteilung der Brände nach Brandursachen. Die Tabellen 2.1–2.5 zeigen Brandstatistiken für 26 Städte weltweit im Jahr 2024. Die Tabellen 2.6–2.8 zeigen die Einsätze, Brände und Brandopfer in 56 Städten weltweit von 2020 bis 2024. Abschließend enthält Tabelle 2.9 Informationen zu Feuerwehrdiensten in 79 Städten weltweit.

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Brief comments

1. Countries of the World

Table 1.1 shows that the CFS CTIF, established in 1995, annually summarizes statistical data from 27-57 countries worldwide, home to 0.9-3.8 billion people. In 1993, 40% of the World's population lived in the 39 countries surveyed. In 2008, more than 50% of the World's population lived in the 31 countries surveyed. In the surveyed countries, 2.5-4.5 million fires were recorded annually, resulting in 17-62 thousand deaths. In just 31 years, more than 1.1 million people have become victims of 114 million fires in these countries. Figure 1.1 shows trends in: a) number of fires per 1000 inhabitants; b) number of fire deaths per 100 thousand. inhabitants; c) number of fire deaths per 100 fires. Red color shows the min. and the max. values for separate countries in every year. Table 1.2 summarizes the volume of work and fire situation in 40 countries in 2024. Table 1.2 shows that in 2024, across 40 countries surveyed, home to 1.5 billion people (1/5 of the World's population), 64 million calls to fire and rescue services were registered, of which 2.8 million (4.3% of all calls) were related to fires. 16.9 thousand people died during these fires, and 46 thousand people were injured. That means that for every 1,000 people in these countries, there were an average of 42 calls per year, of which 1.8 were fire calls. At the same time, on average, for every 100,000 people, 1.1 people died, and 3.0 people were injured in fires during the year; for every 100 fires, an average of 0.8 people died, and 1.7 people were injured. Table 1.3 and Figure 1.2 show the nature of operational work of fire services in 22 countries. More than 64 million fire service calls were analyzed in 20243. The share of fires in the total number of fire service calls is 3.4%, calls to accidents (for technical assistance and rescue) are 6.1%, calls for medical aid are 67% (mainly in Taiwan, Singapore, Ireland, and the USA), false alarms account for 7%, and others 16.4%. Table 1.4 and Figure 1.3 show the distribution of fires by place of origin in 24 countries. Approximately 34.9% of all fires occur in buildings (25.7% in residential buildings and 9.1% in all other facilities), about 11.9% in transport means, 1.2% in forests, 16.7% in grass and bushes, 14.2% in trash and landfills, and 21.1% in other fires. When analyzing the data in this table, it should be borne in mind that different countries have their own rules for recording fires for the categories presented.

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From the final line of Table 1.4, it follows that 46.8% of all reported fires occurred in buildings (including chimney fires) and transport. In Tables 1.5-1.6 and Figures 1.4-1.5, the distributions of those killed and injured in fires by place of origin are presented. These data show that 85.1% of all deaths (from 25% in Bangladesh to 100% in Jourdan) and 73.5% of all injuries (from 21% in Bangladesh to 79% in the USA) occur in residential buildings. Tables 1.7-1.10 present information on the types and numbers of fire service calls, fires, and fire victims for 2020-2024 across 56-75 countries. In these countries, there are an average of 69 million fire service calls and 3.5 million fires per year, in which about 26 thousand people die and approximately 59 thousand people are injured. Figure 1.6 shows that the highest number of calls per 1,000 people (average figures for the period 2020-2024; Table 1.7) occurs in Finland, Luxembourg, and the Czech Republic. Conversely, most fires per 1,000 people (averages for the period 2020-2024, Table 1.8) are in Cyprus, Austria, and Uruguay (Figure 1.7). Figure 1.8 shows that most fire deaths per 100,000 people (average values for 2020-2024, Table 1.9) occur in Belarus, Russia, and Ukraine. Figure 1.9 shows the distribution of fire deaths per 100 fires (average values for 2020-2024, Table 1.9). Figure 1.10 shows that the highest rates of fire injuries per 100,000 people (average values for 2020-2024; Table 1.10) occur in France, Jordan, and Latvia. Figure 1.11 shows the distribution of fire injuries per 100 fires (average values for 2020-2024, Table 1.10). Tables 1.11 and 1.12 present data on firefighter deaths and injuries in 35 and 29 countries, respectively. In 2024, 85 firefighters died, and 55,000. were injured in these countries. Table 1.13 and Figures 1.12-1.14 show the staff numbers of fire services in 66 countries at the beginning of the 21st century. From Table 1.13, it follows that 3.2 billion inhabitants of these countries are protected from fires by 15.7 million firefighters, of which 14 million are volunteers. Table 1.14 and Figure 1.15-1.16 present data on the distribution of firefighters by gender in 46 countries. Table 1.15 presents data on the number of young firefighters in 21 countries. Table 1.16 and Figure 1.17 present the distribution of fires by fire causes. Main causes are carelessness – 25%, fireplace, stove – 10%, and electricity equipment failure – 18%. Figures 1.18-1.19 show the distribution of people who died from “fire, heat, and hot substances” in 2019, according to the World Health Organization (WHO).

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• Cities of the World

It follows from Table 2.1 that, in the 26 cities surveyed, for every 1,000 people in 2024, there were 31.2 fire service calls, of which 1.4 were fires. It also shows that, in 2024, an average of 0.6 people died and 3.3 people were injured per 100,000 people in fires across all the cities listed in the table. Figures 2.1-2.4 show the distribution of cities by the number of fire service calls and fires per 1,000 people per year (average figures for the period 2020-2024, Tables 2.6-2.7) and the number of deaths in fires per 100 thousand people, and per 100 fires per year (average figures for the period 2020-2024, Table 2.8). Table 2.2 and Figure 2.5 present data on the nature of fire services work in 15 cities worldwide in 2024. The share of fires of the total number of fire service calls for 15 cities averaged 3.8%. Accident visits and technical assistance accounted for 7.2% of all calls; trips to provide medical care accounted for 77.6% of all fire service calls. False exits account for 3.2% of all calls and 8.1% for other exits. In Table 2.3 and Figure 2.6, objects and places of occurrence of fires in 14 cities of the World are considered. Summarizing these data, shows that 39.8% of all fires occurred in buildings (including chimneys) (22.3% in residential buildings and 17.6% in all other buildings), 9.7% in transport (i.e. e. more than 49% of all fires originated either in buildings or in vehicles); forest fires, garbage, landfills, grass, and bushes accounted for 35% of all fires. Tables 2.4 and 2.5 and Figures 2.7 and 2.8 show the distribution of people killed and injured in fires by occupancy in 9 cities around the World. They show that 87.2% of the fatalities and 77.3% of the injuries occurred in residential buildings. 97,5% of the dead and 94% of the injuries happened in all buildings. Table 2.6 shows the type of calls for 2020-2024 in 47 cities around the World. These cities have 220 million inhabitants and annually receive an average of 4.3 million fire service calls (i.e., 20 calls per 1,000 people). Table 2.7 shows the number of fires for 2020-2024 across 57 cities worldwide. They have 342 million inhabitants, and an average of 288,000 fires are recorded annually (i.e., 0.8 fires per 1,000 people). Table 2.8 shows the number of fire fatalities from 2020 to 2024 across 52 cities worldwide. 279 million people inhabit them, and annually an average of 1,398 people die in fires; i.e., for every 100,000 people, there are, on average, 0.5 fire fatalities. Table 2.9 and Figures 2.9-2.12 present data on the number of firefighters and their technical equipment at the beginning of the 21st century for 79 cities. There are

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more than 338 million people in these cities. They were served by approximately 256 thousand firefighters, with an average of 1 professional firefighter per 1,687 people (Figure 2.9) and 19.5 sq. km per fire station (Figure 2.12). These data should be of some interest to specialists.

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Breves comentarios

1. Países del mundo

La Tabla 1.1 muestra que el CFS CTIF, establecido en 1995, resumía anualmente datos estadísticos de 27-57 países del mundo, en los que vivían entre 0,9 y 3,8 mil millones de personas. En 1993, el 40% de la población mundial vivía en los 39 países encuestados. En 2008, más del 50% de la población mundial vivía en los 31 países encuestados. En los países encuestados, se registraron entre 2,5 y 4,5 millones de incendios anualmente, en los que murieron entre 17.000 y 62.000 personas. En solo 31 años, más de 1,1 millones de personas han sido víctimas de 114 millones de incendios en estos países. La Figura 1.1 muestra tendencias en: a) número de incendios por cada 1000 hab; b) número de muertes por incendio por cada 100 mil. inh.; c) número de muertes por incendio por cada 100 incendios. El color rojo muestra los valores Min y Max de países distintos en cada año. La Tabla 1.2 resume el volumen de trabajo y la situación de incendios en 40 países en 2024. La tabla 1.2 muestra que en 2024, en 40 países encuestados, en los que vivían 1.500 millones de personas (1/5 de la población mundial), se registraron 64 millones de llamadas de servicios de bomberos y rescate, de las cuales 2,8 millones (4,3% de todas las llamadas) estaban relacionadas con incendios. 16.900 personas murieron durante estos incendios y 46 mil resultaron heridas. Eso significa que por cada 1.000 personas en estos países, hubo una media de 42 llamadas al año, de las cuales 1,8 fueron incendios. Al mismo tiempo, por cada 100.000 personas, de media, 1,1 personas murieron y 3,0 resultaron heridas en incendios durante el año, y por cada 100 incendios, una media de 0,8 personas murieron y 1,7 resultaron heridas. La Tabla 1.3 y la Figura 1.2 muestran la naturaleza del trabajo operativo de los servicios de bomberos en 22 países. En 2024 se analizaron más de 64 millones de llamadas de servicios de bomberos. La proporción de incendios en el total de llamadas de los servicios de bomberos es del 3,4%, las llamadas a accidentes (para asistencia técnica y rescate) 6,1 y las llamadas de ayuda médica son del 67% (principalmente en Taiwán, Singapur, Irlanda y Estados Unidos), las falsas alarmas representan el 7% y otras el 16,4%. La Tabla 1.4 y la Figura 1.3 muestran la distribución de incendios por lugar de origen en 24 países. Aproximadamente el 34,9% de todos los incendios ocurren en edificios (25,7% en edificios residenciales y 9,1% en todas las demás

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instalaciones), aproximadamente el 11,9% en medios de transporte, 1,2% en bosques, 16,7% en incendios de hierba y arbustos, 14,2% en basura y vertederos y 21,1% en otros incendios. Al analizar los datos de esta tabla, debe tenerse en cuenta que cada país tiene sus propias normas para registrar incendios en las categorías presentadas. De la última línea de la Tabla 1.4, se deduce que el 46,8% de todos los incendios reportados ocurrieron en edificios (incluidos incendios en chimeneas) y en el transporte. En las Tablas 1.5-1.6 y las Figuras 1.4-1.5, se presentan las distribuciones de los muertos y heridos en incendios según el lugar de origen. Estos datos muestran que el 85,1% de todas las muertes (del 25% en Bangladés al 100% en Jourdan) y el 73,5% de todas las lesiones (del 21% en Bangladés al 79% en EE. UU.) ocurren en edificios residenciales. Las tablas 1.7-1.10 contienen información sobre el tipo y número de llamadas de los servicios de bomberos, incendios y víctimas de incendios para 2020-2024 en 56-75 países. En estos países, hay una media de 69 millones de llamadas de los servicios de bomberos y 3,5 millones de incendios al año, en los que mueren unas 26.000 personas y aproximadamente 59.000 resultan heridas. La Figura 1.6 muestra que el mayor número de llamadas por cada 1.000 personas (cifras medias para el periodo 2020-2024 (Tabla 1.7)) se da en Finlandia, Luxemburgo y República Checa. Por el contrario, la mayoría de los incendios por cada 1.000 habitantes (promedios para el periodo 2020-2024, Tabla 1.8) se producen en Chipre, Austria y Uruguay (Figura 1.7). La Figura 1.8 muestra que la mayoría de las muertes por incendio por cada 100.000 habitantes (valores medios para 2020-2024, Tabla 1.9) ocurren en Bielorrusia, Rusia y Ucrania. La Figura 1.9 muestra la distribución de muertes por incendios por cada 100 incendios (valores medios para 2020-2024, Tabla 1.9). La Figura 1.10 muestra que la mayoría de las lesiones por incendio por cada 100.000 habitantes (valores medios para 2020-2024, Tabla 1.10) se producen en Francia, Jordania y Letonia. La Figura 1.11 muestra la distribución de lesiones por incendio por cada 100 incendios (valores medios para 2020-2024, Tabla 1.10). Las tablas 1.11-1.12 presentan datos sobre las muertes y lesiones de bomberos en 35 y 29 países. En 2024, murieron 85 bomberos y 55 mil. resultaron heridos en estos países. La Tabla 1.13 y las Figuras 1.12-1.14 muestran el número de personal de los servicios de bomberos en 66 países a principios del siglo XXI. De la Tabla 1.13, se deduce que 3.200 millones de habitantes de estos países están protegidos de incendios por 15,7 millones de bomberos, de los cuales 14 millones son voluntarios.

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La Tabla 1.14 y las Figuras 1.15-1.16 presentan datos sobre la distribución de bomberos por género en 46 países. La Tabla 1.15 presenta datos sobre el número de jóvenes bomberos en 21 países. La Tabla 1.16 y la Figura 1.17 presentan la distribución de los incendios por causas del incendio. Las principales causas son la negligencia – 25%, incendios, esfuerzos – 10% y fallos eléctricos – 18%. Las figuras 1.18-1.19 muestran la distribución de las personas que murieron por "fuego, calor y sustancias calientes" en 2019, según la Organización Mundial de la Salud (OMS).

• Ciudades del mundo

De la Tabla 2.1 se deduce que, en las 26 ciudades encuestadas, por cada 1.000 personas en 2024, hubo 31,2 llamadas a los servicios de bomberos, de las cuales 1,4 fueron incendios. También muestra que, de media, 0,6 personas murieron y 3,3 personas resultaron heridas por cada 100.000 personas en incendios en todas las ciudades listadas en la tabla en 2024. Las figuras 2.1-2.4 muestran la distribución de las ciudades según el número de llamadas de los servicios de bomberos e incendios por cada 1.000 habitantes al año (cifras medias para el periodo 2020-2024, Tablas 2.6-2.7) y el número de muertes por incendios por cada 100 mil habitantes y por cada 100 incendios al año (cifras medias del periodo 2020-2024, Tabla 2.8). La Tabla 2.2 y la Figura 2.5 proporcionan datos sobre la naturaleza del trabajo de los servicios de bomberos en 15 ciudades del mundo en 2024. La proporción de incendios en el total de llamadas de los servicios de bomberos en 15 ciudades fue de media del 3,8%. Las visitas de accidente y la asistencia técnica representaron el 7,2% de todas las llamadas; Los viajes para prestar atención médica representaban el 77,6% de todas las llamadas de los bomberos. Las salidas falsas representan el 3,2% de todas las llamadas y el 8,1% de otras salidas. En la Tabla 2.3 y la Figura 2.6 se consideran objetos y lugares de ocurrencia de incendios en 14 ciudades del mundo. Resumiendo estos datos, se muestra que el 39,8% de todos los incendios ocurrieron en edificios (incluidas las chimeneas) (22,3% en edificios residenciales y 17,6% en todos los demás edificios), el 9,7% en transporte (es decir, más del 49% de todos los incendios se originaron en edificios o vehículos); Los incendios forestales, basura, vertederos, hierba y arbustos representaban el 35% de todos los incendios.

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Las tablas 2.4 y 2.5 y las figuras 2.7 y 2.8 muestran la distribución de personas fallecidas y heridas en incendios según la ocupación en 9 ciudades de todo el mundo. Muestran que el 87,2% de las muertes y el 77,3% de las lesiones ocurrieron en edificios residenciales. El 97,5% de los fallecidos y el 94% de las heridas ocurrieron en todos los edificios. La Tabla 2.6 muestra el tipo de llamadas para 2020-2024 en 47 ciudades de todo el mundo. Estas ciudades tienen 220 millones de habitantes y registran anualmente una media de 4,3 millones de llamadas de servicios de bomberos (es decir, 20 llamadas por cada 1.000 habitantes). La Tabla 2.7 muestra el número de incendios en 2020-2024 en 57 ciudades de todo el mundo. Tienen 342 millones de habitantes y se registran una media de 288 mil incendios anuales (es decir, 0,8 incendios por cada 1.000 habitantes). La Tabla 2.8 muestra el número de muertes por incendio entre 2020 y 2024 en 52 ciudades de todo el mundo. Doscientos setenta y nueve millones de personas habitan allí, y anualmente mueren una media de 1.398 personas en incendios, es decir, por cada 100 mil personas, de media hubo 0,5 muertes por incendio. La Tabla 2.9 y las Figuras 2.9-2.12 presentan datos sobre el número de bomberos y su equipo técnico a principios del siglo XXI para 79 ciudades. Hay más de 338 millones de personas en estas ciudades. Fueron atendidos por aproximadamente 256 mil. bomberos, con una media de 1 bombero profesional por cada 1.687 personas (Figura 2.9) y 19,5 km² por estación de bomberos (Figura 2.12). Estos datos deberían ser de interés para los especialistas.

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Kurze Kommentare

Länder der Welt Tabelle 1.1 zeigt, dass das 1995 gegründete CFS CTIF jährlich statistische Daten aus 27–57 Ländern weltweit zusammenfasste, in denen 0,9–3,8 Milliarden Menschen lebten. 1993 lebten 40 % der Weltbevölkerung in den 39 untersuchten Ländern. Im Jahr 2008 lebten mehr als 50 % der Weltbevölkerung in den 31 untersuchten Ländern. In den befragten Ländern wurden jährlich 2,5 bis 4,5 Millionen Brände registriert, bei denen 17.000 bis 62.000 Menschen starben. In nur 31 Jahren sind in diesen Ländern mehr als 1,1 Millionen Menschen durch 114 Millionen Brände betroffen worden. Abbildung 1.1 zeigt Trends in: a) Anzahl der Brände pro 1000 Einwohner; b) Anzahl der Feuertodesfälle pro 100.000 Einwohner. inh.; c) Anzahl der Feuertodesfälle pro 100 Brände. Die rote Farbe zeigt die Minima und Maxima für verschiedene Länder in jedem Jahr an. Tabelle 1.2 fasst das Arbeits- und Brandaufkommen in 40 Ländern im Jahr 2024 zusammen. Tabelle 1.2 zeigt, dass im Jahr 2024 in 40 befragten Ländern, in denen 1,5 Milliarden Menschen lebten (ein Fünftel der Weltbevölkerung), 64 Millionen Einsätze von Feuerwehr- und Rettungsdiensten registriert wurden, von denen 2,8 Millionen (4,3 % aller Einsätze) mit Bränden zusammenhingen. 16.900 Menschen starben bei diesen Bränden und 46.000 wurden verletzt. Das bedeutet, dass es auf 1.000 Menschen in diesen Ländern durchschnittlich 42 Anrufe pro Jahr gab, von denen 1,8 Brände waren. Gleichzeitig starben auf 100.000 Menschen im Durchschnitt 1,1 Menschen, und 3,0 Menschen wurden im Laufe des Jahres bei Bränden verletzt. Auf 100 Brände kamen im Durchschnitt 0,8 Menschen ums Leben und 1,7 wurden verletzt. Tabelle 1.3 und Abbildung 1.2 zeigen die Art der operativen Tätigkeit der Feuerwehrdienste in 22 Ländern. Im Jahr 2024 wurden mehr als 64 Millionen Einsätze der Feuerwehr analysiert. Der Anteil der Brände an der Gesamtzahl der Feuerwehreinsätze beträgt 3,4 %, Unfallanrufe (für technische Hilfe und Rettung) 6,1 % und medizinische Hilfe 67 % (hauptsächlich in Taiwan, Singapur, Irland und den USA); Fehlalarme machen 7 % aus, andere 16,4 %. Tabelle 1.4 und Abbildung 1.3 zeigen die Verteilung der Brände nach Herkunftsort in 24 Ländern. Etwa 34,9 % aller Brände treten in Gebäuden auf (25,7 % in Wohngebäuden und 9,1 % in allen anderen Einrichtungen), etwa 11,9 % auf

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Transportmitteln, 1,2 % auf Wäldern, 16,7 % auf Gras- und Buschbränden, 14,2 % auf Müll und Deponien sowie 21,1 % auf anderen Bränden. Bei der Analyse der Daten in dieser Tabelle sollte berücksichtigt werden, dass verschiedene Länder eigene Regeln zur Erfassung von Bränden in den vorgestellten Kategorien haben. Aus der letzten Zeile von Tabelle 1.4 folgt, dass 46,8 % aller gemeldeten Brände in Gebäuden (einschließlich Schornsteinbrände) und im Transport auftraten. In den Tabellen 1.5–1.6 und den Abbildungen 1.4–1.5 werden die Verteilungen der bei Bränden Getöteten und Verletzten nach Herkunftsort dargestellt. Diese Daten zeigen, dass 85,1 % aller Todesfälle (von 25 % in Bangladesch bis 100 % in Jordanien) und 73,5 % aller Verletzungen (von 21 % in Bangladesch bis 79 % in den USA) in Wohngebäuden auftreten. Die Tabellen 1.7-1.10 enthalten Informationen zur Art und Anzahl der Feuerwehreinsätze, Brände und Brandopfer für die Jahre 2020-2024 in 56-75 Ländern. In diesen Ländern gibt es durchschnittlich 69 Millionen Feuerwehreinsätze und 3,5 Millionen Brände pro Jahr, bei denen etwa 26.000 Menschen sterben und etwa 59.000 verletzt werden. Abbildung 1.6 zeigt, dass die größte Anzahl von Anrufen pro 1.000 Einwohner (Durchschnittszahlen für den Zeitraum 2020–2024, (siehe Tabelle 1.7) in Finnland, Luxemburg und Tschechien stattfindet. Umgekehrt treten die meisten Brände pro 1.000 Einwohner (Durchschnittswerte für den Zeitraum 2020–2024, Tabelle 1.8) in Zypern, Österreich und Uruguay auf (Abbildung 1.7). Abbildung 1.8 zeigt, dass die meisten Feuertote pro 100.000 Einwohner (Durchschnittswerte für 2020–2024, siehe Tabelle 1.9) in Belarus, Russland und der Ukraine auftreten. Abbildung 1.9 zeigt die Verteilung der Feuertodesfälle pro 100 Bränden (Durchschnittswerte für 2020–2024, siehe Tabelle 1.9). Abbildung 1.10 zeigt, dass die meisten Brandverletzungen pro 100.000 Einwohner (Durchschnittswerte für 2020–2024, siehe Tabelle 1.10) in Frankreich, Jordanien und Lettland auftreten. Abbildung 1.11 zeigt die Verteilung der Brandverletzungen pro 100 Brände (Durchschnittswerte für 2020–2024, siehe Tabelle 1.10). Die Tabellen 1.11–1.12 zeigen Daten zu Todesfällen und Verletzungen von Feuerwehrleuten in 35 und 29 Ländern. Im Jahr 2024 starben 85 Feuerwehrleute und 55 weitere wurden in diesen Ländern verletzt. Tabelle 1.13 und Abbildungen 1.12–1.14 zeigen die Personalzahlen der Feuerwehr in 66 Ländern zu Beginn des 21. Jahrhunderts. Aus Tabelle 1.13 geht hervor, dass 3,2 Milliarden Einwohner dieser Länder von 15,7 Millionen Feuerwehrleuten, davon 14 Millionen Freiwilligen, vor Bränden geschützt werden. Tabelle 1.14 und Abbildung 1.15-1.16 zeigen Daten zur Verteilung der Feuerwehrleute nach Geschlecht in 46 Ländern.

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Tabelle 1.15 zeigt Daten zur Anzahl junger Feuerwehrleute in 21 Ländern. Tabelle 1.16 und Abbildung 1.17 zeigen die Verteilung der Brände nach Brandursachen. Hauptursachen sind Nachlässigkeit (25 %), Feuer (10 %) und Elektrizität (18 %). Die Abbildungen 1.18–1.19 zeigen laut der Weltgesundheitsorganisation (WHO) die Verteilung der Menschen, die 2019 an "Feuer, Hitze und heißen Substanzen" starben.

• Städte der Welt

Aus Tabelle 2.1 folgt, dass in den 26 untersuchten Städten im Jahr 2024 auf 1.000 Einwohner 31,2 Einsätze des Feuerwehrdienstes registriert wurden, davon 1,4 Brände. Es zeigt außerdem, dass im Durchschnitt 0,6 Menschen pro 100.000 Menschen in allen in der Tabelle aufgeführten Städten im Jahr 2024 bei Bränden starben und 3,3 Menschen pro 100.000 Menschen bei Bränden verletzt wurden. Die Abbildungen 2.1–2.4 zeigen die Verteilung der Städte nach der Anzahl der Feuerwehreinsätze und Brände pro 1.000 Einwohner und Jahr (Durchschnittszahlen für den Zeitraum 2020–2024, Tabellen 2.6–2.7) sowie der Anzahl der Todesfälle bei Bränden pro 100.000 Einwohner und pro 100 Bränden pro Jahr (Durchschnittszahlen für den Zeitraum 2020–2024, Tabelle 2.8). Tabelle 2.2 und Abbildung 2.5 zeigen Daten zur Art der Arbeit der Feuerwehr in 15 Städten weltweit im Jahr 2024. Der Anteil der Brände an der Gesamtzahl der Feuerwehreinsätze in 15 Städten betrug im Durchschnitt 3,8 %. Unfallbesuche und technische Unterstützung machten 7,2 % aller Einsätze aus; Fahrten zur medizinischen Versorgung machten 77,6 % aus. Falsche Alarme: 3,2 % aller Anrufe und 8,1 % der übrigen Ausgänge. In Tabelle 2.3 und Abbildung 2.6 werden Objekte und Orte von Bränden in 14 Städten weltweit betrachtet. Zusammenfassend zeigt sich, dass 39,8 % aller Brände in Gebäuden (einschließlich Schornsteine) auftraten (22,3 % in Wohngebäuden und 17,6 % in allen anderen Gebäuden), 9,7 % im Verkehr (d.h., mehr als 49 % aller Brände entstanden entweder in Gebäuden oder Fahrzeugen); Waldbrände, Müll, Deponien, Gras und Büsche machten 35 % aller Brände aus. Die Tabellen 2.4 und 2.5 sowie die Abbildungen 2.7 und 2.8 zeigen die Verteilung der bei Bränden Getöteten und Verletzten nach Belegung in 9 Städten weltweit. Sie zeigen, dass 87,2 % der Todesfälle und 77,3 % der Verletzungen in Wohngebäuden zu beklagen waren. 97,5 % der Toten und 94 % der Verletzten erlitten in allen Gebäuden.

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Tabelle 2.6 zeigt die Art der Einsätze in 47 Städten weltweit im Zeitraum 2020-2024. Diese Städte haben 220 Millionen Einwohner und verzeichnen jährlich im Durchschnitt 4,3 Millionen Feuerwehreinsätze (also 20 Einsätze pro 1.000 Einwohner). Tabelle 2.7 zeigt die Anzahl der Brände in 57 Städten weltweit im Zeitraum 2020-2024. Sie haben 342 Millionen Einwohner, und im Durchschnitt werden jährlich 288.000 Brände registriert (also 0,8 Brände pro 1.000 Einwohner). Tabelle 2.8 zeigt die Zahl der Feuertodesfälle von 2020 bis 2024 in 52 Städten weltweit. Zweihundertneunundsiebzig Millionen Menschen bewohnen sie, und jährlich sterben durchschnittlich 1.398 Menschen bei Bränden, das heißt, auf 100.000 Menschen fallen im Durchschnitt 0,5 Todesopfer bei Bränden. Tabelle 2.9 und Abbildungen 2.9–2.12 zeigen Daten zur Anzahl der Feuerwehrleute und ihrer technischen Ausrüstung zu Beginn des 21. Jahrhunderts für 79 Städte. In diesen Städten leben mehr als 338 Millionen Menschen. Sie wurden von etwa 256.000 bedient. Feuerwehrleute: durchschnittlich 1 professioneller Feuerwehrmann pro 1.687 Einwohner (Abbildung 2.9) und 19,5 km² pro Feuerwache (Abbildung 2.12). Diese Daten sollten für Fachleute von Interesse sein.

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Acknowledgement

The authors of the report thank the National Committees of CTIF, which sent us the 2024 fire statistics for analysis. Now the Center of Fire Statistics of CTIF begins work on report №32. We ask all National Committees of CTIF to send us fire statistics of the countries and cities for the year 2025 before May 1, 2027. The report's authors are always grateful for any suggestions to improve the Center for Fire Statistics' work.

Conclusión

Los autores del informe agradecen a los Comités Nacionales del CTIF, que enviaron las estadísticas de incendios de 2024 para su análisis. Ahora el Centro de Estadísticas de Incendios de CTIF comienza a trabajar en el informe Nº32. Pedimos a todos los Comités Nacionales de CTIF que nos envíen las estadísticas de incendios de los países y ciudades del mundo para el año 2025 antes del 1º de mayo de 2027. Los autores del informe están siempre agradecidos por cualquier sugerencia para mejorar el trabajo del Centro de Estadísticas de Incendios.

Zusammenfassung

Die Autoren des Berichtes danken den Nationalen CTIF-Komitees für die Übersendung der Feuerwehrstatistik aus 2024. Gegenwärtig beginnt das CFS CTIF die Arbeiten am Bericht №32. Wir bitten die Nationalen CTIF-Komitees um Übersendung der nationalen Feuerwehrstatistiken für das Jahr 2025 bis zum 1. Mai 2027. Die Autoren sind wie immer für jeden Hinweis, jede Kritik und jeden Vorschlag zur Verbesserung der internationalen Feuerwehrstatistik dankbar.

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Sources / Fuentes / Quellen

• Data on Fire Statistics of 11 countries in 2024 (Data obtained from responses

to the requests of the Fire Statistics Center).

• Fire and Fire Safety in 2024, Statistics Journal, Statistics of Fires and their

analysis – Moscow, Russia, VNIIPO, 2025.

• The Singapore Civil Defense Force. Annual report, 2025.
• Fire and rescue statistical release. Great Britain. Department for Communities

and Local Government 2025.

• Annual report. New Zealand Fire service commission. 2025.
• Hong Kong Fire Services Department Review 2025.
• LFB | Fire Facts. Fires in Greater London in 2025. www.london-

fire.gov.ukand on

• WHO. Health statistics and information systems.

https://www.who.int/healthinfo/global_burden_disease/estimates/en/index1. html

• IFCAA Fire Statistics 2023-2024.

https://www.fcaj.gr.jp/ifcaa/jp/Revised_IFCAAFireStatistics2023-2024.pdf Contacts / Contactos / Kontakt

E-mail: sokoloff3302@gmail.com Prof. Dr. Sergei V. Sokolov

E-mail: drpeterwagner@freenet.de Dr. Peter Wagner

E-Mail: BCollins@nfpa.org Birgitte Messerschmidt

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Table 1 for filling / Cuadro para completar / Tabelle zum Ausfüllen

Statistical data Name of country:

Name of capital / largest city:

Population (1,000 inhabitants)

Area (sq.km.)

Total number of calls a year:

-fires

-rescue, technical aid.

-medical aid

-false calls

-other calls

Total number of fires:

-structure

• residential (with chimneys)

• all other buildings

-vehicle

-forests

-grass, bushes…

-rubbish

-other fires

Number of fire deaths:

-structure

• residential (with chimneys)

• all other buildings

-vehicle

-other

Number of fire injuries:

structure

• residential (with chimneys)

• all other buildings

-vehicle

-other

Number of fires by fire cause:

electricity equipment failure

gas equipment failure

playing with fire

fireplace, stove

carelessness

smoking

arson

other causes

unknown causes

Number of fires by means of their extinguishing:

before arrival of fire units

small equipment’s

1-jet

2-3 jets

more than 3 jets

foam jets

powder jets

unknown

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Statistical data Name of country:

Name of capital / largest city:

others Number of firefighter deaths

Number of firefighter injuries

Number of all firefighters:

-professionals (full-time)

-part-timer

-volunteers

Number of female firefighters:

-professionals (full-time)

-part-timer

-volunteers

Number of young (junior) firefighters:

Number of fire stations (total)

-professionals only

-part-timer (only)

-volunteers only (only)

-mixed use

Number of fire engines (pumpers)

Number of ladders and hydraulic lifts

Number of other fire automobiles (total):

-fire boats/ships etc.

-helicopter

-containers

-drones

Table/Cuadro/Tabelle 1.1 Number Total Number Number of population, of fires, of fire deaths, per per countries bln.inh. mln. thous. 100000 inh. 100 fires Cantidad Población Total Número de of total en de incendios víctimas fatales por 100,000 por cada 100 paises Miles de Mill. en mill. x 1.000 habitantes incendios Anzahl Gesamt- Anzahl Anzahl der bevölkerung der Brände der Brandtoten je. 100000 je 100 Staaten in Mrd. in Mio. in 1000 Einw. Brände 1993 39 2,4 3,9 30,2 1,3 0,8 1994 27 1,1 4,0 29,5 2,7 0,7 1995 42 1,2 4,5 32,5 2,7 0,7 1996 43 0,9 4,0 29,1 3,2 0,7 1997 48 2,8 3,7 57,7 2,1 1,6 1998 47 3,0 3,6 51,7 1,7 1,4 1999 52 3,1 3,9 51,8 1,7 1,3 2000 57 3,3 4,5 56,2 1,7 1,2 2001 46 3,5 3,8 61,9 1,8 1,6 2002 41 3,5 4,3 62,3 1,8 1,4 2003 39 3,5 4,5 61,1 1,7 1,4 2004 44 3,5 4,1 60,1 1,7 1,5 2005 45 3,5 4,3 57,4 1,6 1,3 2006 37 3,6 4,1 52,2 1,5 1,3 2007 40 3,8 4,0 52,5 1,4 1,3 2008 31 3,5 3,6 48,3 1,4 1,3 2009 31 3,4 3,3 44,7 1,3 1,4 2010 33 2,2 3,2 46,1 2,1 1,4 2011 34 2,3 3,3 48,2 2,1 1,5 2012 35 1,1 3,1 23,7 2,2 0,8 2013 31 1,1 2,5 21,7 2,0 0,9 2014 32 1,1 2,7 20,7 1,9 0,8 2015 31 1,0 3,5 18,4 1,8 0,5 2016 39 1,1 3,0 18,0 1,6 0,6 2017 34 1,1 3,2 16,9 1,5 0,5 2018 46 2,7 4,5 30,8 1,1 0,7 2019 34 1,3 3,1 19,2 1,5 0,6 2020 48 3,3 4,0 20,7 0,6 0,5 2021 38 1,2 3,1 16,8 1,4 0,5 2022 55 1,7 3,7 19,6 1,2 0,5 2023 44 1,4 2,9 16,6 1,2 0,6 2024 40 1,5 2,8 16,9 1,1 0,6 Ẋ 40 2,3 3,7 38,0 1,6 1,0 113,9 1176,6 1,2 1,1 1,2 1,1 1,3 1,3 1,4 1,1 1,2 1,3 je 1.000 Einw. 1,2 Mittelwert der 3,6 1,6 4,4 3,8 Total reported fire statistical data, by country, 1993-2024 Brandanzahl Mittelwert der Brandtotenanzahl Average number Datos estadísticos reportados, por país, 1993-2024 per 1000 inh. por 1000 hab. Year Average number of fire deaths of fires Verdichtete Daten zur Brandsituation der Staaten in den Jahren 1993-2024 Año Jahr Promedio de víctimas fatales Promedio de incendios 2,8 1,4 1,5 1,0 1,0 ∑ 2,3 2,5 1,6 2,7 3,5 2,9 1,7 2,4 1,2 2,6 2,2 2,1 1,9

a) b) c) Fig. 1.1: Trends in a) number of fires per 1000 inh.; b) number of fire deaths per 100 thous.inh.; c) number of fire deaths per 100 fires (Table 1.1) Fig. 1.1: Tendencias en a) número de incendios por cada 1000 habitantes; b) número de muertes por incendios por cada 100 mil habitantes; c) número de muertes por incendios por cada 100 incendios (Tabla 1.1) Bild 1.1: Trends in a) Anzahl der Brände pro 1000 Einwohner; b) Anzahl der Brandtoten pro 100.000 Einwohner; c) Anzahl der Brandtoten pro 100 Brände (Tabelle 1.1) 0,0 2,0 4,0 6,0 8,0 10,0 12,0 14,0 16,0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Number of fires per 1,000 inh. Years 0,0 2,0 4,0 6,0 8,0 10,0 12,0 14,0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Number of fire deaths per 100,000.inh. Years -1,0 1,0 3,0 5,0 7,0 9,0 11,0 13,0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Number of fire deaths per 100 fires Years

fire fire fire deaths per: fire injuries per: deaths injuries calls fires 100,000 inh. 100 fires 100,000 inh. 100 fires Víctimas Víctimas fatales Lesionados Fatales Llamados Incendios 100.000 hab. 100 incendios 100.000 hab. 100 incendios Brand- tote Einsätze Brände 100000 Einw. 100 Brände 100000 Einw. 100 Brände 1 USA 336 806 42 687 000 1 388 000 3 920 11 780 126,7 4,1 1,16 0,28 3,5 0,8 2 Bangladesh 173 100 41 315 25 992 140 341 0,2 0,2 0,08 0,54 0,2 1,3 3 Russia

146 781

347 436 7 575

8 345

2,4 5,16 2,18 5,7 2,4 4 Japan 124 143 10 141 584 75 017 1 451 5 805 81,7 0,6 1,17 1,93 4,7 7,7 5 Philippines 112 729 73 622 22 430 402 1 472 0,7 0,2 0,36 1,79 1,3 6,6 6 Egypt

105 914

46 926 232

831

0,4 0,22 0,49 0,8 1,8 7 Vietnam 100 352 14 797 4 112 100 89 0,1 0,0 0,10 2,43 0,1 2,2 8 Great Britain 67 353 718 095 176 044 331 7 904 10,7 2,6 0,49 0,19 11,7 4,5 9 Korea (South) 51 217 5 155 686 37 614 308

2 094

0,7 0,60 0,82 4,1 5,6 10 Uzbekistan

37 543

8 000 44

137

0,2 0,12 0,55 0,4 1,7 11 Canada 36 995 2 157 867

215 787

- 58,3

5,8

-

- 12 Malaysia 34 100 118 481 41 149 111 483 3,5 1,2 0,33 0,27 1,4 1,2 13 Taiwan 23 400 1 282 076 15 430 176 405 54,8 0,7 0,75 1,14 1,7 2,6 14 Kazakhstan

20 333

11 549 326

332

0,6 1,60 2,82 1,6 2,9 15 Jordan 11 734 660 982 59 557 49 1 686 56,3 5,1 0,42 0,08 14,4 2,8 16 Tadjikistan

10 591

1 775

17

- 0,2 0,16

0,96

- 17 Azerbaijan

10 336

1 649

40

- 0,2 0,39

2,43

- 18 Hungary 9 676 90 354 20 921 96 923 9,3 2,2 0,99 0,46 9,5 4,4 19 Belarus

9 408

6 208 549

535

0,7 5,84 8,84 5,7 8,6 20 Austria 9 197 339 529 65 233

43

36,9 7,1 0,47

0,07

- 21 Switzerland 9 050 81 824 13 168

33

9,0 1,5 0,36

0,25

- 22 Kyrgyzstan

6 735

4 932 67

4

0,7 0,99 1,36 0,1 0,1 23 Bulgaria 6 437 64 061 35 430 126 343 10,0 5,5 1,96 0,36 5,3 1,0 24 Singapore 6 036 245 279 1 990 7 80 40,6 0,3 0,12 0,35 1,3 4,0 25 Slovakia

5 431

7 694 40

249

1,4 0,74 0,52 4,6 3,2 26 New Zealand 5 123 88 805 19 805 17 275 17,3 3,9 0,33 0,09 5,4 1,4 27 Ireland 5 033 126 925 18 939

24

25,2 3,8 0,48

0,13

- 28 Panama 4 510 30 002

5 358

- 6,7

1,2

-

- 29 Georgia

3 695

11 639 42

241

3,1 1,14 0,36 6,5 2,1 30 Mongolia 3 544 5 118 3 482 62 60 1,4 1,0 1,75 1,78 1,7 1,7 31 Uruguay 3 423 44 266 29 550 168 487 12,9 8,6 4,91 0,57 14,2 1,6 32 Western Australia 3 009 34 094 10 153 17 260 11,3 3,4 0,56 0,17 8,6 2,6 33 Lithuania 2 885 33 301 7 667 85 177 11,5 2,7 2,95 1,11 6,1 2,3 34 Jamaica 2 824 19 133 9 775 27 79 6,8 3,5 0,96 0,28 2,8 0,8 35 Moldova

2 400

1 634 104

65

0,7 4,33 6,36 2,7 4,0 36 Slovenia 2 123 29 917 6 851 7 173 14,1 3,2 0,33 0,10 8,1 2,5 37 Latvia 1 830 14 436 5 256 65 277 7,9 2,9 3,55 1,24 15,1 5,3 38 Estonia 1 374 26 314 2 598 34 67 19,2 1,9 2,47 1,31 4,9 2,6 39 Mauritius 1 260 15 711 7 687 14 31 12,5 6,1 1,11 0,18 2,5 0,4 40 Brunei Darussalam 455 6 408 1 223

1

14,1 2,7 0,22

0,08

- 1 530 335 64 414 792 2 805 635 16 954 46 364 42,1 1,8 1,11 0,60 3,0 1,7 Common indicators of fire statistics in the countries of the World in 2024 Datos estadísticos reportados, por país, año 2024 Promedios: Mittelwerte: Table/Cuadro/Tabelle 1.2 Country Incendios Average number: Verdichtete Kennzahlen der Brandsituation in den Staaten für das Jahr 2024 per 1,000 inh.: calls fires Number of Verletztenzahl Brände Brandtotenzahl Verletzte ∑ Por 1.000 hab. je 1000 Einw. País Staat № Llamados Einsätze Número de Absolute Anzahl Habitantes, en miles Population, thous.inh. Einwohner, in 1000 Lesionados

Population thous.inh. in in medical in false in in % % aid % calls % % en en Asistencia en Falsas en en % % médica % alarmas % % Einwohner in 1000 zu in zu in Medizin. in Fehl- in in Bränden % Havarien % Hilfe % einsätze % % 1 USA 336 806 1 388 000 3,3 2 820 500 6,6 28 226 500 66,1 3 287 500 7,7 6 964 500 16,3 2 Bangladesh 173 100 25 992 62,9 3 510 8,5 11 790

28,6

-

- 3 Japan 124 143 75 017

0,7

- 7 344 508 73,3 474 450 4,7 2 128 572 21,2 4 Philippines 112 729 22 430 30,5 827 1,1 10 866 14,8 591 0,8 38 908 52,8 5 Malaysia 34 100 41 149 28,2 74 551 51,1 26 603

18,7

- 3 450 2,4 6 Taiwan 23 400 47 989 3,7 14 095 1,1 1 219 982

95,2

-

- 7 Jordan 11 734 59 557 9,0 73 815 11,2 527 610 79,8 284

0,0

- 8 Hungary 9 676 20 921 23,2 42 583

47,1

- 26 850

29,7

- 9 Austria 9 197 65 233 18,4 246 999

69,6

- 15 450 4,4 27 297 7,7 10 Switzerland 9 050 13 168 16,1 38 136

46,6

- 21 449 26,2 9 071 11,1 11 Bulgaria 6 437 35 430 55,3 12 894 20,1 236 0,4 2 064 3,2 13 436 21,0 12 Singapore 6 036 1 990 0,8 3 173 1,3 228 838 91,4 5 713 2,3 10 728 4,3 13 New Zealand 5 123 19 805 22,5 10 150 11,5 14 716 16,7 35 171 40,0 8 120 9,2 14 Ireland 5 033 18 939 14,8 18 679 14,6 82 348 64,3 8 031

6,3

- 15 Uruguay  3 423 29 550 69,2 821

1,9

- 6 352 14,9 5 982 14,0 16 Western Australia 3 009 10 153 29,8 5 874 17,2 135 0,4 13 316 31,1 4 616 13,5 17 Lithuania 2 885 7 667 24,0 14 347 44,8 0 0,0 133 0,4 9 855 30,8 18 Slovenia 2 123 6 851 22,9 17 855 59,6 2 607 8,7 2 069 6,9 589 2,0 19 Latvia 1 830 5 256

9 180

-

-

- 20 Estonia 1 364 2 598 9,9 8 768

33,3

- 9 843 37,4 5 097 19,4 21 Mauritius 1 260 7 687 48,9 5 919 37,7 1 905 12,1 200

1,3

- 22 Brunei Darussalam 455 1 223 18,9 4 835

74,9

-

- 400 6,2 882 913 1 906 605 3,4 3 427 511 6,1 37 698 644 67,1 3 909 466 7,0 9 230 621 16,4

• - This position includes all kinds of non-fire incidents

Table/Cuadro/Tabelle 1.3 Type of fire service calls in the countries of the World in 2024 Tipo de llamado, por país, año 2024 Struktur der Feuerwehreinsätze in den Staaten im Jahr 2024 Number of calls Cantidad de llamados … Anzahl der Einsätze ... ∑ № Country País Staat accidents* fires other Otros Sonstiges Habitantes, en miles Incendios Accidentes*

residential in % others in % all in % residencial % Otros % todos % Wohnung in % andere in % alle in % 1 USA 336 806 351 000 25,3 119 500 8,6 470 500 33,9 211 500

15,2

- 302 000 21,8 247 000 17,8 157 000 11,3 2 Bangladesh 165 100 10 131 38,8 4 926 18,8 15 057 57,6 400 1,5 62

0,2

-

- 10 681 40,9 3 Russia 146 781 108 491 34,2 30 478 9,6 138 969

43,8

- 9 373

3,0

-

- 168 616 53,2 3 Japan

124 143

-

- 20 972 56,6 3 546 9,6 831

2,2

-

- 11 727 31,6 4 Philippines 112 729 9 362 42,0 3 150 14,1 12 512 56,1 1 380 6,2 391 1,8 4 068 18,2 1 347 6,0 2 603 11,7 5 Vietnam

100 352

-

- 2 439 59,3 392 9,5 204

5,0

-

- 1 077 26,2 6 Korea (South) 51 217 10 437 27,8 13 948 37,1 24 385 64,9 4 831 12,9 976

2,6

-

- 7 402 19,7 7 Malaysia

34 100

-

- 5 563 25,4 3 906 17,8 2 164

9,9

-

- 10 299 47,0 8 Taiwan

23 400

-

- 4 830 31,4 1 319 8,6 1 978

12,8

-

- 7 276 47,2 9 Kazakhstan 20 333 6 964 60,0 2 143 18,5 9 107 78,4 2 506

21,6

-

-

-

- 10 Jordan 11 734 4 306 12,4 2 322 6,7 6 628 1 619 4,7 1 122

3,2

- 3 382 9,8 21 889 63,2 11 Hungary 9 676 6 583 31,5 1 964 9,4 8 547 40,9 1 160 5,5 3 607

17,2

- 1 737 8,3 5 867 28,0 12 Austria

9 197

-

- 24 150 84,0 2 294

8,0

- 2 300

8,0

-

- 13 Bulgaria 6 437 3 403 9,1 279 0,7 3 682 9,9 326

0,9

- 14 683 39,4 9 670 25,9 8 930 23,9 14 Singapore 6 036 968 48,3 415 20,7 1 383 68,9 220

11,0

- 180 9,0 97 4,8 126 6,3 15 Slovakia 5 431 1 418 24,0 480 8,1 1 898 32,2 847 14,4 102 1,7 1 327 22,5 1 639 27,8 84 1,4 16 New Zealand

5 123

-

- 4 872

24,5

-

- 4 873

24,5

- 10 150 51,0 17 Mongolia 3 544 1 632 83,2 198 10,1 132

6,7

-

-

- 18 Uruguay 

3 423

-

- 3 457 16,8 1 478 7,2 1 492

7,3

- 14 147

68,8

- 19 Western Australia 3 009 1 149 11,3 663 6,5 1 812 17,9 1 135 11,2 39 0,4 5 000 49,3 1 655 16,3 509 5,0 20 Lithuania 2 885 1 496 19,5 1635 21,3 3 131 40,8 934 12,2 177 2,7 1 113 14,5 1589 20,7 723 9,4 21 Slovenia 2 123 1 939 28,3 1 587 23,2 3 526 51,5 778 11,4 639 9,3 208 3,0 395 5,8 1 305 19,0 22 Latvia 1 830 1 545 29,4 1 129 21,5 2 674 50,9 610

9,5

- 440 8,4 1 532

29,1

- 23 Estonia 1 374 604 23,2 367 14,1 971 37,4 293 11,3 411

15,8

- 541 20,8 382 14,7 24 Mauritius 1 260 412 6,6 167 2,7 579 9,3 175 2,8 117 1,9 1 577 25,4 3 567 57,5 188 3,0 1 188 043 520 208 25,7 185 153 9,1 705 361 34,9 241 847 11,9 23 817 1,2 337 769 16,7 288 298 14,2 426 834 21,1 Table/Cuadro/Tabelle 1.4 Distribución de tipos de incendios en los países del mundo año 2024 Verteilung der Brände nach Objekten der Brandentstehung in den Staaten im Jahr 2024 in % Distribution of fires by types in the countries of the World in 2024 vehicles forests in % grass, brush rubbish other in % in % in % structure fires Population, thous.inh. Forestal Anzahl der Brände … in % Otros Sonstige in % % Fuego estructural in Gebäuden % Vehículos ∑ № Country País Staat Habitantes, en miles Number of fires … Cantidad de incendios … Einwohner in 10000 Gras usw. % in % % in % Abfall, Müll Basura in % Transport im Wald % Pastizal, Matorral

Fires/ Incendios/ Brände 3,4 % Incidents, accidents/ Accidente/ Havarie 6,1 % Medical aid/ Asist medica/ Medizin. Hilfe 67,1 % False/ Falsos/ Fehleinsätze 7,0 % Other/ Otros/ Sonstiges 16,4 % Fig. 1.2: Type of fire service calls in the countries (2024) Fig. 1.2: Tipo de operaciones en los países (2024) Bild 1.2: Einsatzstruktur der Feuerwehren in den Staaten (2024) Residential buildings/ Edificios residenciales/ Wohngebäude 25,7% Other buildings/ Otros edificios/ Andere Gebäude 9,1 % Vehicle/ Vehículos/ Transport 11,9 % Forests/ Forestales/ Wald 1,2 % Grass,bush/ Pastizales/ Gras 16,7 % Rubbish/ Basura/ Müll 14,2 % Other/ Otro/ Sonstige 21,1 % Fig. 1.3: Distribution of fires by types in the countries (2024) Fig. 1.3: Distribución de incendios en los paíse (2024) Bild 1.3: Verteilung der Brände nach Objekten der Brandentstehung in den Staaten (2024)

residential in % all others in % Residencial en % Otros en % Wohnung in % andere in % 1 USA 336 806 2 920 76,0 170 4,4 510 13,3 240 6,3 2 Bangladesh 165 100 36

25,7

-

- 104 74,3 3 Russia 146 781 6 924 91,4 393

5,2

- 258 3,4 4 Philippines 112 729 400 99,5 2 0,5 0 0,0 0 0,0 5 Korea (South) 51 217 174 56,5 92 29,9 36 11,7 6 1,9 6 Jordan 11 516 49 100,0 0 0,0 0 0,0 0 0,0 7 Hungary 9 676 81 84,4 4 4,2 3 3,1 8 8,3 8 Bulgaria 6 437 100 93,5 1

0,9

- 6 5,6 9 Slovakia 5 431 25 62,5 2 5,0 8 20,0 5 12,5 10 Western Australia 3 009 8 47,1 1 5,9 5 29,4 3 17,6 11 Lithuania 2 885 50 58,8 30 35,3 2 2,4 3 3,5 12 Slovenia 2 123 6 85,7 0 0,0 1 14,3 0 0,0 13 Estonia 1 374 31 91,2 3 8,8 0 0,0 0 0,0 855 084 10 804 85,1 698 5,5 565 4,4 633 5,0 residential in % all others in % residencial en % otros en % Wohnung in % andere in % 1 USA 336 806 9 330 79,1 1 020 8,7 1 070 9,1 370 3,1 2 Bangladesh 165 100 72 21,1 78

22,9

- 191 56,0 3 Philippines 112 729 1 381 93,8 91 6,2 0 0,0 0 0,0 4 Korea (South) 51 217 972 46,4 923 44,1 173 8,3 26 1,2 5 Jordan 11 516 1 253 74,3 433 25,7 0 0,0 0 0,0 6 Hungary 9 676 614 66,5 85 9,2 40 4,3 184 19,9 7 Slovakia 5 431 149 59,8 38 15,3 22 8,8 40 16,1 8 Western Australia 3 009 151 58,1 17 6,5 33 12,7 59 22,7 9 Lithuania 2 885 50 28,2 88 49,7 27 15,3 12 6,8 10 Slovenia 2 123 108 62,4 51 29,5 7 4,0 7 4,0 11 Estonia 1 374 57 85,1 7 10,4 0 0,0 3 4,5 701 866 14 137 73,5 2 831 14,7 1 372 7,1 892 4,6 ∑ otros en % Staat Einwohner in 10000 Anzahl der Verletzten in Gebäuden Transport in % Sonstige in % № vehicles in % other in % País Habitantes, en miles Cantidad de lesionados incendios estructurales vehículos en % Country Population, thous.inh. Number of fire injuries structure fires ∑ Table/Cuadro/Tabelle 1.6 Distribution of fire injuries by type of fire in the countries of the World in 2024 Distribución de lesionados según tipo de incendio en paises del mundo en 2024 Verteilung der Verletzten nach Objekten der Brandentstehung in den Staaten im Jahr 2024 Staat Einwohner in 10000 Anzahl der Brandtoten in Gebäuden Transport in % Sonstige in % Incendios Estructurales vehículos en % otros en % Table/Cuadro/Tabelle 1.5 Distribution of fire deaths by type of fires in the countries of the World in 2024 Distribución de fallecidos según tipo de incendio el países del mundo año 2024 Verteilung der Brandtoten nach Objekten der Brandentstehung in den Staaten im Jahr 2024 № Country Population, thous.inh. Number of fire deaths structure fires vehicles in % other in % País Habitantes, en miles Muertos en incendios

Residential buildings/ Edificios residenciales/ Wohngebäude 73,5 % Other buildings/ Otros edificios/ Andere Gebäude 14,7 % Vehicle/ Vehículos/ Transport 7,1 % Other/ Otros/ Sonstige 4,6 % Fig. 1.5: Distribution of fire injuries by types in the countries (2024) Fig. 1.5: Distribución de lesionados sgún tipo en países (2024) Bild 1.5: Verteilung der Brandverletzten nach Objekten der Brandentstehung in den Staaten (2024) Residential buildings/ Edificios residenciales/ Wohngebäude 85,1 % Other buildings/ Otras constucc/ Andere Gebäude 5,5 % Vehicle/ Vehículos/ Transport 4,4 % Other/ Otros/ Sonstige 5,0 % Fig. 1.4: Distribution of fire deaths by types in the counties (2024) Fig. 1.4: Distribución de fallecidos según tipo de incendio en países (2024) Bild 1.4: Verteilung der Brandtoten nach Objekten der Brandentstehung in den Staaten (2024)

1 USA 336 806 35 026 000 36 624 000 42 059 500 42 412 500 42 687 000 39 761 800 118,06 2 Bangladesh 165 100

67 568

72 272 47 714 41 315 57 217 0,35 3 Japan 124 143 7 932 672

8 016 669

10 257 861 10 141 584 9 087 197 73,20 4 Philippines

112 729

-

- 73 622 73 622 0,65 5 Vietnam 100 300 8 046 7 680

11 383

14 797 10 477 0,10 6 Germany 83 020 4 089 572 4 344 572 4 432 636

4 521 814

4 347 149 52,36 7 Great Britain 67 353 685 083 636 088 707 633 719 015 718 095 693 183 10,29 8 France 67 244 4 290 700 4 680 900 4 968 500

4 771 900

4 678 000 69,57 9 Italy 60 317 884 128 912 593

981 579

- 926 100 15,35 10 Korea (South) 51 217

11 274 559

5 387 921 5 382 745 5 155 686 6 800 228 132,77 11 Poland 37 766 583 300 579 713

608 818

- 590 610 15,64 12 Ukraine 37 441 279 671 238 121 181 935

178 155

219 471 5,86 13 Canada

36 995

-

- 2 157 867 2 157 867 58,33 14 Malaysia 34 100 124 596 168 206 126 704 129 114 118 481 133 420 3,91 15 Peru 32 000 115 677 79 535

79 782

- 91 665 2,86 16 Taiwan

23 400

-

1 274 527 1 282 076 1 278 302 54,63 17 Kazakhstan 20 333 55 102 76 592 55 000

55 000

60 424 2,97 18 Romania 19 053 525 916

591 105

-

558 511 29,31 19 Ecuador

18 000

-

46 216

- 46 216 2,57 20 Netherlands

17 591

135 359

-

135 359 7,69 21 Belgium 11 697 251 551 203 094 245 115

182 438

220 550 18,86 22 Jordan 11 516 768 030 613 373 525 199 531 769 660 982 619 871 53,83 23 Czech Republic 10 827 2 289 149 2 319 720 2 506 162

3 175 345

2 572 594 237,61 24 Greece 10 788 76 305 76 726 80 546

85 098

79 669 7,38 25 Sweden 10 552

120 173

-

119 295

119 734 11,35 26 Portugal

9 857

- 1 528 677

1 575 224

1 551 951 157,45 27 Hungary 9 676 77 328 78 375 92 879 92 879 90 354 86 363 8,93 28 Israel 9 656 65 770 150 137

159 709

- 125 205 12,97 29 Austria 9 197 247 436 300 620

266 876

339 529 288 615 31,38 30 Switzerland 9 050 70 493 85 030 79 058 84 769 81 824 80 235 8,87 31 Paraguay

7 453

-

36 158

- 36 158 4,85 32 Serbia 6 797 27 333 30 919

31 246

- 29 833 4,39 33 Bulgaria 6 437 56 057 55 059 62 492 64 970 64 061 60 528 9,40 34 Singapore 6 036 196 345 213 615 256 837 246 832 245 279 231 782 38,40 35 Denmark 5 944

37 496

40 152

39 921

39 190 6,59 36 Finland 5 565 2 787 190 2 782 980

2 291 400

- 2 620 523 470,89 37 Slovakia 5 431 127 408

1 080 333

-

603 871 111,19 38 New Zealand 5 123 83 669 84 688 87 684 92 509 88 805 87 471 17,07 39 Norway 5 109 84 862

90 605

-

87 734 17,17 40 Ireland 5 033 114 080 119 092 126 536 122 449 126 925 121 816 24,20 41 Panama

4 510

-

43 759

30 002 36 881 8,18 42 Croatia 3 860 37 834 43 843 38 234

45 918

41 457 10,74 43 Mongolia 3 544 4 006 4 380 4 129 4 485 5 118 4 424 1,25 44 Uruguay

3 499

33 173 36 547 32 288 44 266 36 569 10,45 45 Western Australia

3 009

-

- 34 094 34 094 11,33 46 Armenia 2 973

10 669

-

- 10 669 3,59 47 Lithuania 2 885 29 305 29 779 30 235 30 106 33 301 30 545 10,59 48 Jamaica 2 827 12728

11138

20 152

14 673 5,19 49 Slovenia 2 123 28 677

24 706

- 29 917 27 767 13,08 50 Latvia 1 830 19 124 22 215 20 988 16 136 14 436 18 580 10,15 51 Estonia 1 374 14 879 27 502 27 408 30 674 26 314 25 355 18,45 52 Mauritius 1 260 12 098 10 536 12 483 10 617 15 711 12 289 9,75 53 Cyprus 918 11 985 12 333

11 247

- 11 855 12,91 54 Luxemburg

602

229 303

-

229 303 380,90 55 Brunei Darussalam 455

6 759

-

6 408 6 584 14,47 56 Andorra 78

6 623

-

- 6 623 84,91 57 Liechtenstein

39

6 345

7 314

- 6 830 175,12 1 642 438 73 617 952 65 830 752 68 368 949 76 354 219 64 327 849 69 699 944 42,44 per 1,000 inh. a year Table/Cuadro/Tabelle 1.7 Trends in calls in the countries of the World in 2020-2024 Dinámica en las operaciones en países del mundo para los años 2020-2024 Dynamik der Einsätze in den Staaten der Welt für die Jahre 2020-2024 № Country Population, thous. inh. Number of calls Average 2020 2021 2022 2023 2024 per year Promedio 2020 2021 2022 2023 2024 Por año je Jahr je Jahr und 1000 Einw. ∑ Por año y 1000 hab Staat Einwohner in 1000 Gesamtanzahl der Einsätze Mittelwert 2020 2021 2022 2023 2024 País Habitantes, en miles Cantidad de operaciones

0,1 0,3 0,7 1,2 2,6 2,9 3,0 3,6 3,9 4,4 4,9 5,2 5,9 6,6 7,4 7,7 8,2 8,9 8,9 9,4 9,8 10,2 10,3 10,5 10,6 10,7 11,3 11,3 12,9 13,0 13,1 14,5 15,4 15,6 17,1 17,2 18,5 18,9 24,2 29,3 31,4 38,4 52,4 53,8 54,6 58,3 69,6 73,2 84,9 111,2 118,1 132,8 157,4 175,1 237,6 380,9 470,9 0 100 200 300 400 500 Vietnam Bangladesh Philippines Mongolia Ecuador Peru Kazakhstan Armenia Malysia Serbia Paraguay Jamaica Ukraine Denmark Greece Netherlands Panama Switzerland Hungary Bulgaria Mauritius Latvia Great Britain Uruguay Lithuania Croatia Western Australia Sweden Cyprus Israel Slovenia Brunei Darussalam Italy ,,,,,,,,, New Zealand Norway Estonia Belgium Ireland Romania Austria Singapore Germany Jordan Taiwan Canada France Japan Andorra Slovakia USA Korea (South) Portugal Liechtenstein Czech Republic Luxemburg Finland Fig. 1.6: Average number of calls per 1,000 inh. (2020-2024) Fig. 1.6: Promedio de operaciones por 1.000 hab. (2020-2024) Bild 1.6: Mittlere Einsatzanzahl je 1.000 Einwohner (2020-2024)

1 China 1 390 000

252 000

-

- 252 000 0,18 2 USA 336 806 1 388 500 1 353 500 1 504 500 1 389 000 1 388 000 1 404 700 4,17 3 Nigeria 206 100

2 056

-

- 2 056 0,01 4 Bangladesh 165 100 21 073 26 021 27 171 27 909 25 992 25 633 0,16 5 Russia 146 781 454 206 405 971 352 509 360 962 347 436 384 217 2,62 6 Japan 124 143 34 691 35 222 36 375 72 742 75 014 50 809 0,41 7 Phillippines 112 729

15 195

- 16 433 22 430 18 019 0,16 8 Egypt 112 717 51 963 51 533 49 341 45 435 46 926 49 040 0,44 9 Vietnam 100 300 2 764 2 245 3 440 3 562 4 112 3 225 0,03 10 Germany 83 020 230 000 197 834 229 497

286 622

235 988 2,84 11 Great Britain 67 353 186 605 191 210 216 797 172 777 176 044 188 687 2,80 12 France 67 244 282 800 254 151 286 600

277 100

275 163 4,09 13 Italy 60 317 242 205 264 664

270 068

- 258 979 4,29 14 Myanmar 54 580 2 139

2 107

1 362

1 869 0,03 15 Korea (South) 51 217 38 659 36 267 40 108 38 857 37 614 38 301 0,75 16 Spain 47 486 123800 127693

133029

- 128 174 2,70 17 Poland 37 766 128 800 106 466

135 965

- 123 744 3,28 18 Ukraine 37 441 101 279 79 457 80 652

68 549

82 484 2,20 19 Canada

36 995

-

- 215 787 215 787 5,83 20 Malaysia 34 100 38 865 36 886 28 475 34 389 41 149 35 953 1,05 21 Ghana

33 475

-

6 796

- 6 796 0,20 22 Peru 32 000

14 249

13 167

- 13 708 0,43 23 Taiwan 23 400

51 495

-

17 466

34 481 1,47 24 Kazakhstan 20 333 13 933 12 256 12 219 11 805 11 549 12 352 0,61 25 Romania 19 053 33 883

30 597

-

32 240 1,69 26 Ecuador

18 000

-

3 221

- 3 221 0,18 27 Netherlands

17 591

44 313

-

44 313 2,52 28 Cambodia 16 940 937 670 454

761

706 0,04 29 Belgium 11 697 35 208 32 619 32 972

30 885

32 921 2,81 30 Jordan 11 516 32 165 27 983 32 394 33 940 59 557 37 208 3,23 31 Czech Republic 10 827 17 346 16 162 20 813

34 226

22 137 2,04 32 Greece 10 788 31 908 28 894 30 386

28 303

29 873 2,77 33 Tadjikistan 10 591 1 299 1 189 1 261 1 236 1 175 1 232 0,12 34 Sweden 10 552

25 502

-

22 881

24 192 2,29 35 Azerbaijan 10 154 2 118 2 092 2 095 1 907 1 640 1 970 0,19 36 Portugal

9 857

- 29 517

28 350

28 934 2,94 37 Hungary 9 676 20 716 22 428

18 516

20 921 20 645 2,13 38 Israel 9 656 46 458 81 073

78 257

- 68 596 7,10 39 UAE 9 517 1968 2090 3000

2473

2 383 0,25 40 Belarus 9 408 6 071 6 256 5 938 5 677 6 208 6 030 0,64 41 Austria 9 197 54 701 85 361

64 154

65 233 67 362 7,32 42 Switzerland 9 050 13 475 12 660 15 176 14 537 13 168 13 803 1,53 43 Paraguay

7 453

-

5 295

- 5 295 0,71 44 Papua New Guinea

7 200

219

123

- 171 0,02 45 Serbia

6 797

-

24 557

- 24 557 3,61 46 Kyrgyzstan 6 735 2 778 3 050 3 137

3 399

3 091 0,46 47 Bulgaria 6 437 33 693 30 918 35 992 33 974 35 430 34 001 5,28 48 Singapore 6 036 1 877 1 844 1 799 1 954 1 990 1 893 0,31 49 Denmark 5 944

10 920

10 310

11 183

10 804 1,82 50 Finland 5 565 12 043 12 245

11 909

- 12 066 2,17 51 Slovakia 5 431 8 704

7 710

- 7 694 8 036 1,48 52 New Zealand 5 123 22 575 20 005 14 304 17 230 19 805 18 784 3,67 53 Ireland 5 033 21 759 20 545 20 126 17 790 18 939 19 832 3,94 54 Oman

4 527

4 057

-

4 057 0,90 55 Panama

4 395

-

5 326

5 358 5 342 1,22 56 Croatia 3 860 14 452 14 087 15 479

10 414

13 608 3,53 57 Georgia 3 736 13511 11150 13 273 10 564 11 639 12 027 3,22 58 Mongolia 3 544 3 178 2 671 2 918 3 155 3 462 3 077 0,87 59 Uruguay 

3 499

22 691 24 020 24 701 29 550 25 241 7,21 60 Moldova 3 435 1 758 1 608 1 745 1 666 1 634 1 682 0,49 61 Western Australia

3 009

-

- 10 153 10 153 3,37 62 Lithuania 2 885 6 519 8 333 8 410 9 289 7 667 8 044 2,79 63 Qatar 2 881

8 846

-

- 8 846 3,07 64 Jamaica 2 827 10209 8003 7 000

11 389

9 150 3,24 65 Armenia 2 728

2 196

-

- 2 196 0,80 66 Slovenia 2 123 7 778

7 819

- 6 851 7 483 3,52 67 Latvia 1 830 7 551 6 717 6 777 6 401 5 256 6 540 3,57 68 Estonia 1 374 3 989 3 873 3 203 3 240 2 598 3 381 2,46 69 Mauritius 1 260 7858 5766 7113 4770 7687 6 639 5,27 70 Cyprus 918 7 203 7 347

6 451

- 7 000 7,63 71 Bhutan 786 100 155 102

142

125 0,16 72 Luxemburg

602

2 295

-

2 295 3,81 73 Brunei Darussalam 455 1 124 756

717

1 223 955 2,10 74 Andorra 78

247

-

- 247 3,17 75 Liechtenstein 39 45 35

48

- 43 1,09 3 714 018 4 211 945 3 781 769 3 994 997 3 201 407 2 736 891 3 585 402 0,97 Number of fires ∑ Habitantes, en miles 2020 Table/Cuadro/Tabelle 1.8 № Country Population, thous. inh. Gesamtanzahl der Brände Mittelwert Trends in fires in the countries of the World in 2020-2024 Dinámica de los incendios en países del mundeo para los años 2020-2024 País Dynamik der Brandzahlen in den Staaten der Welt für die Jahre 2020-2024 Einwohner in 1000 Average 2024 2021 Staat 2022 2021 2021 Cantidad de incendios 2023 2023 2022 2024 2020 2020 2023 2024 2022 per 1,000 inh. a year Por año y 1000 hab. je Jahr und 1000 Einw. per year Por año je Jahr Promedio

0,01 0,02 0,03 0,03 0,04 0,12 0,16 0,16 0,16 0,18 0,18 0,19 0,20 0,25 0,31 0,41 0,43 0,44 0,46 0,49 0,61 0,64 0,71 0,75 0,80 0,87 0,90 1,05 1,09 1,22 1,47 1,48 1,53 1,69 1,82 2,04 2,10 2,13 2,17 2,20 2,29 2,46 2,52 2,62 2,70 2,77 2,79 2,80 2,81 2,84 2,94 3,07 3,17 3,22 3,23 3,24 3,28 3,37 3,52 3,53 3,57 3,61 3,67 3,81 3,94 4,09 4,17 4,29 5,27 5,28 5,83 7,10 7,21 7,32 7,63 0 1 2 3 4 5 6 7 8 9 Nigeria Papua New Guinea V ietnam Myanmar Cambodia Tadjikistan Bangladesh Bhutan Phillippines Ecuador China Azerbaijan Ghana UAE Singapore Japan Peru Egypt K yrgyzstan Moldova K azakhstan Belarus Paraguay K orea (South) Armenia Mongolia Oman Malaysia L iechtenstein Panama Taiwan Slovakia Switzerland Romania Denmark Czech Republic Brunei Darussalam Hungary Finland Ukraine Sweden Estonia Netherlands Russia Spain Greece L ithuania Great Britain Belgium Germany Portugal Qatar Andorra Georgia Jordan Jamaica Poland Western Australia Slovenia Croatia L atvia Serbia New Zealand L uxemburg Ireland France USA Italy Mauritius Bulgaria Canada Israel Uruguay Austria Cyprus Fig. 1.7: Average number of fires per 1,000 inh. (2020-2024) Fig. 1.7: Promedio de incendios por 1.000 hab. (2020-2024) Bild 1.7: Mittlere Brandanzahl je 1.000 Einwohner (2020-2024)

2020 2021 2022 2023 2024 year 100,000 inh. 100 fires 2020 2021 2022 2023 2024 año 100000 hab. 100 incendios 2020 2021 2022 2023 2024 je Jahr je 100000 Einw. je 100 Brände 1 India 1 425 775 9 110 8 348 7 435

6891

7 946

0,56

2 China 1 409 670

1 183

-

- 1 183 0,08 0,47 3 USA 336 806 3 500 3 800 3 790 3070 3920 3 616 1,07 0,26 4 Nigeria 206 100

147

-

- 147 0,07 7,15 5 Bangladesh 165 100

154

85 102 140 120 0,07 0,47 6 Russia 146 781 8 313 8 473 8 168 7825 7575 8 071 5,50 2,10 7 Japan 124 143 1 326 1 417 1 446 1503 1451 1 429 1,15 2,81 8 Philippines 112 729

253

- 321 402 325 0,29 1,81 9 Egypt 112 717 199 252 203 239 232 225 0,20 0,46 10 Vietnam 100 352 75 85 146 157 100 113 0,11 3,49 11 Germany 83 020 388 364 373

329

364 0,44 0,15 12 Great Britain 67 353 309 335 324 310 331 322 0,48 0,17 13 France 67 244 249 277

373

- 300 0,45 0,11 14 Myanmar 54 580 75

105

77

86 0,16 4,58 15 Korea (South) 51 217 364 276 341 283 308 314 0,61 0,82 16 Spain 47 486 164 204

235

- 201 0,42 0,16 17 Poland 37 766 488 516

508

- 504 1,33 0,41 18 Ukraine 37 441 1 728 1 853 1 651

1468

1 675 4,47 2,03 19 Malaysia 34 100

118

121 115 111 116 0,34 0,32 20 Ghana

33 475

-

50

- 50 0,15 0,74 21 Taiwan 23 400

161

- 193 176 177 0,75 0,51 22 Kazakhstan 20 333

389

344 344 326 351 1,73 2,84 23 Romania 19 053 255

255

-

255 1,34 0,79 24 Ecuador

18 000

-

20

- 20 0,11 0,62 25 Netherlands

17 591

33

-

33 0,19 0,07 26 Cambodia 16 940 23 36 17

54

33 0,19 4,61 27 Belgium 11 697 66 58 54

27

51 0,44 0,16 28 Jordan 11 516 27 44 43 54 49 43 0,38 0,12 29 Czech Republic 10 827 144 110 128

105

122 1,12 0,55 30 Greece 10 788 69 63

72

- 68 0,63 0,23 31 Tadjikistan 10 591 25 10 19 23 17 19 0,18 1,53 32 Sweden 10 552 90 78 99 101 88 91 0,86 0,38 33 Azerbaijan 10 154 49 38 51 40 40 44 0,43 2,21 34 Portugal

9 857

- 51

37

44 0,45 0,15 35 Hungary 9 676 107 100

96

96 100 1,03 0,48 36 Israel 9 656

22

35

- 29 0,30 0,04 37 UAE

9 517

- 6

16

11 0,12 0,46 38 Belarus 9 508 633 672 629 524 549 601 6,33 9,97 39 Austria 9 197 41 51

49

43 46 0,50 0,07 40 Switzerland 9 050 17 17 21 25 33 23 0,25 0,16 41 Papua New Guinea

7 200

-

2

- 2 0,03 1,17 42 Serbia

6 787

-

102

- 102 1,50 0,42 43 Kyrgyzstan 6 735 43 54 29

29

39 0,58 1,25 44 Bulgaria 6 437 130 184 156 113 126 142 2,20 0,42 45 Singapore 6 036 1 3 6 3 7 4 0,07 0,21 46 Denmark 5 944 54 52 58 50 51 53 0,89 0,49 47 Finland 5 565 49 51 51 51 60 52 0,94 0,43 48 Slovakia 5 431 47

60

- 40 49 0,90 0,61 49 New Zealand 5 123 12 13 10 14 17 13 0,26 0,07 50 Norway 5 109 45 41 40 36 36 40

0,78

51 Ireland 5 033 29 20 19 17 24 22 0,43 0,11 52 Panama

4 395

-

6

- 6 0,14 0,11 53 Croatia 3 860 30 31 34

21

29 0,75 0,21 54 Georgia 3 689 65 45

59

42 53 1,43 0,44 55 Mongolia 3 544 77 61 39 70 62 62 1,74 2,01 56 Uruguay  3 499 42 44 184 157 168 119 3,40 0,47 57 Moldova 3 435 117

88

- 104 103 3,00 6,12 58 Westerm Australia

3 009

-

- 17 17 0,56 0,17 59 Lithuania 2 885 95 94 72 100 85 89 3,09 1,11 60 Qatar 2 881

17

-

- 17 0,59 0,19 61 Jamaica 2 824 31 42 24 32 27 31 1,10 0,34 62 Armenia 2 728

12

-

- 12 0,44 0,55 63 Slovenia 2 123 8

0

- 7 5 0,24 0,07 64 Latvia 1 857 84 102 74 68 65 79 4,23 1,20 65 Estonia 1 374 36 39 51 37 34 39 2,87 1,17 66 Mauritius 1 260 7 2 5 7 14 7 0,56 0,11 67 Cyprus 918 3 57

5

- 22 2,36 0,31 68 Bhutan 786 1 4

4

- 3 0,38 2,40 69 Luxemburg

602

0

-

0 0,00 0,00 70 Brunei Darussalam

455

1

2

1 1 0,29 0,14 71 Iceland 357 6

1

-

4

0,98

72 Liechtenstein 39 1 0

0

- 0 0,85 0,78 5 023 678 31 303 28 959 28 015 25 038 16 974 26 058 0,52 0,73 Table/Cuadro/Tabelle 1.9 № Country Population, thous. inh. Anzahl der Brandtoten Average number per Trends in fire deaths in the countries of the World in 2020-2024 Dinámica de los fallecidos en incendios en países años 2020-2024 Dynamik der Brandtotenzahlen in den Staaten für die Jahre 2020-2024 Number of fire deaths Habitantes, en miles Promedio por País Fallecidos por incendios Mittelwert Staat Einwohner in 1000 ∑

0,00 0,03 0,07 0,07 0,07 0,08 0,11 0,11 0,12 0,14 0,15 0,16 0,18 0,19 0,19 0,20 0,24 0,25 0,26 0,29 0,29 0,30 0,34 0,38 0,38 0,42 0,43 0,43 0,44 0,44 0,44 0,45 0,45 0,48 0,50 0,56 0,56 0,56 0,58 0,59 0,61 0,63 0,75 0,75 0,78 0,85 0,86 0,89 0,90 0,94 0,98 1,03 1,07 1,10 1,12 1,15 1,33 1,34 1,43 1,50 1,73 1,74 2,20 2,36 2,87 3,00 3,09 3,40 4,23 4,47 5,50 6,33 0 1 2 3 4 5 6 7 L uxemburg Papua New Guinea Singapore Nigeria Bangladesh China Ecuador Vietnam UAE Panama Ghana Myanmar Tadjikistan Netherlands Cambodia Egypt Slovenia Switzerland New Zealand Philippines Brunei Darussalam Israel Malaysia Jordan Bhutan Spain Azerbaijan Ireland Germany Belgium Armenia France Portugal Great Britain Austria Mauritius India Westerm Australia K yrgyzstan Qatar K orea (South) Greece Croatia Taiwan Norway L iechtenstein Sweden Denmark Slovakia Finland Iceland Hungary USA Jamaica Czech Republic Japan Poland Romania Georgia Serbia K azakhstan Mongolia Bulgaria Cyprus Estonia Moldova L ithuania Uruguay L atvia Ukraine Russia Belarus Fig. 1.8: Average number of fire deaths per 100,000 inh. (2020-2024) Fig. 1.8: Promedio de fallecidos por 100.000 hab. (2020-2024) Bild 1.8: Mittlere Brandtotenanzahl je 100.000 Einwohner (2020-2024)

0,00 0,04 0,07 0,07 0,07 0,07 0,11 0,11 0,11 0,11 0,12 0,14 0,15 0,15 0,16 0,16 0,16 0,17 0,17 0,19 0,21 0,21 0,23 0,26 0,31 0,32 0,34 0,38 0,41 0,42 0,42 0,43 0,44 0,46 0,46 0,47 0,47 0,47 0,48 0,49 0,51 0,55 0,55 0,61 0,62 0,74 0,78 0,79 0,82 1,11 1,17 1,17 1,20 1,25 1,53 1,81 2,01 2,03 2,10 2,21 2,40 2,81 2,84 3,49 4,58 4,61 6,12 7,15 9,97 0 2 4 6 8 10 12 L uxemburg Israel Slovenia Austria New Zealand Netherlands Mauritius France Ireland Panama Jordan Brunei Darussalam Portugal Germany Belgium Spain Switzerland Westerm Australia Great Britain Qatar Singapore Croatia Greece USA Cyprus Malaysia Jamaica Sweden Poland Serbia Bulgaria Finland Georgia Egypt UAE Bangladesh China Uruguay Hungary Denmark Taiwan Armenia Czech Republic Slovakia Ecuador Ghana L iechtenstein Romania K orea (South) L ithuania Estonia Papua New Guinea L atvia K yrgyzstan Tadjikistan Philippines Mongolia Ukraine Russia Azerbaijan Bhutan Japan K azakhstan Vietnam Myanmar Cambodia Moldova Nigeria Belarus Fig. 1.9: Average number of fire deaths per 100 fires (2020-2024) Fig. 1.9: Promedio de fallecidos por 100 incendios (2020-2024) Bild 1.9: Mittlere Brandtotenanzahl je 100 Brände (2020-2024)

2020 2021 2022 2023 2024 per year per 100 thous.inh. per 100 fires 2020 2021 2022 2023 2024 por año por 100000 hab. por 100 incendios 2020 2021 2022 2023 2024 je Jahr je 100000 Einw. je 100 Brände 1 India 1 425 775 468 485 329

284

392

0,03

2 USA 336 806 15 200 14 700 13 250 13 350 11 780 13 656 4,05 0,97 3 Bangladesh 171 186

317

495 281 341 359 0,21 1,40 4 Russia 146 781 8 434 8 403 8 165 8 495 8 345 8 368 5,70 2,18 5 Japan 124 143 5 583 5 433 5 719 5 766 5 805 5 661 4,56 11,14 6 Philippines 112 729

721

- 1 050 1 472 1 081 0,96 6,00 7 Egypt 110 990 878 824

855

831 847 0,76 1,73 8 Vietnam 100 300 144 130 109 136 89 122 0,12 3,77 9 Great Britain 67 353 7 798 7 609 7 543 7 541 7 904 7 679 11,40 4,07 10 France 67 244 24 798 13 905

1 398

- 13 367 19,88 4,86 11 Myanmar 53 900 220

151

-

186 0,34 9,92 12 Korea (South) 51 217 1 915 1 854 2 323 2 194 2 094 2 076 4,05 5,42 13 Poland 37 766 2 838 2 444

3 237

- 2 840 7,52 2,29 14 Ukraine 37 441 1 453 1 383 1 607

1 538

1 495 3,99 1,81 15 Malaysia 34 100

413

400 380 483 419 1,23 1,17 16 Ghana

33 475

-

241

- 241 0,72 3,55 17 Taiwan 23 400

464

- 363 405 411 1,75 1,19 18 Kazakhstan 20 333 363 413 314 311 332 347 1,70 2,81 19 Romania 19 053 681

681

-

681 3,57 2,11 20 Ecuador

18 000

-

107

- 107 0,59 3,32 21 Cambodia 16 940 97 58 59

97

78 0,46 11,02 22 Belgium 11 697 1 247 1 573 1 426

395

1 160 9,92 3,52 23 Jordan

11 516

- 1 648 1 720 1 686 1 685 14,63 4,53 24 Czech Republic 10 827 1 250 1 221 1 552

1 410

1 358 12,55 6,14 25 Greece 10 788 44 44

95

- 61 0,57 0,20 26 Sweden 10 552

784

-

- 784 7,43 3,24 27 Portugal

9 857

- 1 303

1 325

1 314 13,33 4,54 28 Hungary 9 676 756 629

792

923 775 8,01 3,75 29 Israel 9 656

669

-

- 669 6,93 0,98 30 Belarus 9 408 408 388 502 535 535 474 5,03 7,85 31 Kyrgyzstan 6 735 28 44

24

- 32 0,48 1,04 32 Bulgaria

6 437

288 290 289 343 303 4,70 0,89 33 Singapore 6 036 184 194 171 81 80 142 2,35 7,50 34 Finland 5 565 595 531

365

- 497 8,93 4,12 35 Slovakia 5 431 240

191

- 249 227 4,17 2,82 36 New Zealand 5 123 283 260 224 255 275 259 5,06 1,38 37 Croatia 3 860 131 127 158

166

146 3,77 1,07 38 Georgia 3 689 203 184

193

241 205 5,56 1,71 39 Mongolia 3 544

45

33 50 60 47 1,33 1,53 40 Uruguay  3 499 93 381 501 422 - 349 9,98 1,38 41 Lithuania 2 885 141 172 165 186 178 168 5,84 2,09 42 Qatar 2 881

105

-

- 105 3,64 1,19 43 Jamaica 2 827 89 86 49 66 79 74 2,61 0,81 44 Armenia 2 728

42

-

- 42 1,54 1,91 45 Slovenia 2 123 155

33

- 173 120 5,67 1,61 46 Latvia 1 857 273 257 257 257 277 264 14,23 4,04 47 Estonia 1 374 120 103 83 70 67 89 6,45 2,62 48 Mauritius 1 260 9 20 7 29 31 19 1,52 0,29 49 Cyprus 880 103 19

31

- 51 5,80 0,73 50 Luxemburg

643

46

-

46 7,15 2,00 51 Brunei Darussalam 445 17 1

4

0 6 1,24 0,58 52 Liechtenstein

39

1

3

- 2 5,13 4,69 3 172 770 80 799 65 266 56 027 49 042 45 078 59 242 1,87 1,65 ∑ Mittelwert Lesionados por incendios Anzahl der Brandverletzten Table/Cuadro/Tabelle 1.10 Trends in fire injuries in the countries of the World in 2020-2024 Dinámica en lesionados por incendios en países del mundo años 2020-2024 Dynamik der Brandverletzten in den Staaten für die Jahre 2020-2024 № Country Population, thous. inh. País Habitantes, en miles Average number Number of fire injuries Promedio Staat Einwohner in 1000

0,0 0,1 0,2 0,3 0,5 0,5 0,6 0,6 0,7 0,8 1,0 1,2 1,2 1,3 1,5 1,5 1,7 1,8 2,4 2,6 3,6 3,6 3,8 4,0 4,1 4,1 4,2 4,6 4,7 5,0 5,1 5,1 5,6 5,7 5,7 5,8 5,8 6,4 6,9 7,2 7,4 7,5 8,0 8,9 9,9 10,0 11,4 12,5 13,3 14,2 14,6 19,9 0 5 10 15 20 25 India V ietnam Bangladesh Myanmar Cambodia K yrgyzstan Greece Ecuador Ghana Egypt Philippines Malaysia Brunei… Mongolia Mauritius Armenia K azakhstan Taiwan Singapore Jamaica Romania Qatar Croatia Ukraine K orea (South) USA Slovakia Japan Bulgaria Belarus New Zealand L iechtenstein Georgia Slovenia Russia Cyprus L ithuania Estonia Israel L uxemburg Sweden Poland Hungary Finland Belgium Uruguay Great Britain Czech Republic Portugal L atvia Jordan France Fig. 1.10: Average number of fire injuries per 100,000 inh. (2020-2024) Fig. 1.10: Promedio de lesionados por 100.000 hab. (2020-2024) Bild 1.10: Mittlere Brandverletzten je 100.000 Einwohner (2020-2024)

0,20 0,29 0,58 0,73 0,81 0,89 0,97 0,98 1,04 1,07 1,17 1,19 1,19 1,38 1,38 1,40 1,53 1,61 1,71 1,73 1,81 1,91 2,00 2,09 2,11 2,18 2,29 2,62 2,81 2,82 3,24 3,32 3,52 3,55 3,75 3,77 4,04 4,07 4,12 4,53 4,54 4,69 4,86 5,42 6,00 6,14 7,50 7,85 9,92 11,02 0 2 4 6 8 10 12 Greece Mauritius Brunei… Cyprus Jamaica Bulgaria USA Israel K yrgyzstan Croatia Malaysia Qatar Taiwan New Zealand Uruguay Bangladesh Mongolia Slovenia Georgia Egypt Ukraine Armenia L uxemburg L ithuania Romania Russia Poland Estonia K azakhstan Slovakia Sweden Ecuador Belgium Ghana Hungary Vietnam L atvia Great Britain Finland Jordan Portugal L iechtenstein France K orea (South) Philippines Czech Republic Singapore Belarus Myanmar Cambodia Fig. 1.11: Average number of fire injuries per 100 fires (2020-2024) Fig. 1.11: Promedio de lesionados por 100 incendios (2020-2024) Bild 1.11: Mittlere Anzahl der Brandverletzten je 100 Brände (2020-2024)

Average 2020 2021 2022 2023 2024 per year Promedio 2020 2021 2022 2023 2024 anual Mittelwert 2020 2021 2022 2023 2024 je Jahr 1 USA 336 806 62 135 97 90 62 89,2 2 Bangladesh

165 100

-

13

2 7,5 3 Japan 124 143 7

2

4 6 4,8 4 Philippines

112 729

-

- 2 2,0 5 Egypt

105 914

-

- 0 0,0 6 Germany 83 020 2 8 8

7

6,3 7 France

66 309

7

11

- 9,0 8 Poland 37 766 2 0

5

- 2,3 9 Ukraine

37 441

1 6

1

2,7 10 Taiwan

23 400

-

4 2 3,0 11 Kazakhstan 20 333

10

2

- 6,0 12 Ecuador

18 000

-

0

- 0,0 13 Netherlands

17 591

0

-

0,0 14 Belgium 11 584 0 0

1

- 0,3 15 Jordan

11 516

-

0

0,0 16 Czech Republic 10 827 0 2 1

1

1,0 17 Greece 10 788 0 1

0

- 0,3 18 Sweden

10 552

- 0

0

0,0 19 Portugal

9 857

- 2

0

1,0 20 Hungary 9 676 0 0

0

5 1,3 21 Austria

9 104

1

0

- 0,5 22 Bulgaria 6 437 0 0 0 0 0 0,0 23 Singapore 6 036 0 0 1 0 1 0,4 24 Denmark

5 825

-

0

- 0,0 25 Finland 5 565 0 1

1

- 0,7 26 Slovakia 5 431 0

0

-

0,0 27 Croatia 3 860 1 0 1

0

0,5 28 Mongolia

3 544

-

0 5 2,5 29 Lithuania 2 885 0

1

0 0 0,3 30 Latvia

1 857

-

0

- 0,0 31 Serbia

1 659

-

0

- 0,0 32 Estonia

1 374

0 1 0 0 0,3 33 Cyprus

918

0

-

0,0 34 Luxemburg

643

0

-

0,0 35 Liechtenstein 38 0

0

-

0,0 1278528 84 159 150 107 85 117,0 Average 2020 2021 2022 2023 2024 per year Promedio 2020 2021 2022 2023 2024 anual Mittelwert 2020 2021 2022 2023 2024 je Jahr 1 USA 336 806 64 875 60 750 65 650 63 075 53 575 61 585 2 Bangladesh

165 100

-

- 1 1 3 Japan 124 143 1 424

1 460

- 2027 1 637 4 Philippines

112 729

-

- 91 91 5 Egypt

105 914

-

- 28 28 6 France

66 309

10 882

7 773

- 9 328 7 Poland 37 766 244 313

504

- 354 8 Ukraine

37 441

22 54

24

33 9 Kazachstan 20 333

2

9

- 6 10 Equador

18 000

-

0

- 0 11 Belgium 11 584 94 62

81

- 79 12 Jordan

11 516

-

92

92 13 Czech Republic 10 827 271 183 280

230

241 14 Greece 10 788 20 41

34

-- 32 15 Sweden

10 552

-

78

78 16 Portugal

9 857

- 439

403

421 17 Hungary 9 767 60 63

55

108 72 18 Bulgaria 6 437 13 11 44 44 27 28 19 Finland 5 565 63 70

66

- 66 20 Slovakia 5 431 45

9

-

27 21 Croatia 3 860 22 27 30

42

30 22 Lithuania 2 885 23 16 17 31 19 21 23 Slovenia

2 123

48

- 60 54 24 Latvia

1 857

-

0

- 0 25 Serbia

1 659

-

28

- 28 26 Estonia

1 374

47 46 40 54 47 27 Cyprus 918 1

0

-

1 28 Luxemburg

643

45

-

45 29 Liechtenstein 37 0

0

-

0 1 132 221 67 157 74 049 75 110 64 059 55 990 67 273 ∑ Dynamik der Anzahl verunglückter Feuerwehrleute in den Staaten für 2020-2024 Table/Cuadro/Tabelle 1.12 Trends in firefighter injuries in the countries of the World in 2020-2024 Dinámica de Bomberos lesionados en incendios en países años 2020-2024 № Country Population, thous. inh. Number of firefighter injuries País Habitantes, en miles Cantidad de Bomberos lesionados Staat Einwohner in 1000 Anzahl der FM verletzt ∑ Table/Cuadro/Tabelle 1.11 Trends in firefighter deaths in the countries of the World in 2020-2024 Dinámica en Bomberos fallecidos en incendios en países para los años 2020-2024 Dynamik der Anzahl verunglückter Feuerwehrleute in den Staaten für 2020-2024 № Staat País Number of firefighter deaths Cantidad de Bomberos fallecidos Anzahl der FM getötet Population, thous. inh. Habitantes, en miles Einwohner in 1000 Country

Table/Cuadro/Tabelle 1.13 Population Fire thous.inh. stations Habitantes, Estaciones en miles de Bomber. Einwohner Feuer- in 1000 wachen 1 China

1 386 000

-

130 000

7 500 000 7 630 000 2 USA 336 806 58 700 71 700 7 500

383 000

635 100 1 018 100 3 Bangladesh 171 186 492 1 762 32 13 682

1 194

14 876 4 Russia 146 781 18 322 22 735 1 326

271 000

956 600 1 227 600 5 Japan 124 143 28 839 21 485 1 066 168 898 0 746 681 915 579 6 Philippines 112 729 1 535 3 706 34

37 810

59 609 97 419 7 Vietnam 100 300 486 1 876 234

9 678

950 735 960 413 8 Germany 83 020 30 616 38 487 2 606

59 152

1 028 021 1 087 173 9 France 66 309 6 503 7 478 1 231

54 503

198 790 253 293 10 Great Britain 64 903 2 053 2 900 235 40 100 19 000 1 400 60 500 11 Iran 64 000 452 1 300 20

9 285

- 9 285 12 Italy 61 000 902 2 330 307

28 870

20 060 48 930 13 Korea (South) 51 217 242 3 160 585

66 802

92 484 159 286 14 Poland 37 766 496 1 625 539

30 349

505 520 535 869 15 Ukraine 37 441 2 270 3 134 367

53 286

190 031 243 317 16 Canada

35 544

-

26 000

126 650 152 650 17 Malaysia 34 100 341 589 23 13 515 10 704 12 414 36 633 18 Peru 26 000

174

-

-

- 19 Taiwan 23 400 106 186 231

17 471

26 500 43 971 20 Kazakhstan 20 333 435 1 650 375

17 500

43 000 60 500 21 Australia

20 016

4 448

-

-

22 Romania 19 053 391 833 138

25 632

61 833 87 465 23 Ecuador 18 000 52 92 4

523

1 732 2 255 24 Netherlands 17 591 953 1 070 130 3 145 1 089 18 258 22 492 25 Belgium 11 697 320 1 680 270 6 710 0 10 388 17 098 26 Jordan 11 516 445 207 21

4 660

379 5 039 27 Czech Republic 10 827 6 492 4 882 457 13 998 5 382 75 236 94 616 28 Greece 10 788 286 2 104 109

13 530

3 779 17 309 29 Sweden 10 552

935

- 5 055

10 894

15 949 30 Portugal 9 857 434 1 556 186 12 263 0 17 975 30 238 31 Hungary 9 767 939 1 057 115

7 482

18 000 25 482 32 Israel 9 656 122 290 42

2 064

- 2 064 33 Belarus 9 408 714 1 922 178

9 276

6 660 15 936 34 Austria 9 197 5 645 8 500 319

2 739

301 671 304 410 35 Switzerland 9 050

1 272

- 1 376 0 76 274 77 650 36 Serbia 6 797 159 1 183 41

3 415

3 000 6 415 37 Laos 6 522 17 52 1 244 0 0 244 38 Bulgaria 6 437 244 599 52 6 625 0 3 421 10 046 39 Singapore 6 036 28 51 23

2 801

- 2 801 40 Denmark 5 825 286 423 91 1 426

5 189

6 615 41 Finland 5 565 890 1 148 78 3 791 3 400 11 700 18 891 42 Slovakia 5 431 118 248 107

4 109

79 004 83 113 43 Georgia 5 266 119 200 15

5 128

- 5 128 44 New Zealand 5 123 648 661 25

1 750

11 925 13 675 45 Norway 5 109 597 963 70 3 718

8 152

11 870 46 Ireland 5 033 215 300 46 2 012 2 076 0 4 088 47 Costa Rica 4 973

76

-

-

- 48 Panama 4 395 85 15 1

1 708

3 896 5 604 49 Croatia 3 860 2 091 2 413 147 4 135 1 100 58 665 63 900 50 Kuwait 3 800 39 50 11

3 800

- 3 800 51 Albania 3 601 45 68 6

724

- 724 52 Moldova 3 553 62 163 25

1381

90 1 471 53 Mongolia 3 297 64 138 6 3 152

74

3 226 54 Western Australian 3 009

913

-

1 023

23 609 24 632 55 Lithuania 2 885 90 277 56

2 977

1 583 4 560 56 Armenia 2 728 61 147 12

2 172

225 2 397 57 Slovenia 2 123 1 347 1 230 102 943 0 175 139 176 082 58 Latvia 1 857 91 241 37

2 690

547 3 237 59 Bahrain 1 557 13 24 6

604

- 604 60 Estonia 1 374 188 78 12 1 538 48 2 872 4 458 61 Cyprus 918 35 176 6 764 213 182 1 159 62 Luxemburg 643 99 171 26

552

3 346 3 898 63 Brunei Darussalam 455 24 45 2

1 272

- 1 272 64 Barbados 267 6 13 2

214

- 214 65 Andorra 78 4

17

120

- 120 66 Liechtenstein 39 15 13 4 0 0 622 622 3 278 509 180 633 225 851 19 690 1 604 142 68 515 14 065 606 15 738 263 Statistics of fire services in the countries of the World in 2010-2024 (most recent data) Estadísticas de personal y equipos en países en 2010-2024 Personal und Ausstattung der Feuerwehren der Staaten in 2010-2024 Number of firefighters Number of firefighters career part time volunt. Cantidad de Anzahl der Fahrzeuge Country engines País total Rentados Staat Teilzeit ∑ Gesamt Number of LF, TLF Medio tiempo Bombas FF Personal der Feuerwehr total ladders Escalas DL, TM № BF volunt.

358 542 650 690 703 735 743 767 773 797 804 879 893 933 969 972 1000 1014 1027 1046 1162 1165 1202 1217 1244 1248 1256 1305 1322 1339 1367 1374 1404 1468 1619 1743 1990 2087 2113 2155 2251 2471 2501 2523 2573 2573 2578 2927 2941 2981 3358 4085 4678 4974 5593 6577 6893 10364 10662 12512 26730 34417 0 5000 10000 15000 20000 25000 30000 35000 40000 Brunei Darussalam Russia Andorra Latvia Ukraine Japan Romania Korea (South) Czech Republic Greece Portugal USA Estonia Croatia Lithuania Bulgaria Kuwait Belarus Georgia Mongolia Kazakhstan Luxemburg Cyprus France Poland Barbados Armenia Hungary Slovakia Taiwan Canada Norway Germany Finland Great Britain Belgium Serbia Sweden Italy Singapore Slovenia Jordan Ireland Malaysia Moldova Panama Bahrain New Zealand Western Australian Philippines Austria Denmark Israel Albania Netherlands Switzerland Iran Vietnam China Bangladesh Laos Ecuador Fig. 1.12: Average number of inhabitants per 1 career firefighter (2010-2024) Fig. 1.12: Promedio de hab. por 1 Bombrero rentado (2010-2024) Bild 1.12: Mittlere Einwohneranzahl auf 1 Berufsfeuerwehrmann (2010-2024)

12 30 60 63 65 70 76 104 114 117 120 122 136 154 165 182 218 233 262 295 308 322 326 331 336 358 375 383 430 532 574 590 623 633 641 650 662 684 782 784 792 881 931 1000 1022 1027 1060 1073 1138 1157 1231 1247 1248 2155 2285 2415 2578 4678 4974 6893 7982 11508 26730 0 5000 10000 15000 20000 25000 30000 Slovenia Austria Croatia Liechtenstein Slovakia Poland Germany Vietnam Czech Republic Switzerland Russia Western… Japan Ukraine Luxemburg China Romania Canada France Finland Estonia Korea (South) Portugal USA Kazakhstan Brunei… New Zealand Hungary Norway Taiwan Latvia Belarus Greece Lithuania Bulgaria Andorra Sweden Belgium Netherlands Panama Cyprus Denmark Malaysia Kuwait Mongolia Georgia Serbia Great Britain Armenia Philippines Ireland Italy Barbados Singapore Jordan Moldova Bahrain Israel Albania Iran Ecuador Bangladesh Laos Fig. 1.13: Average number of inhabitants per 1 firefighter (2010-2024) Fig. 1.13: Promedoi de habotantes por cada bombero (2010-2024) Bild 1.13: Mittlere Einwohnerzahl auf 1 Feuerwehrmann (2010-2024)

0 20 40 60 80 100 Liechtenstein Slovenia Austria Vietnam China Switzerland Western Australian Slovakia Germany Poland Croatia New Zealand Netherlands Luxemburg Czech Republic Canada Japan Finland France Denmark Ukraine Russia Ecuador Kazakhstan Romania Hungary Panama Norway Sweden Estonia Malaysia USA Philippines Belgium Taiwan Portugal Korea (South) Ireland Serbia Belarus Italy Lithuania Cyprus Bulgaria Great Britain Greece Latvia Armenia Bangladesh Jordan Moldova Mongolia Iran Israel Laos Singapore Georgia Kuwait Albania Career Part timer Volunteers Fig. 1.14: Contributions of categories of firefighters to total firefighters number [%] Fig. 1.14: Cantidad de Bomberos según su categoria [%] Bild 1.14: Anteile der Feuerwehrmannkategorien [%]

Population thous.inh. Población en miles Einwohner in 1000 1 USA 336 806 921 300 90 96 800 10 1 018 100 2 Bangladesh 171 186 14 752 99 124 1 14 876 3 Russia* 146 781 233 227 86 37 773 14 271 000 4 Japan 124 143 880 279 96 35 300 4 915 579 5 Philippines 112 729 71 211 73 26 202 27 97 413 6 Germany 82 218 938 525 91 89 471 9 1 027 996 7 France 66 309 202 726 80 50 567 20 253 293 8 Italy 61 000 47 503 97 1 427 3 48 930 9 Korea (South) 51 217 146 035 79 39 006 21 185 041 10 Poland 37 766 476 907 89 58 855 11 535 762 11 Malasyia 34 100 23 252 96 978 4 24 230 12 Taiwan 23 400 15 322 88 2 149 12 17 471 13 Romania 19 053 85 858 98 1 607 2 87 465 14 Ecuador 18 000 1 821 81 434 19 2 255 15 Netherlands 17 591 21 113 94 1 379 6 22 492 16 Belgium 11 584 16 733 98 413 2 17 146 17 Jordan 11 516 4 527 90 512 10 5 039 18 Czech Republic 10 827 80 112 99 1 064 1 81 176 19 Greece 10 788 15 638 90 1 671 10 17 309 20 Sweden 10 552 14 658 92 1 291 8 15 949 21 Portugal 9 857 22 956 76 7 189 24 30 145 22 Hungary* 9 767 24 952 98 551 2 25 503 23 Israel 9 656 2 045 99 19 1 2 064 24 Austria 9 197 280 807 92 23 603 8 304 410 25 Switzerland* 9 050 68 191 88 9 459 12 77 650 26 Serbia 7 187 3 104 98 65 2 3 169 27 Bulgaria 6 437 9 527 96 409 4 9 936 28 Singapore 6 036 2 287 82 514 18 2 801 29 Denmark 5 825 6 305 95 310 5 6 615 30 Finland 5 565 16 873 90 1 894 10 18 767 31 Slovakia 5 431 67 455 81 15 845 19 83 300 32 New Zealand 5 151 10 962 80 2 713 20 13 675 33 Norway 5 109 11 673 98 197 2 11 870 34 Ireland 4 459 3 547 100 0 0 3 547 35 Croatia 3 860 53 898 84 10 002 16 63 900 36 Mongolia 3 297 3 224 100 2 0 3 226 37 Armenia 2 972 2 164 97 67 3 2 231 38 Lithuania 2 886 4 539 100 21 0 4 560 39 Slovenia 2 123 116 061 66 60 921 34 176 982 40 Latvia 1 857 5 587 100 0 0 5 587 41 Serbia 1 659 3 351 98 64 2 3 415 42 Estonia 1 374 3 839 86 619 14 4 458 43 Cyprus 918 1 063 92 96 8 1 159 44 Luxemburg 643 2 330 60 1 568 40 3 898 45 Brunei Darussalam 455 1 103 87 169 13 1 272 46 Liechtenstein 39 588 95 34 5 622 1 478 376 4 939 930 89 583 354 11 5 523 284

• - only professionals

Population thous.inh. Habitantes en miles Einwohner in 1000 1 USA 336 806 2 Russia 146 781 3 Japan 124 143 4 Germany 82 218 5 France 66 309 6 Korea (South) 51 738 7 Poland 38 265 8 Romania 19 053 9 Jordan 11 516 10 Greece 10 788 11 Hungary 9 856 12 Belarus 9 408 13 Austria 9 197 14 Finland 5 565 15 Slovakia 5 431 16 Croatia 3 860 17 Slovenia 2 123 18 Latvia 1 857 19 Cyprus 918 20 Luxemburg 643 21 Liechtenstein 39 599 708 ∑ Female Femenino Total Total Männer Personal der Feuerwehr Frauen Gesamt Masculino País Table/Cuadro/Tabelle 1.14 Fire service personnel by gender in the countries of the World in 2010-2024 (most recent data) Personal de Bomberos según género en países del mundo años 2010-2024 (Datos mas recientes) Number of firefighters Cantidad de Bomberos № Country Male Personal der Feuerwehren der Staaten nach Gender in 2010-2024 Staat % % % % % % ∑ 1 354 450 Table/Cuadro/Tabelle 1.15 Number of young firefighters in the countries of the World in 2010-2024 (most recent data) Cantidad de Cadetes o Brigadiers en los países en 2010-2024 (datos mas recientes) Anzahl der Jugendlichen in den Feuerwehren der Staaten in 2010-2024 № Country Number of young firefighters País Cantidad de jóvenes Staat Jugendfeuerwehrmitglieder 9 400 6 296 66 70 2 198 159 041 32 720 30 941 1 142 83 817 19 940 300 28 800 523 274 694 45 694 4 357 262 354 391 344 28 763 790

Male/ Masculino/ Männer 91 % Female/ Femenino/ Frauen 9 % Fig. 1.15: Fire service personnel by gender in the countries of the World in 2010- 2024 (most recent data) Fig. 1.15: Personal de Bomberos según género en países del mundo años 2010- 2043 (Datos mas recientes) Bild 1.15: Personal der Feuerwehren der Staaten 0,0 0,0 0,1 0,5 0,8 0,9 1,3 1,7 1,8 1,9 2,1 2,4 2,4 2,9 3,0 3,9 4,0 4,1 4,7 5,5 6,1 7,8 8,1 8,3 8,7 9,5 9,7 10,1 10,2 11,0 12,2 12,3 13,3 13,9 13,9 15,7 18,4 19,0 19,2 19,8 20,0 21,1 23,8 27,0 34,4 40,2 0,0 5,0 10,0 15,0 20,0 25,0 30,0 35,0 40,0 45,0 Ireland Latvia Mongolia Lithuania Bangladesh Israel Czech Republic Norway Romania Serbia Serbia Hungary* Belgium Italy Armenia Japan Malasyia Bulgaria Denmark Liechtenstein Netherlands Austria Sweden Cyprus Germany USA Greece Finland Jordan Poland Switzerland* Taiwan Brunei Darussalam Estonia Russia* Croatia Singapore Slovakia Ecuador New Zealand France Korea (South) Portugal Philippines Slovenia Luxemburg Fig.1.16: Diatribution of Female part in fire service by countries (2010-2024) Fig.1.16: Cantidad de Bomberos - Femenino (2010-2024) Bild 1.16: Frauenanteil bei den Feuerwehren (2010-2024)

№ Country Population, thous.inh. Electricity Equipment Failure Gas Equipment Failure Playing with fire Careless ness Smoking Fireplace, stove Arson Other known causes Unknown causes Total № Country Población, miles de habitantes Falla de Equipos Eléctricos Falla de Equipos de Gas Jugar con fuego Descuido Fumado Chimenea, estufa Incendio provocado Otras causas conocidas Causas desconocidas Total № Staat Einwohner in 1.000 Elektri- sche Geräte Gas- geräte Spielen mit Feuer Unvor- sichtig- keit Rauchen Feuer- stätten Brand- stiftung Andere bekannte Ursachen Unbekannt Total 1 USA 336 806

34 090

3 030

15 200 34 850

24 600

- 111 770 2 Bangladesh 165 100 9 069 1 213 759 4 139 789 3 056

519

7 115 26 659 3 Russia 146 781 64 795 1 399 2 006

217 326

21 414 13 137 21 883 5 476 347 436 4 Japan 124 143 2 577 2 781

386

3 058 1 016 2 377 20 813 4 133 37 141 5 Philippines 112 729 201 26 53 0 393 195 505 120 0 1 493 6 Egypt 110 990 9 407

1 770

-

106

16 203 21 855 49 341 7 Korea (South) 51 217 10 587

141

16 922

- 695 5 535 3 053 36 933 8 Poland 37 766 6 099 431 820 4 506 29 792 16 789 43 235 9 073 25 210 135 955 9 Ukrane 37 441 9 828 299 396 22 229 16 060 3 922 2 115 13 015 70 67 934 10 Kazakhstan 20 333 5 716

86

1 764

1 801

2 268

11 635 11 Czech Republic 10 827 2 224 4 106 8 291 1 142 1 367 854 2 604 1 166 17 758 12 Greece 10 788 134

43

508

1 347

75 3 911 14 494 20 512 13 Azerbaijan 10 336

834

11 82 20 84 192

422

1 645 14 Hungary 9 767 71 2 6 159 34 30 311 408 168 1 189 15 Austria 9 104

1 362

-

- 1 403 315 3 867 1 936 8 883 16 Serbia 6 759

184

-

88

290

198 22 392 23 152 17 Kyrgyzstan 6 631

408

282

305

286

- 886 2 167 18 Bulgaria 6 437 2 181 217 48 1 786 117 677 261 1 484 1 721 8 492 19 Finland 5 565

709

167 1 005 357 1 743 908 563 1 216 6 668 20 Slovakia 5 431

403

50 3 056 379 515 704 1 162 1 416 7 685 21 New Zaeland 5 123

2 151

76 996 454 1 034 996 10 032 1 478 17 217 22 Ireland 5 033

198

- 169 192 1 338 1 127 427 5 627 9 078 23 Panama 4 395 1 234

804

12 162

12

-

2 224 24 Western Australia 3 009 428 191 62 1 673 100 145 191 5 736 574 9 100 25 Lithuania 2 885 1 370 25 58 1 370 236 1 070 258 3 267 13 7 667 26 Slovenia

2 123

- 16

204

161 266 887 1 534 27 Latvia 1 883

1 337

34 2 491 1 203 869 161

268

6 363 28 Estonia 1 374

383

41

78 279 113 1 093 611 2 598 29 Cyprus 918 179 28

357

214 80 492

3 282

4 632 1 251 694 168 159 9 460 8 764 227 769 71 415 94 371 94 302 127 900 121 497 984 861 ∑ Table/Cuadro/Tabelle 1.16 Distribution of fires by fire causes in 2021-2024 Distribución de incendios por causas en 2021-2024 Verteilung der Brandursachen 2021-2024

Electricity Equipment Failure / Falla de Equipos Eléctricos / Elektrische Geräte 18% Gas Equipment Failure / Falla de Equipos de Gas / Gas-geräte 1% Playing with fire / Jugar con fuego / Spielen mit Feuer 1% Carelessness / Descuido / Unvorsichtigkeit 25% Smoking / Fumado / Rauchen 8% Fireplace, stove / Chimenea, estufa / Feuerstätten 10% Arson / Incendio provocado / Brandstiftung 10% Other known causes / Otras causas conocidas / Andere bekannte Ursachen 14% Unknown causes / Causas desconocidas / Unbekannte Ursachen 13% Fig. 1.17: Distribution of fires by fire cause in 2021-2024 Fig. 1.17: Distribución de incendios por causas en 2021-2024 Bild 1.17: Verteilung der Brandursachen (2021-2024)

202 207 215 224 227 239 239 253 263 269 270 271 275 280 295 318 334 336 343 348 354 359 380 403 410 421 425 431 433 448 470 473 474 488 542 546 595 600 604 617 620 636 661 704 722 729 742 750 793 810 825 839 872 893 904 908 991 1 007 1 028 1 120 1 271 1 310 1 316 1 318 1 388 1 424 1 568 1 652 1 823 2 007 3 183 3 255 3 618 4 305 6 387 7 132 10 498 23 265 0 5000 10000 15000 20000 25000 Tunisia Guatemala Togo Cambodia Myanmar Sri L anka Peru DPRK (North K orea) K orea (South K orea) L esotho Rwanda Italy Sierra L eone Argentina Chile Tajikistan United K ingdom Malaysia Turkey Afghanistan K azakhstan Germany Malawi France Guinea Romania Burundi Benin South Sudan Senegal Haiti Azerbaijan Poland Papua New Guinea Uzbekistan Zambia Viet Nam Philippines Mexico Thailand Belarus Algeria Madagascar Burkina Faso Chad Ghana Iraq Mali Zimbabwe Somalia Saudi Arabia Angola Uganda Côte d'Ivoire Morocco Cameroon Yemen Japan Brazil Niger Bangladesh Sudan K enya Mozambique Indonesia Tanzania Egypt Ukraine Iran Dem. Rep. of the Congo USA Ethiopia South Africa Pakistan Russian Federation Nigeria China India Countries with more than 200 deaths per year Fig. 1.18: Distribution of estimated deaths from fire, heat and hot substances (WHO 2019) Fig. 1.18: Distribución estimada de fallecidos por "fuego, calor y sust. calientes" Bild 1.18: Verteilung der Toten "Feuer, Flamme, heiße Substanzen" (WHO 2019)

2,0 2,1 2,1 2,1 2,2 2,2 2,2 2,2 2,2 2,3 2,3 2,4 2,4 2,4 2,5 2,5 2,5 2,5 2,5 2,6 2,6 2,7 2,7 2,7 2,8 2,8 2,9 2,9 3,0 3,1 3,1 3,1 3,1 3,1 3,2 3,2 3,3 3,4 3,4 3,4 3,5 3,5 3,5 3,5 3,5 3,5 3,7 3,7 3,8 3,8 3,8 3,9 4,2 4,3 4,4 4,4 4,5 4,7 4,7 4,8 5,2 5,4 5,4 5,6 6,2 6,6 7,3 12,6 0 2 4 6 8 10 12 14 Malawi Turkmenistan Solomon Islands Rwanda Romania Suriname Iran Montenegro Equatorial Guinea Dem. Rep. of the Congo Tonga Ghana Saudi Arabia Cabo V erde Madagascar Tanzania Morocco Guyana K enya Saint Vincent and the… Angola Togo Bahamas Mauritania Senegal Gambia Ethiopia Mongolia Central African Republic Zambia Sudan Estonia L iberia Fiji Comoros Guinea Guinea-Bissau Djibouti Yemen Tajikistan Burkina Faso Côte d'Ivoire Georgia Cameroon Sierra L eone Nigeria Benin Burundi Ukraine Eritrea Mali South Sudan Haiti Mozambique Namibia Russian Federation Chad Botswana Azerbaijan Niger Somalia Zimbabwe L atvia Papua New Guinea South Africa Belarus Eswatini L esotho Countries with more than 2 deaths per 100000 inh. a year Fig. 1.19: Distribution of estimated deaths from fire, heat and hot substances (WHO 2019) Fig.1.19: Distribución estimada de fallecidos por "fuego, calor y sust. calientes" Bild 1.19: Verteilung der Toten "Feuer, Flamme, heiße Substanzen" (WHO 2019)

Table/Cuadro/Tabelle 2.1 Population Area thous. sq.km. fire fire per 1,000 inh.: inhabitants deaths injuries calls fires 100,000 inh. 100 fires 100,000 inh. 100 fires Habitantes Area por en km Fallecidos Lesionados Por 1000 habs. mil cuadrados incend. incend. Operaci. Incendios 100000 hab. 100 incendios 100000 hab. 100 incendios Einwohner Fläche, in in 1 000 qkm Einsätze Brände 100000 Einw. 100 Brände 100000 Einw. 100 Brände 1 Beijing 21 980

16 411

6 310 47

94

0,3 0,2 0,7 0,4 1,5 2 Tokyo 13 911 2 199 1 102 578 5 837 96 797 79,3 0,4 0,7 1,6 5,7 13,7 3 Moscow 13 149 2 561 67 525 6 256 139 372 5,1 0,5 1,1 2,2 2,8 5,9 4 London 9 726 1 707 134 124

16 150

- 13,8

1,7

-

- 5 Seoul 9 332 605 724 128 5 654 23 305 77,6 0,6 0,2 0,4 3,3 5,4 6 Ho Chi Minh City 9 000

2 095

446 20 28 0,0 0,2 4,5 0,3 6,3 7 Kuala Lumpur 8 816 243 4 685 1 555 108 285 0,5 0,2 1,2 6,9 3,2 18,3 8 Hanoi 8 500

3 358

1 238 26 14 0,1 0,3 2,1 0,2 1,1 9 Hong Kong 7 413 1 114 900 803 37 828 33 444 121,5 5,1 0,4 0,1 6,0 1,2 10 Paris 6 900 800 474 053 22 930 28 1264 68,7 3,3 0,4 0,1 18,3 5,5 11 Singapore 6 036 735 245 279 1 990 7 80 40,6 0,3 0,12 0,35 1,3 4,0 12 Bangkok 5 455 1 568 260 252 4 809 16 166 47,7 0,9 0,3 0,3 3,0 3,5 13 St. Petersburg 5 380 1 404 44 542 8 000 119 253 8,3 1,5 2,2 1,5 4,7 3,2 14 Toronto 3 125 630 170 079 41 763

16

54,4 13,4 0,5

0,0

- 15 Taipei 2 490 272 139 630 4 911 6 60 56,1 2,0 0,2 0,1 2,4 1,2 16 Perth 2 394 6 417 23 048 5 219 9 155 9,6 2,2 0,4 0,2 6,5 3,0 17 Vienna 2 028 415 52 943

14 885

- 26,1

7,3

-

- 18 Ulaanbaator 1 768 4 740 2 215 1 895 33 45 1,3 1,1 1,9 1,7 2,5 2,4 19 Budapest 1 682 525 15 781 2 196 13 113 9,4 1,3 0,8 0,6 6,7 5,1 20 Sofia 1 205 492 12 793 3 679 20 42 10,6 3,1 1,7 0,5 3,5 1,1 21 Dublin 1 186 921 98 240 9 967

3

82,8 8,4 0,3

0,0

- 22 Vilnius 602 401 4 553 1 210 11 26 7,6 2,0 1,8 0,9 4,3 2,1 23 Montevideo 530

1 788

- 51

146

-

9,6

27,5

24 Bratislava 477

368

756 2

4

1,6 0,4 0,3 0,8 0,5 25 Tallinn 457 159 5 945 600 4 15 13,0 1,3 0,9 0,7 3,3 2,5 26 Ljubljana 297 275 2 487 655 1 32 8,4 2,2 0,3 0,2 10,8 4,9 143 839 52 203 4 485 683 206 739 831 4 740 31,2 1,4 0,6 0,4 3,3 2,3 Common indicators of fire statistics in the cities of the World in 2024 Verdichtete Kennzahlen zum Arbeitsumfang und zur Brandsituation in den Städten der Welt im Jahr 2024 Indicadores comunes en las estadísticas de incendios en ciudades del mundo en 2024 № Lesionados por calls Brandtotenanzahl je: Mittelwert Average number of fire injuries per: Cantidad de Anzahl der … Number of Fallecidos por Incendios ∑ Einsätze je 1000 Einw.: fires Brände City Ciudad Stadt Brandtoten Verletzten Promedio Operaciones of fire deaths per: Verletztenanzahl je:

Population thous.inh. in in medical in false in in % % aid % calls % % Habitantes en miles en en Asist. en Falsas en in % % médica % Alarmas % % Einwohner in 1000 zu in zu in Medizin. in Fehl- in in Bränden % Havarien % Hilfe % einsätze % % 1 Tokyo 13 911 5 937

0,5

- 851 349 77,2 10 904 4,2 234 488 21,3 2 Moscow 13 149 6 256 9,3 3 159

4,7

- 18 235 27,0 39 875 59,1 3 London 9 726 16 150 12,0 53 157

39,6

- 64 810 48,3 6 0,0 4 Seoul 9 332 5 654 0,9 56 179 9,1 553 506

90,0

-

- 5 Hong Kong 7 534 37 828 4,4 39 320 4,6 784 243

91,0

-

- 6 Paris 6 900 22 930 4,9 48 550 10,5 392 309

84,6

-

- 7 Taipei 2 490 4 911 3,5 2 516 1,8 132 203

94,7

-

- 8 Perth 2 394 5 219 22,7 4 116 17,9 109 0,5 10 530 45,7 3 064 13,3 9 Vienna 2 028 14 835 28,0 33 218

62,7

-

- 4 890 9,2 10 Budapest 1 682 2 196 13,9 7 338

46,5

- 6 247

39,6

- 11 Sofia 1 205 3 679 28,8 1 364 10,7 236 1,8 407 3,2 7 107 55,6 12 Dublin 1 186 9 967 10,1 4 837 4,9 81 435 82,9 2 001

2,0

- 13 Vilnius 602 1 210 26,6 1 325 29,1 0 0,0 20 0,4 1 998 43,9 14 Tallinn 457 600 10,1 1 781

30,0

- 2 864 48,2 700 11,8 15 Ljubljana 297 655 26,3 1 402 56,4 96 3,9 312 12,5 22 0,9 72 893 138 027 3,8 258 262 7,2 2 795 486 77,6 116 330 3,2 292 150 8,1 Sonstiges Tipo de operación en grandes ciudades del mundo en 2024 Struktur der Feuerwehreinsätze in den Großstädten der Welt im Jahr 2024 fires accidents other Total number of calls a year … Total de operaciones por año ∑ № City Ciudad Stadt incendio accidentes Anzahl der Einsätze je Jahr ... Type of fire service calls in the cities of the World in 2024 Table/Cuadro/Tabelle 2.2 otros

Population thous.inh. residential in % others in % all in % residencial en % otros en % todos en % Einwohner in 1000 Wohnung in % andere in % alle in % 1 Tokyo

13 911

-

- 3 302 72,6 230 5,1 6

5,1

-

- 1 010 22,2 2 Moscow 13 149 2 736 42,7 1 296 20,2 4 032 62,9 824

12,9

- 18 0,3 1 535

24,0

- 3 Seoul 9 332 2 242 39,8 1 986 35,2 4 228 75,0 402 7,1 14

0,2

-

- 1 010 17,9 4 Hong Kong 7 534 1 136 22,7 2 133 42,6 2 853 65,3 222

4,4

- 664

13,3

- 848 16,9 5 Bangkok

5 455

-

- 655 13,6 236 4,9 2 481

51,6

-

- 1 437 29,9 6 Taipei

2 490

-

- 761 66,9 122 10,7 33

2,9

-

- 221 19,4 7 Perth 2 394 842 16,1 421 8,1 1 263 24,2 629 12,1 26 0,5 1 767 34,0 1 117 21,4 417 8,0 8 Vienna

2 028

-

- 5 738 91,7 174

2,8

- 343

5,5

-

- 9 Budapest 1 682 767 34,3 366 16,4 1 133 50,7 101 4,5 58

2,6

- 150 6,7 794 35,5 10 Sofia 1 205 351 8,3 1 0,0 352 8,3 414 9,8 4 0,1 1 838 43,5 1 594 37,8 20 0,5 11 Vilnius 602 64 5,3 202 16,7 266 22,0 146 12,1 16 1,3 145 12,0 482 39,8 155 12,8 12 Bratislava 477 96 12,7 94 12,5 190 25,2 79 10,5 1 0,1 132 17,5 281 37,3 70 9,3 13 Tallinn 457 96 16,0 73 12,2 169 28,2 43 7,2 52

8,7

- 254 42,3 82 13,7 14 Ljubljana 297 185 28,2 143 21,8 328 50,1 71

10,8

- 6 0,9 103 15,7 147 22,4 61 013 8 515 22,3 6 715 17,6 15 230 39,8 3 693 9,7 2 691 7,0 4 913 12,8 5 516 14,4 6 211 16,2 Habitantes enmilies Table/Cuadro/Tabelle 2.3 other in % in % rubbish in % Number of fires … in % grass, brush vehicles Distribución de incendios por tipo en grandes ciudades del mundo en 2024 Verteilung der Brände nach Objekten der Brandentstehung in den Großstädten der Welt im Jahr 2024 Distribution of fires by types in the cities of the World in 2024 Anzahl der Brände … in Gebäuden ∑ № City Ciudad Stadt in % forests structure fires Vehículos en % forestales Cantidad de incendios … en % pastizales matorrale Sonstige in % Incendios estructurales otros en % en % basura en % in % Abfall, Müll in % Transport im Wald in % Gras usw. in %

Fires/ Incendios/ Brände 3,8 % Incidents, accidents/ Accidentes/ Havarie 7,2 % Medical aid/ Ayuda médica/ Medizin. Hilfe 77,6 % False/ Falsas alarmas/ Fehleinsätze 3,2 % Other/ Otros/ Sonstiges 8,1 % Fig. 2.5: Type of fire service calls in the cities (2024) Fig. 2.5: Estructura de operaciones en ciudades (2024) Bild 2.5: Struktur der Feuerwehreinsätze in den Städten (2024) Residential buildings/ Edificios residenciales/ Wohngebäude 22,3 % Other buildings/ Otras construcciones/ Andere Gebäude 17,6 % Vehicle/ Vehículos/ Transport 9,7 % Forests/ Foresta/ Wald 7,0 % Grass,bush/ Pastizales, matorrales/ Gras 12,8 % Rubbish/ Basura/ Müll 14,4 % Other/ Otros/ Sonstige 16,2 % Fig. 2.6: Distribution of fires by types in the cities (2024) Fig. 2.6: Distribución de incendios por tipos en ciudades (2024) Bild 2.6: Brände nach Objekten der Brandentstehung in den Städten (2024)

residential in % all others in % residencial en % otros en % Wohnung in % alle anderen in % 1 Moscow 13 149 124 89,2 15

10,8

-

- 2 Seoul 9 332 20 87,0 2 8,7 1 4,3 0 0,0 3 St. Petersburg 5 380 108 90,8 11

9,2

-

- 4 Perth 2 394 6 66,7 1 11,1 2 22,2 0 0,0 5 Budapest 1 682 10 76,9 0 0,0 0 0,0 3 23,1 6 Vilnius 563 6 54,5 4 36,4 0 0,0 1 9,1 7 Bratislava 477 1 50,0 0 0,0 0 0,0 1 50,0 8 Tallinn 457 4 100,0 0 0,0 0 0,0 0 0,0 9 Ljuljana 297 1 100,0 0 0,0 0 0,0 0 0,0 33 731 280 87,2 33 10,3 3 0,9 5 1,6 residential in % all others in % residencial en % otros en % Wohnung in % alle anderen in % 1 Moscow 13 149 311 83,6 61

16,4

-

- 2 Seoul 9 332 212 69,5 84 27,5 9 3,0 0 0,0 3 St. Petersburg 5 380 234 92,5 19

7,5

-

- 4 Perth 2 394 107 69,0 7 4,5 20 12,9 21 13,5 5 Budapest 1 682 84 74,3 18 15,9 2 1,8 9 8,0 6 Vilnius 602 5 19,2 13 50,0 5 19,2 3 11,5 7 Bratislava 477 2 50,0 0 0,0 0 0,0 2 50,0 8 Tallinn 457 10 66,7 4 26,7 0 0,0 1 6,7 9 Ljubljana 297 21 65,6 7 21,9 4 12,5 0 0,0 33 770 986 77,3 213 16,7 40 3,1 36 2,8 ∑ otros en % Stadt Einwohner in 10000 Anzahl der Verletzten in Gebäuden Transport in % Sonstige in % № vehicles in % other in % Ciudad Habitante en miles Cantidad de lesionados Incendio estructural vehículos en % City Population, thous.inh. Number of fire injuries structure fires ∑ Table/Cuadro/Tabelle 2.5 Distribution of fire injuries by types in the cities of the World in 2024 Distribución de lesionados según el origen del incendio en ciudades del mundo en 2024 Verteilung der Verletzten nach Objekten der Brandentstehung in den Städten im Jahr 2024 Stadt Einwohner in 10000 Anzahl der Brandtoten in Gebäuden Transport in % Sonstige in % Incendio estructural vehículos en % otros en % Table/Cuadro/Tabelle 2.4 Distribution of fire deaths by types in the cities of the World in 2024 Distribución de fallecidos según el origen del incendio en ciudades del mundo en 2024 Verteilung der Brändtote nach Objekten der Brandentstehung in den Städten im Jahr 2024 № City Population, thous.inh. Number of fire deaths structure fires vehicles in % other in % Ciudad Habitantes en miles Cantidad de fallecidos

Residential buildings/ Construcciones residenciales/ Wohngebäude 77,3 % Other buildings/ Otras construcciones/ Andere Gebäude 18,7 % Vehicle/ Vehículos/ Transport 3,1 % Other/ Otros/ Sonstige 2,8 % Fig. 2.8: Distribution of fire injuries by types in the cities (2024) Fig. 2.8: Distribución de lesionados según tipo de construcción en ciudades (2024) Bild 2.8: Verteilung der Brandverletzten nach Objekten der Brandentstehung in den Städten (2024) Residential buildings/ Construcciones residenciales/ Wohngebäude 87,2 % Other buildings/ Otras construcciones/ Andere Gebäude 10,3 % Vehicle/ Vehículos/ Transport 0,9 % Other/ Otros/ Sonstige 1,6 % Fig. 2.7: Distribution of fire deaths by types in the cities (2024) Fig. 2.7: Distribución de fallecidos según tipo mde incendio en ciudades (2024) Bild 2.7: Verteilung der Brandtoten nach Objekten der Brandentstehung in den Städten (2024)

2020 2021 2022 2023 2024 per year per 1,000 inh. 2020 2021 2022 2023 2024 por año por 1000 hab 2020 2021 2022 2023 2024 Jahr 1.000 Einw. 1 Dhaka 21 741

4 551

9 987

- 7 269 0,3 2 Istanbul 15 910 63 087 136 510 143 775

122 544

116 479 7,3 3 Tokyo 13 911 997 765 942 125

1 036 745

1 102 578 1 019 803 73,3 4 Manila 13 804

4 900

-

- 4 900 0,4 5 Moscow 13 149 67 106 78 962 69 842 69 300 67 525 70 547 5,4 6 Lima 10 719

38 163

-

- 38 163 3,6 7 Jakarta 10 562

38 000

-

- 38 000 3,6 8 London 9 726 98 581 109 590 125 392 126 464 134 124 118 830 12,2 9 Seoul

9 332

-

775 071 724 128 749 600 80,3 10 Ho Chi Minh City

9 000

1 308

-

1 308 0,1 11 Kuala Lumpur

8 816

-

- 4 685 4 685 0,5 12 Hanoi 8 499 937 1 246

1 325

- 1 169 0,1 13 Hong Kong 7 413 706 226 786 261 810 219 810 218 900 803 802 745 108,3 14 Paris 6 900 417 466 463 851

498 162

474 053 463 383 67,2 15 Singapore 6 036 196 345 213 615 256 837 246 832 245279 231 782 38,40 16 Bangkok 5 455

49 441

58 256

260 252 122 650 22,5 17 St. Petersburg

5 380

-

43 488 44 542 44 015 8,2 18 Berlin 3 664 470 238 479 008 492 604

514 866

489 179 133,5 19 Toronto 3 125 124 547 134 539 169 784 184 841 170 079 156 758 50,2 20 Athens 3 074 17 030 20 661 24 035

18 784

20 128 6,5 21 Kyiv 2 887 16 477 16 383 9 278

10 640

13 195 4,6 22 Taipei 2 490

131 474

137 038 139 630 136 047 54,6 23 Perth

2 394

-

- 23 048 23 048 9,6 24 Bucharest 2 162 103 158

118 717

-

110 938 51,3 25 Vienna 2 028 35 617 41 273 43 030 47 272 52 943 44 027 21,7 26 Hamburg 1 964 257 280 282 515 316 275

308 328

291 100 148,2 27 Warsaw 1 861 21 085 19 941

21 539

- 20 855 11,2 28 Montevideo  1 774 18 604 15 762 17 376

16 313

17 014 9,6 29 Ulaanbaatar

1 768

-

1 827

2 215 2 021 1,1 30 Budapest 1 682 12 485 12 504

18 527

15 781 14 824 8,8 31 Astana 1 544

3 904

3 000

3 000

3 301 2,1 32 Prague 1 357 321 680 325 208 384 176

468 828

374 973 276,3 33 Brussels 1 222 14 707 14 386

16 455

- 15 183 12,4 34 Sofia 1 205 8 699 9 195 10 905 12 186 12 793 10 756 8,9 35 Dublin

1 186

94 777 99 243 95 942 98 240 97 051 81,8 36 Stockholm 989

5 904

-

6 190

6 047 6,1 37 Zagreb 767 8 635 4 086

3 341

- 5 354 7,0 38 Helsinki

656

7 780

-

7 780 11,9 39 Copenhagen 655

4 948

5 835

5 922

5 568 8,5 40 Riga 609

6 390

6 885

6 886

6 720 11,0 41 Vilnius 602 3 546 3 577 3 601 4 030 4 553 3 861 6,4 42 Lisbon

545

- 22 045 13 114 17 580 32,3 43 Bratislava

477

11 923

-

11 923 25,0 44 Tallinn

457

6 340 6 378 6 527 5 945 6 298 13,8 45 Ljubljana 297 6 091

2 952

- 2 487 3 843 12,9 46 Wellington 216

4 660

4 410

4 416

4 495 20,8 47 Bern 143

2 338

-

- 2 338 16,3 220 153 4 282 065 4 354 995 4 691 089 4 059 040 4 485 683 4 374 574 19,9 Table/Cuadro/Tabelle 2.6 Trends in calls in the cities of the World in 2020-2024 Dinámica de las opetraciones en ciudades del mundo período 2020-2024 Dynamik der Einsätze in den Großstädten der Welt für 2020-2024 № City Population, thous. inh. Number of calls Average: Ciudad ∑ Habitantes en miles Cantidad de operaciones Promedio Stadt Einwohner, in 1.000 Gesamtanzahl der Einsätze in … Mittelwert je

0,1 0,1 0,3 0,4 0,5 1,1 2,1 3,6 3,6 4,6 5,4 6,1 6,4 6,5 7,0 7,3 8,2 8,5 8,8 8,9 9,6 9,6 11,0 11,2 11,9 12,2 12,4 12,9 13,8 16,3 20,8 21,7 22,5 25,0 32,3 38,4 50,2 51,3 54,6 67,2 73,3 80,3 81,8 108,3 133,5 148,2 276,3 0 50 100 150 200 250 300 Hanoi Ho Chi Minh Dhaka Manila Kuala Lumpur Ulaanbaatar Astana Lima Jakarta Kyiv Moscow Stockholm Vilnius Athens Zagreb Istanbul St. Petersburg Copenhagen Budapest Sofia Montevideo Perth Riga Warsaw Helsinki London Brussels Ljubljana Tallinn Bern Wellington Vienna Bangkok Bratislava Lisbon Singapore Toronto Bucharest Taipei Paris Tokyo Seoul Dublin Hong Kong Berlin Hamburg Prague Fig . 2.1: Average number of calls per 1,000 inh. (2020-2024) Fig . 2.1: Promedio de operaciones por 1.000 hab. (2020-2024) Bild 2.1: Mittlere Einsatzanzahl je 1000 Einwohner (2020-2024)

2020 2021 2022 2023 2024 per year per 1,000 inh. 2020 2021 2022 2023 2024 por año por 1000 hab 2020 2021 2022 2023 2024 Jahr 1000 Einw. 1 Delhi 26 495 25 709 27 343

31 958

- 28 337 1,1 2 Shanghai 24 870 4 062 14 685 14 615

16 620

12 496 0,5 3 Dhaka 22 478

2 541

5 984

- 4 263 0,2 4 Beijing 21 980 7 106

7 490

5 856 6 310 6 691 0,3 5 Cairo 21 750 6 887 6 132

5 840

- 6 286 0,3 6 Istanbul 15 910 20 584 20 760 22 554

24 285

22 046 1,4 7 Tehran 14 000

29 433

-

- 29 433 2,1 8 Tokyo 13 911 3 721 3 939

5 087

5 809 4 639 0,3 9 Manila 13 804

4 416

-

- 4 416 0,3 10 Moscow 13 149 7 834 7 413 6 927 6 378 6 256 6 962 0,5 11 Lima 10 800

6 162

-

- 6 162 0,6 12 Jakarta 10 562

1 505

-

- 1 505 0,1 13 London 9 726 17 411 14 929 19 297 16 120 16 150 16 781 1,7 14 Seoul 9 332 5 088 31 515 38 269 5 671 5 654 17 239 1,8 15 Ho Chi Minh City 9 000 290

374

300 446 353 0,0 16 Kuala Lumpur

8 816

-

- 1 555 1 555 0,2 17 Hanoi 8 499 415 355 586 619 1 238 643 0,1 18 Hong Kong 7 509 33 682 33 891 34 775 36 103 37 828 35 256 4,7 19 Paris 6 900 12 947 10 724 11 838 15 546 22 930 14 797 2,1 20 Singapore 6 036 1 877 1 844 1 799 1 954 1 990 1 893 0,31 21 Bangkok 5 455

489

2 707 4 406 4 809 3 103 0,6 22 St. Petersburg 5 380 9 932 9 610 9 781 8 224 8 000 9 109 1,7 23 Alexandria

4 388

3 355

- 3 355 0,8 24 Berlin 3 664 8 493 6 843 9 578

9 584

8 625 2,4 25 Toronto 3 125 32403 32283 36975 38267 41763 36 338 11,6 26 Athens 3 074 4 660 4 382 5 931

5 614

5 147 1,7 27 Kyiv 2 887 5 084 4 875 2 869

3 584

4 103 1,4 28 Damascus

2 503

1 853

940

- 1 397 0,6 29 Taipei 2 490

5 640

- 4 556 4 911 5 036 2,0 30 Perth

2 394

-

- 5 219 5 219 2,2 31 Bucharest 2 162 2 554

2 022

-

2 288 1,1 32 Vienna 2 028 10 570 11 343 12 197 13 925 14 835 12 574 6,2 33 Minsk 2 021 303 296

339

- 313 0,2 34 Hamburg 1 964 10 952

12 058

- 11 505 5,9 35 Warsaw 1 861 3 380 3 239

3 810

- 3 476 1,9 36 Montevideo  1 774 14 536 11 802 12 486

13 327

13 038 7,3 37 Ulaanbaatar 1 768

1 782

1 755

1 895 1 811 1,0 38 Budapest 1 682 2 115 2 135

2 232

2 196 2 170 1,3 39 Astana 1 544 650 718 831

632

708 0,5 40 Prague 1 357 1 797 1 795 2 326

4 351

2 567 1,9 41 Da Nang 1 353

170

-

- 170 0,1 42 Brussels 1 222 3 491 3 304 3 891

1 095

2 945 2,4 43 Sofia 1 205 3 288 3 273 3 440 3 532 3 679 3 442 2,9 44 Dublin 1 186 9 740 9 671 9 087 8 454 9 967 9 384 7,9 45 Yerevan 1 084

2 486

-

- 2 486 2,3 46 Stockholm 989

1 425

-

1 192

1 309 1,3 47 Zagreb 767 1 330 1 334

1 612

- 1 425 1,9 48 Frankfurt Main 759

1 539

-

- 1 539 2,0 49 Helsinki 656 776

795

-

786 1,2 50 Copenhagen 655

1 072

864

1 104

1 013 1,5 51 Riga 609

1 946

1 915

2 082

1 981 3,3 52 Vilnius 602 1 150 1 058 1 022 1 083 1 210 1 105 1,8 53 Lisbon

545

- 1 132

2 211

1 672 3,1 54 Bratislava

477

683

- 756 720 1,5 55 Tallinn 457 880 895 816 717 600 782 1,7 56 Ljubljana 297 1 007

1 001

- 655 888 3,0 57 Wellington 216

738

291

473

501 2,3 342 127 338 048 296 604 343 769 257 865 206 661 288 589 0,8 Ciudad Pobleción en miles Cantidad de incendios Promedio Stadt Einwohner, in 1000 Gesamtanzahl der Brände in … Mittelwert je ∑ Trends in fires in the cities of the World in 2020-2024 Dinámica de los incendios en ciudades del mundo período 2020-2024 Dynamik der Brände in den Großstädten der Welt für 2020-2024 Table/Cuadro/Tabelle 2.7 Average: City Population, thous. inh. Number of fires №

0,0 0,1 0,1 0,1 0,2 0,2 0,2 0,3 0,3 0,3 0,3 0,3 0,5 0,5 0,5 0,6 0,6 0,6 0,8 1,0 1,1 1,1 1,2 1,3 1,3 1,4 1,4 1,5 1,5 1,7 1,7 1,7 1,7 1,8 1,8 1,9 1,9 1,9 2,0 2,0 2,1 2,1 2,2 2,3 2,3 2,4 2,4 2,9 3,0 3,1 3,3 4,7 5,9 6,2 7,3 7,9 11,6 0 2 4 6 8 10 12 14 Ho Chi Minh Hanoi Da Nang Jakarta Minsk Kuala Lumpur Dhaka Cairo Beijing Singapore Manila Tokyo Astana Shanghai Moscow Damascus Bangkok Lima Alexandria Ulaanbaatar Bucharest Delhi Helsinki Budapest Stockholm Istambul Kyiv Bratislava Copenhagen Athens St. Petersburg Tallinn London Vilnius Seoul Zagreb Warsaw Prague Taipei Frankfurt Main Tehran Paris Perth Yerevan Wellington Berlin Brussels Sofia Ljubljana Lisbon Riga Hong Kong Hamburg Vienna Montevideo Dublin Toronto Fig. 2.2: Average number of fires in cities per 1,000 inh. (2020-2024) Fig. 2.2: Promedio de incendios en ciudades por 1.000 hab. (2020-2024) Bild 2.2: Mittlere Brandanzahl je 1000 Einwohner in Städten (2020-2024)

2020 2021 2022 2023 2024 per year per 100,000 inh. per 100 fires 2020 2021 2022 2023 2024 por año por 100000 hab. por 100 incendios 2020 2021 2022 2023 2024 Jahr 100000 Einw. 100 Brände 1 Delhi 26 495 346 591

1 029

- 655 2,5 2,3 2 Shanghai 24 870 55 65 72

69

65 0,3 0,5 3 Dhaka 22 478

14

22

- 18 0,1 0,4 4 Beijing 21 980 43

59

89 47 60 0,3 0,9 5 Cairo 21 750 16 24

36

- 25 0,1 0,4 6 Tehran 14 000

50

-

- 50 0,4 0,2 7 Tokyo 13 885 86 86 91 86 94 89 0,6 1,9 8 Manila 13 804

57

-

- 57 0,4 1,3 9 Moscow 13 149 146 183 174 151 139 159 1,2 2,3 10 Jakarta 10 562

18

-

- 18 0,2 1,2 11 London 9 726 30 50

33

- 38 0,4 0,2 12 Seoul 9 322

37

37 24 23 30 0,3 0,2 13 Ho Chi Minh City 9 000 12

26

12 20 18 0,2 5,0 14 New York City

8 550

-

104 78 91

1,1

15 Hanoi 8 500 6 12 75 71 26 38 0,4 5,9 16 Hong Kong 7 413 24 23 28 31 33 28 0,4 0,1 17 Paris 6 900 27 29

37

28 30 0,4 0,2 18 Singapore 6 036 1 3 6 3 7 4 0,07 0,2 19 Bangkok 5 455

6

12 9 16 11 0,2 0,3 20 St. Petersburg 5 380 133 135 131 132 119 130 2,4 1,4 21 Berlin 3 664 17

16

-

17 0,5 0,2 22 Toronto 3 125 20 19 13 14 16 16 0,5 0,0 23 Athens 3 074 13 13 10

14

13 0,4 0,2 24 Kyiv 2 887 51 72 68

64

64 2,2 1,6 25 Damascus

2 503

3

80

- 42 1,7 3,0 26 Taipei 2 490

23

- 12 6 14 0,5 0,3 27 Perth

2 394

-

- 6 6 0,3 0,1 28 Bucharest 2 162 17

22

-

20 0,9 0,9 29 Haiphong 2 053

1

-

- 1

0,0

30 Hamburg 1 964 8 15 15

10

12 0,6 0,1 31 Warsaw 1 861 13 20

8

- 14 0,7 0,4 32 Montevideo  1 774 21 22 70

53

42 2,3 0,3 33 Ulaanbaatar 1 768

35

19

33 29 1,6 1,6 34 Budapest 1 682 12 14

12

13 13 0,8 0,6 35 Astana 1 544 22 0 21

12

14 0,9 1,9 36 Prague 1 357 13 12 8

9

11 0,8 0,4 37 Da Nang 1 353

0

-

- 0 0,0 0,0 38 Brussels

1 222

7 8

2

6 0,5 0,2 39 Sofia 1 205 11 23 33 13 20 20 1,7 0,6 40 Dublin 1 186 7 1 4 1 3 3 0,3 0,0 41 Yerevan 1 084

3

-

- 3 0,3 0,1 42 Stockholm 989

8

-

6

7 0,7 0,5 43 Zagreb 767 1 3

4

- 3 0,3 0,2 44 Helsinki

656

1

-

1 0,2 0,1 45 Copenhagen 655

5

5

5

5 0,8 0,5 46 Riga 609

24

25

15

21 3,5 1,1 47 Vilnius 602 3 11 4 13 11 8 1,4 0,8 48 Lisbon

545

- 2

2

2 0,4 0,1 49 Bratislava

477

3

- 2 3 0,5 0,3 50 Tallinn 457 8 6 3 9 4 6 1,3 0,8 51 Ljubljana 297 0

0

- 1 0 0,1 0,0 52 Wellington 216

0

0

1

0 0,2 0,1 307 877 1 443 1 569 2 195 1 036 745 1 398 0,5 0,5 Einwohner, in 1000 Anzahl der Brandtoten ∑ Mittelwert je: Table/Cuadro/Tabelle 2.8 Ciudad Habitantes, en miles Fallecidos en incendios, hab. Average number of fire deaths: Dynamik der Brandtotenzahlen in den Stadten für 2020-2024 Dinámica de los fallecidos en incendios en ciudades años 2020-2024 Trends in fire deaths in the cities of the World in 2020-2024 № City Population, thous. inh. Number of fire deaths, inh. Promedio de fallecidos Stadt

0,0 0,0 0,1 0,1 0,1 0,1 0,2 0,2 0,2 0,2 0,2 0,3 0,3 0,3 0,3 0,3 0,3 0,3 0,4 0,4 0,4 0,4 0,4 0,4 0,4 0,4 0,5 0,5 0,5 0,5 0,5 0,6 0,6 0,7 0,7 0,8 0,8 0,8 0,9 0,9 1,1 1,2 1,3 1,4 1,6 1,7 1,7 2,2 2,3 2,4 2,5 3,5 0 1 2 3 4 Da Nang Haiphong Singapore Dhaka Ljubljana Cairo Helsinki Wellington Jakarta Ho Chi Minh Bangkok Perth Shanghai Dublin Beijing Yerevan Seoul Zagreb Tehran Lisbon Hong Kong London Athens Manila Paris Hanoi Berlin Brussels Bratislava Toronto Taipei Hamburg Tokyo Stockholm Warsaw Budapest Copenhagen Prague Astana Bucharest New York City Moscow Tallinn Vilnius Ulaanbaatar Damascus Sofia Kyiv Montevideo St. Petersburg Delhi Riga Fig. 2.3: Average number of fire deaths in cities per 100,000 inh. (2020-2024) Fig. 2.3: Promedio de fallecidos en incendios por 100.000 hab. (2020-2024) Bild 2.3: Mittlere Brandtotenanzahl je 100000 Einw. in Städten (2020-2024)

0,00 0,03 0,04 0,05 0,07 0,08 0,10 0,11 0,12 0,12 0,13 0,17 0,18 0,19 0,19 0,19 0,20 0,21 0,22 0,24 0,27 0,32 0,35 0,35 0,39 0,40 0,41 0,42 0,49 0,52 0,53 0,58 0,59 0,76 0,77 0,85 0,89 1,08 1,20 1,29 1,43 1,55 1,60 1,91 1,94 2,28 2,31 2,97 4,96 5,91 0 1 2 3 4 5 6 7 Da Nang Dublin Ljubljana Toronto Wellington Hong Kong Hamburg Perth Lisbon Yerevan Helsinki Tehran Seoul Zagreb Berlin Brussels Paris Singapore London Athens Taipei Montevideo Bangkok Bratislava Warsaw Cairo Prague Dhaka Copenhagen Shanghai Stockholm Sofia Budapest Vilnius Tallinn Bucharest Beijing Riga Jakarta Manila St. Petersburg Kyiv Ulaanbaatar Tokyo Astana Moscow Delhi Damascus Ho Chi Minh Hanoi Fig. 2.4: Average number of fire deaths per 100 fires (2020-2024) Fig. 2.4: Promedio de fallecidos por 100 incendios (2020-2024) Bild 2.4: Mittlere Brandtotenzahlen je 100 Brände in Städten (2020-2024)

engines ladders career part time volunt. total Bombas Escalas Profes. Med. tpo. Volunt. total LF, TLF DL, TM BF Teilzeit FF Gesamt 1 Delhi 26 495 1 483 66 222 14 3 616 0 0 3 616 2 Shanghai 24 644 1 600

107

-

-

- 3 Dhaka 22 478 1 464 17 339 15

1 713

- 1 713 4 Beijing 21 980 16 411 416 850 200

6 900

- 6 900 5 Istanbul 14 657 5 343

125

-

4 842

344 5 186 6 Tehran 14 000 750 132 361 32

5 243

- 5 243 7 Tokyo 13 885 1 769 214 673 86 18 748 844 21 721 41 313 8 Manila 13 804 620 142

108

3 616

- 3 616 9 Moscow 13 149 2 561 113 250 52 7 645 0 0 7 645 10 Jakarta 10 562 662 154 238 18 2 571

1 756

4 327 11 London 9 726 1 707 103 142 11 5 992 0 0 5 992 12 Seoul 9 322 605 24 124 52 7 434 0 4 382 11 816 13 New York City 8 550 834 218 198 143

11 051

- 11 051 14 Hanoi 8 499 3 360 26 179 32 1 106

252

1 358 15 Hong Kong 7 413 1 114 84 80 95

11 476

- 11 476 16 Paris 7 019 760 78 164 64 8 598 0 683 9 281 17 Singapore 6 036 735 28 51 23

2 801

- 2 801 18 Damascus 5 500 400 20 23 2 690 0 0 690 19 Bangkok 5 455 1 568 43 138 63 1 993

0

1 993 20 St. Petersburg 5 380 1 436 68 180 41 4 630 0 421 5 051 21 Chicago 5 000 776 100 99 61 4 500 0 0 4 500 22 Los Angeles 4 000 1 217 106 98 48 3 586 0 0 3 586 23 Yokohama 3 709 437 96

96

3 479

- 3 479 24 Berlin 3 664 892 95 200 41 4 282 0 1 530 5 812 25 Sidney 3 600 531 75 225 15 1 800 0 0 1 800 26 Kuwait City 3 500 1 000 33 50 11

3 500

- 3 500 27 Madrid 3 166 608 14 45 14 1 800 0 0 1 800 28 Melbourne 3 150 811 46 100 8 1 956 60 0 2 016 29 Athens 3 074 412 27 243 17

4 705

834 5 539 30 Kyiv 2 887 851 29 101 31 2 030 0 11 830 13 860 31 Osaka 2 752 222

89

-

3 484

- 3 484 32 Taipei 2 490 272 44 187 34 1 873 0 1 585 3 458 33 Perth 2 394 6 417

93

-

873

2 879 3 752 34 Johannesburg 2 300 573 15 32 10 810 0 0 810 35 Bucharest 2 162 240 36 78 14 2 680 0 0 2 680 36 Havanna 2 100 740 18 32 9 800 0 0 800 37 Vienna 2 028 415 70 71 20 1 771 0 212 1 983 38 Minsk 2 021 348 32 78 33

825

0 825 39 Kuala Lumpur 1 950 243

19

-

950

200 1 150 40 Warsaw 1 861 517 17 56 21 1 588 0 433 2 021 41 Hamburg 1 852 755 86 238 24

2 659

- 3 086 42 Budapest 1 682 525 42 44 11 1 090 0 832 1 922 43 Belgrade 1 659 360 19 151 5 719

0

719 44 Ulaanbaatar 1 515 4 704 14 32 4 696 12 6 714 45 Astana 1 444 722 12 62 26

1 600

- 1 600 46 Kuala Lumpur 1 401 243 13 17 4 608 0 271 879 47 Munich 1 367 310 32 79 19

1 445

687 2 132 48 Prague 1 357 496 62 154 25

919

670 1 589 49 Brussels 1 222 162 8 17 13 1 101 0 0 1 101 50 Sofia 1 205 492 13 40 4 785 0 79 864 51 Dublin 1 186 921

14

-

842

- 842 52 Yerevan 1 078 227 13 28 4

590

- 590 53 Cologne 1 021 405 37 32 14

1 957

743 2 700 54 Stockholm 989 187

9

- 514

41

555 55 Bishkek 874 169 9 34 3

384

- 384 56 Zagreb 767 641 65 88 8

358

5 822 6 180 57 Frankfurt Main 759 248 40 83 12

1 000

900 1 900 58 Kishinev 732 120 5 30 7 656

• -

656 59 Helsinki 656 716 34 37 7 488 0 355 843 60 Copenhagen 655 89 7 13 7 357 16 67 440 61 Oslo 624 454 8 7 4 456

2

458 62 Riga 609 304 10 36 6

413

- 413 63 Vilnius 602 401 7 24 5 794 0 4 798 64 Rotterdam 600 280

15

-

-

- 65 Dortmund 588 280 27 54 11

748

707 1 455 66 Essen 587 210 26 48 10 750 0 550 1 300 67 Dusseldorf 587 217 17 56 11 890 0 294 1 184 68 Seattle 563 217 33 33 11

1 044

- 1 044 69 Bremen 547 325 26 66 7 478 0 603 1 081 70 Lisbon 545 100 11 29 8

928

- 928 71 Hannover 525 204 21 56 9 596 0 636 1 232 72 Bratislava 477 368 4 15 2 293 0 301 594 73 Tallinn 457 159 6 8 3 186

0

186 74 Brno 379 230 26 53 7 210 67 213 490 75 Ljubljana 297 275 39 41 2 130 0 4 173 4 303 76 Ostrava 289 214 33 54 9 279 104 291 674 77 Brunei Darussalam 240 570 9 5 11 644 0 1 700 2 344 78 Wellington (NZ) 216 290 11 10 2 145 0 110 255 79 Pilsen 171 138 22 16 5 138 48 189 375 338 686 80 432 4 117 7 901 1 650 185 847 3 202 67 257 256 306 Cantidad de Ciudad Number of Anzahl der Personal der Feuerwehr Area, km cuadrados Stadt Cantidad de Bomberos ∑ Table/Cuadro/Tabelle 2.9 City Population, thous. inh. Area, sq. km. Fire stations Personal und Ausstattung der Feuerwehren in den Großstädten in den Jahren 2010-2024 № Einwohner, in 1.000 Feuer- wachen Habitantes en miles Statistics of fire services in the cities of the World in 2010-2024 (most recent data) Estadísticas de personal y equipamiento en grandes ciudades del mundo años 2010-2024 Number of fire fighters Estaciones Bomberos Fläche, in qkm.

373 522 539 587 646 653 660 697 741 758 759 774 783 786 790 807 816 856 881 903 946 1 000 1 036 1 066 1 110 1 111 1 115 1 116 1 144 1 145 1 162 1 172 1 239 1 254 1 329 1 344 1 368 1 409 1 422 1 475 1 477 1 490 1 535 1 543 1 610 1 623 1 628 1 720 1 759 1 805 1 827 1 835 1 924 2 000 2 053 2 142 2 155 2 177 2 276 2 285 2 304 2 307 2 450 2 457 2 625 2 670 2 737 2 742 2 840 3 027 3 186 3 817 4 108 7 327 7 684 7 971 13 122 0 2 000 4 000 6 000 8 000 10 000 12 000 14 000 Brunei Darussalam Darussalam Cologne Seattle Lisbon Hong Kong Athens Dusseldorf Hamburg Tokyo Vilnius Frankfurt Main New York City Essen Dortmund Osaka Bucharest Paris Berlin Hannover Astana Munich Kuwait City Ostrava Yokohama Brussels Chicago Los Angeles Kishinev Bremen Vienna St. Petersburg Warsaw Pilsen Seoul Taipei Helsinki Oslo Dublin Kyiv Riga Prague Wellington (NZ) Sofia Budapest Melbourne London Bratislava Moscow Madrid Brno Yerevan Copenhagen Stockholm Sidney Kuala Lumpur Zagreb Singapore Ulaanbaatar Bishkek Ljubljana Kuala Lumpur Belgrade Minsk Tallinn Havanna Tehran Bangkok Perth Johannesburg Istanbul Beijing Manila Jakarta Delhi Hanoi Damascus Dhaka Fig. 2.9: Average number of inhabitants per 1 career firefighter Fig. 2.9: Promedio de habitantes por 1 Bombero profesional Bild 2.9: Mittlere Einwohneranzahl auf 1 Berufsfeuerwehrmann

69 102 124 208 336 378 399 404 426 429 452 456 496 506 539 555 587 600 630 638 641 646 720 754 756 773 774 778 789 790 803 807 847 854 875 903 921 1000 1023 1065 1066 1110 1111 1115 1116 1362 1395 1409 1475 1489 1563 1594 1623 1696 1720 1759 1782 1827 2000 2122 2155 2276 2307 2441 2450 2457 2625 2670 2737 2826 2840 3186 3817 6258 7327 7971 13122 0 2000 4000 6000 8000 10000 12000 14000 Ljubljana Brunei Darussalam Darussalam Zagreb Kyiv Tokyo Cologne Frankfurt Main Dortmund Hannover Ostrava Essen Pilsen Dusseldorf Bremen Seattle Athens Lisbon Hamburg Berlin Perth Munich Hong Kong Taipei Vilnius Paris Brno New York City Helsinki Seoul Osaka Bratislava Bucharest Wellington (NZ) Prague Budapest Astana Warsaw Kuwait City Vienna St. Petersburg Yokohama Brussels Chicago Los Angeles Kishinev Oslo Sofia Dublin Riga Copenhagen Melbourne Kuala Lumpur London Kuala Lumpur Moscow Madrid Stockholm Yerevan Sidney Ulaanbaatar Singapore Bishkek Belgrade Jakarta Minsk Tallinn Havanna Tehran Bangkok Istanbul Johannesburg Beijing Manila Hanoi Delhi Damascus Dhaka Fig. 2.10: Average number of inhabitants per 1 firefighter Fig. 2.10: Promedio de habitantes por 1 Bombero Bild 2.10: Mittlere Einwohneranzahl auf 1 Feuerwehrmann

0% 20% 40% 60% 80% 100% Ljubljana Zagreb Kyiv Perth Brunei Darussalam… Pilsen Ostrava Brno Bremen Tokyo Hannover Bratislava Dortmund Frankfurt Main Taipei Budapest Wellington (NZ) Essen Prague Helsinki Jakarta Seoul Munich Kuala Lumpur Cologne Berlin Dusseldorf Warsaw Copenhagen Hanoi Kuala Lumpur Athens Hamburg Vienna Sofia St. Petersburg Stockholm Paris Istanbul Melbourne Ulaanbaatar Vilnius Oslo Delhi Dhaka Beijing Tehran Manila Moscow London New York City Hong Kong Singapore Damascus Bangkok Chicago Los Angeles Yokohama Sidney Kuwait City Madrid Osaka Johannesburg Bucharest Havanna Minsk Belgrade Astana Brussels Dublin Yerevan Bishkek Kishinev Riga Seattle Lisbon Tallinn Career Part timer Volunteers Fig. 2.11: Contributions of categories of firefighters [%] Fig. 2.11: Proporción de Bomberos según categoría [%] Bild 2.11: Anteile der Feuerwehrmannkategorien [%]

2,5 3,8 4,3 4,4 4,6 5,7 5,9 6,2 6,2 6,3 6,5 6,6 6,7 7,1 7,1 7,8 8,0 8,1 8,3 8,8 8,8 9,1 9,4 9,7 9,7 9,7 9,9 10,4 10,9 10,9 11,5 12,5 12,5 12,7 12,8 12,8 13,3 15,0 15,3 16,6 17,5 17,6 18,7 18,7 18,8 18,9 20,0 20,3 20,8 21,1 21,1 22,5 22,7 24,0 25,2 26,3 26,4 26,5 29,3 30,3 30,4 30,4 36,5 37,8 38,2 39,4 41,1 42,7 43,4 56,8 57,3 60,2 63,3 65,8 69,0 86,1 92,0 129,2 336,0 0 50 100 150 200 250 300 350 400 Osaka New York City Jakarta Manila Yokohama Tehran Vienna Taipei Frankfurt Main Pilsen Ostrava Seattle Bucharest Ljubljana Sidney Chicago Prague Essen Tokyo Hamburg Brno Lisbon Berlin Munich Hannover Paris Zagreb Dortmund Minsk Cologne Los Angeles Budapest Bremen Copenhagen Dusseldorf Kuala Lumpur Hong Kong Shanghai Athens London Yerevan Melbourne Rotterdam Kuala Lumpur Bishkek Belgrade Damascus Brussels Stockholm Helsinki St. Petersburg Delhi Moscow Kishinev Seoul Singapore Wellington (NZ) Tallinn Kyiv Kuwait City Riga Warsaw Bangkok Sofia Johannesburg Beijing Havanna Istanbul Madrid Oslo Vilnius Astana Brunei Darussalam… Dublin Perth Dhaka Bratislava Hanoi Ulaanbaatar Fig. 2.12: Average response area per one fire station [sq.km] Fig. 2.12: Area de respuesta promedio por 1 estación de Bomberos [km cuad.] Bild 2.12: Mittlere Ausrückebereichsfläche 1 FW [qkm]

70

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CTIF Survey on Hospitals

Hospitals are an integral part of the modern infrastructure of every country, especially in cities. Due to various special features, hospitals are classified as high-fire-risk buildings. In light of the large hospital fires that have occurred in recent years, this chapter aims to provide a broader perspective on fires in healthcare facilities. It is clear that, due to local political, economic, and cultural contexts, hospital systems around the world are not uniformly organized. The risks associated with hospital fires are often recurring and can be described with varying degrees of detail. Numerous publications analyze these dangers primarily from a hospital perspective. However, the focus here is also on the rescue forces, particularly fire brigades. When fires occur in hospitals, firefighters face unique hazards and challenges that require specialized knowledge and planning. A hospital's complex layout, vulnerable patients, varied equipment, and hazardous materials can turn even a simple response into a complex incident. Firefighters must be aware of the hazards typical in hospital settings and the dangers they pose to ensure safe and effective emergency operations. What sets a hospital apart from other buildings? Unlike typical structures, hospitals often do not prioritize fire safety in their design, focusing instead on patient care, privacy, infection control, specialized functions, and organizational needs. However, fire and smoke safety remain essential considerations. Firefighters face complex layouts and compartmentalized hospital spaces. These facilities often have unusual floor plans with large open areas, multiple wings, and interconnected sections. A lack of familiarity with the building can lead to confusion during emergencies, delaying evacuation. Strong compartmentalization—such as isolation rooms, safety doors, and fire-resistant walls - can hinder quick movement and access for firefighting efforts. Hidden spaces such as technical rooms, ceiling voids, utility openings, and elevator shafts can allow fire and smoke to spread, posing risks to responders. Additionally, hoses, cables, beds, wheelchairs, and medical equipment scattered in corridors can create tripping hazards and obstruct movement, increasing the danger during evacuations. One of the biggest dangers in hospitals is the presence of patients who cannot evacuate independently. Many are immobile - whether in beds, wheelchairs, or on ventilators—and require substantial resources for safe evacuation and coordination. Critical care patients, newborns, and surgical patients on life support cannot be moved quickly or safely, and the emergency may limit their ability to move. Evacuations require swift yet careful action. Additionally, the high volume of visitors and staff, many of whom are unfamiliar with emergency procedures and evacuation routes, can cause traffic congestion, panic, and additional rescue challenges. The potential danger in hospitals can be considerable: • Hospitals contain various hazardous substances and systems that pose risks that are rare in other areas. • Medical gas systems with pressurized oxygen, nitrous oxide, and other medical gases, when released, can accelerate the spread of fire or pose a risk of explosion. • Cryogenic systems contain extremely cold liquids. Exposure can cause thermal burns, skin damage, and eye and lung damage.

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• Inert gas systems, when leaking, displace oxygen and pose a choking hazard. • Damaged cylinders or lines pose serious risks. • Laboratories, pathology departments, and storage areas can contain chemical and pharmaceutical substances such as volatile chemicals, toxins, flammable liquids, and radioactive materials. • Biological hazards such as infectious waste, blood products, and contaminated materials can expose firefighters to pathogens. Hospitals' technological systems pose electrical and mechanical risks. High-voltage equipment such as life support devices, imaging machines (like MRI and X-ray units), and surgical tools requires substantial electrical power. Contact with water or damaged wiring can cause electric shocks. Imaging equipment has specific hazards: it generates strong magnetic fields that can attract ferrous objects, turning them into dangerous projectiles that can cause serious injury or death. This includes metallic items brought into the room, such as oxygen tanks, wheelchairs, scissors, and pens, as well as metallic implants in patients. These devices can also produce heat and may require cryogenic fluids for cooling. If the cooling system fails, the magnet could overheat, causing the cryogenic liquid to vaporize suddenly. To ensure critical hospital operations continue during power outages, backup power sources such as emergency generators and uninterruptible power supplies are used. However, they can confuse and increase the risk of shocks. While hospitals are typically well protected by fire safety systems, these systems can also pose challenges. Although designed to slow the spread of fire, features such as smoke barriers and partitions can hinder firefighters' access to affected areas or delay patient evacuation. Open atriums can allow smoke to move rapidly between floors, putting patients and emergency personnel at risk. Consequently, smoke control and management systems are often installed. However, these systems may restrict access due to room isolation, creating unfamiliar environments for firefighters. Additionally, frequent false alarms can desensitize staff, causing reluctance to evacuate or respond to genuine emergencies. Responding to hospital emergencies generates environmental and psychological stress. Alarms, intercom announcements, and stressed individuals contribute to noise and sensory overload, creating a chaotic environment. Witnessing critically ill or dying patients, along with the urgency to act, can lead to persistent psychological stress for firefighters. Additionally, emergency personnel face the risk of infection, particularly during outbreaks or in specialized infection areas, due to potential exposure to contagious diseases. Many hospitals are built vertically, particularly in cities. The use of high-rise hospital buildings is permitted in many countries. During emergencies, stairwell congestion can occur because evacuating patients via stairs is challenging, especially when elevators are out of service due to a power outage or an emergency call. Additionally, helipads may be present, introducing specific hazards and evacuation considerations during crises. Hospitals must balance protecting patient privacy and safety with providing open access to care, a balancing act that complicates emergency response efforts. Measures such as locked doors, security checks, and badge access can slow firefighters' entry and impede swift movement. Special areas, including psychiatric wards, children's units, and high-security zones, often require staff assistance or specialized knowledge for safe access and evacuation. During emergencies, some patients may be confused, aggressive, or unpredictable, requiring additional resources for management and safety to ensure proper evacuation. An effective response requires coordination with hospital staff. Collaboration is essential in emergencies. This coordination must be trained for in advance. Misunderstandings can have serious consequences. Firefighters may not be familiar with hospital procedures. They may be unaware of hospital-specific emergency protocols or the layout of critical areas such as intensive

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care units or operating rooms. Role confusion can occur when hospital staff tries to help but inadvertently obstructs rescue or firefighting operations. Once a fire is controlled, hospitals still pose certain risks. Firefighter gear may become contaminated with biological, chemical, or radiological hazards, requiring proper decontamination. Fire damage can cause structural instability, especially in older buildings, weakening floors, ceilings, or walls, and increasing the risk of collapse after the fire. Additionally, ongoing patient care and hospital operations may require continued firefighter oversight if issues such as smoke, water damage, or power outages persist. Each hospital fire poses unique challenges due to vulnerable occupants, hazardous materials, complex infrastructure, and intense emotional stress. Fire departments need ongoing training, incident planning, and close coordination with hospital personnel to ensure safety for responders, staff, and patients. In the case of new hospital developments, involving fire departments early in the design and construction stages is crucial. This ensures safety measures are incorporated and helps firefighters familiarize themselves with the facility's layout and systems before operations begin. Fire brigades aware of existing hospitals should conduct regular inspections, monitor for any changes, and maintain close contact with hospital staff. Ultimately, prevention remains the most essential aspect. The topics presented above summarize diverse experiences and statements from fire brigades worldwide. We have deliberately refrained from identifying sources. All suggestions are building blocks for the overall concept of the WHO: establish and enforce norms for fire, electrical, and structural safety in health care facilities. 1 The risk potential of hospitals is enormous; fires are only a small part: • Occupational infections: The most common occupational infections of concern in the health sector are tuberculosis, hepatitis B and C, HIV/AIDS, and respiratory infections (coronaviruses, influenza). • Unsafe patient handling: Lifting, transferring, repositioning, and moving patients without using proper techniques or handling equipment can cause musculoskeletal injury (e.g., back injury and chronic back pain). • Exposure to hazardous chemicals: The most common dangerous chemicals in the health sector include cleaning and disinfecting agents, sterilants, mercury, toxic drugs, pesticides, latex, and laboratory chemicals and reagents. • Radiation exposure: Ionizing (X-rays, radionuclides) and non-ionizing radiation (UV, lasers) may occur in health-care settings and pose specific risks to the health and safety of health workers. • Psycho-social risks and mental health: Time pressure, lack of control over work tasks, long working hours, shift work, lack of support, and moral injury are important risk factors for occupational stress, burnout, and fatigue among health workers. • Violence and harassment: These are incidents involving work-related abuse, threats, or assaults among health workers, including physical, sexual, verbal, and psychological abuse and workplace harassment. • Risks in the ambient work environment: These are work-related factors, such as thermal discomfort (heat or cold stress) and noise, which may harm a health worker's health. • Occupational injuries: Common injuries among health workers include slips, trips, and falls; road traffic injuries (ambulance crashes, motorcycle and bicycle injuries); electric shock; and explosions and fire.

1 WHO (2021): Global patient safety action plan 2021–2030: towards eliminating avoidable harm in health care, ISBN 978-92-4-003270-5 (electronic version), ISBN 978-92-4-003271-2 (print version).

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• Environmental health hazards: Unsafe and insufficient drinking water and inadequate sanitation and hygiene, hazardous healthcare waste, and climate-related risks may cause work-related diseases and injuries among health workers. 2 After the stressful years of the COVID-19 pandemic, many questions remain unanswered. As the Center of Fire Statistics received many questions about hospital fires, it was decided to conduct an international survey among the CTIF member states. Fifteen countries, including CTIF member states, took part in the survey: Austria, Brunei Darussalam, Bulgaria, Estonia, Greece, Hungary, Japan, Korea Republic, Latvia, Liechtenstein, Lithuania, Philippines, Poland, Singapore, and Slovakia.

19 questions were sent to the countries. The participants were asked to answer clearly with “Yes” or “No” and were given the opportunity to add remarks. We present the results of the study below. Any comments or questions are welcome at any time.

2 https://www.who.int/tools/occupational-hazards-in-health-sector.

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Table 1: Is there any special information about the number of hospitals in the country? Country Yes No Remark Austria

X

Statistics Austria: https://www.statistik.at/en/statistics/population-and- society/health/health-care-and-expenditure/health-care-facilities-and-staff Brunei Darussalam

X

Brunei has 4 districts. Every district has its own hospital.

Bulgaria

No information available. Estonia X In total, there are 124 hospitals and 1 hospital located within a detention facility.

Greece

X Non. Hungary

X

83 hospitals, https://okfo.gov.hu/egeszsegugyi-intezmenyek, https://okfo.gov.hu/en. Japan

X

Non. Korea, Republic

X

2,655 Priority Managed Medical Facilities. Latvia

X

41 hospitals. https://www.lrvk.gov.lv/en/news/inpatient-healthcare-the- goal-in-itself-is-to-maintain-a-fragmented-hospital-network-not-the- interests-of-patient?utm_source=chatgpt.com Liechtenstein

X

Non. Lithuania

X

According to the data available, there are 61 inpatient healthcare facilities in Lithuania. Philippines

X

6,110 hospitals.

Poland

X Non. Singapore

X

Non.

Slovakia

Non. Figure 1: Is there any special information about the number of hospital buildings in the country?

73% of the participating states affirmed that the requested information exists. The values given range from 4 to 6,110 hospital buildings in the respective state. 14% of the answers were negative. 13% of responses did not give any information.

73% 14% 13% Is there any special information about the number of hospitals in the country? Yes No No information

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Table 2: Is there a special definition of what a hospital is? Country Yes No Remark Austria

X

Under the Federal Law on Hospitals and Spas (KAKuG), hospitals include general hospitals, special hospitals, rehabilitation facilities, convalescent homes, nursing facilities for chronically ill patients, and sanatoria. Independent outpatient clinics are not included. https://www.ris.bka.gv.at/GeltendeFassung.wxe?Abfrage=Bundesnormen &Gesetzesnummer=10010285 Brunei Darussalam

X

Non.

Bulgaria

No information available. Estonia X

Pursuant to Section 22, subsection 1 of the Health Services Organization Act, a hospital is an economic unit formed in order to provide outpatient and inpatient health services. According to § 2, health services are the activities of health care professionals for the prevention, diagnosis, or treatment of diseases, injuries, or intoxication in order to reduce the malaise of persons, prevent the deterioration of their state of health or development of the diseases, and restore their health. Certain health services are listed in the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) and the Nordic Medico-Statistical Committee, Classification of Surgical Procedures (NOMESCO NCSP). Greece

X Non. Hungary X

According to the Act CLIV of 1997 on healthcare: f) healthcare provider: regardless of ownership form and operator, any individual healthcare entrepreneur, legal entity or organization without legal personality authorized to provide healthcare services on the basis of an operating license issued by the state healthcare administration authority; g) healthcare institution: among the healthcare providers defined in point f); ga) providers offering outpatient specialist care or inpatient specialist care in clinics (hereinafter collectively referred to as: medical institutions), and gb) the state ambulance service; gc) the state blood supply service, and gd) the institutions of the state health administration, insofar as they also provide healthcare services. Japan X

Non. Korea, Republic X

Non. Latvia X

State and local government institutions, performers of economic activity, and commercial companies that are registered in the Register of Medical Treatment Institutions comply with the mandatory requirements for medical treatment institutions and their structural units as set out in laws and regulations, and provide medical treatment services. https://likumi.lv/ta/en/en/id/44108-medical-treatment-law Liechtenstein X

Non. Lithuania X

The Law on Healthcare Institutions of the Republic of Lithuania: https://www.e-tar.lt/portal/it/legalAct/TAR.C81BD50A27C6/asr) defines the concepts of healthcare institutions, university hospitals, and inpatient active treatment personal healthcare services. Philippines X

A health care facility is defined as a place devoted primarily to the maintenance and operation of health facilities for the diagnosis, treatment, and care of individuals suffering from illness, disease, injury, or deformity, or in need of obstetrical or other surgical, medical, and nursing care. It shall also be constructed as any institution, building, or place where beds, cribs, or bassinets are installed for twenty-four-hour (24-hr) use or longer by patients in the treatment of diseases. Poland

X Non. Singapore X

Non. Slovakia

Non. 76

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Figure 2: Is there a special definition of what a hospital is?

73% of the answers are “Yes”; there are regulations regarding the definition of hospitals. But 14% of the countries gave the answer “No”, and 13% said that no information is available.

73% 14% 13% Is there a special definition of what a hospital is? Yes No No information

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Table 3: How many hospital fires were recorded in 2024? Country Yes No Remark

Austria

X No nationwide Austrian-specific figure available. Brunei

Darussalam

X Nil. Bulgaria

X

10 (Ten) fires. Estonia

X

In Estonia, fire incidents and the risk of fire incidents are distinguished. In 2024, 4 fire incidents (including one in a non-operational hospital building that had been abandoned) and 8 fire-risk incidents occurred in hospitals. Greece

X

16 fires Hungary

X

80 fires. Japan

X

Non. Korea, Republic

X

634 cases of rescue/aid in hospitals. Latvia

X

2 (Two) fires. Liechtenstein

X

0 (Zero). Lithuania

X

3 fires at hospitals were recorded.

Philippines

X Data no available. Poland

X

101 fires. Singapore

X

5 (Five) fires. Slovakia

X

9 (Nine) fires.

Figure 3: How many fires were recorded in hospital buildings in 2024?

For 80% of all responses, it was informed that there were confirmed fires in hospital buildings in 2024 (interval from 0 to 634 fires).

80% 20% 0% How many hospital fires were recorded in 2024? Yes No No information

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Table 4: How many hospital fires were associated with the fire of the façade? Country Yes No Remark

Austria

X No Austrian national data specifically links hospital fires to façade fires. Brunei

Darussalam

X Nil.

Bulgaria

No data available. Estonia

X None of the fire or risk of a building fire incidents were associated with the fire of the façade. Greece X

16 fires Hungary

X Non. Japan

No data available. Korea, Republic

X No specific statistical category in source. Latvia X

0 (Zero) fire. Liechtenstein X

0 (Zero). Lithuania

Non. Philippines

X Data no available. Poland

X Not applicable. Singapore X

0 (Zero). Slovakia

No data available. Figure 4: How many fires in hospital buildings were associated with the fire of the façade?

When asked about the number of fires in hospital buildings in which the façade played a role, 27% answered “Yes”; however, in most cases, there was no substantive feedback. As a result, the concrete case numbers are in the clear single-digit range. Only Greece reported 16 cases.

27% 46% 27% How many hospital fires were associated with the fire of the façade? Yes No No information

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Table 5: Are there any national publications on the subject of hospital fires? Country Yes No Remark Austria

X

Fire safety requirements for hospitals and care homes are set out in OIB Guideline 2. Brunei

Darussalam

Not sure. Bulgaria

No data available. Estonia

X We have not found any national publications on hospital fires, but there is a publication titled "Analysis of Construction Requirements According to the Specific Characteristics of Hospitals and Nursing Homes" that addresses fire safety in these facilities. Greece

Unknown. Hungary

X There were not that number of cases. Japan X

Non. Korea, Republic

X Non. Latvia

X Non. Liechtenstein

X Non. Lithuania

X Non. Philippines

X Non. Poland

X Not applicable. Singapore

X Non. Slovakia

X Non. Figure 5: Are there any national publications on the subject of hospital fires?

The question about existing national publications was answered negatively, at 67%. Only 13% of the responses are positive.

13% 67% 20% Are there any national publications on the subject of hospital fires? Yes No No information

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Table 6: Do the fire brigades have specially trained teams for firefighting in hospitals? Country Yes No Remark Austria

X

Some hospitals have their own company fire brigades due to the nature of their buildings and the need for local knowledge and familiarity with the facilities. Austrian fire services, particularly the six professional fire brigades in some major cities, maintain specialist units (e.g. CBRN) that are relevant to hospital operations. Brunei Darussalam

X

Fire marshal.

Bulgaria

No data available. Estonia

X First responders regularly conduct familiarization exercises at hospitals to enhance and maintain their situational awareness. Greece

X Non. Hungary

X Non. Japan X

Non. Korea, Republic

X Non. Latvia

X Non. Liechtenstein

X Non. Lithuania

X Non. Philippines X

As mandated by Rule 6 of the Revised Implementing Rules and Regulations (RIRR) of RA 9514, or the Fire Code of the Philippines. Poland

X Not applicable. Singapore X

All hospitals have Company Emergency Response Teams (CERT). Slovakia

X Non. Figure 6: Do the fire brigades have specially trained teams for firefighting in high-rise buildings?

The question of special training for firefighters provided a clear answer: 60%—no and 33%—yes. In most cases, firefighting training in hospital buildings are part of general fire brigade training.

33% 60% 7% Are there specially trained teams for firefighting in hospitals? Yes No No information

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Table 7: Do the fire brigades use helicopters for hospital fires? Country Yes No Remark

Austria

X Not as a standard tool for hospital fires specifically. Brunei

Darussalam

X Non.

Bulgaria

No data available. Estonia

X Non. Greece

X Non. Hungary

X Non. Japan X

Non. Korea, Republic X

Non. Latvia

X Non. Liechtenstein

X Non. Lithuania

X Non. Philippines

X In the Philippine context, Fire Brigade is defined as a collective term for a group of firefighters who primarily perform fire suppression activities in specified areas, such as, but not limited to, community/barangay, company, and other government and non-government establishments (RA 9514). Simply stated, they are a company fire brigade with only limited training. Poland

X Not applicable. Singapore

X Non. Slovakia

X Non. Figure 7: Do the fire brigades use helicopters for hospital fires?

Helicopters are used in only 13% of the participating countries.

13% 80% 7% Do the fire brigades use helicopters for hospital fires? Yes No No information

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Table 8: Do the fire brigades use drones in hospital fires? Country Yes No Remark Austria

X

Austrian fire brigades are increasingly deploying drones (UAVs) for operational support in firefighting — including situational assessment, mapping and documentation, and detection of heat sources (e.g., smoldering hotspots), hazardous substances or radiation sources — but no dedicated use specifically for combating fires in hospitals is known. Brunei Darussalam

X

Non.

Bulgaria

No data available. Estonia X

Yes, for risk assessment and increasing situational awareness.. Greece

X Non. Hungary X

The incident commander can use it when exploring the building outside and during or after the fire for fire investigation. Japan

No information available. Korea, Republic X

Non. Latvia

X Non. Liechtenstein

X Non. Lithuania X

For reconnaissance purposes. Philippines

X Non. Poland

X Not applicable. Singapore

X Non. Slovakia X

Non. Figure 8: Do the fire brigades use drones in high-rise fires?

In hospital fires, drones are used in 47% of countries; however, they are not used in 40% of countries.

47% 40% 13% Do the fire brigades use drones in hospital fires? Yes No No information

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Table 9: Is it allowed to operate hospitals in high-rise buildings? Country Yes No Remark Austria

X

In Austria, buildings with an evacuation level above 22 meters are subject to OIB Guideline 2.3, which sets out stricter requirements (e.g., pressurized stairwells and safety stairwells). Hospitals in high-rise buildings are not prohibited, but must have a comprehensive fire protection plan in accordance with OIB Guideline 2.3. Brunei

Darussalam

X Not sure.

Bulgaria

No data available. Estonia

X By the rules - no, but there are two hospitals in Estonia built between 1970 and 1980 that are high‑rise buildings. Both were fully renovated between 2010 and 2020, as far as possible, to comply with fire‑safety requirements for high‑rise buildings Greece X

Non. Hungary X

Not prohibited but not common. Japan X

Non. Korea, Republic X

1 Medical facility in a 30+ floor building. Latvia X

Non. Liechtenstein

X No high-rise buildings allowed in Liechtenstein. Lithuania X

Non. Philippines X

With limitations on the locations of OR, ER, etc. Poland X

Non. Singapore X

Non. Slovakia X

Non. Figure 9: Is it allowed to operate hospitals in high-rise buildings?

73% of the country allows hospitals to operate in high-rise buildings. All other countries answered the question negatively, or there is a lack of evaluable data.

73% 20% 7% Is it allowed to operate hospitals in high- rise buildings? Yes No No information

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Table 10: Is it allowed to operate facilities for disabled people in hospital buildings? Country Yes No Remark Austria

X

Mixed use with care or disability facilities is common in Austrian hospitals and is governed by the applicable building and fire safety regulations, as well as the provisions of the KAKuG. Brunei Darussalam

X

Not sure.

Bulgaria

No data available. Estonia X

Non. Greece X

Non. Hungary X

Non. Japan X

Non. Korea, Republic X

Non. Latvia X

Non. Liechtenstein

Non. Lithuania X

Building regulations stipulate that all buildings, including hospitals, which are adapted to the needs of physically and mentally disabled persons, must have safety zones on each floor for the evacuation of people, taking into account the number of disabled persons. Safety zones may be installed in stairwells, fire-escape corridors, and passageways to smoke-free stairwells. Philippines X

BP 220 Handrail. Ramps provision. Poland X

Non. Singapore X

Non. Slovakia X

Non. Figure 10: Is it allowed to operate facilities for disabled people in high-rise buildings?

87% of the countries surveyed state that facilities for disabled people may be used in hospital buildings. However, in 21% of countries, the relevant information is unavailable.

87% 0% 13% Is it allowed to operate facilities for disabled people in hospital buildings? Yes No No information

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Table 11: Is it allowed to operate facilities like kindergarten, schools, etc., in hospital buildings? Country Yes No Remark Austria

X

OIB-Guidelines 2 addresses mixed-use buildings and requires that the relevant provisions for each specific use (e.g., educational facilities, hospitals) be applied separately for each area. Authorization depends on compliance with fire protection requirements and building authority approval. Brunei

Darussalam

X Not sure.

Bulgaria

No data available. Estonia

X Non. Greece

Unknown. Hungary

X Non. Japan X

Non. Korea, Republic X

An affiliated daycare center can be permitted. Latvia

There is no prohibition as such. The condition is that a different use must be safely separated for fire safety. Such solutions have not existed in Latvia so far. Liechtenstein

X Non. Lithuania X

Building regulations for hospital buildings do not prohibit the establishment of kindergartens and schools. When establishing premises for pre-school educational institutions (kindergartens, nurseries) in hospitals, the following additional requirements apply: the building must be fire resistant; it must have a separate exit leading directly outside; preschool facilities (kindergartens, nurseries) must be separated from hospitals by fire-resistant partitions with a fire resistance rating of at least EI 45 and fire-resistant floors with a fire resistance rating of at least REI

Philippines

X Kindergarten and schools fall under Educational Occupancy (Div. 9, RIRR RA 9514). Poland X

Possible, but with limitations. Singapore X

Non. Slovakia X

Non. Figure 11: Is it allowed to operate facilities such as kindergartens, schools, etc., in hospital buildings? In 47% of countries, it is allowed to operate facilities such as kindergartens and schools in hospital buildings. However, in a further 33%, this is prohibited. 47% 33% 20% Is it allowed to operate facilities like kindergarten, schools etc. in hospital buildings? Yes No No information

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Table 12: Is it allowed to operate department stores and warehouses in hospital buildings? Country Yes No Remark Austria

X

Retail or storage uses within hospital buildings are not categorically prohibited. Still, they would require separate fire compartmentation and compliance with OIB-RL 2 provisions for retail (Retail outlets) and storage areas, as well as approval from the authority. Brunei Darussalam

X

Not a warehouse, just a small shop.

Bulgaria

No data available. Estonia

X Non. Greece X

Non. Hungary X X Non. Japan X

Non. Korea, Republic

X Non. Latvia

There is no prohibition as such. The condition is that a different use must be safely separated for fire safety. Such solutions have not existed in Latvia so far. Liechtenstein

X Non. Lithuania X

Building regulations for hospital buildings do not prohibit the installation of shopping centers and warehouses. However, in such cases, other fire safety requirements must be implemented regarding separation, layout, and the installation of fire engineering systems. Philippines

X However, kiosks are allowed to sell food. Poland X

As a separate fire zone for its own needs. Singapore X

Non. Slovakia X

Non. Figure 12: Is it allowed to operate department stores and warehouses in hospital buildings?

In 60% of countries, it is allowed to operate department stores and warehouses in hospital buildings. However, in 33% of countries, this is prohibited. 60% 33% 7% Is it allowed to operate department stores and warehouses in hospital buildings? Yes No No information

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Table 13: Is it permissible to operate mixed uses in hospital buildings (residential, hotel, offices, business)? Country Yes No Remark Austria

X

OIB-Guidelines 2 explicitly addresses mixed-use buildings, stipulating that the relevant OIB requirements for each respective use type apply independently. For complex mixed-use areas, a comprehensive fire protection plan is mandatory. Brunei

Darussalam

X Not sure.

Bulgaria

No data available. Estonia

X Non. Greece X

Non. Hungary

X Non. Japan X

Non. Korea, Republic

X Non. Latvia

There is no prohibition as such. The condition is that a different use must be safely separated for fire safety. Such solutions have not existed in Latvia so far. Some hospitals have cafes and pharmacies. These premises are correspondingly separated for fire safety. Liechtenstein

X Non. Lithuania X

Building regulations for hospital buildings do not prohibit the installation of business premises. Residential premises in hospitals must be separated from other premises by fire-resistant partitions with a fire-resistance rating of at least EI 45 and fire-resistant floors with a fire-resistance rating of at least REI 45. They must have a separate evacuation route to the outside. Philippines

X Foods are precooked, only warming. Poland X

Separate fire section. Singapore X

Non. Slovakia X

Non. Figure 13: Is it permissible to operate mixed uses in hospital buildings (residential, hotel, office, and business)?

In 47% of countries, mixed-use (residential, hotel, office, and business) is permitted in hospital buildings. However, in 13%, no information is available.

47% 40% 13% Is it permissible to operate mixed uses in hospital buildings? Yes No No information

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Table 14: Are there rules about the minimum number of stairwells in hospital buildings? Country Yes No Remark Austria

X

OIB-Guidelines 2, in conjunction with OIB-Guidelines 2.3, regulate stairwell requirements based on building class and escape level. In buildings with more than one required escape route, an independent second stairwell must be accessible from each floor with occupied rooms. Requirements for stairwells (in hospitals) are also set out in OIB Guideline 4, "Safety of Use and Accessibility". The number of escape routes may also depend on the number of people they are intended for, as the width of the routes is determined by this factor. Brunei Darussalam

X

Brunei guideline regulation (Ministry of Development).

Bulgaria

No data available. Estonia X

The general rule is that there must be two separate escape staircases. Greece X

Non. Hungary

X The number of stairwells is based on evacuation calculations. On the one hand, the time factor determines how long it takes to evacuate the building; on the other hand, the distance to the exit determines how far the patient ward is from the exit. So, it is not determined by a minimum number. Japan X

Non. Korea, Republic X

Non. Latvia X

There must be at least two, but usually there are several, depending on the number of people and the distance to the evacuation exit. Liechtenstein X

As in all other buildings. Lithuania X

If the top floor of a healthcare building has a floor elevation of no more than 6 m and there are no more than 20 people on the floor where a single escape route is installed, it is permissible to install a single escape route. In all other cases, there must be at least two escape routes from each floor of the building. Philippines X

Depending on the occupant load. Poland X

None. Singapore X

Non. Slovakia X

Non. Figure 14: Are there rules about the minimum number of stairwells in hospital buildings?

In most countries, the number of stairwells in high-rise buildings is considered highly important (87%). However, 7% of the information is missing. 87% 6% 7% Are there rules about the minimum number of stairwells in hospital buildings? Yes No No information

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Table 15: Are there rules about the minimum number of elevators in hospital buildings? Country Yes No Remark Austria

X

OIB Guideline 2 (Fire safety) requires a firefighting lift for care homes and hospital wards with beds when there are more than four above‑ground stores unless an equivalent vertical evacuation solution exists. At the same time, OIB Guideline 4 (Safety of Use and Accessibility) mandates ramps or passenger lifts for barrier‑free access and allows enclosed vertical lifting devices with fully enclosed carriers and doors as an alternative when no more than two stores must be overcome. Brunei Darussalam

X

Not sure.

Bulgaria

No data available. Estonia

X Non. Greece X

Non. Hungary

X The number of elevators is based on evacuation calculations. On the one hand, the time factor determines how long it takes to evacuate the building; on the other hand, the distance to the exit determines how far the patient ward is from the exit. So, it is not determined by a minimum number. Japan X

Non. Korea, Republic X

Non. Latvia

X There are none, and there is also a prohibition on using the elevators in the event of a fire. Liechtenstein X

Non. Lithuania X

Only hospitals taller than 10 stories are required to install firefighter lifts in accordance with the LST EN 81-72 series of standards. Philippines X

National Building Code requires at least 1 elevator in a building with 5 floors; RA 9514 also requires 1 fireman's lift elevator; Amendment in RIRR of RA 9514 now required stretcher elevator in hospital/s if ICU, Delivery Room (DR), Emergency Room (ER), ICU, and Operating Room (OR) are located above the 4th floor. Poland X

None. Singapore X

Non. Slovakia X

Non. Figure 15: Are there rules about the minimum number of elevators in hospital buildings?

In most countries, the number of stairwells in hospital buildings is considered highly important (73%). However, in a further 20% of countries, no regulation exists. 73% 20% 7% Are there rules about the minimum number of elevators in hospital buildings? Yes No No information

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Table 16: Are there rules on water supply for fire brigades in hospital buildings? Country Yes No Remark Austria

X

TRVB 137 F (extinguishing water requirement) specifies fire water requirements by building use, including specific rates for special-use buildings. Also, the ÖBFV’s VB-01/23 “water supply” provides national standards for fire water supply infrastructure. Brunei Darussalam

X

Not sure.

Bulgaria

No data available. Estonia

X Non. Greece X

Non. Hungary X

Non. Japan X

Non. Korea, Republic X

Non. Latvia X

There are separate building regulations for external and internal fire- fighting water supplies, but hospitals are not singled out. The building’s volume primarily determines the required water quantity. Liechtenstein

X Non. Lithuania X

All hospital buildings must be supplied with water for firefighting from fire hydrants, open water sources, and water reservoirs. If the hospital has a volume greater than 5,000 cubic meters, an internal fire water supply system with fire hydrants must also be installed within the building. Philippines X

It depends on NFPA 13; the tank should be sized to a 1.2 water supply to sustain at least 90 minutes of fire suppression. Poland X

None. Singapore X

Non. Slovakia X

Non. Figure 16: Are there rules on water supply for fire brigades in hospital buildings?

In most countries, rules on water supply for fire brigades in hospital buildings are essential (80%). However, 7% of the information is missing.

80% 13% 7% Are there rules on water supply for fire brigades in hospital buildings? Yes No No information

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Table 17: How many deaths were caused by fires in hospitals (2024)? Country Yes No Remark

Austria

X No Austria-specific data available. Brunei

Darussalam

X Nil. Bulgaria X

1 (one). Estonia

X

0 (Zero). Hospital fires caused none of the deaths.

Greece

X Non. Hungary

X

1 (one). Japan

X

1 (One).

Korea, Republic

X No specific statistical category in the source. Latvia

X

0 (Zero). Liechtenstein

X

0 (Zero). Lithuania

X

0 (Zero). Philippines

X

0 (Zero). Poland

X

1 (One). Singapore

X

0 (Zero).

Slovakia

X No data available.

Figure 17: How many deaths were caused by fires in hospitals (2024)?

In 67% of the countries, information about fire deaths in hospitals is available. Four countries report one victim per country. However, 33% of the information is missing.

67% 33% 0% How many deaths were caused by fires in hospitals? Yes No No information

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Table 18: How many injuries were caused by fires in hospitals (2024)? Country Yes No Remark

Austria

X No Austria-specific data available. Brunei

Darussalam

X Nil. Bulgaria

X

11 (Eleven).

Estonia

X Hospital fires caused none of the injuries.

Greece

Unknown. Hungary X

1 (One). Japan X

34 (Thirty-four). Korea, Republic

X No specific statistical category in the source. Latvia X

0 (Zero). Liechtenstein X

0 (Zero). Lithuania X

2 (Two). Philippines X

2 (Two). Poland X

4 (Four). Singapore X

0 (Zero). Slovakia X

9 (Nine) Figure 18: How many injuries were caused by fires in hospitals (2024)?

In 67% of the countries, information about fire injuries in hospitals is available. However, 6% of the information is missing.

67% 27% 6% How many injuries were caused by fires in hospitals? Yes No No information

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Table 19: How many affected (non-death, non-injured) were caused by fires in hospitals (2024)? Country Yes No Remark

Austria

X No Austria-specific data available. Brunei

Darussalam

X Nil.

Bulgaria

No information available. Estonia

X By affected persons, we mean individuals who escaped from fires, were evacuated, or were rescued. We do not have an overview of affected persons in other roles (e.g., individuals who were present in a building during a fire but did not need to escape independently or with whom the rescue team had no direct contact). According to 2024 data, out of 12 incidents (4 fire incidents and 8 risk-of-fire incidents), only 1 person escaped the fire independently. Greece

Unknown. Hungary X

26 (Twenty-six). Japan

Not applicable. Korea, Republic

X No specific statistical category in the source. Latvia X

13 people evacuated. Liechtenstein X

0 (Zero). Lithuania X

In the event of a fire, 21 persons were evacuated. Philippines X

None. Poland

X None. Singapore

X Non. Slovakia X

404 (Four hundred four) Figure 19: How many people were affected (non-death, non-injured) by fires in hospitals?

In 40% of the countries, information about affected people is available. However, 20% of the information is missing.

40% 40% 20% How many affected (non-death, non- injured) were caused by fires in hospitals? Yes No No information

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EU FireStat II- Project

Harmonized fire statistics as a tool for enhancing pan-European fire safety efforts

Fire safety remains primarily the responsibility of individual European Union (EU) Member States, reflecting the principle of subsidiarity and acknowledging differences in building traditions, climate conditions, and local regulatory frameworks. Nevertheless, many fire safety challenges transcend national borders and require coordinated efforts. Reliable and comparable fire statistics are essential for understanding fire risks, making data-driven, risk-informed decisions, evaluating prevention strategies, and supporting evidence-based policymaking. Recognizing the lack of harmonized fire data across Europe, the European Union initiated a pilot project between 2020 and 2023 (EUFireStat), funded by the European Parliament.

The pilot project sought to assess existing practices within the EU and internationally, define common terminology, and propose a harmonized structure for fire safety statistics. A key outcome was the demonstration of the added value of standardized data collection and the establishment of a set of variables grouped into different tiers: Tier 1 variables include essential information such as fatalities, injuries, age of fatalities, primary causal factors, building type, incident location, date, and time, and Tier 2 variables provide additional details, including the number of floors, area of fire origin, heat source, first item first ignited, article contributing to ignition, and fire safety measures. These variables, combined with their definitions, represent a basis for meaningful comparisons and trend analyses across countries.

EUFireStat 2: The Preparatory Action

Building upon the findings of the pilot project, the EUFireStat 2 was launched in February 2026 under the Directorate-General for Internal Market, Industry, Entrepreneurship and SMEs (DG GROW). The four-year project, scheduled to continue until February 2030, aims to test and refine the proposed system through practical implementation and data collection. The EUFireStat 2 project is implemented by a multidisciplinary consortium bringing together expertise in fire safety, research, education, and international cooperation. The consortium is led by Efectis (France) and includes DBI (Danish Institute of Fire and Security Technology), Teched (Croatia), the University of Liverpool, CTIF (International Association of Fire and Rescue Services), and ZAG (Slovenian National Building and Civil Engineering Institute). Through collaboration among these organizations, the project aims to establish a robust, harmonized framework for fire incident data collection and analysis across Europe.

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The primary objectives of EUFireStat 2 are to contextualize Tier 1 and Tier 2 variables within current European practice, gain experience from real-world data collection, develop a centralized database, provide training and guidance to participating organizations, and evaluate the feasibility and costs of a broader European deployment. Importantly, the project is intended to support Member States without requiring them to replace their existing national systems. Instead, it aims to establish a common framework that can accommodate varying national contexts while improving comparability.

Development of a European Fire Data Infrastructure

A major component of the project is the creation of a web-based database to collect, store, and process fire incident information from participating countries. Data can be submitted through several mechanisms, including online forms, file uploads, application programming interfaces (APIs), and automated data connectors. The system focuses on collecting Tier 1 and Tier 2 variables. The platform will also provide built-in dashboards and reporting capabilities. These tools will allow participating organizations to monitor data completeness, analyze trends, and generate customized analyses. Such analytical capabilities are expected to enhance understanding of fire patterns and support decision-making at local, national, and European levels. To facilitate implementation, training programs and technical support mechanisms are being developed. A helpdesk system will assist with both methodological questions and information technology issues. Continuous testing and assessment will ensure that the methodology remains practical and adaptable to different organizational structures and operational realities.

Cost-Benefit Analysis and Future Roll-Out

An important aspect of EUFireStat 2 is the evaluation of the costs and benefits of a harmonized European fire statistics system. The analysis encompasses implementation expenses, operational requirements, administrative capacity, and potential cost savings resulting from improved prevention and protection measures. Surveys and stakeholder consultations are being conducted to account for the diverse circumstances of countries, regions, and municipalities.

The project also includes developing a roll-out framework that addresses technical challenges, governance issues, standardization requirements, and potential impacts on Fire and Rescue Services. Risk assessments will examine technological constraints, economic implications, and effects on vulnerable communities and high- risk areas.

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Conclusion

The EUFireStat 2 project represents an important step toward strengthening fire safety cooperation across Europe. By establishing harmonized terminology, common variables, and a shared data infrastructure, the project aims to provide reliable evidence for policy development and risk reduction strategies. Participation by Member States and Fire and Rescue Authorities is essential for testing and refining the methodology in diverse national contexts. More than 15 Member States have already responded to the invitation to participate, and additional countries are still welcome to join as the project progresses.

Additional information can be found in the EU FireStat project website: https://eufirestat-efectis.com/ For any additional questions, kindly contact the project team at: EU.FireStat@efectis.com

Response to the invitation to participate in the EU FireStat 2 project

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Bibliography

Titel: Humanity and Fires Author(s): Bruschlinsky N., Sokolov S., Wagner P. Publisher: EDURA (Poland), Publication date: 2010 Number of pages: 500 Language: English ISBN: 978-83-88777-29-5 About: On the occasion of INTERSCHUTZ 2010 in Leipzig (Germany), the book provides an overview of the current fire protection problems worldwide at the end of the 20th century. The fire hazards are defined. In addition, an overview of the development of fire risks across 70 countries worldwide is provided. In the last part of the book, the problems of urbanization, geophysical, and other aspects of fire protection are discussed. The book concludes with a reconstruction of the fire hazards up to the year zero of our era and gives an outlook on the 24th century. Note: Some copies of this publication are available from CTIF's Fire Statistics Center. Please contact us: E-mail: drpeterwagner@freenet.de.

Titel: Red Book of Fires. Selected problems of fires and their effects. Edition 2 (Czerwona Księga Pożarów. Wybrane problemy pożarów oraz ich skutków. Tom 2) Editor: Piotr Guzewski, Dariusz Wróblewski, Daniel Małozięć Author(s): N.N. Bruschlinsky, S.V. Sokolov, P. Wagner Publisher: CNBOP-PIB, Józefów, Poland Publication date: 2014 Number of pages: 592 Language: Polish ISBN: 978-83-61520-87-0 About: A wide range of current problems in modern fire protection is discussed. CTIF Statistics Center contributions in this book are presented in Chapter 3: Fire Risk and Prevention in Nowadays and Forecast For The Future.

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Titel: Novel Approaches in Risk, Crisis and Disaster Management, Reihe: Natural Disaster Research, Prediction and Mitigation Editor(s): M. Chalaris, D. Emmanouloudis, Jet- Chau Wen, Z-P. Wu Author(s): N.N. Bruschlinsky, S.V. Sokolov, P. Wagner Publisher: Nova Science Publishers, New York, USA Publication date: 2018 Number of pages: 440 Language: English ISBN: 978-1-53613-239-7 About: Today, governments are often faced with crises that are so unpredictable (e.g., the attacks of September 11, 2001), so unexpected in their nature or scale (e.g., the SARS and H1N1 pandemic outbreaks, the Indian Ocean tsunami, or Hurricane Katrina), and with such far-reaching social and economic impacts that they seem almost impossible to overcome. Nevertheless, it is possible to overcome these forms of crisis. As previous experience has shown, success in limiting the impact of significant hazards on people and property depends not only on the active participation and effective coordination of a wide range of actors at different levels of government administration, but also on preparation and the ability to respond quickly, efficiently, and effectively to unexpected events. It is crucial for the success of such an undertaking that national authorities have the right technical tools (reformed risk, crisis, and disaster management systems) and an appropriate institutional framework for disaster management. However, as this book shows, human capital remains the most critical factor in this equation. The CTIF Center for Fire Statistics has contributed the following chapters to this book: Chapter 1: Problems of Fire Protection in the Modern World (pp. 1-66), Chapter 7: Modelling the Process of Fire and Rescue Services Activities (pp. 181-304).

99

© Copyright by Center for Fire Statistics of CTIF 2026

Titel: The Challenges of Disaster Planning, Management, and Resilience Editor: M. Chalaris Author(s): S.V. Sokolov, P. Wagner Publisher: Nova Science Publishers, New York, USA Publication date: 2023 Number of pages: 587 Language: English ISBN: 979-8886972290 About: Major disasters, both natural and man-made, have led to an increased need to improve the effectiveness of existing prevention, mitigation, and response capabilities. The types of disasters that many countries face depend to some extent on their geography and climate, and as a result, they have built different response strategies. There is evidence of growing vulnerability to disasters as worsening climate change may increase the destruction of human life, ecosystems, and infrastructure. This book aims to explore and analyze different approaches and practices for dealing with both traditional and novel forms of resilience and crisis, and to suggest a way forward for science based on sound decision-making at various levels. CTIF contributions in this book are in Chapter 16. 100 Years – 100 Cities: Evaluation of Urban Fire Risks.

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Titel: 100 Cities – 100 Years – Evaluation of Urban Fire Risks (Volume I). 3 Editor (s): P. Wagner, S.V. Sokolov. Author(s): 59 from several cities, and some more in anonymous form. Publisher: Generis Publishers. Publication date: 2025. Number of pages: 678. Language: English. ISBN: 979-8-89966-224-9. About: Over the centuries, cities have become hubs of economic, scientific, administrative, and cultural activity, a trend that accelerated in the 20th century. While urban life offers many benefits, city administrations face mounting challenges. Streets are congested with vehicles, leading to noise and air pollution. Housing is scarce, prompting vertical growth and urban sprawl. Issues such as water supply, waste management, and safety require constant attention. Cities rely on specialized services such as police, fire brigades, and emergency teams to address these challenges. This book focuses on fire safety, an essential aspect of urban infrastructure. Over the past century, advancements in building materials, construction methods, and usage have revolutionized cityscapes, accompanied by significant progress in fire prevention. Yet, the risk of urban fires persists, making this topic as vital as ever. Volume I contains: Chapter 1, World Fire Risks; Chapter 2, About the Term City; Chapter 3, Historical Fire Gap; and Chapter 4, Urban Fire Risks in the Cities (4.1. Accra (Ghana), …, 4.46. Dhaka (Bangladesh)). In Volumes II and III, more cities are described in alphabetical order.

3 https://www.generis-publishing.com/book.php?title=100-cities-100-years-2510.

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© Copyright by Center for Fire Statistics of CTIF 2026

Titel: 100 Cities – 100 Years – Evaluation of Urban Fire Risks (Volume II). 4 Editor (s): P. Wagner, S.V. Sokolov. Author(s): 59 from several cities, and some more in anonymous form. Publisher: Generis Publishers. Publication date: 2025. Number of pages: 715. Language: English. ISBN: 979-8-89966-282-9. About: Over the centuries, cities have become hubs of economic, scientific, administrative, and cultural activity, a trend that accelerated in the 20th century. While urban life offers many benefits, city administrations face mounting challenges. Streets are congested with vehicles, leading to noise and air pollution. Housing is scarce, prompting vertical growth and urban sprawl. Issues such as water supply, waste management, and safety require constant attention. Cities rely on specialized services such as police, fire brigades, and emergency teams to address these challenges. This book focuses on fire safety, an essential aspect of urban infrastructure. Over the past century, advancements in building materials, construction methods, and usage have revolutionized cityscapes, accompanied by significant progress in fire prevention. Yet, the risk of urban fires persists, making this topic as vital as ever. Volume II contains: Chapter 4, Urban Fire Risks in the Cities (4.47. Dubai (United Arab Emirates), …,4.115. Oslo (Norway)). In Volumes I and III, more cities are described in alphabetical order.

4https://libro-terra.com/shop/architecture/100-cities-100-years-3130/.

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Titel: 100 Cities – 100 Years – Evaluation of Urban Fire Risks (Volume III). 5 Editor (s): P. Wagner, S.V. Sokolov. Author(s): 59 from several cities, and some more in anonymous form. Publisher: Generis Publishers. Publication date: 2026. Number of pages: 565. Language: English. ISBN: 979-8-89966-344-4. About: Over the centuries, cities have become hubs of economic, scientific, administrative, and cultural activity, a trend that accelerated in the 20th century. While urban life offers many benefits, city administrations face mounting challenges. Streets are congested with vehicles, leading to noise and air pollution. Housing is scarce, prompting vertical growth and urban sprawl. Issues such as water supply, waste management, and safety require constant attention. Cities rely on specialized services, such as police, fire brigades, and emergency response teams, to address these challenges. This book focuses on fire safety, an essential aspect of urban infrastructure. Over the past century, advancements in building materials, construction methods, and use have revolutionized cityscapes, alongside significant progress in fire prevention. Yet, the risk of urban fires persists, making this topic as vital as ever.

Volume III contains: Chapter 4, Urban Fire Risks in the Cities (4.116. Paris (France), …, 4.167. Zurich (Switzerland)), and Chapter 5, Evaluation of Urban Fire Risks. In Volumes I and II, more cities are described in alphabetical order.

5 https://generis-publishing.com/book.php?title=100-cities-100-years-3186.

FD06828 ｜ 1972_美国_AAR7226.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1972 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

.l ( :J N A

T I --

0 N A L T R A N ·s p 0 R T A T I 0 N s A F E T y B 0 A R D

SA-426 File No. 1-0005 AIRCRAFT ACCIDENT REPORT HUGHES AIR WEST DC-9, N9345 AND U.S. MARINE CORPS F-48, 151458 NEAR DUARTE, CALIFORNIA JUNE 6, 1971 ADOPTED: AUGUST 30, 1972 NATIONAL TRANSPORTATION SAFETY BOARD Washington, D. C. 20591 REPORT NUllBfR: NTSB·AAR· 72-26

TECHNICAL REPORT STANDARD TITLE PAGE

1. Report No.

I 2.Government Accession No. J.Recipient's Catalog No. NTSB-AAR-72-26

1. Title and Subtitle

S.Report Date Hughes Air West DC-9, N9345, and U. s. Marine Corps September 22, 1972 F-4B, 151458, near Duarte, California, June 6, 1971 6.Performing Organization Code 7, Author(s) 8.Performing Organization Report No.

1. Performing Organization Name and Address
2. Work Unit No.

Bureau of Aviation Safety 11 .Contract or Grant No. National Transportation Safety Board Washington, D. c. 20591 13.Type of Report and Period Covered 12.Sponsoring Agency Name and Address Aircraft Accident Report June 6, 1971 NATIONAL TRANSPORTATION SAFETY BOARD Washington, D. c. 20591 14.Sponsoring Agency Code IS.Supplementary Notes This report contains new Aviation Safety Recommendations A-72-200 thru 204. 16.Abstract A Hughes Air West DC-9, N9345, and a U. S. Marine Corps F-4B, 151458, collided in flight near Duarte, California, at approximately 1811 P.d.t., June 6, 1971. All 49 occupants aboard the DC-9 and the pilot of the F-4B were fatally injured. The radar intercept officer, the only other occupant of the F-4B, ejected safely after the collision. The DC-9 was climbing to Flight Level 330 under radar control of the Los Angeles Air Route Traffic Control Center, and the F-4B was en route to MCAS El Toro at approximately 15,500 feet, in accordance with Visual Flight Rules. The collision occurred at approximately 15,150 feet. The visibility in the area, at the time of the accident, was good, and there were no clouds between the two aircraft. The National Transportation Safety Board determines that the probable cause of this accident was the failure of both crews to see and avoid each other but recognizes that they had only marginal capability to detect, assess, and avoid the collision. Other factors involved included, a very high closure rate, comingling of IFR and VFR traffic in an area where the limitation of ATC system precludes effective separation of such traffic, and failure of the crew of BuNo458 to request radar advisory service and particularly considering the fact that they had an inoperable transponder. There are four new recommendations. 17.Key Words 18.Distribution Statement Midair collision, Scheduled air carrier (IFR) Released to public Military aircraft (VFR), Daylight Unlimited distribution 19.Security Classification 20.Security Classification 21.No. of Pages 22.Price (of this report) (of this page) 44 UNCLASSIFIED UNCLASSIFIED NTSB Form 1765.2 (11/70) ii

TABLE OF CONTENTS Synopsis . . • • • • • • • • .. . . . 1 1. Investigation • • • • . • • • • • • 3

1. 1

History of the Flight • • • • • • . . 3 1.2 Injuries to Persons • • • • • • • . 6

1. 3

Damage to Aircraft • . . • . • • . 6 1 .. 4 Other Damage . • • . . • • • • . 0 6

1. 5

Crew Information .. . . • • .. • . . . 6 1.6 Aircraft Information . . • • • . .. . 6 1.7 Meteorological Information . . • • .. 6

1. 8

Aids to Navigation . • . . . .. • • • 7

1. 9

Communications • • . • • • • • • • .. 8 1.10 Aerodrome and Ground Facilities • • . 8 1 .. 11 Flight Recorders . • • . • . • • . • 8 1 .. 12 Wreckage • • • • • • • • • • • 9

1. 13

Fire . • . . . • . . . • . 10 1.14 Survival Aspects . • • . • . • . 10 1.15 Tests and Research . . . . . • • • . 1 1 1 .. 16 Other • .. • . . • • . • . . 14 2. Analysis and Conclusions • . • • . • 14 2.1 Analysis . . . . • . . . . 0 .. 14 2.2 Conclusions . • . • • .. • • • • • 25 (a) Findings • . • • • • • . • • 25 (b) Probable cause • . . .. . 27 3. Recommendations .. • . . . • • 0 • .. 0 27 Footnotes .. .. a • • • • • • • 0 32 Appendices Appendix A 0 • • • .. • • • .. • 0 34 Appendix B • • . . 0 . • ct .. • . 35 Appendix c . .. . .. . .. .. . . 37 Attachments Attachment 1 - Collision Area Attachment 2 - Computed Ranges, Bearings and Closure Rates Attachment 3 - Visibility Chart DC-9 Attachment 4 - Visibility Chart F-4B

SA-426 File No. 1-0005 NATIONAL TRANSPORTATION SAFETY BOAR£ WASHINGTON, D. C. 20591 AIRCRAFT ACCIDENT FEPORT

Adopted: September 22, 1972

HUGHES AIR WEST DC-9, N9345, AND U. S. MARINE CORPS F-4E, 151458 NEAR DUARTE, CALIFORNIA JUNE 6, 1971 SYNOPSIS A Hughes Air West DC-9, N9345, and a u. s. Marine Corps F-4B, Bureau No. 151458, collided in flight near Duarte, California, at approximately 1811 P.d.t., June 6, 1971. All 49 occupants, 44 passengers and five crewmembers, aboard the DC-9, and the pilot of the F-4B were fatally injured. The radar intercept officer, the only other occupant in the F- 4B, ejected from the aircraft after the collision and parachuted to the ground. He was not injured. Both aircraft were destroyed by the collision, ground impact, and fire. The Hughes Air West DC-9 was under radar control of the Los Angeles Air Route Traffic Control Center, climbing to Flight Level 330• The F-4B was being flown at approximately 15,500 feet, in accordance with Visual Flight Rules, en route to the Marine corps Air Station, El Toro, California. The collision occurred at an altitude of approximately 15,150 feet. The visibility in the area, at the time of the accident, was good and there were no clouds between the two aircraft during the final minutes of flight.

- 2 - The National Transportation Safety Board determines that the probable cause of this accident ~as the failure of both crews to see and avoid eacb other but recognizes that they had only marginal capability to detect, assess, and avoid the collision. Other causal factors include a very hiqh closure rate, comingling of IFR and VFR traffic in an area where the limitation of the ATC system precludes effective se~aration ·of such traffic, and failure of the crew of BuNo458 to request radar advisory service, particularly considering the fact that they had an inoperable transponder. As a result of this accident the Safety Board recommends that the Federal Aviation Administration: (1) install video tape on all radar displays and 11area 11 micro~hones in air traffic control facilities; (2) provide positive control airspace from takeoff to landing for all IFR traffic; and (3) insure that all radar facilities are capable of receiving Code 7700, and establish definitive procedures for the handling of such traffic. The safety Board also recommended that the Federal Aviation Administration and the Department of Defense cooperatively develop a program to inform all airspace users of the heaviest traffic areas. In addition, it was recommended that the Department of Defense: (1) restrict hiqh-speed, low-level operations to designated areas and routes; (2) delineate explicit circumstances where the 10,000 feet/250 knots limitation may be exceeded; (3) consider using air intercept radar for collision avoidance purposes; and (4) publicize the availability of the FAA Radar Advisory service and consider making the use of this service mandatory. ·

- 3 - 1. INVESTIGATION 1.1 History of the Flight Hughes Air west Flight 706 (RW706) was a regularly scheduled flight from Los Angeles, California, to Seattle, Washington, with intermediate stops at Salt Lake City, Utah, Boise and Lewiston, Idaho, and Pasco and Yakima, Washington. The flight departed Los Angeles International Airport at 1802 j/ and. following radar vectors from Los Angeles Departure Control, contacted the Los Angeles Air Route Traffic Control center (ARTCC) at 1806. In accordance with a request, the flight reported leaving 12,000 feet at 1809, and the controller advised, "Air West seven zero six red, turn left heading zero four zero until receiving Daggett proceed direct." RW706 acknowledged, "OK, zero four zero direct to Daggett." This was the last recorded transmission from the flight. The u. s. Marine Corps F-4B, Bureau No. 151458 (BuNo458) departed the Marine corps Air Station (MCAS) El Toro, California, on June 4. 1971, as part of a flight of two aircraft. The flight was scheduled for an overnight cross- country to McChord Air Force Base (AFB), Washington, and return. McClellan AFB, California, was to be used for refueling northbound, and Mountain Home AFB, Idaho, was to be used southbound. Although the transponders on both aircraft apparently failed shortly after departure from MCAS El Toro, the flight of two was permitted to proceed to McChord AFB under control of the ATC System by radar. on June 5, the flight continued to Mountain Home AFB, but the radio in BuNo458 failed during the landing approach. After landing, the crews discussed the operational status of the two aircraft, and the flight leader decided that he would proceed to MCAS El Toro. The wingman and his Radar Intercept Officer (RIO) were instructed to await repairs to EuNo458 and then return to MCAS El Toro. The mechanical difficulties with the aircraft at this time included: 1. Inoperative transponder 2. Inoperative radio 3. oxygen system leak 4. Degraded radar system

- 4 - Maintenance personnel at Mountain Home AFB re~laced a fuse to fix the radio, but they did not have the ~ersonnel to check the transponder. They confirmed the oxygen leak, but could not repair it. No attempt was made to restore the radar to peak performance at that time. The crew of BuNo458 filed a Visual Flight Rules (VFR) flight plan to Naval Auxiliary Air Station (NAAS) Fallon, Nevada, below the Area Positive Control (APC) , 1/ because of the inoperative transponder and fuel requirements. On .this leg of the flight the oxygen leak increased, and the oxygen was turned off shortly after takeoff from Mountain Home AFB. The maintenance personnel on duty at NAAS Fallon were unable to provide the appropriate repairs, so the pilot contacted his squadron duty officer for instructions. Be was advised to proceed to MCAS El Toro at low altitude. After refueling, the crew again filed a VFR flight plan below APC. The takeoff was delayed from 1400 to 1716 because MCAS El Toro was closed for an airshow between 1400 and 1630. The intended route of flight was direct Fresno, J-65 Bakersfield, J-5 Los Angeles, direct MCAS El Toro. The flight departed at 1716, climbed initially tc 7,500 feet, and then climbed to 15,500 feet to clear mountains and some clouds ap~roximately 50 miles from NAAS F~llon. After crossing the mountains, they descended to 5,500 feet and remained at that altitude until they reached Bakersfield. Approximately 15 miles north of the Bakersfield Flight Service station a position report was made, and the MCAS El Toro weather was checked. The crew also decided to deviate from the original plan at this point. They flew east of the planned course, over Palmdale, to avoid the anticipated heavy traffic over Los Angeles. The flight continued in a low profile, min1mun1 altitude 1,000 feet above the ground, until approximately 15 miles northwest of Palmdale. Due to deteriorating visibility, they again climbed to 15,500 feet. The RIO stated that the climb was made, using maximum engine power, without afterburner, and took less than 2 minutes. Shortly after level-off, the Distance Measuring Equipment (DME) feature of the VORTAC 3/ indicated 50 miles to MCAS El Toro. The pilot executed a 3600 aileron roll at this time, which took ap~roximately 3 seconds to complete. The RIO estimated that the true · airspeed in the climb and after level-off was 420 knots, and that the collision occurred approximately 1 minute and 20 seconds after the roll. During most of this

- 5 - period, he was operating the radar in the mapping mode, but, due to the extremely degraded air-to-air detection capability, no airborne targets were seen. Since the radarscope was in the stowed position, the RIO was leaning forward, and his line of sight was directed downward at approximately a 450 angle while using the radarscope. Approximately 3 to 10 seconds prior to collision, the RIO raised his head, observed the DC-9 in his peripheral vision approximately 500 to the right and slightly beneath his aircraft. He shouted to the pilot, but the pilot had initiated an evasive roll before the RIO finished the warning. Be did not see RW706 take any evasive action. After takeoff from Los Angeles, RW706 was given two radar traffic advisories by departure control, and control was subsequently transferred to the R-18 sector of Los Angeles ARTCC. The data and radar positions of this sector were manned by developmental controllers!/, each of whom was beinq supervised by a journeyman controller. Consequently, four individuals were observing the radarscope at the R-18 position prior to the collision. They all agreed that no primary targets were observed in proximity to RW706 at any time. Five traffic advisories were given to other aircraft in the R-18 sector in the 6-minute timespan prior to the collision. After the collision, BuNo458 began to tumtle violently about the lateral axis. The RIO waited about 5 seconds, and, after seeing numerous warning lights in the cockpit, he ejected from the aircraft. The ejection was successful, and he parachuted to the ground without injury. Witnesses in the area of the accident gave widely varying accounts of the collision. Thirty-four witnesses saw or heard jet aircraft prior to the collision, and 24 persons observed the two aircraft on converging courses. Fifteen persons saw a fighter aircraft in a rolling or evasive maneuver prior to collision. Three persons on the ground and two pilots, at varying distances from the immediate collision area, observed a fighter aircraft proceeding along the route of flight described by the RIO. (See Attachment 1.) Several witnesses in the area of the collision reported seeing a fighter aircraft doing rolls and circling in the area.

1. 2

Injuries to Persons Injuries Fatal r::c-9 F-4B Nonfatal DC-9 F-4B None DC-9 F-4B 1.3 Damage to aircraft 5 1 0 0 0

1

6 - Passengers 44 0 0 0 0 0 Others 0 0 0 0 Both aircraft were destroyed by the collision, ground impact, and subsequent fire. 1.4 Other Damage Both aircraft crashed in a remote mountaincus area, and all ground damage was restricted to underbrush which was burned in the ground fire. 1.5 crew Information The crews of respective flights. both aircraft were qualified for the (See Appendix E for details.) 1.6 Aircraft Information The DC-9 was properly certificated and both aircraft had been maintained in accordance with existing regulations. The weight and center of gravity of each were within prescribed limits. The DC-9 was serviced with Jet A fuel and the F-4B with JP-5 fuel. (See Appendix c for details.) 1.7 Meteorological Information The weather in the vicinity of the accident site was characterized by low-level haze and smoke, scattered low clouds and high, thin, broken or scattered clouds. There was no frontal weather in the area. The pertinent portion of the aviation area forecast issued by the National ~eather Service at Los Angeles was in part, as follows: Scattered, variable to broken clouds at 23,000 feet. visibility 3 to 6 miles, haze and smoke. Coastal

- 7 - stratus increasing and moving onto immediate coast 1900 to 2100 then spreading inland about 20 miles by midnight with higher coastal terrain occasionally obscured. The Vandenberg .AFB 1700 radiosonde ascent showed a shallow layer of relatively moist unstable air near the surface to the base of an ao c., inversion near 1,000 feet with the top near 4,000 feet. The associated winds aloft observation was., in part, as follows: Height (feet m.s.l.> surf ace 1.,000 3.,000 6.,000 9.,000 12,000 15.,000 Direction (Otrue) 265 260 340 020 110 060 020 Velocity «knots) 5 5 5, 7 9 16 19 Official sunset at LOs Angeles was at 2002.

1. 8

Aids to Navigation • The Los Angeles ARTCC uses three ARSR-1E radar systems for the control of traffic. Each of these systems has a range of approximately 150 miles, and is dis~layed at the control positions on an RBDE-5 horizontal scan converter with a 21-inch cathode ray tube. The antennae for the ARSR- 1E systems rotate at 5 r.p.m. Additionally, each sector has a vertical display which is used as a backup system, and an aid in receiving radar handoffs. The vertical display is also an RBDE-5 scan converter. The R-18 sector controller at the time of the accident was monitoring the San Pedro ARSR-1E system on the horizontal display. This is a joint-use system with the military. The antenna is located near Long Beach, California. The controls were adjusted to the 55-mile range, with 5-mile range marks. The display was off- centered approximately 40 miles to the southwest. The moving target indicator (MTI) 5/ was set at level 4, and the staggered pulse repetition frequency (PRF) circuit was

• operating. 6/

- 8 - The R-18 controller had the ASR-4 the RBDE-5 sector vertical display. The located at Los Angeles International range of approximately 50 miles. The rotation is 12.75 r.p.m. system selected on ASR-4 antenna is Airport, and has a rate of antenna The R-36 sector controller was monitoring the Boron ARSR-1E radar system on the horizontal scan converter at the time 0£ the accident. The Boron antenna is located in the vicinity of Edwards AFB, California. The contrcller had the San Pedro radar system on the sector vertical display. He had radar-identified RW706 and was waiting for them to call prior to assuming control responsibility. Ee observed a transponder Code 7700 ]/ appear on his horizontal display api;:roximately 5 miles northwest of the marker for RW706. He also heard an emergency beacon signal on the VHF Guard Channel ~/ which he was monitpring. He did not see the Code 7700 on the vertical display. The Code 7700 target appeared about two sweeps before the target of RW706 disappeared. The Code 7700 then moved in a wide, counterclockwise, circular path, first toward the south-southeast and then toward the northeast. It disappeared in the vicinity of Norton AFB, approximately 10 minutes after it was first observed. Statements from other controllers in the center confirmed that the code 7700 was received on the Boron and Mt. Laguna radar systems, but not on the San Fedro system. The Safety Board attempted to identify the source of the Code 7700 but was unsuccessful. No explanation has been found for the failure of the San Pedro system tc receive the Code 7700 .. 1.9 communications There were no reported difficulties with communications between either RW706 or BuNo458 and the respective ground facilities contacted by each. 1.10 Aerodrome and Ground Facilities Not ai;:plicable. 1.11 Flight Recorders RW706 was equipped with a Sundstrand ~ata control flight data recorder, Model FA-542, serial No. 1810. The outer case sustained extreme external heat and fire damage, but only minor mechanical damage. The metal foil was

- 9 - intact, but deposits of soot, molten metal, and other residue required extensive cleaning to expose the recorded parameters. All parameters were functioning; however, the traces were faint and difficult to identify in certain areas after the cleaning process. The total elapsed time of recording was 8 minutes 55 seconds. Based on altitude information prior to departure from Los Angeles, the recorder was recording altitude 51 feet low. The recorded values at time 8 minutes 54.6 seconds were + 0.74g, 041°, 321 knots, and 15,125 feet. During the following 0.6-second time period, the vertical acceleration trace moved to + 5.0g at 8 minutes 55.2 seconds and instantaneously to -1.8g. The last recorded parameter values prior to electrical power loss at 8 minutes 55.2 seconds were -1.Sg, 0410, 327 knots, and 15,150 feet. RW706 also was equipped with a United control cockpit voice recorder, Model V-557, serial number unknown. The fire damage consumed the dust cover, and all thermal- protective water and glycol had been expended. There was no deformation of the stainless steel magazine, but only iron oxide dust was found in the tape storage compartment. As a result, no data were available. BuNo458 was not equipped with any flight recorders and none were required. 1.12 wreckage The main wreckage of the two aircraft was scattered over approximately 2 square miles. The DC-9 crashed in a canyon with approximately 60° slopes. structure from Fuselage station (FS) 427 aft, including wings and empennage was located in this area. One piece of F-4B aft fuselage structure was also found at the DC-9 crash site. This piece of the F-4E had become entangled in electrical wiring which was installed between FS318 and FS1099 of the DC-9. The F-4B main wreckage site was located in another canyon approximately three quarters of a mile southeast of the DC-9. The only major structure not identified at this site included most of the right outer wing, the centerline, top, aft, fuselage structure and the empennage.

- 10 - Wreckage portions of the DC-9 forward fuselage were removed, and a full-scale three-dimensional mockup of this section was made. A silhouette of the F-4B was then constructed with lumber. This silhouette was placed in various positions and attitudes to attempt to match the two distinct damage paths through the DC-9. one path was long and narrow, oriented at an angle of 300 to the ~C-9 fuselage reference plane, and passed through the fuselage in the area below the main passenger loading door and first 10 windows. The other path was rectangular and passed through the forward, lower, cockpit area. When the F-4B vertical stabilizer was positioned at approximately FS110 (the fuselage area beneath the windscreen) on the left side of the DC-9 the right wing was in the damage area under the cabin door and windows. Both damage paths were on a descending angle of approximately 200 through the DC-9c However, both damage swaths were larger than the F-4B structure, and this angle could vary as much as 100 in either direction. It is not known whether the downward trajectory of the t~o swaths resulted primarily from the relative flightpaths of the two aircraft or the progressive disintegration of the F-4B structure as it passed through the DC-9. 1.13 Fire No evidence of in-flight fire was found on the oc-9; however, the F-4B caught fire following the collision. There was a severe ground fire at each of the main crash sites. A total of seven fire trucks, two helicopters, one air traffic controi unit, and approximately 72 officers and men responded to the fire alarm. 1.14 survival Aspects This was a nonsurvivable accident for the occupants of the DC-9. The midair collision was survivable for the occupants of the F-4B. The RIO successfully ejected and he was subsequently rescued uninjured. The pilot was not able to eject and the F-4B collision with the ground was non- survivable. BuNo458 was equipped with a Martin-Baker B7 rocket ejection seat in each cockpit. This seat was not designed to be fired through the canopy, and incorporated a canopy

- 11 - interrupter block in the actuation linkage to prevent such an occurrence. The front seat face curtain, the primary means of firing the seat, was not recovered. The alternate firing handle had been actuated. Distortion of the actuation linkage indicated that the canopy interrupter block prevented further movement of the mechanism and subsequent ejection of the pilot. In addition to the canopy unlock system provided in the ejection sequence, two manually operated systems are provided. However, regardless of which method is used to unlock the canopy, cases have been reported wherein the front canopy failed to jettison when the aft canopy was jettisoned first. As a result of these occurrences a change in the canopy jettison mechanism was instituted to incorporate ballistic canopy thrusters to assure that the canopy would separate from the aircraft. This modification had not been installed in BuNo458. This change was being incorporated in all F-4B aircraft on a fleetwide basis, and modification of aircraft at MCAS El Toro was scheduled to begin in July 1971. 1.15 Tests and Research A radar f ligbt check of the San Pedro radar was conducted on June 8, 1971, using an F-4B.- Routine scheduled maintenance had been performed on the system between the time of the accident and the flight check. The RIO bad not been formally interviewed by safety Board investigators at that time. Consequently, the flight track was only an approximation of the presumed track. The San Fedro system was capable of tracking the primary target of the F-4B above 7,500 feet. several controllers commented that they had never seen the radar perform so well. The Safety Board coordinated with the Federal Aviation Administration (FAA) and the u. s. Marine corps to conduct another flight check of the San Pedro radar on June 16, 19710 The track of BuNo458 described by the RIO was duplicated as closely as possible on three runs, with some variations in the altitude on one run. Three additional runs were conducted in the general area the flight traversed, but with flight track and altitude variations as suggested by the witness group. The radarscope, channel;

- 12 - and control settings were the same as at the time of the accident, except that the secondary target was offset so that it would not interfere with tracking the F-4B primary target. Tracking continuity was poor and the primary target was visible less than 50 percent of the time. The secondary target did provide assistance in following the aircraft movement during voids in the primary target coverage. Photographs of the test runs, as displayed on a maintenance monitor, were taken on virtually every sweep of the antenna. These photographs were studied by the air traffic control group. The examination corroborated the initial reaction to the tracking quality of the F-4B target, but it also demonstrated that the primary target alone was not of sufficient strength to assure notice by a controller who was unaware of the aircraft presence. · The F-4B in each test was not configured the same as BuNo458 at the time of the accident. The first test F-4B was in a clean configuration, and the second F-4B test aircraft was equipped with two large wing tanks. A baggage tank was installed on the fuselage centerline of BuNo458. Consequently, BuNo458 represented a larger reflective cross- section for radar detection than the first test aircraft, and less reflective surface than the second aircraft. The validity of the flight checks also was compromised by such variables as meteorological phenomena and deterioration in operating parts of the radar or improved performance due to replacement of failed parts. A visibility study was conducted to determine the physical limitations to vision from the cock~it of each aircraft. A flightpath for each aircraft was reconstructed. (See Attachment 1.) The collision geometry and closure rates for the last 40 seconds also was reconstructed. (See Attachment 2.) The flightpath of RW706 was based on the flight recorder data, and the F-4B flightpath was predicated on the statement of the RIO. A dual lens camera was used to record a panoramic view from the design eye-reference point at each crewmember•s station. (See Attaqhments 3 and 4.) These binocular photographs show the position of each air- craft in the field of vision of each crewmember, based on his fixed-eye-reference point. Naturally, any movement from this position would affect the location of the other aircraft in his field of vision.

- 13 - In the course of thi$ investigation, the McDonnell- Douglas Corporation provided information concerning roll and pitch rates for the F-4B aircraft. The following bas been extracted from the supplied data: Subject What would be the maxi- mum rate of steady nose- Full Stick Throw 1/2 1/4 Stick Throw Stick Throw down pitch? · -10 deg./sec. -4 deg./sec. -2.5 deg./sec. Concerning the nose- down pitch rate, what would be the time interval required from the first control input to; (a) Achieve initial air- craft movement? 0.10 sec. (b) Achieve the maximum steady nosedown pitch rate 1.0 sec. How many degrees nose- down would have been achieved at the point that the maximum pitch rate had been attained 15.0 deg. Altitude lost and air- speed at 200 nosedown pitch: a) alt. loss 16 ft. b) KTAS 420 Altitude loss and airspeed Ci) 200 nosedown flightpath angle: 0.10 sec. 6.5 sec. 9.0 deg. 210 ft. 426 a) alt. loss 180 ft. 385 ft. b) KTAS 424 430 0.10 sec. 6.0 sec. 5.0 deg. 590 ft. 436 620 ft. 437 In addition to the above, the data indicated that a bank of 300 could be achieved in as little time as 0.75 second. If roll-and-pitch control inputs are coupled during the maneuver, the time to achieve a given bank/pitch

- 14 - ~ttitude is less than the time required if the attitude is achieved as the result of two separate maneuvers. In this instance, the data indicate that a 200 nosedown, 300 left bank attitude could be achieved in less than 3 seconds. 1.16 Other The Staff Vice President, Flight Operations for Air west, stated that attempts were made to foster crew vigilance and scanning by minimizing crew duties in the cockpit, use of checklist procedures, encouraging use of the autopilot as much as possible, and through emphasis in their training program. However, tbe various manuals and training programs did not specifically contain any statement relating to lookout doctrine or scanning techniques, nor did the company have any plan to implement such a program. The pilot of BuNo458 received training in lookout doctrine and scanning techniques in flight school. After assignment to the squadron, the pilot and RIO received additional training on scan techniques with emphasis on tactical intercept and pursuit. Each pilot and RIO receives formal upgrading and refresher vision training at least once every 3 years. Additionally, the crews routinely include reminders in lookout doctrine during briefing for each multiple aircraft flight. 2. ANALYSIS AND CONCLUSIONS 2.1 Analysis (a) ATC and Radar Factors The primary function of radar is to ~rovide the controller with a visual presentation which will assist him in the control and separation of known traffic. It also provides the controller with another limited capability that of ~roviding separation of identified from unidentified traffic through the medium of the traffic advisory when workload permits. In some cases, due to the technical limitations 0£ the radar equipment, adequate separation has not been achieved. Because of the mix of known and unknown traffic it is not only incumbent upon aircrews to maintain a high degree of vigilance to "see and avoid", tut also upon the controllers in monitoring the radar display. In this accident three independent radar systems failed to detect the primary target of EuNo458 and as a result no warning was

- 15 - given to the crew of RW706 regarding the direction and distance of the hazard. If the crew of Rw706 had been provided with this information their chances of seeing and avoiding the other aircraft would have been enhanced. One solution to the limitations of radar would be the establishment of some minimum standard of reflective capability for all aircraft and the incorporation of some form of signal enhancement equipment aboard all aircraft, as necessary to meet the standard, as previously recommended by the Board. (See Report Number: NTSE-AAS-70-2, pages 119- 128.) The radar coverage chart (classified for military security) for the San Pedro system indicates that the collision occurred at an altitude which is within the basic radar line of sight coverage. The limitations to radar advisory service within that coverage area include more than the controller workload. Other factors affecting detection of primary targets include: (1) Radar cross-section presented by the design and configuration of the aircraft (2) weather conditions such as precipitation and temperature inversions (3) Ground clutter (4) Elind spots In this instance, detection of BuNo458 was hampered by the aircraft radar cross-section and a temperature · inversion. Although simulations of the flightpath indicate that the primary target was intermittently detectable, the low probability of such detection is dramatized in the following computation: The total elapsed time a target would have been detectable was 120 seconds, equal to 10 sweeps of the antenna. At approximately 420 knots (7 miles per minute), the aircraft would travel 1.4 miles during each sweep. The target would actually move a total of 2.5 inches, or 0.25-inch/sweep, across the 21-inch display. The small time element involved and short 9istance moved, in combination with the prcbability of less than 50 percent primary target tracking continuity, indicate that it would have been extremely difficult for the controllers to differentiate between normal clutter and an aircraft return, if any target was displayed at all.

- 16 - The volume of traffic and controller workload associated with the R-18 sector were sufficiently light to permit radar traffic advisories if requested. Advisories on possible conflicting traffic were being given to other controlled aircraft during the time period surrounding the collision. All four controllers associated with the activity at the position stated that no primary targets were observed in the vicinity of RW706. Consequently, the Board concludes that no readily discernible target from EuNo458 was displayed. If a request for radar advisories had alerted the controllers to the presence of an aircraft in that area, any intermittent or questionable target sighted could have been tentatively identified as EuNo458. The R-18 controller could have advised RW706 of the conflicting traffic under these circumstances. (b) Reports of Aircraft Acrobatics During the investigation considerable public attention was focused on witness reports of an aircraft performing acrobatics in the vicinity of the collision. The RIO testified that only one aileron roll was performed by the pilot of BuNo458, as he leveled off at 15,500 feet. An analysis of the flight from NAAS Fallon indicates that there was insufficient time available for any repeated maneuvers to have been performed. The witnesses might have been observing another aircraft, or they were actually viewing the gyrations of BuNo458 following the collisicn. Whereas no specific Federal Aviation Regulation prohibited the aileron roll, the ability of the crew to see other aircraft during the maneuver was unquestionably minimal due to the rapidly changing attitude and the acceleration forces imposed. The Board concludes that the aileron roll had no other significance to the accident, since the two aircraft were separated by approximately 13 miles at the time. However, it was imprudent of the pilot to perform such a maneuver in other than an acrobatic area. (c) Operational Factors This accident is another example of a heterogeneous mix of VFR and IFR traffic, with each aircraft ccmplying with applicable regulations, resulting in a midair collision. several factors in the operation of the two aircraft combined to provide the conditions suitable for a midair collision ..

- 17 - 1. Operation of BuNo458 Mechanical difficulties with BuNo458, and the resulting operational decisions, ~laced the aircraft at low altitude and high airspeed, instead of in the APC, as would normally be expected on cross-country flights. The transponder had failed on the previous day, making entry into the positive control airspace dependent on the discretion of the air traffic control facility. When the oxygen system also became defective, with no opportunity to repair either system, the decision to proceed to MCAS El Toro at relatively low altitude was the obvious solution to both problems. The transponder was not required, and cockpit pressurization negated the physical need for supplemental oxygen, even if the leak depleted the entire supply. The oxyqen leak did increase, and most of the flight to NAAS Fallon was flown without supplemental oxygen. At this point, the pilot was instructed by higher authority to complete the flight with the defective systems. An additional significant factor in the operation of BuNo458 was the high-cruising airspeed, which is typical of modern jet aircraft. The high airs~eed was used to avoid high specific fuel consum~tion and the less stable flight regime encountered at slower airspeeds. consequently, the proba- bility of visual detection was minimized by the speed, size, and unexpected presence of BuNo458. · In addition to these operational constraints imposed on the pilot of BuNo458, consideration of traffic and weather conditions was also evidenced in the planning and conduct of the flight .. The pilot of BuNo458 was sufficiently aware of the heavy volume of traffic in the Los Angeles area to alter his flight to the east in order to avoid any conflict. He further demonstrated concern for adequate vigilance by climbing to 15,500 feet because of the deteriorating visibility. However, the advantage which would have accrued from the deviation around Los Angeles was largely offset by the subsequent climb to higher altitude. This placed EuNo458 in the airspace segment normally used by eastbound traffic climbing to the high-altitude route structure. Two other decisions significant effect on attempt to request radar have alerted the by the pilot of BuNo458 also had a the collision. First he did not traffic advisories. This would appropriate controller that a

- 18 - nontransponder target was in the area and undoubtedly would have resulted in an attempt to establish radar identification. Even if radar contact bad not been accomplished at that time, the general location would have been established, and traffic advisories could have been issued accordingly. In spite of the fact that crews sometimes do not sight the traffic even though the advisories are issued in specific terms (clock code and distance) the issuance of a general warning (geographic location and direction of flight) would have served to narrow the field of search, thereby increasing the probability of detection. Secondly, he requested the RIO to conduct a radar mapping exercise at a time when he was traversing an area of dense traffic. Although it may be argued that outside visibility from the rear cockpit is relatively poor, all possible assistance in maintaining a lookout should have been used. If any radar exercise were to have been conducted, it should have been in the search mode. Even in the degraded condition of the radar, this would have been preferable. 2. Operation of RW706 An analysis of the final 0.6 second of flight recorder operation shows that at 8 minutes 54.6 seconds, the vertical acceleration transducer sensed a ~ositive g force, moving from +0.74g and culminating in a +5.08g reading at 8 minutes 55.2 seconds. At the instant the stylus recorded this, it moved instantaneously to a -1.Sg reading. The return to, and overtravel beyond, a +lg (normal) position (-1.8q), with no measurable elapsed time, strongly suggested rapid response or normalizing of the spring-restrained seismic mass in the electromechanical transducer after high excitation in the positive direction. These g recordings were made possible by the recording rate of 10 per second for this parameter, whereas the other three parameter rates are one per second. The Safety Eoard believes that these excursions on the acceleration trace resulted from shock loading at impact and not from any attempted evasive maneuver by RW706.

- 19 - Since the crew of RW706 took no evasive action prior to the col1ision. this indicates that either they did not see BuNo458 or saw it too late to take appropriate action. There are several factors which individually or co1lectively could have reduced the ability of the DC-9 crew to see and avoid the F-4B. The crew probably engaged the autopilot to maintain climb schedule and, under radar control. probably expected traffic advisories of converging targets from the controller. Further reduction in 1 outside vigilance might have resulted from such normal cockpit functions as determining or changing various radio frequencies. adjusting settings or controls of the flight director or thrust levers. However. the probable reasons why the RW706 crew did not see BuNo458 were: (1) both aircraft had a nearly constant relative bearing to each other; (2) the high closure speeds; (3) the lack of conspicuity of Eullo458; and (4) the lack of recurrent training in etficient lookout doctrine and scanning techniques. (d) Human Factors in Target Detection and Assessment The Board's cockpit visibility study (Attachments 3 and 4) indicates that at least 40 seconds prior to impact, BuNo458 was less than 450 to the left of the DC-9 captain's and first officer's normal sight line. Ap~roximately 35 seconds prior to col1ision. RW706 completed a left turn and was then climbing on a constant heading. Although the target size of BuNo458 was small at this time (0.017-inch). the smoke trail from engine exhaust would have at least tripled the effective target size. The visual angle subtended by such a target would be approximately 10.8 minutes of arc. The empirically derived threshold for detection is nominally 4 minutes of arc. At approximately 15 seconds before the collision, just prior to the onset of the "blossoming effect" which occurred as the intruder target size increased dramatically, the size of BuNo458 and a smoke trail twice its length would have grown to ap~roximately 0.117-inch. In the next 10 seconds, the target size would triple, in the last 5 seconds it would expand to fill the entire visual field. These figures are predicated on the constant foreshortened length of BuNo458 which wou1d result from the relative positions of the ttio

- 20 - aircraft, and no attempt was made to adjust for the target size during the evasive action taken by EuNo458. The cockpit visibility study (Attachments 3 and 4) also indicates that RW706 would have been approximately 390 to the right of the normal sight line of the pilot of BuNo458 and approximately 370 for the RIO, for the last 40 seconds prior to collision. The target size of RW706, allowing for the foreshortening due to angular displacement, 35 seconds 'prior to impact was approximately 0.037-inch. At this point the target would subtend approximately 1 minutes of arc, which is well within the detectable threshold mentioned earliera No addition to target size was made for engine exhaust because one engine was modified, which reduced the visible smoke emission. This would have presented less than optimum density for detection. During the final 15-second period prior to collision, the target size of RW706 blossomed rapidly. tripling in size between 15 seconds and 5 seconds and then expanding to fill the entire visual field in the final 5 seconds. Although the F-4B and DC-9 target images were t~eoretically of sufficient size to permit detection at 35 seconds prior to collision 0 a number of factors could have contributed in this case to reduce the likelihood of detection at that timea In the analysis of any midair collision, laboratory data on human response and capabilities ~/ must be adjusted to real-world conditions~ The extent to which these data vary depends on the effect of many factors: ieeee windshield refractance, surface irregularities and cleanlinessg size and location of windshield frames, the background against which a target is viewed, atmospheric light scatter, and viewer training, ability, and preoccupation. All may be involved to varying degrees at the time a target is within a perceptible thresholdc The extent to which these factors affected detection of RW706 or BuNo458 cannot be determined preciselyc However, the various studies comparing laboratory data to real-world situations show dramatic reduction in the probability of visual detection due to the .factors listed above~ A nonstructu.red or ill-defined homogeneous background presents a less-than-desirable field when the search for a target is conductedo The lack of defined background texture, coupled ~ith a constant background hue, can severely limit not only the detectability of a target but

- 21 - also the ability to perceive target motion, once the target is detected. While the effects of atmospheric light scatter, and the reported haze layer at 9,000 feet cannot be quantitatively determined in this accident, it is reasonable to surmise that RW706 presented less than optimum conspicuity when viewed against the haze layer. Moreover, its motion relative to the background haze would be difficult to detect. Had either aircraft displayed high intensity strobe lights, the increased conspicuity probably would have enhanced early detection of each aircraft. Another factor which can affect the detectability of airborne targets is the myopic nature of the human eye when an air-to-air search is being conducted. The condition results from the tendency of the eye to focus at ap~roximately 20 feet during a visual search into an essentially empty visual field. Although this condition is more prevalent at extremely high altitudes where the horizon becomes ill-defined and high ambient lighting becomes a factor 0 it is also possible that a myopic condition could exist at markedly lower altitudes when a pilot is searching against an ill-defined homogeneous fielda The possibility therefore exists that the crews of RW706 and BuNo458 could have been subject to some degree of myopic vision with a resultant reduction in their ability to detect a small target .. Finally, the effectiveness of crew scanning is dependent on training and the time sharing of activities inside and outside of the cockpit. Based on a fixed-eye reference point, neither target was masked by intervening cockpit structure for any significant period of time; however, each target was in the peripheral visual field ..1.Q/ of all crewmembers.. The lack of relative motion of either target in the peripheral vision of any crewmember could have made early detection of the other aircraft highly unlikely. Similarly, the small size and lack of relative movement of either target, even though detected at 35 seconds prior to collision, would undoubtedly have precluded accurate assessment of the vertical and horizontal separation or rate of change of target size. Thus even if the tC-9 and F-4 crews detected the other aircraft, the cues for accurate assessment of the collision geometry could have been marginally adequate. It may be postulated that as the closure distance decreased from 20 to 10 seconds prior to the collision the

- 22 - target would become better defined and Rw706•s climb attitude could be more accurately discerned by the pilot of BuNo458. Thus a sighting during the period between 20 and 10 seconds prior to collision might not have been interpreted as an imminent collision threat because of the smallness of the target size. However, target size notwithstanding, the fixed bearing of RW706 and its location near the horizon would have suggested that a collision threat existed and that he should maneuver to assure a comfortable separation. Moreover, the F-4B pilot's military flying experience, including tactical intercept training should have increased the likelihood of the initiation of a right turn or other maneuver which would have increased the miss-distance. The lack of any such maneuver indicates that he did not sight the DC-9 in sufficient time to have executed an appropriate maneuver to avoid the collision. In light of the above discussion of the likelihood of early detection, the Safety Board concludes that although detection of RW706 by the pilot of EuNo458 might have occurred as much as 35 seconds prior to collision, it is more likely that it occurred at some time markedly less than 20 seconds prior to the collision. The possibility of an early detection of BuNo458 by the crew of RW706 was considered. However, with BuNo458 located near the horizon and on a constant or nearly constant bearing, early detection probably would have ~rompted the crew of RW706 to monitor the progress of BuNo458 thereafter and seriously to consider altering their climb schedule or heading to ensure safe passing separation. Assuming continued assessment by the RW706 crew, as the range decreased, the likelihood of their making a ~recautionary alteration in flightpath would seem to increase. Therefore, in the absence of any such deviation in flightpath, the Safety Board concludes that it is most likely that the crew of RW706 never saw BuNo458, or saw it moments prior to the collision and had no time to initiate an evasive maneuver~ In order to determine a likely time for detection of RW706 by the pilot of BuNo458, it was necessary to consider the RIO•s warning coincident with the rolling maneuver as a starting point, together with aircraft response times and laboratory data suggestive of pilot response times in collision.situations. The data suggest that it would take 0.24 second to accommodate to foveal vision, cnce a target was detected. Neural processes would take an additional 0.3

- 23 - second. The data further suggest as much as 3 seconds could have elapsed during recognition and assessment of the various cues and determination that a potential threat existed. Approximately 2 seconds could have then elapsed while deciding whether an evasive maneuver was necessary and if so, the type of maneuver to initiate. Another 0.5 second could have elapsed for human motor response. Aircraft performance data indicate approximately 3 seconds could have been required for aircraft response, depending en the rate and type of control input. Based on the RIO's testimony and analysis of other events, the pilot's partici~ation in the radar mapping exercise was completed approximately 20 seconds prior to the collision. However, this remaining 20 seconds was most likely not entirely spent in constant visual search of surrounding airspace. such intracockpit duties as monitoring the attitude indicator to maintain flightpath attitude, airspeed, and status of aircraft subsystems would have occupied some finite amount of this time. Thus, the time available for detecting any outside target could have been significantly less than 20 seconds. It is postulated that 10 seconds could have been spent performing a noncontinuous visual search of the surrounding airspace, while the remaining 10 seconds were shared with scanning cockpit dis~lays. Because the DC-9 target was very small, stationary, and located in bis peripheral vision, it is most likely that the pilot did not see the DC-9 until just moments before the collision. The completely unexpected appearance of the DC-9, together with its dramatic growth in size during the 10 seconds prior to collision rendered proper assessment of the situation extremely difficult if not impossible. The Safety Board concludes therefore, that it is likely that the pilot of BuNo458 detected RW706 less than 10 seconds before the collision and that the evasive maneuver was initiated approximately 2 to 4 seconds before collision. Within the final remaining 2 to 4 seconds a left roll was made as an attempt to avoid a collision. A more appropriate maneuver consistent with previous training would have been a roll to the right to increase miss-distance. However, the Board cannot determine with certainty that even this type of maneuver would have assured safe passage of the F-4 .. The Board further concludes that the visual cues for accurate assessment of the collision geometry by the pilot of BuNo458 probably were inadequate. Then, when target range had been reduced sufficiently to afford improved visual cues, the time remaining was so brief as to make

- 24 - unduly difficult the accurate assessment 0£ the geometry and proper response. (e) Consideration of See and Avoid Concept section 91.67 of the Federal Aviation Regulations (FAR) jj/ places the burden on both crews to see and avoid other aircrafto Assuming detection of the other aircraft, FAR 91~67(c) placed an additional responsibility on BuNo458 to respect the right of way of RW706 Nonetheless, as can be appreciated from the foregoing analysis of this collision, the likelihood of a pilot's either not seeing an intruder at all or seeing the intruder and misinterpreting visual cues and then attempting an evasive maneuver based on incomplete visual cues, is highly probable. The problem-solving process required of pilots in these situations is often highly complex, and in many cases the problem is impossible to solve in time to avoid a collision. This is demonstrated by the fact that the crew of BuNo458 had received recent training in lookout doctrine and scanning techniques but were unable to avoid the collision. conversely, the crew of RW706 received no formal company training on lookout doctrine or scanning techniques, and no such training is required by either the company or the FAA. Although Air west pilots are evaluated for "alertness", this evaluation appears to encompass conditions inside the cockpit as well as outside. There are no definitive criteria to determine how effectively a pilot maintains a proper lookout. It may be argued that previous military training in lookout doctrine and scanninq techniques, coupled with years of flying experience, would result in excellent time-sharing for responsibilities inside and outside. However, it is equally true that years of experience without constant review and improvement would result in establishment and reinforcement of im~roper habit patterns. overcoming such a behavioral pattern, which involves no conscious process, would require a concerted retraining program with periodic recurrent trainings The Board believes it significant that there is no indication that the crew of RW706 ever sa~ BuNo458 under these circumstancesG The Board, therefore, reiterates the position taken many times before that for certain

- 25 - operational conditions, the "see and avoid" concept is simply inadequate and the development of collision avoidance systems must be vigorously pursued. Whereas this accident resulted from high closure rates andQ consequently, small target size until shortly before the collision, the Board also recognizes the more common type of midair collision occurring between aircraft at relatively low closure rates. The Board believes that for this latter type of collision, the detectability and assessment of the collision threat from an intruding aircraft can be enhanced by proper pilot techniques and a more thorough understanding of visual phenomena. The Safety Eoard•s publications _!1/ related to midair collisions between aircraft in visual meteorological conditions have stressed the need for increased pilot vigilancec Recommendations have been sent to the FAA, the air carriers, commercial operators, pilot associations, and the many aviation-oriented interest groups to increase the awareness of pilots to the midair-collision threat. It is therefore gratifying to see that many ox the professional ~ublications and meetings of these organizations are focusing on the many facets of this problem. Similarly, a terminal control area has been implemented in the Los Angeles area, since the accidente This action is a positive step toward reducing the threat of midair collisions, but the Board believes the conce~t would not prevent the recurrence of this accidenta Esta~lishment of climb and descent corridors, as previously recommended by the Board would tend to eliminate this type of accident~ 2 .. 2 Conclusions (aa Findings 1. Both aircraft were airworthyo 2G All f lightcrew members were qualif iedo 3o RW706 was operatinq in accordance with an IFR flight plan under radar control of the Los Angeles ARTCC .. 4o BuNo458 was operating in accordance with a VFR flight plan and was not under control

- 26 - of the ATC system. 5. The air traffic controllers were qualified for their assigned duties. 6. BuNo458 was not detected on radar because of an inoperative transponder, the aircraft radar cross-section, and a low level temperature inversion in the area. 1. There was no restriction to in flight visibility in the area of the accident. 8. The pilot of BuNo458 exercised ~ocr judgment in performing an aileron roll, but the roll did not contribute to the accident. 9. The pilot of BuNo458 attempted to· eject from ~he aircraft, but he was unable tc do so because the forward canopy did not jettiscn.

1. If BuNo458 had requested radar traffic advisories,

the controller could have advised RW706 of the presence of BuNo458 and the probatility of avoiding the collision would have increased significantly. 11. USMC flightcrews receive training in lookout doctrine and scanning technique. 12. No formal training or evaluation of crew scanning technique and lookout doctrine is accomplished by Air West. 13. Both aircraft were theoretically cf sufficient size to permit detection by each other at 35 seconds prior to collision. However, detection and assessment were probably compromised by target size due to high closure rate, target contrast and location in the peri~heral visual field, and other visual limitations. 14e At 35 seconds before impact, both aircraft were on an essentially constant relative bearing and would have been difficult to detect because each target would be near the minimum detectable size and would remain relatively

- 27 - stationary. 15. In view of the absence of evasive action on the part of RW706 (i.e., no alteration of heading, climb profile or airs~eed) it is logical to conclude that the crew did not sight BuNo458 in time to initiate such evasive action. 16. The pilot of the F-4B probably first observed the target of the DC-9 at about 8 to 10 seconds prior to collision, devoted the first portion of this brief period to assessing such cues as relative bearing, speed, and climt angle, and initiated a reflex evasive maneuver approxi- mately 2 to 4 seconds prior to the collision. (b) Probable Cause The National Transportation Safety Board determines that the probable cause of this accident was the failure of both crews to see and avoid each other but recognizes that they had only marginal capability to detect, assess, and avoid the collision. Other causal factors include a very high closure rate, comingling of IFR and VFR traffic in an area where the limitation of the ATC system precludes effective separation of such traffic, and failure of the crew of BuNo458 to request radar advisory service, particularly considering the fact that they had an inoperable transponder. 3. RECO~ENDATIONS As a result 0£ this accident the National Transportation Safety Board recommends that the Administrator of the Federal Aviation Administration: 1o Install video tape at all FAA ATC radar displays, both term~nal and en route for use as an investigation tool. (A-72-200) 2 .. Install an open "area" microphone at each terminal and center sector position to record all conversation at the control positions. (A-72-201

1. Establish climb and descent corridors extending

from the top of the TCA's to the base of APC, to remain in

- 28 - effect until the base of APC has been lowered to the top of the TcAas. (A-72-202) 4o Establish more definitive procedures for the guidance of controller personnel in handling Code 7700 aircraft.. (A-72-203) So Review radar performance monitoring procedures to assure that all radar facilities are capable of receiving Code 7700 transponder returnsa (A-72-20q) The National Transportation Safety recommended (A-71-52) that the FAA take action: Board also the following coordinate with the Department of Defense, and, in areas where a large intermix of civil and military traffic exists, develop a program to insure that appropriate graphical depictions of airspace utilization and typical flow patterns are prominently displayed at all airports and operational bases for the benefit of all airspace users. The Federal Aviation Administration responded, in a letter dated November 10, 1971, as follows: "This is in response to your safety recommendation, A-71-52, issued 9 November 1971. "Recommendation number 4 of our Near Midair collision Report of July 1969 is similar to your recommendation .. "As a result of that recommendation we: 1o Developed a new Fart 4 of the Airman's Information Manual in January 1970 (Graphic Notices and Supplemental Information). As graphics are made availatle, they are included in the semiannual Part 4 or are carried in the every 28-day Part 3, witil they can be transferred to Part 4 .. 2. Developed various types of graphic displays of normal IFR and VFR routes.

• 29 -

Developed graphics for the 22 large terminal hubsa Fifteen are published in the AIM, and the remaining seven are in various stages of processing.

Developed graphics for other than large huts including Air Force Bases. Eight are published in the AIM and three are in the final stages of development. Nine of the eleven display Air Force Base activities. "In addition to the above, we have developed a VFR Terminal Area Chart (copy enclosed) which we will be testing and evaluating. This chart of Chicago Area depicts the Terminal Control Area, VFR and IFR routes and military operations at NAS Glenview. The chart is designed for use by pilots and for display at all airports and operational bases. "As you can see, we have expanded upon the original recommen- dation in our Near Midair Collision Report. As a continua- tion of this expansion, we will coordinate furtber with the Department of Defense to incorporate ot~er military bases into the program. "After review of the material we would appreciate any further cerning this matter .. 11 have outlined above, we comments' you may have con- On February 8, 1972, the Safety Board further recom- mended (A-72-12 & 13) that the FAA:

Develop VFR Terminal Area Charts, similar to that prototype portraying the Chicago TCA, for all other TCA 1 s and, if feasible, for other large air traffic hubs a

Initiate a program to publicize the existence of, and the location of, these graphics for prospective users. The program should incorporate, in part, Examograms and, in airmen examinations, questions referring to these graphics. The Federal Aviation Administration concurred with these recommendations in a letter, dated February 15, 1972. Other recommendations (A-71-48 thru 51) were sent to the Department of Defense on November 2, 1971, suggesting the following actions:

Review the low-level excess of

restricted

30 - feasibility of restricting all types of training, which requires airspeeds in the FAR limitations, to designated areas and low-level navigation routes.

Rephrase the wording contained in your altitude/ airspeed limitations, and delineate explicitly those instances wherein airspeeds in excess of the 10,000 feet/250 RIAS limitations are authorized. The Board believes that the exceptions should be limited to the following: "a. Climbs and descents to traffic patterns, authorized and/or designated training areas and low-level navigation routes. "b. Those instances where safety of either crew or aircraft require operations in excess of the limitation.

Explore the feasibility of using the air intercept radar on all military aircraft to provide collision avoidance assistance as an additional aid to the 11see and be seen" concept; and should this prove feasible, institute and establish procedures to use the radar for this pirpose on all flights where its use is not required for more urgent military mission requirements.

Institute a program to provide more publicity to the existence, function, and use of the FAA Radar Advisory service in those instances where VFR flight is required through high-density traffic areas. consideration should be given to making the request for such service a mandatory ~rocedure. 11 The Department of Defense responded, in a letter dated December 2, 1971, as follows: "This letter is in res~onse to the National Transportation Safety Board safety recommendations A-71- 48 thru 51, which you forwarded to Secretary Laird on 9 November 1971. "These recommendations have been referred to the military services for their consideration. I am advised that during their initial review the recommendations

- 31 - were considered sound and would be implemented to the extent feasible. The details of such action are being staffed. The results of this staffing will be the promulgation of specific instructions and guidance to their operating commands. "Thank you for your helpful recommendations which are so important to our mutual interest in achieving the greatest degree of air safety." The safety Board previously made recommendations on the problem of midair collisions in the Board's special accident prevention study "Midair Collisions in u. s. Civil Aviation 1968" which was released in July 1969, and the "Report of Proceedings of the National Transportation Safety Board into the Midair Collision Problem - November 4 through 10, 1969" which was released February 22, 1971. BY THE NATIONAL TRANSPORTATION SAFETY BOARD: /s/ JOHN H. REED Chairman /s/ FRANCIS H· McADAMS Member /s/ ISABEL A. BURGESS Member /s/ WILLIAM R. HALEY Member LOUIS M. THAYER, Member, was absent, not voting. September 22, 1972

- 32 - FOOTNOTES j/ All times herein are Pacific daylight, based on the 24- hour clock. 2/ Airspace within which all traffic is under positive control, and all aircraft must operate in accordance with Instrument Flight Rules (IFR). At the time of the accident, the positive control began at Flight Level 240. 3/ A collocated very bigh frequency omnirange and ultrahigh frequency tactical air navigational aid. The DME feature gives a slant range measurement to the facility. 4/ A controller qualified in the type of work being done, i.e •• radar, data, tower, etc., but who is not checked out in the specific position of a facility, i.e •• R-18, D-18, etc. 5/ MTI is a feature of the display which tends to eliminate returns from stationary targets. It is infinitely adjustable within the range capability of the radarscope, and has six preselected levels of signal attenuation available. 6/ PRF was designed to virtually eliminate any blind speed effect which could occur when targets are traveling tangent to the antenna, within the range of the MTI selection. Such targets would otherwise not appear on the radarscope due to apparent lack of motion. 7/ code 7700 is a universally used emergency code for transponders. j!/ Guard channel is the international emergency frequency. It is 121.5 MHz for very high frequency (VHF) communi- cations. ~/ A study of Requirements for a pilot Warning Instrument for Visual Airborne Collision Avoidance, Sperry Gyroscope Company, Great Neck, Long Island, December 1963; and Vision In Military Aviation, J.W. Wulfeck, et al., WADC Technical Report 58-399, November 1958, Wright Air Developm~nt Command, Wright-Patterson AFB, Ohio.

- 33 - .lQ/ Foveal vision takes place within 20° of the center portion (fovea) of the eye. Peripheral vision occurs outside this 200 cone of foveal vision • ..11/ FAR 91.67 states in part: "When weather conditions permit, regardl.ess of whether an operation is conducted under Instrument Flight Rules or Visual Flight Rules, vigilance shall be maintained by each person operating an aircraft so as to see and avoid other aircraft in compliance with this section. When a rule of this section gives another aircraft the right of way, he shall give way to that aircraft and may not pass over, under, or ahead of it, unless well clear." FAR 91.67(c) provides that: 11When aircraft of the same category are converging at approximately the same altitude ••• the aircraft to the other's right has the right of way •••• 11 12/ Midair Collisions in u.s. Civil Aviation-196~; Aircraft Accident Report NTSB-AAR-69-2; Aircraft Accident Report NTSE-AAR-69-4; Aircraft Accident Report NTSE-AAR-70-15; and Report of Proceedings into the Midair Collision Problem NTSE-AAS-70-2.

- 34 - APPENDIX A INVESTIGATION AND HEARING 1. Investigation The Board received notification of the accident at ap~roximately 1830 on June 6, 1971, from the Federal Aviation Administration. An investigating team was immediately dispatched to the scene of the accident. working groups were established for Operations Air Traffic Control, Witnesses, Weather, Buman Factors, Structures, Powerplants, Systems, and Flight Recorder. In addition the maintenance records for each aircraft were reviewed. The Federal Aviation Administration, Department of Navy, Hughes Air West, McDonnell-Douglas corporation, and Air Line Pilots Association all participated in the investigation as interested parties. The on-scene investigation was completed on June 19, 1971. 2. Hearing A public hearing was held at Pasadena, California, on July 27 to July 30, 1971. Parties to the Hearing included the Federal Aviaticn Administration, Department of Navy, Hughes Air west, McDonnell-Douglas corporation, Air Line Filots Association and Aircraft owners and Pilots Association. 3. Reports A preliminary factual report of the investigation was released by the Board on July 26, 1971. A summary of the testimony was issued on August 20, 1971.

- 35 - APPENDIX B Crew Information Captain Theodore Nicolay, aged SO, held airline transport pilot certificate No. 474317, with ratings in airplane multiengine land, F-27, DC-3, and DC-9. Be had accumulated 15,490 total flying hours, including 2,562 hours in the DC-9. Be completed his last ~rof iciency check on March 8, 1971, and his FAA first-class medical certificate was issued on January 25, 1971, with no limitations. First Officer Price Bruner, aged 49, held airline transport pilot certificate No. 611777, with ratings in airplane multiengine land, F-27/227, DC-3, DC-9 and commercial privileges in airplane single-engine land. Be had accumulated 17,128 total flying hours, including 272 hours in the DC-9. He completed his last ~roficiency check on December 7, 1970, and his FAA first-class medical certificate was issued on December 18, 1970, with no limitations .. The f lightcrew members had been on duty ap~roximately 6 hours, including about 1 hour 50 minutes f ligbt time, when the accident occurred. Their rest period prior to reporting for duty was 18 hours 13 minutes. Hostess Joan R. Puylaar, aged 34, was hired on August 22, 1959. Hostess Particia Shelton, aged 28, was hired on October 18, 1963. Hostess Helena Koskimies, aged 30, was hired on October 16, 1967. All cabin crewmembers completed their emerqency recurrent training in September 1970. prescribed First Lieutenant James R. Phillips, aged 27, held commercial pilot certificate No. 1619834, with ratings in airplane single- and multiengine land. He also held a valid flight instructor certificate. Be had accumulated 440 total

- 36 - military flying hours, including 170 hours in the F-4B. He also had accumulated approximately 400 hours in civil aircraft. He completed his last Naval Air Training and Operating Procedures Standardizations Programs (NATOPS) flight check on December 8, 1970, possessed a Standard Instrument card, and passed bis annual medical examination on June 23, 1970, with no limitations. First Lieutenant Christopher E. SChiess, aged 24, joined the u. s. Marine corps on November 7, 1969, and completed his RIO training January 3, 1971. He had accumulated 195 total flying hours, including 89 hours in the F-4B. He was current on all prescribed training and passed his annual medical examination on July 13, 1970. Both crewmembers had been on duty approximately 1 hours 4 minutes, including 1 hour 53 minutes flying time at the time of the accident. Their rest period prior to reporting for this flight was 19 hours 10 minutes.

- 37 - APPENDIX C Aircraft Information N9345, a McDonnell-Douglas DC-9-31, serial No. 47441, was owned by the C.I.T. Corporation, 650 Madison Avenue, New York, New York, 10020, and operated by Hughes Air West, San Francisco International Airport, San Francisco, California, 94128. It had been flown a total of 5,542 hours at the time of the accident. A review of the records indicated that all applicable Airworthiness Directives either had teen complied with or were scheduled for completion. Pratt & Whitney JT8D-7 engines were installed as follows: Position 1 2 serial Number P65704-D P654152-B/D Time Since overhaul 5265.69 2263.06 The aircraft weighed 86,518 pounds at engine start and the center of gravity was 21 percent MAC. Both are within the allowable limits. Bureau Number 151458, a McDonnell-Douglas F-4B, was received on April 15, 1964, and had been operated by various squadrons of the u. s. Marine Corps. At the time of the accident, it was assigned to VMFA-323, and had teen flown a total of approximately 2,03-0 hours. A review of the records indicated that the aircra~ was maintained in accordance with the appropriate regulations. General Electric J79-8 engines were installed as follows: Position serial Number 401437 421669 Time Since overhaul 842.5 258.8

- 38 - The aircraft weighed approximately 43,310 pounds at engine start. Both the takeoff weight and center of gravity were within prescribed limits.

0 (' ( -1 /y ICONT T LOS -.NGELES .-,ppffoACH CO TROL ON IH f OR 16f.O 1! ~? ~~ -·-f .~ LOS ANGELES

PRIOR TO EVASIVE IMNEUVER DC-9-31 F-48 39° IMG 145' IMG 400K TAS 42DK TAS I FLT. RECORDER ) IR I 0 TEST! MONYI SUN POSITION WAS 14'N OF TRUE WEST AN.D. 20' ABOVE THE HORIZON ~ COMPUTED RANGES, BEARINGS, AND CLOSURE RATES TRUE NORTH ~------------------4.JSNM--------------------J DC-9 FLIGHT PATH---- ATTACHMENT 2 420K TAS NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. IWGHES AB! WEST DOUGIAS DC-9-31. N9345 U.S. MARINE CORPS F-411, BUNO 151458 MmAIR COWSIJN NEAR DUARTE, CALIFORNIA IJNE 6, 1971

CAPTAIN'S SIDE WINDOW ~ ..... CAPTAIN'S SIDE WINDOW LATERAL VISIBILITY - DEGREES ~"~~~~wgmso I I I I I I I I I I I I I LEFT CAPTAIN'S FRONT WINDSHIELD CO-PILOT'S FRONT WINDSHIELD EB ZERO REFERENCE 10 lS 20 2S 30 3S 40 4S SO SS 60 I I I I I I I I I I I RIGHT CO-PILOT'S SIDE WINDOW F-4 CALCULATED FLIGHT PATH LEFT RIGHT I I I I I I I I I I I I I I I I I I I I I I ~"~~wgms osmgw~~~~"~ LATERAL VISIBILITY - DEGREES · ATTACHMENT 3 DC-9 VISIBILITY FROM CAPTAIN'S DESIGN EYE REFERENCE POINT DC-9 VISIBILITY FROM FIRST OFFICER'S DESIGN EYE REFERENCE POINT NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON D.C. HUGHES AIR WEST DOUGLAS DC-9-31, N9345 U.S. MARINE CORPS F-48, BUNO 151458 MIDAIR COLLISION NEAR DUARTE, CALIFORNIA JUNE 6, 1971 :-~·.71

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-25-

-30- 20- V> LU LU 15- "" D.. <..? 10- > LU Cl 5- ~ 0- :J - 5- ;; Vi -10- ~ -15- ~ 6 -20- g ~ -25- LU > -30- CAPTAIN'S SIDE WINDOW LATERAL VISIBILITY - C 60 55 50 45 40 35 30 25 20 15 10 I I I I I I I I I I I LEFT 0 I EB ZERO REFERENCE CAPTAIN'S FRONT WINDSHIELD CO-PILOT'S FRONT WINDSHIELD EB ZERO REFERENCE 10 I F-4 CALCULATED FLIGHT PATH LEFT I I I I I I I I I I I I 60 55 50 45 40 35 30 25 20 15 10 0 10 LATERAL VISIBILITY - C

CLEAR AREAS REPRESENT BINOCULAR VISION SHADED AREAS REPRESENT MONOCULAR VISION ONLY 40 SEC PRIOR TO COLLISION LEFT RIGHT o: 130 120 110 100 90 80 7o 60 50 40 30 20 10 o 10 20 30 40 50 60 7o 80 90 100· 110 120 130 140 I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I LATERAL VISIBILITY - DEGREES VISIBILITY IS COMPLETELY OBSCURED 130 120 110 100 90 I I I I I I I I I I ZERO REFERENCE LEFT 80 70 60 50 40 30 20 10 0 10 20 I I I I I I I I I I I I I I I I I I I I I LATERAL VISIBILITY - DEGREES 40 SEC PRIOR TO COLLISION RIGHT 30 40 50 60 70 80 90 100 110 120 130 140 I I I I I I I I I I I I I I I I I I I I I I I I ATTACHMENT 4 F-4B VISIBILITY FROM PILOT'S DESIGN EYE REFERENCE POINT F-4B VISIBILITY FROM RIO'S DESIGN EYE REFERENCE· POINT NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. HUGHES AIR WEST DOUGLAS DC-9-31, N9345 U.S. MARINE CORPS F-48, BUNO 151458 MIDAIR COLLISION NEAR DUARTE, CALIFORNIA JUNE 6, 1971

30>-- "' 25>- "' ~ 20t- ~ ~·1si- lOr- ~ 5>- ::; -0>- ;; v; --5

z--10

6 ~ --15 ~ 0 --20· ~ --25 --30 30>- "' 25- "' "' 20>- "' ~ ~ 15f- ' 10- ~ s- ; -0'- ;; v; --5

.... z --10 lS ~ --15 ;:: 0 ffi --20

--25 --30 II CLEAR AREAS REPRESENT BINOCULAR VISION SHADED AREAS REPRESENT MONOCULAR VISION ONLY LEFT 140: 130 120 110 100 90 00 7o 60 50 40 30 20 10 o 10 20 30 40 50 I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I LATERAL VISIBILITY - DEGREES VISIBILITY IS COMPLETELY OBSCURED 140 130 120 110 100 90 I I II I I I I I I II LEFT 80 70 I I I I ZERO REFERENCE 60 50 40 30 20 10 0 10 20 30 40 50 I I I I I I I I I I I I I I I I I I I I I I I LATERAL VISIBILITY - DEGREES

FD06893 ｜ 1975_美国_HAR7502.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1975 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

1111111111111111111111111111 PB241 574 Information is our business. SERIES OF MULTIVEHICLE COLLISIONS AND FIRES UNDER LIMITED VISIBILITY CONDITIONS, NEW JERSEY TURNPIKE, GATE 15 AND U.S. ROUTE 46, OCTOBER 23-24, 1973 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. MAR 75 u.s. DEPARTMENT OFCOMMERCE National Technical Information Service

TECHNICAL REPonT STANDARD TITLE PAGE

1. Report No.

I 2.Government Accession No. 3.Re/> "It's Catalog No. NTSB-HAR-75-2 5.Repo, ~ .

1. Author{s)

a.Performing OrganiL. Report No. 9. Performing Organization Name and Address IO.Work Unit No. National Transportation Safety Board 1448-B Bureau of Surface Transportation Safety II.Contract or Grant No. Washington, D. C. 20594 13.Type of Report and Period Covered 12.Sponsoring Agency Name and Address Highway Accident Report Oelober 23/24, 1973 NATIONAL TRANSPORTATION SAFETY BOARD Washington, D. C. 20591

1. Sponsori ng Agency Code
2. Supplementary Notes

This report contains Highway Safety Recommendations No. H-75-3 through H-75-8. 16.Abstract This report describes and analyzes the situation that existed before, and during, the series of multivehicle collisions which occurred under fog and smoke conditions on a high-speed, limited-access highway--the New Jersey Turn- pike--during the late hours of October 23 and early morning of October 24, 1973. In that period, nine multivehicle collisions occurred, eight under limited-visibility conditions which were caused by smoke from burning material on an abandoned garbage dump in the Hackensack Meadowlands and fog which was a result of con- ducive environrnental conditions. Sixty-six motor vehicles were,involved, nine persons were killed, and 39 others were injured. The National Transportation Safety Board determines that the probable cause of this series of multivehicle collisions was the penetration of vehicles into areas of severely reduced visibility due to fog and smoke, the latter occasioned by fires adjacent to the turnpike which had not been promptly extinguished. The delay in closing the affected roadways by the New Jersey State Police contributed to the number of accidents. This re!:,ort contains recommendations to the New Jersey State Police, New Jersey Turnpike Authority, U. S. Enviromnental Agency, and the New Jersey Department of Environmental Protection, which are intended to prevent the recurrence of an accident of this type. PRICES SUBJECT TOOlANGf 17.Key Words fE.Distribution Statement New Jersey Turnpike, Multivehicle Collis ions, This document is available Hackensack Meadowlands, Abandoned Garbage to the public through the Dump Fires, Fog, Police Procedures Under Limited National Technical Informa Visibility Conditions, E.P.A., N.J. Department of tion Service, Springfield, Environmental Protection Virginia 22151 19.5ecurity Classification 20.Security Classification 21.No. of Pages 22.Price (of this report) (of this page) ~7 '#

f

C;' UNCLASSIFI ED UNCLASSIFIED ,?,T) '},;). NTSB Form 1765.2 (11/70)

NATIONAL TRANSPORTATION SAFETY BOARD Washington, D.C. 20594 PB 241 574

• ---- ------.

SS·H·33 H'IGHWAY ACCIDENT REPORT SERIES OF MULTIVEHICLE COLLISIONS AND FIRES UNDER LIMITED VISIBILITY CONDITIONS, NEW JERSEY TURNPIKE, GATE 15 AND U.S. ROUTE 46, OCTOBER 23 AND 24, 1973 ADO PTED: MARC H 5, 1975

ERR A T A

Make the following changes in the subject report: Page 4, paragraph 5, line 7: Change pave to paved. Page 7, paragraph 4, line 4: Change troppers to troopers. Page 13, paragraph 2, line 7: Change are to ~. Page 14, first full paragraph, line 9: Change ~ to~. Page 14, paragraph 2, first line: Change NSW to SNW. Page 14, paragraph 2, line 5: May 5, 1975 Change NSW to SNW. REPORT NUMBER: NTSB·HAR·75·2 .. II Roproduced by NATIONAL TECHNICAL INFORMATION SERVICE US DeplItlrnonl of Commorce Springfield, VA. 22151

FOREWORD The accident described in this report has been designated a major accident by the National Transportation Safety Board under the criteria established by the Safety Board's regulations. The report is based on facts obtained from an investigation and public hearing conducted by the Safety Board. Assisting in the inve stigation we re the New Jer sey Turnpike Authority, the New Jersey State Police, the New Jersey Department of Environmental Protection, the Hackensac k Mea dowlands Development Commis sion, the Town of Lyndhurst, Radio Station WOR, and the U. S. Environ- mental Protection Agency. The public hearing was conducted in New Brunswick, New Jersey, on December 11, 12, 13, and 14, 1973. The conclusions, the dete rmination of pro ba ble cause, and the recommendations herein are tho se of the Safety Boa rd.

• iii -

TABLE OF CONTENTS Page SYNOPSIS 1 FACTS.. .. . .. . . . . 2 The Accidents 2 Accident Site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2 Environmental Factor s . . . . . . • • . . . . . . • . • . • • . . . . • . . . . . . . . . . 6 Police Traffic Supervision. . . . .. . .. . .. . .. . .. . .. . . . . . . . . . . . . .. 8 Operating Procedures Under Limited- Visibility Conditions. . .. 8 Chronology of Events .......... ...........•..•............. 10 Activities of Turnpike Maintenance Personnel 10 Rescue and Emergency Services. . . . . . . . . . . . . • . . . . . . . . . . . .. 10 ANALYSIS ................•...........••..................... 11 Significance of Driver Behavior .•.......................... 15 Weather. . . . 16 Prevention and Control of Sanitary Landfill Fires. . . . . . . . . . .. 17 C ONC L USIONS 17 PROBABLE CAUSE .•...........•....•....•....••.......•..... 20 RECOMMENDA TIONS ...........•...........•.....•....•....... 20 APPENDICES: Appendix A: Chronology of Events. . • . . • . .. . . . . . . . . • . • . . . .. 23 Appendix B: History of the Fire Area 28 Appendix C: Chronology of the Fires and Firefighting Efforts ..•..•...........•...•.•....•........ 30 Appendix D: The New Jersey Turnpike Authority Automatic Traffic Control and Surveillance System. . . . . • . . . . . . . . . . . . . . . . . . .. 35 Appendix E: Safety Recommendation to New Jersey State Police .. .. . .. . . . . . . . . . . . . • . . . . . . . . . . • . .. 38 Appendix F: Applicable Sections of the Emergency Fog Procedures (New Jersey State Police - Troop D) . . . . . • . . • . . . . . . • . . • • . • • • . . . . . . . . . . ..

40

iv -

-.:1- NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D. C. 20594 HIGHWAY ACCIDENT REPORT Adopted: March 5, 1975 SERIES OF MULTIVEHICLE COLLISIONS AND FIRES UNDER LIMITED VISIBILITY CONDIT IONS, NEW JERSEY TURNPIKE, GATE 15 and U. S. ROUTE 46, OCTOBER 23 AND 24, 1973 SYNOPSIS At 11 :20 p. m., e. d. s. t., October 23, 1973, on the northern section of the New Jersey Turnpike, between Gate 15 and U. S. Route 46, the first of a series of nine collisions occurred. Eight accidents followed between that time and 2 :45 a. m., October 24, 1973. The latter collisions occurred under limited visibility conditions. The conditions were caused by a combination of smoke from burning material in an abandoned garbage dump in the Hackensack Meadowlands and fog. Although respons ible officials were aware of the hazardous con- ditions before the collisions, precautions to assure the safety of the motorists did not prevent the series of accidents. At 12:45 a. m., officials began to clos e affected areas of the Turnpike. By 3: 04 a. m. on October 24, 1973, the areas were closed. During that time, eight people were killed in six collisions. In all, 66 motor vehicles were involved; 9 persons were killed, and 39 others were injured. The National Transportation Safety Board determines that the probable cause of this series of mulcivehicle collisions was the penetration of vehicles into areas of severely reduced visibility due to fog and smoke, the latter occasioned by fires adjacent to the turnpike which had not been promptly extinguished. The delay in closing the affected roadways by the New Jersey State Police contributed to the number of accidents.

• 2 -

FACTS The Accidents On October 14, 1973, through October 30, 1973, open fires burned on the Hackensack Meadowlands adjacent to the westerly route of the New J ers ey Turnpike between mileposcs 111 and 112. Between 11 :20 p. m. e. d. s. t., October 23, and 2:45 a. m., October 24, 1973, nine multiple-vehicle collisions occurred on the easterly and westerly routes of the Turnpike between Gate 15 and U. S. Route 46. (See Figure 1.) At 11 :20 p. m., the first accident occurred in the southbound lanes of the westerly route at milepost 114 + 30. Between 12:15 a. m. and 1:55 a. m., five accidents occurred in the northbound lanes of the westerly route, between mileposts 110 + 27 and III + 8. At 2:45 a. m. , the seventh accident occurred in the southbound lanes of the easterly route at 111ilepost 110 + 24, and at 2:45 a. m., the eighth and ninth accidents occurred in the northbound lane of the easterly route, at mileposts 110 + 17 and 110 + 18, respectively. The last eight accidents occurred during limited-visibility conditions. These nine accidents involved 47 trucks, 18 automobiles, and 1 bus. Several of the vehicles were dest royed, and the remaining were damaged in varying degrees. In accident No.6 a tractor-tank trailer unit, which was carrying: a cargo of asphalt, caught fire. At the Safety Board's public hearing, the State Police suggested that SOlne vehicles entered the roadways at excessive speeds. The in- vestigative reports furnished to the Safety Board by the State Police, however, do noc mention speeds. During the 9 separate accidents, 9 persons were killed, and 39 were injured. The Turnpike in the affected areas was closed to traffic for about 8 hours after the last accident. Accident Site The sections of the New Jersey Turnpike, on which all the acci- dents occurred, are located within the Hackensack Meadowlands District. The district is administered by the Hackensack Meadowlands Development Commission. The district is composed of largely unde- veloped salt meadows and marshes. The land area is about 19,730 acres and extends throuf!h 14 northern New Jersey plunicipalities in Bergen and Hudson Counties. ,. ., ~ Not To Scale VJ lID CLIFFSIDE PARK

I

- (17) ; APProx. L5mi. UNION CITY 9- W CD D03-73-768A 10/24;73-154A TRP. J. MUIR 110+35 SNW I-CAR-2 TRUCKS 1-DEAD O-INJ. D03-73-762A ./.._-':)f.; 10/24;73 - 1:54 AM 0 === ~ CD TPR. R. PLACE ~ D03-73-765A ""'~ 111+3 SNW ~R;"'!'-10/24;73-12:15AM 3-CARS B-TRUCKS // TRP. J. MUIR "'" O-DEADI-INJ. ~ CD 1l1+10SNW ~ D03-73-769A 2-TRUCKS o-DEAD " ••" 10/24;73 -2:45 AM I-INJ. ~ TRP. N. O'RIOLO 1l0+24NSE f9\ ~ !1-CAR3-TRUCKS I-BUS SECAUCUS .V If. //~ ;-;... O-DEAD IS-INJ. D03-73-77IA "~ W7 I t \f ~ E~ 10;24;73 - 2:45 AM W TRP.W.POST ~~ ,~.. £> ~.< 110+17SNE 1,'f}E 6f, ~ "4-E

2-CARS 1-TRUCK D03-73-770A ,,'- 2-DEAD O-INJ. 10/24;73 _ 2:45 AM TRP _R. POLAK 110+19SNE CD t--- NORTH BERGEN OJ ~oc~ 0 9 ,_O-DEAD 3-INJ. ~ NEW JERSEY TURNPIKE GATE 15E TO U.S. ROUTE 46 SERIES OF MULTIPLE VEHICLE COLLISIONS, OCTOBER 23/24,1973 1 'V JERSEY CITY CD D03-73-764A 10/24;73 - 1:55AM TRP. R. WEGRZYNER KEARNY 110 + 27 SNW 7-CARS 20TRUCKS 5-DEAD Ia-INJ ... Figure 1. Accident sites and collision data.

4 - The Fire Area. -- The fires from October 14 through October 30, were primarily burning on an old abandoned garbage dump. The area involved, about 100 acres, is located adjacent to the Turnpike, between mileposts 111 and 112NSW. Three parties jointly own the property: The City of Lyndhurst, Radio Station WOR, and a private party, Anthony Desiderio. The only structures are radio towers and a transmitter building, which are located on the WOR property. On October 14, extinguish the fires. mostly underground. the Lyndhurst Fire Department attempted to The following day about 100 acres were burning, During the 8 days immediately preceding the accidents, the fires burned at varying degrees of intensity. Attem?ts to extinguish the burn- ing refuse were sporadic and unsuccessful. The fires were still smolder- ing on October 23, 1973, and smoke was seen rising about the Meadowlands. In the 7 days following the accidents, firefighting efforts were accelerated. Additional manpower and equipment arrived on scene and the fires were contained by October 30. New Jersey Turnpike. -- The series of accidents occurred on road- ways (Gates 15 through 16) which are heavily traveled thoroughfares. (See Figure 1.) On October 23, 1973, the traffic volume was about 55, 000 vehicle s. Each leg, ea sterly and westerly, from milepost 105 to 116, includes a northbound and a southbound roadway. Each roadway consists of three l2-foot lanes. The lanes are bordered on each side by l2-foot pave shoulders and separated by a double - band, W - section steel guard- rail. A single W -section guardrail is located on the right edge of each road. The roadways are generally level and the curvature is relatively flat. The roadways near the fire and on which five of the accidents :Jccurred are elevated 10 feet above the surrounding meadowlands. There is no artificial illumination. Traffic controls consist of lane markings, delineators, and elec- tronically controlled hazard-warning and speed-limit signs. The New Jersey Turnpike Authority maintains an electronically ::ontrolled system of hazard-warning and speed-limit signs to advise notorists of adverse conditions and speed limits appropriate for those ::onditions. The hazard-warning sign can be activated to display in

5 - red neon any of the following: I'Drive Slow, II "Snow, " "Ice, " "Fog, " or "Accident Ahead." The variable speed-limit signs display the normal speed limit of 60 mph in red neon and can be set from 60 mph to 30 mph in decrements of 5. There is a combination of hazard-warning and speed-limit signs within 1 mile of the entrance to the Turnpike, with a maximum spacing of one sign every 5 miles. There are 75 hazard-warning signs and 80 speed-limit signs on the Turnpike system. The signs are triggered by a tone-coded radio signal from New Brunswick and are activated and deactivated at the request of the New Jersey State Police, who patrol the Turnpike. At 11:08 p. m., October 23, a State Police patrol unit reported heavy fog on the westerly route and requested that the speed limit be reduced to 45 mph for the llwhole area. II The speed limit at mileposts 109.lSNW, 114.lSNW, and 112. 5SNW was reduced from 60 to 45 mph. The hazard-warning signs at mileposts 109.1 read llDrive Slow Ahead- Fog, If at milepost 114.1, llFog, II and at milepost 112.5, llDrive Slow Ahead." At milepost 115. 8NSW, the sign was not fully operational, and its message remained "60 mph, II throughout the night. On October 24, the remaining signs were activated in the following sequence: Time 0024 0025 0034 0225 0255 0225 0256 0257 0257 0323 Sign Location 107.2 SNW

• I SNW
• I SNW

1. 4 NSI
2. 4 NSO
3. 4 SNI
4. 4 SNO
5. 4 NSI
6. 4 NSO
7. 2 SNI 8 NSO

Message 45 MPH - DSA l..l - Fog - Accident 45 MPH - DSA - Fog -- Accident 35 MPH - DSA - Fog - Accident 45 MPH - DSA - Accident 45 MPH - DSA - Accident 35 MPH - DSA - Accident 35 MPH - DSA - Accident Returned to 60 MPH Returne d to 60 MPH 35 MPH - DSA 1/ DSA means "Drive Slow Ahead. " Because of construction activity, the easterly leg of the Turnpike in the vicinity of milepost 107 had been posted for 45 mph by both electronic speed advisory and illuminated placards. At 1:59 a. m., the ~gn at 113SNE was activated to read "45, DSA - Fog, " 6 - All vehicles that entered into areas of reduced visibility, except those that entered at Gate 15E and 16E, first passed at least one of the above hazard-warning signs. Fog Accident History.

• Turnpike records for 1969 through

October 22, 1973, indicate 70 fog-related traffic accidents. Eight were between Gates 15 and Route 46. Six persons were injured during the eight accidents. During the 70 accidents, 8 persons were killed and 92 were injured. Closings.

• Turnpike records from 1969 through 1973 re veal

that reductions in speed caused by limited visibility were not uncommon. However, records indicated that fog-related closings of the Turnpike were rare. In 1969, the Turnpike was closed once, and in 1970, the Turnpike was closed twice. Environmental Factors When the accidents occurred, there was a large, high-pressure area over the Middle Atlantic States with the east-west axis of the ridge located over central New Jersey. Teterboro Airport, about 5 miles northeast of the accident area, reported that smoke was ;restricting visibility on October 23, 1973, and most of the next day. The reports indicated that, at times, smoke combined with ground fog or haze. Early on October 23, a pilot re- ported that the top of the ground fog and smoke as 1,100 feet, and noted that smoke was emanating from large swamp fires south of Teterboro. By midnight, the surface visibility at Teterboro was restricted to 1/2 mile by ground fog and smoke and was 1/2 to 3/4 mile through 5:50 a. m. on October 24. At Newark Airport, about 6 1/2 miles southwest of the accident area, haze and smoke, and ground fog and smoke were reported early on October 23, and smoke was again reported after 9:53 p.m. On October 24, similar conditions were reported. The visibility diminished to 1 1/2 miles by 5:24 a. m. and to 0 by 6:07 a. m. The October 23, 7:15 p. m. upper air observation was taken at Fort Totten, New York, a bout 16 1/2 mile s from the accident area. 7 - The observation showed an inversion layer l../ extending from the surface to l, 059 mean sea level (msl). On October 24, at 7: 15 a. m., the Fort Totten observation revealed a surface-based inversion layer with its top at 1,755 msl. These reports were not received by either Turnpike officials or the State Police. The New Jersey Turnpike Authority receives weather forecasts from a private weather forecasting service, the Northeast Weather Service, at 7 a. m. and 3 :30 p. m. daily. During adverse weather conditions, forecasts were received every 4 hours. On October 23, at 3:15 a. m. and 5:40 a. m., the central control dispatcher for the New Jersey Turnpike Authority received forecasts of fog with visibilities ranging from 1/8 mile to O. At 3:30 p. m., a fog alert was received. The alert indicated a chance of patchy fog after midnight with visibility between 2 and 4 miles in haze and smoke, and 1/8 mile in the fog patches. The alert was distributed to the Director of Traffic Engineering, Maintenance and Toll Collection, the Commander of Troop D, and other involved persons, all of whom are located within Authority Headquarters. A summary of the alert was transmitted by teleprinter to Troop D stations and to maintenance districts throughout the Turnpike system. The summary read as follows: "Fog Alert. Fair to partly cloudy tonight, chance of patchy fog after midnight, dissipating early Wednesday morning. Partly cloudy Wednesday. Then mostly fair Wednesday night and Thursday. " Weather forecasts were received in headquarters at 3:30 and 7:30 p. m., and the contents were identical. There is no record to indicate that the 7:30 forecast was transmitted throughout the system. There we re no written instructions to insure that all troppe rs in the field were routinely made aware of the forecast. 1/ A layer in the atmosphere in which the temperature increases with height as opposed to the normal decrease of temperature with height. The base of the inversion is that point where the temperature begins to increase, and the top is that point where the temperature begins to decrease. Such a layer is characterized by stable, nonturbulent conditions. The top of the inver sion acts as a cap or lid, con- taining below it pollutants such as dust, haze and smoke, or fog which may have developed.

8 - Police Traffic Supervision Troop D of the New Jersey State Police is responsible for the full range of police functions on the 117 miles of the Turnpike. These responsibilities include traffic control and direction, traffic law en- forcement, accident investigation, and general services to motorists. Manpower allocations to perform those functions are arrived at by mutual agreement between the State Police and the New Jersey Turn- pike Authority. Newark Station. -- Newark station of Troop D is responsible for a patrol area which extends from Gate 14 to U. S. 46, on both the westerly and easterly routes--13. 5 miles in each direction. Before May 1973, the area was normally patrolled by six one-man patrol units. After that date, because of personnel security, the six one-man units were changed to three two-man units during certain hours. On October 23, the evening shift consisted of eight one-man patrol units and a sergeant. Three of the units were scheduled for duty until 11 p. m. During the following shift, Shift 3, three two-man patrol units, under the supervision of a sergeant, were assigned to patrol the Turnpike. Special detail patrol personnel (radar teams and investigators) were available to augment the patrol force, if necessary. Operating Procedures Under Limited-Visibility Conditions The State Police employ a Standard Emergency Fog Procedure (see Appendix F) as a guide for action during hazardous fog conditions. It sets forth criteria for activating appropriate hazard-warning signs, for reducing speed limits, and for assigning special-detail patrols. Three fog conditions are defined: Light, medium to heavy, and dense. Visibility range is defined in terms of the number of reflectors (spaced 150 feet apart) a trooper can see ahead when patrolling. On April 13, 1973, the Traffic Engineer for the Turnpike Authority sent a memorandum to the Commanding Officer of Troop D, to the Director of Maintenance, and to Director of Tolls. The memorandum contained an addendum to the fog procedures which was issued as a temporary measure until the new fog procedures could be completed. A section of the addendum read:

9 - "Our present experience shows that both the east and west alignments have equal density of fog. This means that thus far we have not had fog on one alignment and not the other. In view of this, we shall have to close both alignments when fog occurs in the northern end of the Turnpike. " In response to an inquiry from the Safety Board as to the oper- ational status of the addendum, the Turnpike Authority, in a letter dated March 7, 1974, stated: "In answer to your inquiry regarding the significance of the Addendum to Fog Procedure (Exhibit II-C(l)), that memorandum was not a directive to Troop "D" requiring compliance. "The involvement of the New Jersey Turnpike Authority in the operating policies of Troop' D' is limited to the role of providing consultation for the purpose of outlining related operating policies. All final decisions regarding operating policies of Troop I Dr on the Turnpike are made by the Com- mander of Troop' D' and/or the Superintendent of State Police. That memorandum was a directive to the Maintenance and Toll Collection Departments in the event they were requested and required by the State Police to close certain areas of the Turnpike and provide assistance at the locations indicated. " The Safety Board sent a similar inquiry to the State Police. No response was received. In testimony at the public hearing, however, the Deputy Commander of Troop D testified that the addendum was a proposal which had not been adopted by "our office" and was not in effect on the date of the collisions. The Turnpike Maintenance Department utilizes an Emergency Fog Procedure as a guide to allocating personnel and assignments when they are notified by the State Police that adverse fog conditions require that the Turnpike be clo se d. The Maintenance Department's central control dispatcher normally notified the New Brunswick police dispatcher if any of the three fog conditions exist and prescribed oper- ating procedures are then invoked.

10 _ Chronology of Events Based on evidence from police and central control communica- tions tapes and records, statements from the participants, and testi- mony at the public hearing, a detailed chronology of the events as they occurre d between lOp. m., October 23, 1973, and 3:35 a. m., October 24, 1973, is contained in Appendix A. Activities of Turnpike Maintenance Personnel Based on need, the Turnpike Maintenance Department allocates personnel to assist the State Police. DJring adverse fog conditions on the Turnpike, central control (maintenance) is usually notified by the police, and the prescribed operating procedures found in the Emergency Fog Procedure s (maintenance) are activate d. Although on October 23 there was no formal request from the police to activate the fog procedure, central control followed the procedure as necessary. Night maintenance crews were dispatched to assist the police at accident .ites and in the closing of the Turnpike. Management and supervisory personnel were notified of the situation. Additional personnel were called in between 2:30 and 2:50 a. m. to supplement those already on duty. Rescue and Emergency Services Vehicle fires were extinguished by the eight fire units from the City of Newark Fire Department and an undetermined number of units from other communities. Personnel participated in both firefighting and rescue activities. Nine ambulance or rescue units responded to the westerly route. Six units responded to the easterly. A fact-finding com~ittee of the Interagency Commission on Emergency Medical Care (New Jersey) reported, "The victims were treated, handled, and transported to hospitals as efficiently as pos- sible in the circumstances that pre\Tailed. " ?.! 2/ "Report on N.J. Turnpike Disasters, October 23-24, 1973," Interagency Commission on Emergency Medical Care (New Jersey), Hillsdale, New Jersey, December 1973.

11 - ANALYSIS These accidents suggest that certain characteristics of the system in operation on October 23 and 24, 1973, lowered its reli- ability and subsequently its effectiveness. Those characteristics were: (1) The erratic human detection capability and reporting of the reduced highway visibility; (2) the time lags between limited- visibility reports and affirmative police action; and (3) the time- consuming techniques employed to actually stop the flow of traffic on the affected sections of roadway. The following is an analysis of the events as they occurred on October 23 and 24, 1973, and their relationships to the system then in use. Detecting and Reporting Visibility. -- Any system designed to protect motorists against hazardous conditions which are created by changing weather conditions and traffic problems requires continuous observations and continuous reports of those conditions. Visual ranges on the highway must be continuously and accurately detected and evaluated. The system is usually implemented in one of three ways: (1) Individuals in the field report their observations; (2) sophisticated electronic-detection devices are used; or (3) both 1 and 2 are used. The New Jersey Turnpike Authority relied on reports of human observations; police patrol units were used. Over a 14-year period, 51 men were added to Troop D. The Turnpike environment includes not only adverse weather conditions, but also criminal law enforcement. One-man patrol units were discontinued during certain hours, and two-man units were dispatched instead. Unfortunately, manpower was not increased when the two- man units were utilized. As a result, the number of patrol cars and the frequency of patrols over the roadways were reduced. On the night of the accident, the number of patrol cars was reduced for shift 3 from 6 to 3. During the investigation of accident 1 by two of the police units as signed to the northern portion of the Turnpike (Gate 14 to U. S. Route 46), there was only one police patrol vehicle available to patrol both the easterly and westerly align- ments. While the two units were investigating the accident and a

12 - replacement unit from another command was en route (11:30 p. m. - 12: 15 a. m. ), accidents 2 and 3 occurred. The fog and smoke con- dition at the site of accidents 2 and 3, had it been reported by a patrol unit, might have initiated the closing of SNW under the Emer- gency Fog Procedure. Fortunately, fog and other adverse weather conditions can be predicted with reasonable accuracy. Whenever such conditions are forecast or reported, additional manpower should be alerted for recall to patrol duty. The human observation capability must be in- creased before a situation becomes hazardous. Before additional personnel arrive, patrols can be increased by reverting back to one- man patrol units. By doing so, points of patrol would be increased, and the one-man units would be at risk for only a short time. Two- man units can be reformed and operational again when the additional personnel arrive for duty. The New Jersey Turnpike Authority is installing an automatic traffic control and surveillance system. The system will cover 36 miles of roadway in the northern section of the Turnpike and is expected to be in operation at the end of 1975. (See Appendix D. ) Time lag in affirmative police action. -- The human-observation system requires conscientious decisions and prompt actions. The official-in-charge on the scene had the information available to him to make prompt decisions and to implement prompt actions. He had infor- mation sufficient to indicate that visibility on the Turnpike was reduced; he was aware of the guidelines in the Emergency Fog Procedure; and he had been granted permission to recall additional patrols and to close the roadway whenever necessary. Visibility on the westerly route was reported at 11:08 p. m. to be 1/2 delineator. The speed limit signs on the SNW roadway between mileposts 109.1 and 112.5 were actuated to read 45 mph. Accidents 2 and 3 occurred at 12 :15 a. m. at mileposts Ill. 10 and 111SNW under a posted speed of 45 mph. The criterion for the posted speed limit under visibility conditions of 25 - 100 yards in the fog procedure requires a limit of 30 mph in each direction to adequately cover the affected area.

13 - It is also to be noted that the reported visibility of 1/2 delineator is only 75 feet, 'since the delineators are 150 feet apart. Accordingly, the condition was not only at the lowest visibility which would justify as much as 30 mph but was also at the margin for application of Section III in which "consideration" is given to closing. Instead of either of these actions, the posted speed was lowered only to 45 mph. The fog procedure specified 45 mph for visibility of 200-300 yards (5-6 delineators). It is not known how the visibility in the area of mileposts 111 varied during the period between the 45 mph reduction and acci- dents 2 and 3. It pro bably varied both a s to density and length of the obscured area. The procedure, as written ~/ did not permit these to be considered, although they would have an effect on the risk. The number of patrols had already been reduced by the use of two-man patrols after 11 p. m. However, the increased patrols re- quired by the Emergency Fog Procedure for a 45 mph speed limit were not requested until 12: 11 a. m., an hour after the speed limit was reduced and only a few minutes before accidents 2 and 3. (Unit 825, dispatched from New Brunswick a little earlier, was for the purpose of cove ring the are vacated by units to attend the scene of accident 1, and did not provide increased patrol coverage.) It cannot be determined whether a reduction of the speed limit signs from 45 mph to 30 mph would have insured speeds at the acci- dent site s of accidents 2 and 3 which were lower and would have prevented the accidents. Some vehicles continued to operate at high speeds, while others slowed, according to the evidence. The pre- sumption for using the procedure, however, must be that the different speeds are intended to have an effect when displayed. The display of the 45 mph speed instead of the required 30 mph speed permitted all drivers to move at 45 mph, and did not warn those drivers who obey such signs to move at the 30 mph speed which was justified by the poor visibility that had recently existed. The duty officer stated that a decision to close the Turnpike is difficult to make for the following reasons: (1) Traffic must be rerouted to other roadways not as well equipped to handle it as the Turnpike; (2) a large number of people would be inconvenienced; 3/ The Safety Board is aware that the Emergency Fog Procedure has been revised. A copy of the revision was requested by the Board, but not made available due to civil actions presently pending against the New Jersey State Police and the Turnpike Authority.

14 - and (3) the person, or persons, who made the decision could be subject to much criticism. The flow of traffic into affecte d sections of the Turnpike. -- Based on the discussion above, it may be concluded that limited- access roadways endangered by limited visibility must be closed timely and efficiently. To do so is the most effective emergency measure to save lives. Thus, the actual closing of the Turnpike also requires examination. Based on the evidence available, the southerly flow of traffic on the westerly route was blocked by wreckage of accident 1. Traffic entering south of accident 1 was slowed or stopped at mile- post IllNSW because of 0 visibility. Accidents 2 and 3 at 13: 15 a. m. blocked northbound traffic on the westerly route. The order to close the southerly to northwesterly roadway (SNW) at 1:36 a. m., 1 hour 16 minutes later, did not prevent a number of vehicles from moving into the area. Three additional accidents (4, 5, and 6) occurred on the SNW roadway at 1:54 and 1:55 a. m. blocking northbound traffic. According to radio transmis sions between police units and Newark station and central control and maintenance units, the westerly was not secured by Turnpike personnel until some 40 minutes later. The closing of the westerly did not, as would have been required by the addendum to the fog procedures, initiate the closing of the easterly route. Three additional accidents (7, 8, and 9) occurred on that route at 2:45 a. m. A basis for closing NSW existed 54 minutes before the occur- rence of accidents 4, 5, and 6. This basis was the report of 0 visibility at mileposts 112 northwesterly which, according to the fog procedure required consideration of closing. A decision to close NSW at that time would not have required a significant re- routing of traffIc to other roadways off the Turnpike, nor would a large number of people have been inconvenienced. The requirement of the addendum to the fog procedure not implemented would have been that the easterly route be closed at the same time. However, that addendum was not in effect and the potential threat of fog and smoke to the easterly route could have been handled by a directed patrol. It is to be noted also that the words of the Emergency Fog Procedure, Section III (Dense Fog), do not definitively order that the Turnpike be closed when conditions of 0 to 75 feet of visibility

15 - are experienced, or make it entirely clear who in the field has the authority or responsibility to give the direct order for closing. In this case, the State Police had sufficient evidence of a need for closing to request the necessary permission once under the pro- visions of the existing fog procedure, then have it confirmed, but the actual direct order to close was not made until accidents had already occurred in areas of 0 visibility. It is possible that con- ditions which met the closing criteria came and went much faster than closing could be accomplished or reversed. The fog procedure made no mention of what should be done in that situation. A fog procedure with concrete predetermined criteria and authority for immediate closing could be promulgated for, and effectively imple- mented by, field personnel. It is likely that such definitive instruc- tions would eliminate hesitancy in the closing of the Turnpike under conditions of 0 to 75 feet of visibility because of considerations of possible criticism for doing so. It is also possible that conditions which met the closing criteria came and went much faster than closing could be accomplished or reversed. The fog procedure makes no mention what should be done in that situation. Motorists need to be warned explicitly that they are approach- ing hazardous areas. Although signs which read 45 mph and those with the message "fog ahead" obviously warn of a hazard, they do not inform the motorists accurately of the immediacy and serious- ness of the danger. In at least one instance the sign did not reflect the lower speed justified by the fog procedure. If motorists had been advised to exit the roadway as soon as the order to close the SNW roadway was issued, fewer vehicles, if any, would have been involved in the 1:54 and 1:55 a. m. accidents. Significance of Driver Behavior In addition to an adequate warning system at the location of hazard, the public must also be made aware of the need to reduce speed posed by restricted visibility on high-speed, limited-access roadways. The variety of dangers posed has not been systematically solved as yet. General awareness of hazard, however, can be brought about through public and driver education. In addition, the public must be made aware of existing or predicted limited-visibility conditions. This information can be disseminated most readily through the news media. The Safety Board is cognizant of the importance of driver behavior in limited-visibility conditions. Driver behaVior, or

16 - driver error, as it may have affected these collisions, was not different from that found in other limited-visi bility accidents which have been investigated and documented by the Board in two previous accidents 4/ and a special study 'i./. The study included findings that influence driver behavior or error in an environment of limited visibility. Weather The limited visibility at the accident sites was brought about by a combination of smoke and fog in the area and the influence of a temperature inversion on the dispersion of that smoke and fog. Weather data collected for the Middle Atlantic States from two local (New Jersey) airports, from a New York weather station, and from the observations of persons involved in the happenings on October 23 and 24, 1973, were studied. These data indicate that a high-pressure area, which per- sisted from October 18 to October 28, was located over the Middle Atlantic States. The general weather situation created by the high pressure affected New York City, the accident area, southern New Jersey, and western Pennsylvania. The high-pres sure system was conducive to radiation fog. Radiation fog occurs mainly from the cool- ing of the ground on clear and calm nights. Statements from persons at the accident site, substantiate that smoke and fog conditions were prevalent at eight of the accident sites and did in fact affect drivers' visual range. The dispersion of pre- vailing fog and smoke was adversely affected by a temperature inversion. i./ National Transportation Safety Board, Multi-Vehicle Collisions Under Fog Conditions, Followed by Fires, New Jersey Turnpike North of Gate 2, November 29, 1969, NTSB-HAR -71-3. National Transportation Safety Board Interstate Bus -Automobile Collision and Rollover on Indiana Route 57, South of Petersburg, Indiana, November 24, 1969, NTSB-HAR-7l-4. §.../ National Transportation Safety Board, Reduced-Visibility (Fog) Accidents on Limited-Access Highways, NTSB-HSS-72-4.

17 - Prevention and Control of Sanitary Landfill Fires The Safety Board emphasizes the need to manage abandoned and existing landfills to eliminate hazards to public safety- -parti- cularly those near high-speed highways. §../ Although there is little chance of fire at landfills being operated under current guidelines, abandoned dumps, such as the Hackensack Meadowlands site, are susceptible to underground fires. Current guidelines and operating practices adequately provide for fire control, but do not apply to abandoned or closed dumps. ]...1 If the abandoned dumps within the Hackensack Meadowlands remain exposed, the potential for fires will continue. The fires may be reignited by spontaneous combustion, hunters' firearms, children's playing, etc. Should a substantial fire start, it could take days, or even weeks, to assemble sufficient men and machines to fight the fire. Hence, it is possible for the hazardous conditions of October 23 and 24 to recur. CONCLUSIONS 1. The de sign, construction, and maintenance of Turnpike roadways were not factors in this accident. 2. The exact proportions of smoke and fog involved at each area of 0 visibility could not be determined. 3. Before the accidents, sufficient equipment and manpower were not made available to fight the dump fire. After the accidents, such manpower and equipment were made available . .!:. / The U. S. Environmental Protection Agency has published "Proposed Guidelines For Thermal Processing and Land Disposal of Solid Wastes" in the Federal Register on April 27, 1973 (40 CFR 240, 241). However, the proposed guidelines do not relate to the closing of a bandone d landfills. 7/ Chapter VIn of the New Jersey State Sanitary Code, "Refuse Disposal, It requires sanitary landfills and prohibits open burning. It does not require, however, for the proper closing of currently abandoned landfills. The only reference to abandoned landfills is Regulation 8, which cites responsibility for landfill fires as follows: liThe primary responsibility for current operations or in the case of discontinued operations in the event of a fire shall be with the local board of health and the person, agent, or municipality having title to the premises whereon the fire exists and they shall be responsiblE for extinguishing the same. "

18 - 4. Smoke generated by the dump fire combined with patchy fog and a temperature inversion to cause limited visi- bility on the Turnpike. 5. Based on weather data from the Northeast Weather Serv- ice, a temperature inversion was predictable. The temperature inversion created a "lid'! on the a rea in the vicinity of the accident site and prevented the fog and smoke from rising into the upper atmosphere. 6. Neither Federal nor State environmental protection regu- lations apply to abandoned dumps. 7. Limited visibility was not a factor in t he first accident which occurred at 11:20 p. m.near milepost 114 + 30 NSW. 8. When the Troop D station received the "fog alert'! at 3:30 p.m., no extraordinary precautions were scheduled for the purposes of observing and reporting visibility conditions on the Turnpike. 9. Had State Police (Newark Station) been aware of the 7:30 p. m. !'fog alert, II additional personnel might have been placed on patrol for visual observations. 10. There was no written policy or procedure to assure that each on-duty trooper of State Police Troop D is made aware of weather reports as they were received from the Northeast Weather Service. 11. The State Police failed to decide promptly to close first the we sterly and then the easterly route s, in the manner authorized by the Emergency Fog Procedure. The Emergency Fog Procedure did not assign the duty to decide closing action to anyone. 12. If the provisions of the addendum to the Emergency Fog Procedures, dated April 13, 1973, which required the closing of both routes when fog occurred on the northern end of the Turnpike, had been implemented, it is probable that accidents 7, 8, and 9 (all of which occurred

19 - on the easterly route) would have been prevented. An emergency fog procedure should provide the basis for prompt orderly actions and decisions so loss is minimized. 13. The two-man patrol units not only decreased the frequency of patrol to detect rapidly developing limited-visibility conditions over any given location, but also seriously taxed the police in their efforts to cope with the multiple emer- gencies on the Turnpike. 14. The hazard-warning and speed-limit signing system on the Turnpike did not provide a method which was fully respon- sive to the problems associated with highway operations under the limited-visibility conditions. 15. In the time period before the 2nd and 3rd accidents, the State Police did not follow the Emergency Fog Procedure in that the first speed reduction was less than that literally required by the procedure and the required in- crease in patrols to provide necessary coverage in the area was delayed for one hour after it was justified. 16. The reliance on human observers to locate limited visibility on the roadway could delay activation of the hazard-warning system. 17. The lapse of time between the occurrence of accidents 2 and 3 (12:15 a. m.) and the decision to initiate manual procedures to close the SNW at Gate 15W (1:36 a. m. ) was excessive in relation to the conditions and criteria of the Emergency Fog Procedure, and permitted the occurrence of accidents 4, 5, and 6. 18. The automatic traffic control and surveillance system being installed on the Turnpike will provide an effective means through which traffic conditions on the roadway can be con- tinuously determined and translated into meaningful driver actions and vehicle speeds. 19. State Police at the public hearing testified that the severity of vehicle dam,'lge in several of the accidents was evidence that vehicles penetrated those areas of limited visibility at rates of speed which prevented appropriate evasive action.

20 - 20. The actions of drivers involved in this series of collisions support the concern of the Safety Board that, at present, there is a need for improved criteria in driver education that will aid drivers in determining safe driving speeds under various conditions of limited visibility. 21. The response of other jurisdictions in providing emergency rescue services was excellent. The delay, in some cases, in arriving on- site can be attributed to the conditions that existe d on the Turnpike. PROBABLE CAUSE The National Transportation Safety Board determines that the probable cause of this series of multivehicle collisions was the pene- tration of vehicles into areas of severely reduced visibility due to fog and smoke, the latter occasioned by fires adjacent to the turnpike which had not been promptly extinguished. The delay in closing the affected roadways by the New Jersey State Police contributed to the number of accidents. RECOMMENDATIONS On January 2, 1975, the National Transportation Safety Board made a recommendation relating to this accident to the New Jersey State Police. (See Appendix E.) The Safety Board further recommends that: 1. The New Jersey State Police insure that all Northeast Weather Service reports are distributed, as received, to all Troop D stations and are thoroughly understood by all patrol personnel. (Recommendation H-75-3) 2. The New Jersey Turnpike Authority consider, in the imple- mentation of the automatic traffic control and surveillance system, methods through which the manual closing of the Turnpike could be accomplished immediately and traffic movements deterred safely and without delay. (Recommendation H-75-4)

21 - 3. The U. S. Environmental Protection Agency revise its proposed guideline s, "Thermal Proces sing and Land Disposal of Solid Wastes, " to include measures to pre- vent abandoned dumps and landfills from becoming hazards to public health and safety. (Recommendation H-75-5) 4. The State of New Jersey Department of Environmental Protection revise its sanitary code for solid waste dis- posal to require owne rs of properties that contain old dumps to close such sites properly. (Recommendation H-75-6) 5. The New Jersey Department of Environmental Protection, the U. S. Environmental Protection Agency, the Hackensack Meadowlands Development Commis sion, and the U. S. Corps of Engineers cooperate to eliminate the possibility of fire and smoke from the old dumps within the Hackensack Meadowlands. (Recommendation H-75-7) 6. The National Highway Traffic Safety Administration modify Federal Highway Traffic Safety Standard No.4, 'IDriver Education," to include more de finitive information relative to reduced-visibility driving. This recommendation was also made by the Safety Board in its special study, "Reduced- Visibility (Fog) Accidents on Limited-Access Highways, II issued in 1972. (Recommendation H-75-8)

22 - BY THE NATIONAL TRANSPORTATION SAFETY BOARD /s / JOHN H. REED Chairman /s / FRANCIS H. McADAMS Member /s/ LOUIS M. THAYER Member /s/ ISABEL A. BURGESS Member /s/ WILLIAM R. HALEY Member March 5, 1975

23 - APPENDIX A CHRONOLOGY OF EVENTS October 23, 1973, 10 p. m. Patrol unit 836 (two-man car) left the station to patrol the area between Gates 12 and 14 and the Bay Extension. They received no information on adverse weather conditions. 10:05 p. m. Patrol unit 844 (two-man car) departed the station with the responsibility to patrol both the easterly and westerly for the first hour and the easterly thereafter. They received no fog alert or any other weather information. 10:15 p. m. The shift 3 sergeant (unit 837) telephoned central control to inquire about a current weather forecast. No fo recast was available. 10:20 p. m. The night supervisor of central control dispatch re- ceived a verbal report of smoke conditions on the westerly route of the Turnpike. He was neither advised of, nor read, any other weather reports. 10:40 p. m. The shift 3 radio dispatcher of the Newark Station neither read nor received any weather reports. 10:55 p. m. Unit 844 was dispatched to check smoke conditions on the westerly route between Gates l6W and l8W. 11 p. m. Unit 897 was advised by the sergeant to check continually for fog and smoke on the westerly route. Although the sergeant did not see a weather report, he was aware of weather forecasts (radio) pre- dicting patchy fog in the vicinity. Unit 897 was assigned to the westerly route. 11:07 p. m. Unit 844 advised Newark Station of a "very heavy" fog condition on the we sterly route from l5W north to Route 46 with about 1/2 delineator visibility and recommended that the speed limit be reduced to 45 mph. One trooper later recalled, lIThe visibility problem we en- countered was a thick, white smoke and not fog--it was worse than fog. " 11 :08 p. m. Newark requested the hazard-warning and speed limit signs on the north and southbourid roadways of the westerly route be l. activated because of "fog due to that smoky condition. " ~ 11:20 p. m. Accident No.1 occurred.

APPENDIX A

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11:20 p. m. Central control received from the Northeast Weather Service a "fog followup" on the 7:30 p. m. fog alert report. The report was shown to the New Brunswick Police dispatcher. 11 :37 p. m. Unit 897 was dispatched by Newark to accident 1. Unit 844 was dispatched to assist at the accident site. 11:46 p. m. westerly route be south. Unit 897 requested that the southbound roadway of the closed. Wreckage blocked traffic from proceeding 11: 50 p. m. Central control telephoned several operations officials of the Turnpike Authority and advised them of the fog alert. 11 :59 p. m. Unit 844 advised Newark that visibility at the accident site was not impaired. October 24, 1973, 12:03 a. m. Unit 825 was dispatched from the New Brunswick area to cover the southern portion of Newark's patrol area. 12:11 a. m. The shift sergeant telephoned the Troop duty officer and requested permission to activate the Exxon patrols, !/ extend New Brunswick patrols into Newark's area, close the westerly route, and call in off-duty troopers, if necessary. Permission was granted. The conservation did not include any discussion of visibility conditions. 12:15 a. m. Accidents 2 and 3 occurred under conditions of limited visibility. 12:16 a. m. Newark requested that the Exxon patrols be activated for the Newark and New Brunswick patrol areas. Newark was alerted to recall off-duty troopers. 12: 17 a. m. Unit 836 was detaile d to accidents 2 and 3. Exxon patrols were dispatched by central control from service plazas 7S through 12S, for a total of seven units on duty. 12:22 a. m. The sergeant informed the Acting Station Commander of the current situation and was advised that the Commander would re spond to accident No. 1. V Radio equipped road service trucks from service plants on the Turnpike.

• 25 -

APPENDIX A 12:45 a. m. Unit 837 and the Station Commander were on-site at accident No. 1. Unit 844 was detailed to help maintenance personnel close the westerly to southbound traffic. 12:50 a. m. closed to traffic. The southbound roadway of the westerly route was Traffic was diverted to the easterly route. 12:57 a. m. Unit 836 advised Newark that they were engulfed in smoke at milepost 111. 10SNW. 1 a. m. The sergeant requested the station to recall two off- duty troopers and advise the duty officer "welre getting zero visibility, 112 northwesterly, II and that "it may become neces sary to close the westerly." Confirmation from the duty officer was requested on earlier permission to close the westerly if required. Permission again was granted. 1:11 a. m. Gates l5W and l5E were instructed to direct all north- bound traffic to the easterly route. 1:12 a. m. Central control advised unit 837 that the district (maintenance) supervisor was calling in five additional men. 1: 13 a. m. Unit 836 advised that the smoke was lifting at 111SNW and that they expected traffic to move. Unit 837 proceeded south on the westerly route. They noted I'light patchy smoke" at milepost l12NSW, which did not present a hazard to traffic. 1:20 a. m. Central control recorded weather and road conditions on the Bell telephone line. ?:./ 1:30 a. m. Unit 837 was requested by Newark Station to advise on the closing of the westerly route. Unit 837 responded by stating that milepost 110 through 112SNW now had visibility, but there was less than one delineator north of 18W and up to the missing mile. Newark was instructed by unit 837 to assign the incoming off-duty troopers to one-man units for exclusive patrol of the fog area. 2/ A telephone number which can be dialed to obtain information on traffic and weather conditions on the Turnpike. APPENDIX A

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1:32 a. m. Central control was advised by unit 837 to prepare for the closing of the westerly route. 1:36 a. m. Unit 837 ordered that the westerly route be closed and that all traffic be diverted to the easterly route. Visibility on the easterly route was unlimited. 1:54 - 1:55 a.m. Accidents No.4, 5, and6 occurred on the westerly route. The first of the recalled troopers arrived at the Newark Station. 2:03 a. m. Unit 897 was dispatched to the accidents. En route via the southbound roadway of the we ste rly route, 897 encountered stalled traffic at milepost lllNSW. As it proceeded around the stalled. traffic, 897 became engulfed by heavy smoke and fog. Visibility was O. 2:15 a. m. The duty officer was notified by New Brunswick of the situation. The duty officer telephoned the Troop Commander and re- quested the Newark District State Police lieutenant to survey the situation and report back to him. 2:22 a. m. Explosions and fire were reported in the vicinity of accidents 4, 5, and 6. 2:25 a. m. Unit 837 instructed Newark to recall the police radar team to duty and to notify the duty officer of accidents 4, 5, and 6. 2:33 a. m. Newark advised unit 837 that the duty officer was notified and en route. 2: 34 a. m. Central control was advised that the section of the westerly located at the split was secured. 2:42 a.m. Central control notified the Executive Director, Traffic Engineer, and Maintenance Engineer (of the Turnpike Authority) of the situation. 2 :45 a. m. Accidents 7, 8, and 9 occurred on the easterly route. 2:49 a. m. Unit 837 advised that personnel at Gate l5E were closing the easterly route and the entrances to the westerly route. Unit 837 advised central control to close the easterly route immedi- ately. Units 848 and 895 were dispatched from Gate 14 and north to effect the closing.

27 - APPENDIX A 3:04 a. m. Unit 895 advised Newark that all traffic was " routed out of 14" and lithe inner and outer are both detoured out of 14. II 3:08 a. m. Central control recorded weather and Turnpike closing information on the Bell telephone line. 3:35 a. m. The district lieutenant advised the duty officer of the current situation. The duty officer, Troop Commander, and traffic lieutenant came to the Newark Station.

28 - APPENDIX B HISTORY OF THE FIRE AREA About 2,500 acres, including eight major garbage dumps, are located within the Hackensack Meadowlands District. All, including the fire area, have been abandoned as garbage dumps for some time. The fire area measured 98 acres and contained a depth of 12 to 15 feet of compacted refuse. It had been abandoned for about 10 years. In 1963, RKO General (WOR Radio) purchased 67 acres within the fire area. The land was obtained from the Township of Lyndhurst who advised the new owners that the area was compacted garbage with a light covering of silt. In 1968, RKO General added an additional 3 feet of silt to protect against the ignition of fires and subsequent damage to their radio towers, antennae, ground systems, and transmis sion stations. The remaining portion of the fire area was owned by the Town of Lyndhurst and the Desiderio family. This section of the fire area, when abandoned as a garbage dump, was not covered with adequate layers of dirt. An EPA official who visite d the site before, during, and after the fires stated that it contained about 1 or 2 inches of dirt cover. Two types of fires, marsh and landfill, are commonly found in the Meadowlands. Marsh fires, the most common, occur about 12 times a year. Landfill fires are not so common, but usually of greater magni- tude and concern. Fires of approximately 2 weeks in duration were fought on the landfill area in 1966, 1967, and 1969. The method of disposing of refuse 10 years ago was simply to dump it openly. Whenever possible, dump operators would burn refuse and compact it by driving heavy equipment over it. It was not required that the refuse be covered with layers of dirt. Unburned and partially burned refuse contains about 50 percent paper and other combustibles. If layers of refuse are not tightly com- pacted, air voids form. Such air voids support combustion. Conse- quently, when a surface fire starts, it can spread downward as well as horizontally.

29 - APPENDIX B The spreading of water across the surface of a landfill fire causes the paper refuse to absorb the water as it drains downward. As a result, fires that extend 1- to IS-feet below the surface area are difficult to extinguish. To extinguish such fires, it is necessary to dig them up, spread the burning material out, and thoroughly soak it with water. To dispose of refuse in a well controlled, fire preventive, and sanitary luanner, sanitary landfills are now used. The main function of the sanitary landfill is to spread the refuse in thin layers about 2-feet thick and compact it with heavy equipment. At the end of each day of operation, no less than 6 inches of earth is placed on the com- pacted refuse. Unless a second layer of refuse is going to be put on the landfill within a 6-month period, an intermediate cover of 12 inches is provided. Finally, when a landfill is to be closed permanently, a 24-inch cover of earth is recommended.

30 - APPENDIX C CHRONOLOGY OF THE FIRES AND FIRE FIGHTING EFFOR TS 1/ SUNDAY, OCTOBER 14, 1973 The fire began at approximately noon time in the marsh area north- east of WOR towers. The Lyndhurst Fire Department was dispatched and attempted to extinguish the fire. MONDAY, OCTOBER IS, 1973 The fire had spread from the marsh area on WOR property, both north and south, to the old landfill on Lyndhurst and Desiderio property. Approximately 100 acres were burning, mostly underground, on the abandoned garbage dump. Although responsibility for abatement of the fire by concerned officials was not agreed upon, several agencies responded and engaged in firefighting efforts. At 9:30 p. m., the fire was confined to the area identified as the western lot. It was impos sible to fight the fire in the other location because of lack of water, inexcessability to the area of the fire and the safety hazard of sending inexperienced men under nighttime con- ditions into the fire area. TUESDAY, OCTOBER 16, 1973 The efforts to control the fire from spreading westward were successful. However, the fire was still burning on Lyndhurst property and both lots adjacent to it. Some progre s s was being made between 4 and 5 p. m. to contain that fire. Concerned parties sought assistance from State agencies. WED~ESDAY, OCTOBER 17, 1973 A bulldozer was at work and water was pumped Erom a creek to assist the bulldozer operator. This operation continued for the entire day. !.I Summarized from reports of the Hackensack Meadowlands Develop- ment Commission. Can also be found in Exhibits IV -C and IV -D of the Public Docket in Safety Board Headquarters, Washington, D. C. 20594.

31 - APPENDIX C Because the smoke could threaten visibility on the Turnpike, the Authority was requested to assign personnel, or equipment, to help extinguish the fire. Although a (N. J.) Bureau of Forestry official visited the site, many other forest fires in the northwestern portions of the State at that time preclude d their as sistance at this time in firefighting efforts. THURSDAY, OCTOBER 18, 1973 An overnight wind shift in direction caused the fire to spread and firefighting efforts had to be expanded. Information was received that neither the Turnpike Authority, nor the Forestry personnel could send either personnel or equipment. Private industries located in the sur- rounding area were contacte d for as sistance. The use of an additional large water pump was volunteered. As the result of the meeting between concerned officials, the HMDC agreed to coordinate firefighting efforts. FRIDAY, OCTOBER 19, 1973 The additional pump arrived at 1 p. m. and was prepared for use. SATURDAY, OCTOBER 20, 1973 An inspection of the fire area at 8:30 a. ITl. revealed that the area was too hot to allow firefighters to enter. Bulldozers were used to establish a beachhead at the northeasterly corner of the fire. This would enable men to enter, and afford extra protection for a gas pipeline which crosses the area and roadways of the Turnpike. SUNDAY, OCTOBER 21, 1973 Although the fire was burning underground with very little open flaITle, it was now more intense. The sITloke was heavy and limited the activities of bulldozer operators. They, however, had already extin- guished approxiITlately 20 acres of the fire along its southerly boundarie( It was anticipated that at least 3 bulldozers, 2 pUITlpS, and about 10 ITlen would be working at the site the next day.

APPENDIX C

• 32 -

MONDAY, OCTOBER 22, 1973 (VETERAN'S DAY) Adverse northerly winds had subsided and enabled bulldozer operators to work along the area closest to the Turnpike. The pur- po se wa s to suppre s s the smoke as soon as pos sible. The smoke threatened visibility on the Turnpike. At 2 :30 p. m., an additional bulldozer arrived at the scene. TUESDAY, OCTOBER 23, 1973 The site was engulfed at 8 a. m. by dense fog. Some progress against the fire was being made. The wind was from the north, how- ever, making it difficult for the bulldozer operators to function at full capacity. WEDNESDAY, OCTOBER 24, 1973 (The morning after the collisions.) The site at 8 a. m. was extremely foggy. Twenty inmates from the Rahway State Prison were obtained by the Bureau of Forestry to assist in the fighting of the fire. The prisoners arrived at 3 p. m., and assisted in the layout of approximately 500 feet of casing for connection to the pump. At approximately 5 p. m., the pump which was installed on October 19 was successfully tested. D~ring the day, the 3 bulldozers were all working at the site. Offers of assistance were received from the New Jersey National Guard and Forestry Service. Both agreed to dispatch equipment and personnel. THURSDAY, OCTOBER 25, 1973 The National Guard arrived on the site at 7:30 a. m. Meanwhile, firefighting efforts were proceeding through the work of prisoners, water pumps and hoses, and 2 bulldozers which were located at the hotte st point of the fire. Three Guard bulldozers had arrived at the site and began oper- ations along with two private bulldozers. The large pump continued to operate and a decision was made to keep it operating all night. Forestry Department personnel arrived at 6 p. m. The pump failed and was shut down fo r the night.

FRIDAY, OCTOBER 26, 1973

• 33 -

APPENDIX C The pump was repaired and pumping operations resumed. The three Guard bulldozers plus the two private bulldozers, continued operations. At approximately 12 p. m., the pump again failed. At 1:30 p. m., the pump resumed operations. At the end of the day's operation, 50 acres, or 50 percent, of the fire area was contained. SATURDAY, OCTOBER 27, 1973 An irrigation-pumping system was installed. A strong wind coming from the north in huge gusts made it very difficult to work. By noontime, the irrigation-pumping system was operating. The fire was being wetted down through 3 large sprinklers. By the end of the day, about 75 acres of the fire area was being controlled. SUNDAY, OCTOBER 28, 1973 The wind was slight and from the north. The fire by day's end was reduced to ten acres of the landfill area. The ten acres, however, were burning in the center of the site. MONDAY, OCTOBER 29, 1973 Heavy rain and high winds prevented all water abatement work at the site except for three (N. J.) Department of Transportation bull- dozers. The prisoners were sent back to Rahway and the pumps were shut down. The three Department of Transportation bulldozers, and a private bulldozer continued to operate. With the help of the rain, they controlle d the fire. TUESDAY, OCTOBER 30, 1973 The prisoners operated both pumps and hoses all day. By 4 p. m. the last ten acres burning were contained, and only small puffs remained.

APPENDIX C WEDNESDAY, OCTOBER 31, 1973

• 34 -

No fire at the site, consequently, no operations. THURSDAY, NOVEMBER 1, 1973 No fire in evidence at the site. The Forestry Department was requested to provide prisoners to as sist in casing removal. FRIDAY, NOVEMBER 2, 1973 Prisoners arrived at 9 a. m. and removed all casings. The pump was removed. Small puffs of smoke were observed at the northwest edge of the Lyndhurst property. SATURDAY, NOVEMBER 3, 1973 A bulldozer and the Lyndhurst Fire Department assisted in the abatement of the puffs of smoke.

• 35 -

APPENDIX D THE NEW JERSEY TURNPIKE AUTHORITY AUTOMATIC TRAFFIC CONTROL AND SURVEILLANCE SYSTEM The system will cover all portions of the Dual-Dual roadway, the easterly and the westerly roadways, and all interchanges north of Interchange 9 (except for Interchanges 14A, 14B, and 14C located on the Newark Bay-Hudson County Extension). The tota11ength of coverage is 36 miles. The field components of the system consist of: 760 detector loops, detector equipment, 120 detector equipment cabinets, communication cable. The vehicle detectors will be loops embedded in the pavement. An electronic sensor located in a roadside senses the inductance change caused by the passage of each vehicle and sends a tone signal to the computer. The computer calculates from this signal the vehicle speed and length, totals and averages the results, compares with normal values, triggers an alarm if congestion is detected, and adjusts signs to caution drivers and to discourage additional traffic from enter- ing a congested roadway. The Computer Control Center will be located at the New Jersey Turnpike Authority Administration Building and will consist of: Three PDP 11 /40 computers, computer peripherals, Map display showing the area covered, the location of the detectors, as well as the location and status of changeable message signs, speed warning signs and speed limit signs, and communication console. In addition, a fourth computer with some peripherals will be installed at the Interchange 14 area. APPENDIX D

• 36 -

Upon integration of all the field components, signs, and the computer system, the system will perform the following: Maximum Capacity - The New Jersey Turnpike has ~ade a substantial investment in constructing the Dual-Dual roadway and the westerly roadway. The Automatic Surveillance and Control System will achieve maximum utilization of all open lanes when one roadway is congested and the other is not, by replacing manual sign control with an automatic sign control. Rapid Detection of Accidents - By distributing detectors at half mile intervals along the main roadway, incidents that produce congestion will be rapidly detected. The more serious the incident, the more rapidly it will be detected. A complete blockage of saturated flow will be detected in three minutes or less and the required sign changes will be made immedi- ately after incident detection. Routing Data for Emergency Vehicles - To facilitate emergency vehicle service s, the system will auto- matically provide emergency vehicle routing data for each source of congestion. In this way, the dispatcher can direct police to the incident by the best possible route. After police evaluation, the dis- patcher can also direct ambulance, fire, or tow equipment, as required, by the fastest route. Improve Safety - By automatically setting the speed limit and "congestion ahead ' ! displays, warnings of impending danger will be accurately and quickly provided. Further, when the congestion is dissipated, the signs will automatically be returned to normal, creating driver confidence in the signs and improving compliance with reduced speeds, when displayed. Rapid, accurate sign settings and improved driver compliance will all further enhance the safety record of the New Jersey Turnpike.

37 - Data Management - APPENDIX D In addition to the significant improvements in traffic flow provided by the system, the system has other important features. The system will produce printed reports including: TRAFFIC REPORT - volumes, speeds, occupancy SYSTEM STATUS REPOR T - sign status, incident status, failure status SYSTEM LOG - time of sign changes, incident detection, operator inputs These reports can be used for future planning, permanent records of accidents and breakdowns, and system evaluation. The system will also provide four data terminals for monitoring and controlling the system. Finally, a dynamic map will be provided for displaying and demonstrating overall roadway performance. The map will show traffic levels at all detector stations and the settings of all signs.

38 - NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. APPENDIX E ISSUED: January 2, 1975 Forwarded to: Superintendent New Jersey State Police Post Office Box 68 West Trenton, New Jersey 08625 SAFETY RECOMMENDATION(S) H-74-44 In its continuing investigation of the multi-vehicle collisions on the New Jersey Turnpike, between Gate 15 and U. S. Route 46, on October 23 and 24, 1973, the National Transportation Safety Board has become aware of a major safety improvement being installed on the Turnpike--an automatic traffic control and surveillance system. As the system has been explained to us, it will provide a sophis- ticated means through which traffic congestion can be rapidly detected and reported on the easterly and westerly roadways and at interchanges north of Interchange 9 (except for Interchanges l4A, l4B, and l4C on the Newark Bay-Hudson County Extension). Total coverage is 36 miles. The system can detect congestion in 3 minutes--sooner than it would be detected by more frequent police patrols. The Safety Board recognizes that such a system can be effective in the prevention of large-scale accidents, such as those which occurred on October 23 and 24, 1973. However, until such system is fully opera- tional, additional police patrols should be used, particularly in the winter months when the incidence of fog is greatest. The National Transportation Safety Board therefore, reiterates its recommendation of April 16, 1971, that: The New Jersey State Police take steps to provide more frequent patrols on affected Turnpike sections when fog or other weather conditions are forecast to reduce visibility, so that earliest practical warning may be available when conditions warrant

39 - APPENDIX E -2- the activation of hazard-warning and reduced-speed- limit signs. Increasing patrol frequency should take priority over routine police matters, if necessary, during periods of potentially hazardous weather or visibility conditions. REED, Chairman, McADAMS, THAYER, BURGESS, and HALEY, Members concurred in the above recommendation. BY~~ed Chairman

40 - APPENDIX F APPLICABLE SEC TIONS OF THE EMERGENCY FOG PROCEDURE (NEW JERSEY STATE POLICE-TROOP D) Section II - MEDIUM TO HEAVY FOG - Visibility 75 feet to 1/2 mile and/or medium to heavy fog occurring adjacent to Turn- pike roadways. Notifications The New Brunswick Police Dispatcher will notify: 1. Troop Duty Officer. 2. Central Control Dispatcher. 3. Division Headquarters, West Trenton, N. J., (via teletype) including information on any speed reductions. 4. In the event of a speed reduction to 45 miles per hour because of fog, this information will be relayed to the Newark office of Associated Press (20l-MI 2-0151) and United Press International (201 - MA 4-7070). 5. Weather and road condition announcements will be placed on the Bell Telephone (CH 7 -0900) by the Central Control Dispatcher. Action 1. Activate the necessary "Drive Slow - Fog Ahead'! signs in each direction to adequately cover the affected area. 2. Post the following speed limits in each direction to adequately cover the affected area: Visibility 500 -700 yards Visibility 300 -500 yards Visibility 200 -300 yards Visibility 150-200 yards Visibility 100-150 yards Visibility 25-100 yards (11-14 ( 7 -1 0 ( 5-6 ( 3-4 ( 2-3 ( 1-2 delineators) 55 MPH delineators) 50 MPH delineators) 45 MPH delineators) 40 MPH delineators) 35 MPH delineators) 30 MPH Increase patrols to provide necessary coverage in fog areas. Central Control will put Exxon on patrol in any area vacated by State Police patrols at the .request of the New Brunswick Police Dispatcher.

41 - APPENDIX F 4. Whenever fog conditions necessitate the reduction of the speed limit to 35 miles per hour, the following personnel will be notified immediately by shift leader, and report for duty: a. Station Commander In affected areas. Immediately upon arrival at station, the Station Commander will immediately proceed to patrol the station area affected by fog to ascertain overall conditions. He will be held directly accountable for the immediate reporting of changes in conditions, supervision of all patrols, and for rendering assistance to the Duty Officer. 5. When the speed has been reduced to 35 miles per hour or below, all marked cars will be operated with dome light in ope ration. SEC TION III - DENSE FOG - Visibility 0 to 75 feet on Turnpike roadways. 1. Consideration of closing the Turnpike in the affected area will be made known immediately to the Central Control Dispatcher and time allotted, before closing, to enable him to contact Toll Collection and Maintenance, in order that they can dispatch their forces. 2. After having obtained authorization from the Commander of Troop lID" or Duty Officer, close the Turnpike in the affected area, manning all posts as assigned in the follow- ing paragraphs. 3. The Duty Officer will correlate the procedures of the Troop with the Maintenance Duty Supervisor and requests for assistance will be made by the Duty Officer to the Maintenance Duty Supervisor. 4. State Police patrols will conduct continuous sweeps of their assigned areas, noting changes in weather conditions, assist stranded motorists, and report the presence of any unauthorized traffic moving within the closed areas. Service areas will be checked from time to time to dis- courage illegal departures onto the Turnpike.

APPENDIX F

• 42 -

Patrol charts will be used during all emergencies, day or night, and patrols will not frequent station unless called. 6. Marked patrol cars will be assigned to the nearest service areas to convoy stranded patrons to the nearest exit in their direction of travel. 7. No section of the Turnpike will be closed to traffic except after authorization and direction has been received from the Commanding Officer of Troop "D" or the Troop Duty Officer. 8. All emergency measures taken must be constantly reviewed and removed as promptly as possible. 9. ALL MAINLINE CLOSINGS will be set up, manned, and terminated by State Police personnel. At each mainline closing and at the Route 3 westbound ramp, Maintenance personnel will furnish a sign trailer and two men, to assist, as soon as possible, once the locations of the closings have been determined.

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FD06894 ｜ 1975_美国_HAR7503.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1975 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

SS-H-32 HIGHWAY ACCIDENT REPORT G EO R G E W 0 LL MAN ME A T S, INC., TRUCK/AUTO /GREYHOUND BUS COLLISION AND FIRE, NEW JERSEY TURNPIKE, BORDENTOWN, NEW JERSEY OCTOBER 19,1973 ADOPTED: MARCH 12, 1975 NATIONAL TRANSPORTATION SAFETY BOARD W as hi ngton, D. C. 20594 REPORT NUMBER: NTSB-HAR-75-3 REPRODUCED BY: NUS. U.S. Departmenl of Co~merce National Technic. ~ ,Inforynat,on Service . Springfield, Virginia 22161 PB241989 1111111111111111111111111111

TECHNICAL REPORT DOCUMENTATION PAGE I. Report No. T 2.Government Accession No. 3.Recipient's Catalog No. N'J'SIl-IIi\J~-7 5-3

1. Title and Subtitle
2. Report Date

lIighw:ly Accident I~erort - (~eorge Wollman Neats, Inc. , Narchl2 1975 Truck/ Auto/(;reyitoullcJ Bus Collision and Fire, New Jersey 6.Performing Organization Turnpike, Bord en town, New Jersey; October 19, 1973. Code

1. Author(s)
2. Performing Organization

Report No.

1. Performi ng Organization Name and Address

IO.Work Unit No. l465A No.tional Trallsportation Safety Board II.Contract or Granl No. Bureau of Surface Transportation Safety Washing ton, n. c. 205~4 13.Type of Report and Pe r i od Covered f-- • Agf"ncy Name and Address III.<:Jn-JAY ACCIllI~NT REPOJn' 12.Sponsorlng Uctober 19, 1973 NAT! ONAl TRANSPORTATION SAFETY BOARD Washington, D. C. 20594 f1f.Sponsoring Agency Code IS. Supplementary Notes 'J"ilis l"cI)llr t c(llltaills lllgll\vay Safety necollllllcnd:ttions 11-75-9 through 11-75-ll. 1--16 . Abs t rae t A tr"ctor-selllitrailcr w:ts traveling south in the extreme right-h:tnd l:tne of the Nct} _Jcrsey 'J'urllplkc .1t "i>out 55 I1Iph. A c: reyhoul\u hus :tlld :t priv.,te :tuto were travel- ing north on the Turnpike. The driver of the southbound truck's ta ted that without any prior tvarning he heard a loud noise which sounded like a gunshot, the tractor immed ia te1y veered to the left and struck and crashed through the median guardrail into the northbound lanes. The truck struck the auton¥Jbile and crushed it between the truck awl bus. The truclc ran off the northbound lanes and down a 50-foot embanlc- ment o The truckdriver was ejected. lIe was not wearing the available seatbe1t. The autoll¥Jbile driver and'his passenger, the busdriver, and six bus passengers, died in the crash. The truckdriver and 10 bus passengers were injured. The Nationo.1 Transportation Safety TIoard determines that the probable cause of the accident Has the sudden deflation of the left front tire on the tractor which caused the driver to lose control of the vehicle. The sudden deflation resulted from a gross failure of the tire sidewall due to under inflatiori caused by an undetected nail puncture. Contribut ing to the fo.talities and injuries was the inadequacy of the median guo.rdrail to prevent the tractor-semitrailer from entering into the opposing lanes of traffic. 17.Key Words 18.Distribution Stiltement , This document is available Interstate bus, tractor-senutrailer, private auto, front to the pub lic through the National Technical Inform.:J.- tire failure, fire, guardrails, seat belts, driver tion Service, Springfield, training, occupant ejection Virginia 22151 19.5eeurity Classification 20.Security Classification 21, No. of Pages 1}2.price (of this report) (of this page) UNCLASSIFIED UNCLASSIFIED ' ., I i ~rSB Form 1765.2 (Rev. 9/74) ,

FOREWORD The accident described in this report has been designated a major accident by the National Transportation Safety Board under the criteria estab lished in the Safety Board's regulations. The report is based on facts obtained from an investigation by the Safety Board. Information was also provided by the Bureau of Motor Car- rier Safety of the Federal Highway Administration, Civil Aeromedical Institute of. the Federal Aviation Administration, the National Highway Traffic Safety Administration, and the New Jersey State Police. The conclusions, the determination of probable cause, and the recommendations herein are those of the Safety Board. iii

SYNOPSIS FACTS • The Accident • Accident Site Environmental Factors TABLE OF CONTENTS Marks on the Roadway and Median The Truck Witnesses Vehicle Damage . Rescue Activities Injuries to Persons Other Inform3tion ANALYSIS Left Front Tire Failure Loss of Vehicle Control Front-Tire Failures The B~CS Front Tire Failure Study The B~~S Driver Training Study . Driver Training. Performance of the Median Barrier and Guardrail CONCLUS IONS PROBABLE CAUSE RECOHMENDATIONS • APPENDICES Appendix A: Front Tire Failure Accidents - Property Carriers Appendix B: Inspection of Left Front Truck Tires iv 1 1 1 4 5 5 5 6 6 11 11 12 13 13 15 16 17 17 17 18 19 20 20 23 23 24

-.1..- NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D. C. 20594 HIGHWAY ACCIDENT REPORT Adopted: March 12, 1975 GEORGE WOLLMAN MEATS, INC., TRUCK/AUTO/ BUS COLLISION AND FffiE, NEW JERSEY TURNPIKE, lIORDENTOWN, NEW JERSEY OCTOBER 19, 1973 SYNOPSIS At 8 p.m. on October 19, 1973, a tractor-semitrailer was traveling south in the right lane of the southbound portion of the New Jersey Turn- pike at about 55 mph. A Greyhound bus was traveling north in the right lane of the northbound portion of the Turnpike. A private auto was travel- ing in the center lane of the northbound portion and was passing the bus. The left front tire of the truck blew out; the tractor veered to the left and crashed through the median guardrail into the northbound lanes. The truck struck the automobile and crushed it between the truck and the bus; the automobile split in half, and the rear half caught fire. The truck ran off the northbound lanes, through a guardrail, down a 50-foot embankment, and turned onto its right side. The truckdriver was ejected; he was not wearing an available seatbelt. The autolOObile driver, the automobile passenger, the busdriver, and six bus passengers died in the crash. The truckdriver and 10 bus pas- sengers were injured. Property damage amounted to $100,000. The National Transportation Safety Board determines that the probable cause of the accident was the sudden deflation of the left front tire on the tractor which caused the driver to lose control of the vehicle. The sudden deflation resulted from a gross failure of the tire sidewall due to under inflation caused by an undetected nail puncture. Contributing to the fatalities and injuries was the inadequacy of the median guardrail to prevent the tractor-semitrailer from entering into the opposing lanes of traffic. FACTS The Accident At 8 p.m. on October 19, 1973, a truck was traveling in the right lane of the southbound portion of the New Jersey Turnpike at 55 mph. (See Figure 1.) A Greyhound bus was traveling in the right lane of the north- bound portion of the Turnpike. A 1972 Ford }1ustang sedan was traveling

les during the cra~ sequence. BRIDGE GUARDRAIL NOT TO SCALE + + 12' LANE 10' SHOULDER ------=-- N

- 3 - in the center lane of the northbound portion of the Turnpike, and was passing the bus. The driver of the truck stated that he had no steering control problems with the truck until after he heard a sudden loud noise, which sounded like a gunshot. He said, "The left front seemed to drop, and I couldn't keep the unit from going to the left;" he said that he did brake, "a little," but that the unit went "sharp left" into the guard- rail and that, "it happened very quickly." The truck struck the curbing of the concrete median located on a bridge-over structure. At that point, the driver was dislodged from behind the steering wheel but remained in the cab. The truck then struck and crashed through the median guardrail which was located on the grass median and traveled into the northbound lanes where it struck the automobile. (See Figures 2 and 3.) Figure 2. Approach of truck toward guardrail. Note: A - tire marks on concrete median. A - tire mark on pavement. n - tracking of vehicle across grass median. C - 56 feet of guardrail damage. D - truck penetration, of shoulder guardrail.

4 - Figure 3. Wavy tire marks leading up to concrete median. The automobile was spun clockwise and into the left front of the bus, where it was crushed between the truck and the bus. The automobile split in half, and the rear half caught fire. The front half traveled 14 feet east of the impact point and caught on the guardrail of the right north- bound shoulder. The bus and rear half of the automobile traveled 30 feet north in the right lane and stopped. The truck continued across the northbound lanes, ran off the east shoulder, proceeded over the front half of the automobile, crashed through the guardrail, plunged down the 50-foot embankment during which the driver was ejected, and stopped at the bottom where it overturned onto its right side. Accident Site The a.ccident occurred on the New Jersey Turnpike near Bordentown, New Jersey, at milepost 57+18 delineators. Delineators are 150 feet apart. In that area, the New Jersey Turnpike consists of six 12-foot lanes, three northbound and three southbound. The north and southbound

5 - lanes are separated by a l6-foot grass median. Two W-section guardrails are located in the median--one for each direction of travel. On the outer edges on each side of the road, a la-foot gravel shoulder is bounded by a W-section guardrail. On the right side of the northbound lanes the guardrail protects against a 50-foot embankment. A concrete bridge is located north of the point at which the truck impacted the median barrier, automobile, and bus. A l6-foot-wide con- crete median is located down the £enter of the bridge. The double W- section guardrail continues down the center of the median. The truck impacted the median barrier 25 feet south of the bridge. Fifty-six feet of barrier in the grass median was damaged. lwenty feet of guardrail on the northbound shoulder was crushed to the ground by the front of the auton~bile and by the truck. Environmental Factors The road was dry, the weather was fair, and traffic was medium to heavy. The accident occurred in a rural area; it was dark, and there was no artificial lighting. The road was level, in good repair, and had a posted speed limit of 60 mph. Narks on the Roadway and Median A wavy tire mark started at the center of the middle southbound lane and continued 112 feet to the point at which the truck struck the con- crete bridge median. Another 6 feet of tire marks were visible on the curbing, A second tire mark, which ran parallel to the wavy mark, began at the east (left) edge of the southbound lane and continued 15 feet to the right edge of the grassy median. (See Figure 3.) These ti~e tracks continued through the grassy median at a 190 angle for 25 feet to the point of impact with the median barrier. FrOln the barrier, 97 feet of tire tracks and tire marks were visible in the median and in the north- bound lanes to the point at which the truck struck the automobile. The point at which the truck struck the automobile and the bus was identified by gouge marks in the road surface and dirt, debris, and rust-colored wo.ter in the center lane of the northbound portion. The bus and auto-· mobile involved in the accident did not leave tire marks on the highway before impact with the truck. The Truck The tractor-semitrailer was leased by George Wollman, Inc., from Hubler Rentals, Inc., of Allentown, Pennsylvania. The 1970 Mack tractor had a cab-over-en~ine and front wheel brakes and was diesel-powered. It had three axles and manual steering, and was equipped with seatbelts.

6 - The deflated left front tire was a "Super Traction Safety Rib" made for Super Tire Engineering Co., of Camden, New Jersey, by a manufacturer in Israel. The tire size was 10:00-20; it was made of Nylon ~nd had a 12- ply rating. The tire load rating was 5,780 Ibs. at 85 Ibs/in cold in- flation pressure, and the gross axle weight rating was 11,560 lbs. The tire tread design was five rib, and tread depth exceeded requirements. The truck operator1s maintenance records indicated that on April 15, 1973, cwo new front tires were installed on the tractor. At that time, the odometer on the tractor read 97,922 miles. On July 6, 1973, the left front tire on the tractor was replaced at 108,231 miles. Maintenance per- sonnel could not recall the reason for the replacement. The 1970 Trailmobile trailer was equipped with a refrigeration unit, tandem axles, dual wheels, and air brakes~ It was carrying 35,797 lbs. of meat which was loaded from the floor to 3 feet above the floor. The tread depth of the trailer tires was greater than the minimums required by regulations. Hitnesses A witness, who was following 100 yards behind the ~ruck, stated that his vehicle and the truck were traveling about 60 mph. He further stated that suddenly, the truck swerved sharply to the left, went through the guardrail, and collided with the bus. After the collision a fire began. One motorist stated that she was traveling in the left lane ahead of the Mustang and just ahead o( the bus, when she saw truck headlights corn- ing toward her from the southbound lanes. She ·accelerated her car to get out oLthe path of the truck. She then heard a noise and felt a jolt. She stopped her car and found that the metal, demountable flange from the left front wheel of the truck had lodged in the left front fender of her car. A second motorist waS following the Mustang in the left lane nnd about 33 feet behind the bus. He stated that he saw the truck com= through the median guardrail, hit the rear of the Mustang, crash into the side of the Hustang in the center lane, and crush it into the front of the bus. Vehic le Dam3.g e Automobile--The automobile was cut in half and crushed. The pile of cwisted metal no longer resembled an automobile. The rear half of the vehicle was burned. (See Figures 4 and 5.) Truck--The tractor was ripped from the chassis and destroyed; tllere- fore, only the undercarriage and tires could be examined. (See Figure 6.) The tractor was burned, and the brakeshoe on the left front drive axle was broken.

Iii .~ \ . . :' t: . j. I / .. . I .. ~

• 7 -

Figure 4. Front half of Mus tang. Figure 5. Rear half of Mustang.

- 8 - r ... "7 ' =~.:.:" "-- .":=~7~:·f,"~.=;,,:.~'~:"'"I:&. Figure 6. Damaged tractor. The left front tire was deflated and burned on the inside sidewall, The outside sidewall was unburned and contained a jagged, l4-inch opening, (See Figure 7,) This opening was located between the bead and the tread and followed the circumierence of the tire. The mean tread groove was 15/32 of an inch. 1/ TILe inside sidewall was burned and cut in two places. One cut at the-bead side flange area had not penetrated through the ply. The second cut was large and ex- tended 3 inches on the tread face and 2 inches down the shoulder. The cords in the sidewall of the tire were broken for almost the full cir- cumference of the inside of the tire. Over a 6-m~mth period following the acc ident, the tire was examined by several investigators and tire experts. During an examination on April 24, 1974, the head of a nail was found protruding from a groove in the tire tread. The head of the nail was discolored and difficult to detect. It was located at the bottom of the second groove from the out- side of the tire and 40 inches forward of the 14-inch tear in the outside tirewall. l/ "49 CFR 393.75 Tires: (b) Any tire on the front wheels of a bus, truck, or truck tractor shall have a tread groove pattern depth of at least 4/32 of an inch when measured at .any point on a major tread groove. ~leasurements shall not be made where tie bars, humps, or fillets are located,··

- 9 - Figure 7. 14-inch tear in outside wall of left front truck tire. The point of the nail dtd not protrude through the inside of the casing. It could not be felt by a person rubbing the interior of the casing with his fingers. (See Figure 80) After the accident, the inner tube was missing from the tire and was not recovered. However, the inner tube must have been present before the accident, because the tire could not have supported the load without it. The flap was in ,good condition and had not been wrinkled or pinched. The flap splice was smooth and the edges were round and would not have damaged or cut the inner tube. The fabric which surrounded the valve. hole was abraded o The inside sidewall and tread face of the right front tire was burned. The tread was about 6/32 inch deep in the groove near the center of the tread pattern. Except for the left front tire, the other tractor tiies were inflated and appeared to be in good condition. The front of the trailer was dam3.ged heavily. (See Figure 90) The front of the unit was torn open. The body was torn from the frane, and the frame was sprung. The spring assemblies Were broken and separated from the chassis. Except for the inner, left rear tire, the tires were inflatedo The inner, left rear tire, was deflated, but there was no visible dalll.:1ge.

10 - Figure 8. Head of nail e~bedded in the left front tire of the truck. Figure 9. Damaged rigllt front end of the trailer.

11 - Bus--The front of the bus was torn open, and the driver's seat and compart;ent were destroyed (See Figure 10.) The sidewall of the right- front tire was cut, and rubber was missing. The tire was flat. , , ' ,. I ii' . :- ,: ., C, I , ! ' .... ~ ~_,' ,r I. . ~

• 12 -

In the Bus--lhe busdriver and five passengers were killed in the ac- cident. The remaining 11 passengers were hospitalized; 3 were in serious condition. One of the three died 5 days after the accident. In the Truck--The truckdriver, who was not wearing the available seatbelt, ~7 was ejected from the truck as it plunged down the embankment. He received lacerations on his left leg, and bruises and abrasions to his head. He was treated at a nearby hospital and released. Other Inform~tion Background of the Truckdriver--The 21-year-old truckdriver held a valid New Jersey driverls license. On July 22, 1973, he ho.d becn examined and found physically qualified to operate motor vehicles in intersto.tc con~erce. New Jersey Motor Vehicle Department records reveal no traffic violation convictions or previous traffic accidents. While in the U. S. Anrry, he was a truckdriver for 2 years. Af ter being discharged from the Army, he completed a 3-week driver training course for cOlThllercial vehicles at Ryder School. The school teaches the following with respect to blow- outs: IIKeep a firm and stead grip on. the steering wheel--don It over- steer to correct the swerve or pull. If a front tire goes, there will be a strong pull toward the side with a blowout. A rear blowout tends to cause weaving of the rearend. Above all, donlt slam on brakes! Brake smoothly •••• 11 The truckdriver stated that before starting the trip, he made a visual inspection of the tires and other equipment and found no defects.]) Front Tire Failure Statistics--Bureau of Motor Carrier Safety (B!-1CS) report 4/ states, "Consistently, we have found that the second leading cause ~fter brake failures) of mechanical defect accidents is tire fail- ures. And consistently, over 60 percent (almost 2/3) of these accidents are caused by front tire failures: These front tire failures (775 out of 1,186), reported in the period 1968-1970, resulted in 25 fatalities, 409 injuries, and 4.8 million dollars in property damage. 11 (See Appendix A.) ~/ 49 CFR 392.16 requires drivers of co~ercial vehicles to wear a seatbelt if the vehicle is so equipped. ]..1 49 CFR 392.7 Equipment, Inspection, and Use--No motor vehicle shall be driven unless the driver thereof. shall have satisfied himself that the following parts and accessories are in good working order ••• tires •••• !::./ IICon~ercial Vehicle Front Tire Failures", published by the Bureau of Motor Carrier Safety, Federal Highway Administration, no date. - 13 - Another BMeS report 51 states that, in 1971, accidents involving front tire failures were ~esponsible for 10 fatalities, 155 injuries, and $2.1 million in property dam~ge. These data do not include private carriers who were exempt from BMCS requirements until January 1, 1973. ANALYSIS Left Front Tire Failure Load Condition--In a proposed rulem~king ~/ the BMeS states that two of the main causes of tire failure are operating while tires are either overloaded or underinflated. The truckdriver said that during his pretrip inspection, the tires appeared to be inflated properly and that he did not notice any problem with the steering of the truck. Further, tests conducted by the manufacturer of the tractor indicated that at 50 mph an experienced driver should notice a steering problem when the left front tire pressure dropped to 60 Ibs/in2 , and at 50 Ibs/in2 an inex- perienced driver would be aware that he had a problem. Therefore, the tire pressure of the left front tire is believed to have been a~ least 60 Ibs/in2 or higher. If tire inflation pressure was 85 Ibs/in , and gross vehicle weight was 65,997 Ibs., the load on each of the front tires would have been about 3,799 Ibs. The safe tire load rating for that tire at 85 Ibs/in2 was 5,780 Ibs. Therefore, the tire, if normally inflated, was not overloaded. Since there is no evidence to indicate when the nail entered the tire, there is no way to determine when the tire first began to lose pressure and became underinflated. Rapid Deflation--A State of New Jersey court order obtained by the owner of the truck prevented destructive testing of the tire and pro- hibited sample specim::ns to be taken from the tire. This inability to test the failed parts of the tire together with the fact that the inner tube was never found prevented an accurate reconstruction of the failure of the tire. Based on the presence of the nail in the tire and evidence from a visual examination, the tire failure probably occurred as follows: 7/ r~s the tire rotated under load conditi?ns, the point of the nail penetrated the inner tube and caused a slow leak. As the air pressure slowly dropped, the tire running in an underinflated con- ~/ "1971 Analysis oof Motor Carrier Accidents Involving Vehicle Defects on Mechanical Failure," published annually by the Bureau of Motor Carrier Safety, Federal Highway Adminis tration, March 1973. !il 49 CFR 393 Docket No o M-56; Notice No. 74-4, "Proposed Prohibition Against Operating with Overloaded or Underinflated Tires," April 17, 1974. ]j Based on a report of a Safety Standards Engineer, National Highway Traffic Safety Administration. (See Appendix A.)

- 14 - dition began to heat up in the shoulder area around the circumfer- ence of the tire. The heat in the nylon ply cords of the tire in- creased to the point where the cord-to-rubber adhesion failed. Once this occurred, the cords separated in ribbons in the hottest area, namely, the shoulder area (Figure lla). Under visual exam- ination, the separated cords appeared stringy in separate sections (Figure llb). As the separation continued to grow the rent in the cords and fcibric progressed until the separation became large enough to permit the inner tube to blowout through the hole. With the blowout all of the renuining air in the tire escaped and the rim dropped to ride on the inside of the tire, dropping the left front corner of the truck eight inches. 1I Figure llA. Separated ply cords in interior of sidewall of left front tire. Arrow in center of picture indicates where the sharp end of the nail is located. Figure llb. Arrow points to stringy character of separated ply cords in interior of sidewall of left front tire. liThe cords in the tire on the inboard side appeared to be completely broken through the cord body and the interior of the tire sidewall bore shaffing marks. This indicated that after the blowout the tire ran under the rim flange or the paveJ11o~nt in an uneven, wobbly ffi3.nner. 1I (See Figure 3.)

- 15 - The Board believes that the l4-inch cut in the outer sidewall of the tire occurred when the tire impacted the guardrail. The cut ends of the cords in the tire wall support this belief. Loss of Vehicle Control The driver stated that when the blowout occurred and when the left front of the vehicle had dropped, steering efforts to counteract the veer to the left were unsuccessful. The vehicle, traveling at 55 mph (80 ft/sec) when the tire blew out, struck the median curb 112 ft., or approxim~tely 1.40 seconds, later. Granting a nornul n1'3.ximum of 0.75 seconds for driver reaction and 0.35 seconds for brake reaction, the driver would have had 0.30 seconds, or 24 feet, for the brakes to slow the vehicle before it struck the curb. Federal Motor Vehic Ie Safety Standard 121 8/ specifies a s to.pping-dis- tance requirement at 55 mph of 219 feet •. Based on the 219 feet as the most dem~nding criteria for stopping distance for a vehicle of this type, it could decelerate at a rate of 14.9 ft/sec2 • Using this deceleration rate (requiring a full brake application) and the 0.30 seconds available, the vehicle speed when it struck the m=dian curb would have been 52 mph. Had the driver applied only his trailer brakes, the speed would have been 53.4 mph (assuming the 4 trailer brakes would decelerate the vehicle at 1/2 the rate available when all 10 vehicle brakes are applied). Accord- ingly, significant speed reduction was not attainable before the left front wheel of the truck struck the curb. The only conceivable corrective actions available to the truckdriver were slowing the vehicle down, and attempting to maintain directional control by turning the steering wheel to the right. When the left front tire blew out, the wheel, rim, and remaining tire material dropped 8 inches (section height of the tire) onto the road surface, creating a drag on the left side. This caused the tractor to turn to the left into a curve with a calculated radius of 377 feet -- a drastic change of direction for a vehicle as heavy as this at the speed it was traveling. Also, as a result of this change of direction, the truck was subjected to a lateral force of 0.535g. The drag effect or loading couple is difficult to calculate, however, rough calculations suggest that the magnitude of the loading couple and the resultant lateral acceleration was beyond the physical capability of the truck- driver and mechanical advantage of the steering system to overcome. The driver stated that he could not steer the vehicle to the right. The fact that the driver was not using his seatbelt may have con- tributed to his inability to control the truck. Had he been wearing the !i/ Federal Motor Vehicle Safety Standard 12l--Air Brake Systems- Trucks, Buses, and Trailers.

- 16 - seatbelt, he probably would have remained behind the steering wheel and would have had more leverage because he would have been more firmly anchored in his seat. However, it is unknown to what degree this added leverage would have aided the driver in avoiding the accident or reducing its severity as there have been no studies in this area. Statistics show that it is more safe to remain inside the vehicle than to be ejected. A Bureau of Motor Carrier Safety study (Crash/Injury Ejection Study Commercial Vehicle Accidents 1970-1971, published December 1973) indicated the following: Based on 782 accidents, the fatality rate for ejectees not wearing a seatbelt was 42 percent; the fatality rate for nonejectees not wearing a seatbelt was 28 percent; and for those persons wearing a seatbelt and not ejected, the fatality rate was only 15 percent. Thus, in terms of prevention of fatalities in the wide variety of trucking accidents, there is almost a 3 to 1 advantage for those who wear seatbelts as opposed to those who do not and are ejec.ted. There is almost a 2 to 1 advantage in survival for those who wear a seatbeltas opposed to those who do not when occupants are not ejected. Front Tire Failures It is difficult to discover small objects which have become embedded in tires. If the nail had been embedded in the tire before the trip was begun and had been discovered during the pretrip inspection, the truck- driver could have removed it. This nail, however, was so embedded that 20 persons, including experts, examined the tire before the nail was dis- covered. Inspection cannot prevent all accidents because punctures can occur on the road. While existing and proposed regulations 9/ which deal with tire safety are important improvements, there is still another aspect of tire safety that is not covered--preventing small and large objects from pene- trating the tire body and causing a failure. There are several ways to approach the problem of front tire fail- ures: (1) Prevent their occurrence initially (if technically possible), (2) develop an automatic correction device not reliant on driver action, (3) develop a device that minimizes the effect of the failure, (e.g., dual chamber safety tire), but may still require correct driver steering and braking action to bring the vehicle to a safe stop, or (4) provide more definitive and realistic driver training with respect to proper evasive action to take than now exists. There will be some situations of sudden emergency in which driver action can prevent an accident. The Safety Board believes that any approach that minimizes driver input (hence less change for human error) .would seem the more desirable. 2/ Federal Motor Carrier Safety Regulation 49 CFR 571.119--New Pneu- matic Tires for Vehicles Other than Passenger Cars.

- 17 - The BMCS Front Tire Failure Study The BMCS is testing equipment to control front-tire failures under a contract titled, IIControl of Large Commercial Vehicle Accidents Caused By Front-Tire F.1i lures, II RFP-103. This work is to be completed by August 27, 1975 •. The BMCS will explore front-tire failures in detail and evaluate the effectiveness of at least the following equipment in the prevention of, or lessening of, the severity of front-tire failures: 1. Effects of vehicle loading and weight distribution, 2. Power steering, 3. Safety stabilizer, or equivalent devices,

1. Front-end alignment changes, i.e., increased caster, king-pin

inclination changes,

1. Tire type and quality,

Tube-type versus tubeless tires, 7. "Safety" tire or wheels, 8. Wheels designed to retain failed tires at high speeds, 9. Radial versus bias-type construction, 10. Improved driver and/or carrier preventive maintenance. The BMCS Driver Training Study There is no BMCS regulation requ~r~ng that drivers be trained through a formalized training course such as are available at professional driver training schools. The Bureau of Motor Carrier Safety has recognized the need of such training by initiating a research contract titled, "Driver Training Program for Commercial Vehicle Drivers." This program includes 24 areas (e.g. hours of service and drivers logs, braking, shifting, road skills, defensive driving) dealing with the operations of a commercial vehicle. In the area of road skills, there is a section concerned with front-tire failures and how to deal with them. The program will be tested and evaluated in terms of content and to determine the quality of driver such a course would produce. Driver Training The instruction given the driver at the Ryder Driver Training School W3.S not objective or definitive. The instruction on braking

18 - ("smoothlytl) describes only the rate of application, not how much. Fur- ther, it is not clear from the technical factors whether the use of brakes, even "smoothly" was the most desirable ac tion to take. Any brak- ing of the front wheels could further increase the drag effect of the deflated left front tire and make corrective action that much more diffi- cult. Blowout trainine is all classroom discussion. Unless a driver actually experiences a blowout and the after effects on the vehicle, he really does not know what to expect or how to counteract it. The in- struction to "not oversteer" could make drivers cautious about full use of steering. How does one know how much to steer in order to not over- steer? Phraseology such as lIdo not oversteer'l and. "brake smJothly" are vague and have as many meanings as there are drivers to interpret them. The Safety Board attempted to gather information on what drivers are (or should be) taught with respect to action after front tire failures. Representatives of the trucking industry, professional driving instruc- tors, and Federal safety experts were surveyed. There was a consensus of opinion that: (1) There is little information available on this sub- ject, (2) what is generally taught now as evasive action is probably as exact as can be stated in light of the absence of exact information and the variation in vehicle configuration, and (3) that an actual driving ex- perience involving a forced blowout on a skid pad would be valuable. Many questions need to be answered with respect to driver training. Can drivers be taught to control trucks with front tire failures at all speeds? Can more definitive information on this subject be developed? Is it necessary to subject drivers to an actual blowout situation? Hopefully, answers to these questions and a meaningful recommenda- tion for a front tire failure situation will be forthcoming from the BMCS driver training study. Performance of the Median Barrier and Guardrail The median guardrail offered little resistance when the truck struck and crashed through it. In fact, the truck continued on, struck the car and the bus, and crashed through the guardrail on the opposite side of the highway. This is not surprising because the standard W-beam guard- rail, such as that found on the T~rnpike and a majority of the Nation's highways is not designed to retain heavy vehicles. In 1962, the Highway Research Board suggested the use of a 4,000-lb. test vehicle at an impact angle of 250 and an impact speed of 60 mph. These criteria, which omit- ted adequate protectio'n agains t trucks, have been accepted by the American Association of State Highway Transportation Officials (AASHTO) and the Federal Highway Administration. They have become the baSis for the various States to qualify for Federal-aid funds for median and roadside guardrail construction. Consequently, guardrail design has been limited to the retention of the typical American automobile under the crash con- ditions previously speCified.

19 - The Safety Board recognizes the inability of guardrail designs to retain heavy vehicles and has spoken specifically to this in several of its reports. 10/ At present, the Federal Highway Administration has an extensive re- search and development project, "Advanced Vehicle Protection Systems," which includes the heavy-vehicle problem. According to FHWA, the proj- ect's objective is "to establish design standards to obtain adequate guardrails, bridge rails, and median barriers, and to devise adequate structural solutions for other roadside obstacles in collisions with heavy vehicles. Designed specifically to contain heavy vehicles, the new traffic barriers are intended to prevent penetration, redirect ve- hicles, and reduce accident severity for all vehicle-barrier collisions." The Safety Board views this project as a significant step forward in the development of new barrier systems that will protect all users of the highway and urges the FRWA to continue and expedite its efforts. CONCLUSIONS

The penetration of the left front tire and tube by a nail prob- ably led to the failure of the tire, which led to the loss of control of the vehicle by the driver.

• It is doutful that the truckdriver could have seen the nail in

the tire at routine inspection because m1ny experts examined the tire later before it was found. 3 0 Hhen the truckdriver first heard the loud noise, he did not know that it was a blowout or what direction the noise came from. He was first aware of the blowout when the left front end of the tractor dropped and the truck began to veer to the left.

The left front tire was not overloaded.

Of the several approaches to front tire failures, those that re- quire a minimum amount of driver action seem the most desirable.

The truckdriver took the recommended evasive action in response to the tire failure, but was unsuccessful.

Once the tractor began to veer to the left the ability to turn the steering wheel was beyond the capability of the truckdriver. 10/ Chartered Bus Crash on U. S. Route 22 (Interstate 78), Near New Smithville, Pennsylvania, July 15, 1970; Runoff and Overturn of Intercity Bus on Interstate 95, Richmond, Virginia, September 3, 1972; and Multiple-Vehicle Collision Followed by Propylene Cargo - Tank Explosion, New Jersey Turnpike Exit 8, Septew)er 21, 19720 - 20 - 8. The truck driver did not have sufficient time to reduce the speed of the vehicle to a point where evasive actions may have been effective. 9. Had the truckdriver worn his seatbelt he would have been secured to the seat more firmly and might have been able to control his truck better after the initial impact with the curb. 10. The Ryder School did not provide behind-the-wheel training in counteracting the steering effects (ilf blowouts; however, it is questionable whether training alone could have prevented the steering effect in this accident. 11. Answers to questions dealing with driver training with respect to controlling front tire failures must await completion of a BCMS study in this area. 12. The W-section guardrail installed on the median and shoulders of the Turnpike was not designed to retain and redirect heavy commercial vehicles, traveling at Turnpike speeds. 13. The automobile driver and the busdriver had no opportunity to take evasive action to avoid the errant truck. PROBABLE CAUSE The National Transportation Safety Board determines that the prob- able cause of the accident was the sudden deflation of the left front tire on the tractor which caused the driver to lose control of the vehicle. The sudden deflation resulted from a gross failure of the tire sidewall due to under inflation caused by an undetected nail puncture. Contributing to the fatalities and injuries was the inadequacy of the median guardrail to prevent the tractor-semitrailer from entering into the opposing lanes of traffic. RECOMMENDATIONS The National Transportation Safety Board recommends that the Federal Highway Administration: 1. Upon completion of the research dealing with the development of a commercial driver training course, distribute such training course information to all professional commercial driver train- ing schools. (Recommendation H-75-9) 2. An~nd the Federal Motor Carrier Safety Regulations (Section 391.11) to require that all candidate drivers be familiar through

• 21 -

formal training with such driving em~rgencies as front tire failures, brake fade, jackknife situations. (Reconmlendation H-75-l0)

Expedite that portion of the FHWA research project, IIAdvanced Vehicle Protection Systems,1I that will provide data fpr design of new barrier construction and improvements to existing systems. Dynamic vehicle impact tests should be made using both intercity buses and heavy trucks. (Recommendation H-75-11) BY THE NATIONAL TRANSPORTATION SAFETY BOARD March 12, 1975 /s/ JOHN H. REED -------------------------- Chairnnn /s/ FRANCIS H. McADAMS ---------------------- Member /s/ LOUIS N. THAYER Member / s/ ISAll~ A !.~12R:..:..;G:..::E:..::S...;;S _______ _ Member /s/ WILLIAM R. HALEY Member -------------------------

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APPENDIX A Table 1 Front Tire Failure Accidents - Property Carriers No. of Tire Failure Accidents Reported to BMCS Fatalities Injuries Property Damage Year Front Other Front Other Front Other Front Other 1968 247 147 6 4 123 41 $1,231,256 $851,976 1969 264 146 11 9 150 45 $1,780,211 $785,842 1970 264 118 8 5 136 37 $1,808,773 $711,415 Source: ·Commercial Vehicle Front-Tire Failures, U.S. Department of Transportation, Federal Highway Administration, Bureau of Motor Carrier Safety, Washington, D. C. 20590 Preceding page blank 24 APPENDIXB INSPECTION OF LEFT FRONT TRUCK TIRE U.S. DEPARTMENT OF TRANSPORTATION NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION WASHINGTON. D.C. lOS90 Mr. A. L. Schmieg National Transportation Safety Board FAA. Bu i Id ing Room 817 E Washington, D. C. 20591 Dear Mr. Schmieg: IN REPLY REFER TO: N41-33 At your request we had Safety Standards Engineer, Xr. John A. Diehl, meet with Mr. George Larsen, Jr., of your office, on November 7, 1973, at Exit ~o. 4, New Jersey Turnpike, to in- spect a tire and rim that was involved in an accident. Inspection observations: 1. Tire Da ta a. Tire and rim located at barracks three miles north of Exit No.4. Tire Size Designation 10.00-20, l2-ply rating~ Load for front wheel useage 5,780 pounds at 85 psi cold inflation pressure. Gross Axle Weight Rating 11,560 pounds. b. Brand ~C1me Super Tire Engineering Company Made in Israel 12-ply rating. c. Inspection of Tire A nail was found in the bottom of the second groove in from the side of the tire chat was not ourned. It protru~ed a~proxi~aLely ~ of an inch from the bottom of the groove. An inspe6tio~ inside th~ casing showed that the "Ciil die: ~.:..t protruJe inco th2 ::ir2 \·l~·,ereby it could be found ~! passing a finger or hand ov~r the openins. The size of the ho le WC'.S very sma 11 and hardly discernable. The nail 2ppeared to be the size of a neil used in :-;,o;(iug vegettibl.e cr:ltes. The. nail

25 can be found on a radial line from the letter "N" in the word "traction." However, as the tire was rotating under load the nail penetrated the inner tube and caused the tire to deflate, as a slow leaker. When this occurred the tire pressure dropped and the tire heated up in the shoulder area around the circumference of the tire. The cords in the tire on the burned side were completely broken through the cord body. The cords were broken because the nail had caused a slow leak and the tire was running under inflated. Underinflation caused the heat in the cord body to rise to the point where the rubber to cord adhesion failed. Once this occurred the cords separated in bundles or ribbons in the hottest area, namely the shoulder. The cords appeared stringy, in separate sections and as the separation continued to grow, the rent in the fabric or cords progressed, until a separation large enough caused the remaining air pressure in the inner tube to expel it from the tire through the destroyed parts of the cord body. The cord failure sometimes represent the II s trings" of a mop. There are some cords that hold together and other cords become separated giving a stringy look to the cord body in the failed area. There was another cut in the tire on the opposite side of the tire approximately 14 inches long. This cut apparently occurred when the tire and wheel i~pacted the guard rail. The cut ends of the cords in tr.c cord body definitely indicated this. This was not the cause of the tire failure, because it shows as an impact cut. The cords in the tire on the burned side were completely broken thrcugh the cord body. This indicated that after the inner tube was blownout the tire ran on the rim flange or the pavement, and thus also further destroyed the cords just below the shoulder in the cord body except for a length of approximately ten inches. d. Inspection of the flap The flBP was in good condition and showed no evidence that the inner tube had been wrinkled in the flap area, at the time of mounting the tire, tuce, and [La? to the rim. The flap splice was smooth and the edges w~re ~ound and of such a nature that the edges of the flap would not da~age or cut the inner tube. The valve hole in the flap revealed that the valve had abraded the fabric surrou:1dir'g the valVE! hole, as the inner tube ~vas los t through the oroken part. of the tire cord budy.

26 e. Inner tube The inner tube was never loca ted after the acc ident. However, it is the opinion of the Safety Standards Engineer that the inner tube caused the tire failure, because there were no valve warks inside the tire and this indicates the inner tube failed first, causing the rapid loss of air, yet in a revolution or two there was still enough pressure to cause the flange to become di3engaged and impacted the adjacent vehicle. The tire running a short distance caused the cord body to fail and there was still enough pressure to expell the inner tube from inside the tire. f. Rim and De~ountable Flange The rim body had no identification or stamping that would reveal the manufacturer. The rim was bent out of round and the flange as well. However, the wheel was placed on the floor and one end of the flange was mounted in the gutter slot and it matched the gutter contour perfectly, indicating the deQountable flange was the correct flange for the riQ. The flange had the following data stamped near the edge of the flange: 20-7.5 8-A-3-190 followed by the Tire and Rim Associa- tion stamping s)~bol, but the letter indicating the manufacturer was not discernible, making it impossible to dete'rmine the rim raanufacture. The rim and flange were the correct size and contour for the tire size designation. II. Tire Data - Exit No. 8, ~ew Jersey Turnpike The remains of the tractor were located in the guarded yard at Exit No.8. The right front ti~e and spoked wheel assembly, 6 spokes, Has still mounted to the axle, also bent, but still inflated. The tire design was the same tread design as that of the fail~d left front wheel assembly. The tire identification number of this tire ~as CD 2J l81E 113. This tire had approxiDately 3/lG remaining tread depth in the groove near the centerline of the five-rib tread pa t'tern and mJ.tched that of the tire firs t ins pee: ted.

27 The letter~ CD are the plant code for The Alliance Tire and Rubber Company, Hadera, Israel. The 2J indicates tire size code for the 10.00-20 tire size designation. The 113 indicates that this tire had been manufactured the elevench week of 1973. These data were ~bliterated on the left front tire because of the burned condition of the tire. It was stated that you have a man in your group who has all the data on the 1970 Hack Tractor that was involved in the accident, and from Mack Truck Company, the wheel and rim source at the time of manufacture can be determined. If we can be of further assistance, please let us know. Sincerely, E. T. Driver, Director Office of Operating Systems Motor Vehicle Programs

FD06936 ｜ 1977_美国_AAR7709.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1977 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

TECHNICAL REPORT DOCUMENTATION PAGE I . Re ort No. NTEB-AAR-77-9 I 2.Government Accession No. I 3.Reci.pient's Catalog No. I L . Title and Subtitle Aircraft Accident Report - 5.Report Date New York Airways, Inc., Sikorsky S-61L, N619PA October 13, 1977 Pan Am Building Heliport, New York, New York May 16, 1977 1 . Author(s) 6.Performing Organization 8.Performing Organization Code Report No. 3 . Performing Organization Name and Address 10.Work Unit No. National Transportation Safety Board 1I.Contract or Grant No. Washington, D.C. 20594 Bureau of Accident Investigation 12.Sponsoring Agency Name and Address 2090B 13.Type of Report and Period Covered Aircraft Accident Report May 16, 1977 Washington, D. C. 20594 NATIONAL TRANSPORTATION SAFETY BOARD 14.Sponsoring Agency Code 15.Supplementary Notes i6.Xbstract About 1735 e.d.t., on May 16, 1977, the right landing gear of a New York Airways, Inc., Sikorsky S-61L; N619PA, failed while the aircraft was parked, with The aircraft rolled over on its right side and was substantially damaged. At the rotors turning, on the rooftop heliport of the Pan Am Building in New York, New York time of the accident four passengers had boarded the aircraft and other passengers were in the process of boarding. The passengers and the three crewmemhers onboard received either minor or no injuries; however, four passengers who were still outsid the aircraft and were waiting to board were killed and one was seriously injured. was seriously injured when they were struck by a separated portion of one of the mai One pedestrian on the corner of Medison Avenue and 43rd Street was killed and anothe rotor blades of the aircraft. the accident was the fatigue failure of the upper right forward fitting of the right main landing gear tube assembly. Fatigue originated from a small surface pit of undetermined source. All fatalities were caused by the operating rotor blades as a result of the collapse of the landing gear. The National Transportation Safety Board determined that the probable cause of

1. Key Words

Fatigue hailure; landing gear; fracture of right hand main landing gear forward fitting; fracture initiation P/N S6125-5033-22; surface pit. and propagation; stress corrosion cracking; fitting I9.Security Classification 20.Security Classification (of this report) (of this page) UNCLASSIFIED UNCLASSIFIED NTSB Form 1765.2 (Rev. 9/74) I 18.Distribution Statement This document is available National Technical Informa- to the public through the Virginia 22151 tion Service, Springfield 21.No. of Pages I22.Price 32 I

TABLE OF CONTENTS I ! Page Synopsis . . . . . . . . . . . . . . . . . . . . . . 1 Investigation . . . . . . . . . . . . . . . . . . . 2 History of the Flight . . . . . . . . . . . . . . . 2 Injuries to Persons . . . . . . . . . . . . . . . . 4 Damage to Aircraft . . . . . . . . . . . . . . . . . 4 Other Damage . . . . . . . . . . . . . . . . . . . . 4 Personnel Information . . . . . . . . . . . . . . . 4 Aircraft Information . . . . . . . . . . . . . . . . 4 Meteorological Information . . . . . . . . . . . . . 5 Aids to Navigation . . . . . . . . . . . . . . . . . 5 Communications . . . . . . . . . . . . . . . . . . . 5 Aerodrome Information . . . . . . . . . . . . . . . 5 Flight Recorders . . . . . . . . . . . . . . . . . . 5 Wreckage and Impact Information . . . . . . . . . . 6 General Examination . . . . . . . . . . . . . . . . 6 Landing Gear Examination . . . . . . . . . . . . . . 6 Medical and Pathological Information . . . . . . . . . 7 Fire . . . . . . . . . . . . . . . . . . . . . . . . 7 Survival Aspects . . . . . . . . . . . . . . . . . . 8 Tests and Research . . . . . . . . . . . . . . . . . 9 Additional Information . . . . . . . . . . . . . . . 10 History of Heliport Operation . . . . . . . . . . . 10 History of S-61L Forward Lower Landing Gear to Fuselage Attachment Fitting Failures . . . . . . . 11 Normal Helicopter Operations . . . . . . . . . . . . 12 New Investigation Techniques . . . . . . . . . . . . 12 Analysis . . . . . . . . . . . . . . . . . . . . . . 13 Conclusions . . . . . . . . . . . . . . . . . . . . 16 Findings . . . . . . . . . . . . . . . . . . . . . . 16 Probable Cause . . . . . . . . . . . . . . . . . . . 17 Safety Recommendations . . . . . . . . . . . . . . . 17 Appendixes 1 . 1.1 1.2 1.3 1.4 1.5 1.6 1.8 1.7 1.9 1.10 1.12 1.11 1.12.2 1.12.1 1.13 1.14 1.15 1.16 1.17 1.17.1 1.17.2 1.17.3 1.18 2 . 3 . 3.2 3.1 4 . 5 . Appendix A . Investigation and Hearing . . . . . . 19 Appendix B . Personnel Information . . . . . . . . 20 Appendix C . Aircraft Information . . . . . . . . 22 Appendix D . Wreckage Distribution Chart . . . . . 23 Appendix E . Right Main Landing Gear Area (Photograph and diagram) . . . . . 25 Appendix F . Laboratory Photographs . . . . . . V (Figures 1 through 10) 27 ii

NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT Adopted: October 13, 1977 NEW YORK AIRWAYS, INC. SIKORSKY S-61L, N619PA PAN AM BUILDING HELIPORT NEW YORK, NEW YORK MAY 16, 1977 SYNOPSIS New York Airways, Inc., Sikorsky Model S-61L helicopter, N619PA, failed while the aircraft was parked, with rotors turning, on the rooftop heliport of the Pan Am Building in New York, New York. The aircraft rolled over on its right side and was substantially damaged. Four process of boarding. The passengers and the three crewmembers onboard passengers had boarded the aircraft and other passengers were in the received either minor or no injuries; however, four passengers who were was seriously injured. One pedestrian on the corner of Madison Avenue still outside the aircraft and were waiting to board were killed and one and 43rd Street was killed and another was seriously injured when they were struck by a separated portion of one of the main rotor blades of the aircraft. About 1735 e.d.t. on May 16, 1977, the right landing gear of a The National Transportation Safety Board determines that the probable cause of the accident was the fatigue failure of the upper right forward fitting of the right main landing gear tube assembly. Fatigue originated from a small surface pit of undetermined source. All fatalities were caused by the operating rotor blades as a result of the collapse of the landing gear. K

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INVESTIGATION 1.1 History of the Flight On May 16, 1977, New York Airways, Inc. (NYA) Flight 972, a passenger f l i g h t from the rooftop heliport (JPB) of the Pan American Sikorsky S-61L, N619PA, was being operated as a regularly scheduled Building at 200 Park Avenue, Manhattan, New York, t o John F. Kennedy International Airport (JFK), New York, New York. landed a t the heliport at about 1732. -/ H There were 20 passengers and a crew of 3 aboard. The f l i g h t originated as F l i h t 971 from JFK Airport and After approaching from the northeast and landing, the a i r c r a f t was taxied t o the boarding gate, which required a 180' turn t o the left and a short t a x i of 10 t o 20 f e e t t o position the a i r c r a f t properly. The captain stated t h a t he used the t a i l r o t o r instead of h i s brakes t o which was a normal procedure. The a i r c r a f t was chocked and passengers a s s i s t i n taxiing. He set h i s brakes and l e f t the t a i l wheel unlocked, began t o deplane. According t o witnesses and passengers, the landing ~ had been smooth and gentle. The collective was bottomed (negative pitch) and torque was about 18 percent on each engine. The engine speed controls (ESC) were positioned t o maintain 100 percent rotor speed (NR) and the automatic f l i g h t control The f i r s t o f f i c e r s t a t e d t h a t a s he f i l l e d out the flightlog, he had h i s system was on with a l l controls centered--a normal operating procedure. knee against the collective t o insure t h a t it was bottomed. The captain remained i n h i s s e a t with h i s hands on the controls. The captain estimated t h a t they had been s i t t i n g on the heliport were boarding. He heard a " faint noise," which he believed t o have come f o r 1 t o 2 minutes. Passengers had deplaned and the outbound passengers noise" and a buckling sound. The crumpling sound was accompanied by a from the rotor system, followed immediately by a "crumpling, crunching s e t t l i n g and yawing motion, followed by a r o l l of the a i r c r a f t t o the right. A s he heard the first " faint noise," the captain reached f o r the EX'S t o shut the engines down. He pulled them back immediately t o the a i r c r a f t rolled beyond its 45" position. When the ESC's are i n the the ground i d l e detent and then i n t o the engine shutoff position before shutoff positfon, f u e l is shut off in the engine f u e l control units. The captain stated t h a t when the blades struck the concrete they were not being powered by the engines. 1/ A l l times herein a r e eastern daylight, based on the 24-hour clock. 3 - s l i g h t l y t o the right and heard a crunching noise, followed immediately by a "gentle smooth r o l l" t o the right. The f i r s t o f f i c e r stated t h a t he f e l t the a i r c r a f t settle right a t the captain who was i n the r i g h t cockpit seat and saw the with t h e a i r c r a f t . The relationship of this t i p path remained constant, captain reach f o r the ESC's. He also saw t h e blade t i p path plane rotating from the upright position, throughout the e n t i r e r o l l . He reached up t o help the captain p u l l the ESC's but the captain already had h i s hands on them; he s t a t e d that the whole sequence happened quickly. After hearing the f i r s t sound, the f i r s t o f f i c e r looked t o h i s With the ESC's in the shutoff position, the a i r c r a f t continued the r o l l and the main rotor blades struck the heliport concrete surface. The captain heard the breaking of plexiglass as the blades struck the f i r s t o f f i c e r ' s overhead window. When the a i r c r a f t stopped the captain completed the procedure t o shut down the a i r c r a f t . A l l switches were turned off . The captain s t a t e d t h a t it did not occur t o him t o use the rotor brake a f t e r the a i r c r a f t began t o r o l l ; the events developed too rapidly t o allow the rotor brake t o be effective. and four outbound passengers had boarded or were boarding the a i r c r a f t ; one passenger was approaching the f i r s t step of the a i r s t a i r door. The f l i g h t attendant, who was positioned inside the a i r c r a f t at the entrance door s t a t e d that, as a woman passenger was coming up the airstair she heard a "loud metallic crumbling sound," which she believed t o be coming from the r i g h t underside of the a i r c r a f t . She noticed a vibration which was followed immediately by the a i r c r a f t t i l t i n g t o its r i g h t side. As the a i r c r a f t continued its r o l l t o the right, she heard the engines who had j u s t boarded f e l l backward against the door. She braced herself stop. She stated t h a t the woman on the a i r s t a i r door and a passenger s o she would not f a l l as the door closed when the a i r c r a f t came t o rest on its r i g h t side. After the motion stopped, the f l i g h t attendant inquired about the safety of the four passengers who were inside the a i r c r a f t and upon ascertaining t h a t they were a l r i g h t , she began t o give instructions regarding evacuation. A t the time of the accident, inbound passengers had deplaned of the accident stated t h a t as he placed h i s l e f t foot on the f i r s t step A passenger who was approaching the a i r s t a i r door a t the time of t h a . a i r s t a i r , he heard a loud noise l i k e an engine backfire and then he noticed the a i r c r a f t moving l a t e r a l l y f i r s t and then begin t o tilt toward him. He said t h a t he'stepped back as the helicopter t i l t e d further toward him and he began moving toward the front of the a i r c r a f t while keeping his hands on the a i r c r a f t ' s side. In the few seconds that it took the a i r c r a f t t o stop, he had moved forward t o a position adjacent t o the cockpit. He was not injured.

4 - north and longitude 73' 58' west. The elevation of the accident site is 855.23 feet m.s.1. The accident occurred during daylight hours at latitude 40' 45' 1.2 Injuries to Persons Injuries

Crew Passengers Fatal Minor/None Serious 1.3 Damage to Aircraft 0 4 0 3 17 1 Others 1 1 2 The aircraft was substantially damaged. 1.4 Other Damage were damaged by separated main rotor blade leading edge counterweights. An office on the 36th floor of the west side of the Pan Am Building was extensively damaged when an 11-foot section of a main rotor blade penetrated a window. The New York Airways passenger waiting/control tower area located in the east corner of the heliport had five windows shattered and a light fixture knocked from its structure. A 6-foot section of the rooftop edge railing on the north side was penetrated and bent outward by a main blade section. 1.5 Personnel Information Two automobiles located on the streets below the accident site for the flight. (See Appendix B.) 1.6 Aircraft Information The three crewmembers were properly certificated and qualified accordance with Federal Aviation Administration (FAA) requirements and New York Airways procedures. The aircraft was certificated, equipped, and maintained in 1976;were examined. There were no notable patterns of malfunctions or items of malfunction related to the failure of the right landing gear. The program of inspection and recording was comprehensive and complete. The program calls for: (1) A daily preflight. (2) A "safety inspection" every 40 hours--an in-depth inspection to discover any irregularities. The entire aircraft is opened up and additional functional tests are performed. (3) A phase check. One of five phases is performed every 70 hours. All five phases are completed within 350 hours. The type of inspection and corrective maintenance is progressive. Selected items and AD compliance work, if any, are performed during these checks. The records of maintenance and inspection from June to December

5 - At the time of the accident, the landing gear had a total time of 6,913:15 hours. There was no service life limit on the landing gear or on its components. Overhaul was required every 9,900 hours. The gross weight and c.g. were within prescribed limits for both takeoff and weighed about 17,668 lbs when the accident occurred. (See Appendix C.) landing. About 950 lbs of Jet A-1 fuel were onboard, and the aircraft 1.7 Meteorological Information the'heliport were as follows: Broken clouds at 1,500 ft, visibility--15 mi, temperature--71° F, wind--260° at 12 kn, altimeter setting--30.26 in Hg. At the time of the accident, surface weather observations for 1.8 Aids to Navigation Not applicable 1.9 Communications Not applicable 1.10 Aerodrome Information at 200 Park Avenue, New York. The heliport is operated by New York Airways, Inc., and was certificated under an airport operating certificate issued by the Federal Aviation Administration on January 3, 1977, with an effective date of February 1, 1977. It is an Index A heliport based on the requirements of 14 CFR 139, with no exemptions. The heliport is owned by the Grand Central Corporation and leased to New York Airways, Inc. New York Airways is responsible for the administration, operation, and maintenance of the heliport. The heliport is located on top of the Pan American Building, and has an effective landing area of 131 feet by 131 feet. Only VFR and special VFR operations are authorized. Approach and departure routes for the heliport are specified in the certification manual for the windsock is located at the northwest corner and another at the extreme heliport. The heliport pavement is of reinforced concrete. A lighted northeast corner of the heliport. The heliport is located at an elevation of 855.23 feet m.s.1. 1.11 Flight Recorders

recorder (CVR), Serial No. 4129. The recording was complete from landing at JFK Airport through the landing on the Pan Am Building heliport to the accident event. N619PA was equipped with a Fairchild A-100 cockpit voice

6 - cockpit area microphone recorded a "cracking" sound and banging sound as the blades contact the roof. There was no recorded crew conversation f o r the period t h a t N619PA was on the roof. Two minutes and twenty-one seconds following the landing, the equipped, with a f l i g h t data recorder. The a i r c r a f t was not equipped, nor was it required t o be 1.12 Wreckage and Impact Information 1.12.1 General Examination rotor system, the copilot's enclosure (fuselage s t a t i o n (F.S.) 72, water Aircraft damage was limited t o the main rotor blades, the main l i n e (W.L.) 170), the r i g h t s i d e of the fuselage j u s t forward of the right main landing gear attachment points (F.S. 209.5, W.L. 89 and 156), the r i g h t main landing gear supports (F.S. 221), and the horizontal s t a b i l i z e r mounted on the r i g h t side of the t a i l rotor pylon (F.S. 704.5, W.L. 191). A l l access panels and f a i r i n g s were i n place and been opened a f t e r the rollover t o disconnect the battery. attached, except f o r the nose battery compartment access door which had Each blade was 28 feet 10 inches long and weighed 209.3 lbs. A l l blades had bent upward along t h e i r span, and heavy surface contact smears were located on t h e i r bottom surfaces beginning at midspan and continuing outward toward the tip. The five color coded main rotor blades had been damaged exclusively. heliport were outboard sections of these f i v e rotor blades. The longest distance traversed by the blade portions was four blocks north and one block west of the Pan American Building. The only p a r t s of the helicopter t h a t were thrown from the t h e t i p caps, were recovered in the area below the heliport on the roofs The outboard sections of the f i v e main rotor blades, including of lower buildings o r a t street level. (See Appendix D.) systems or powerplants. The f u e l tanks, which were located in the lower fuselage tub s t r u c t u r e beneath the passenger cabin floor, were i n t a c t with no evidence of f u e l leakage. About 120 gallons of f u e l was removed from the a i r c r a f t a f t e r the accident. 1.12.2 Landing Gear Examination There was no preimpact damage noted to any of the a i r c r a f t ' s " Examination of the landing gear showed t h a t . t h e left main gear assembly was i n t a c t with no v i s u a l damage. The r i g h t main landing gear had separated from its upper (F.S. 221,.W.L. 164) and lower (F.S. 221 and 243.5, W.L. 106) fuselage attachment f i t t i n g s and was lying beneath the a i r c r a f t . The a i r c r a f t was righted, and the r i g h t landing gear and lower fuselage were examined.

7 - tires were fully inflated; the tires were removed and the axle examined. Visual examination disclosed no evidence of damage. The oleo was fully extended. The energy absorbing strut, which angles from the upper fuselage attachment fitting (F.S. 221, W.L. 164) outboard to the oleo strut's upper attachment fitting, had separated through its lugs at both the upper and lower ends. The two tires, axle, and main oleo strut were intact. Both The lower landing gear supports consist of two sets of upper and lower tube assemblies which form two "V's"; the apex of each "V" attaches to the upper and lower ends of the main oleo strut (outboard) and to the fuselage attachment fittings (inboard). The forward upper and lower tubes (F.S. 221, W.L. 106) attach to the forward fuselage attachment fitting through P/N 6125 - 50333 - 22 fitting which is bolted and bonded to the forward upper tube. The aft upper and lower similar manner. (See figures 1 and 2, Appendix E.) The lower attachment tubes attach to the aft fuselage fitting (F.S. 243.5, W.L. 106) in a ,tube was bent downward and had broken adjacent to the inboard tube assemblies fitting. The forward upper tube assembly had separated at the main oleo strut attachment fitting. The complete tube was still attached to the P/N 6125-50333-22 fitting. However, this fitting, which also has a lug to which the lower tube attaches had fractured. The fractured areas were examined in the Safety Board's metallurgical laboratory and under the Safety Board's control at Sikorsky Aircraft/United Technologies' laboratories. 1.13 Medical and Pathological Information mortem examination of the four passengers that had not yet boarded the aircraft and the one pedestrian revealed that they died as the result of portions of those blades. The cause of death of the four passengers was impact trauma caused by strikes from the main rotor blades and separated found to be multiple lacerations, fractures, and internal injuries. The cause of death of the pedestrian was found to be fractures of the skull and lacerations of the brain. No occupants of the aircraft were seriously injured. Post- evidence of pre-existing physical problems which could have affected their judgment or performance. A review of the cockpit crew's medical records disclosed no immediate vicinity of the aircraft as a precautionary measure. There was no fire; however, foam was laid over the area in the

1. 15

Survival Aspects This was a survivable accident for the a i r c r a f t occupants. When the a i r c r a f t came t o r e s t on its right side the f i r s t o f f i c e r , who was i n the l e f t s e a t , was hanging i n h i s harness. The captain looked back and saw that the cockpit door, which is a two-panel sliding door, was p a r t i a l l y open and was jammed. This door was f u l l y open before the accident. Although the captain's emergency evacuation station was i n the cabin, he realized that he could not enter the cabin through the door. The captain unbuckled the first officer; the f i r s t officer then opened h i s emergency exit, which is the window on h i s side, and exited by pushing the window f r e e and climbing out on top of the a i r c r a f t . He d i d not see anyone moving efi the heliport. He went around the t a i l The f i r s t officer climbed off the a i r c r a f t on the bottom side. what he believed t o be transmission f l u i d on the ground. Two cargo section t o the other side of the a i r c r a f t a t the rotor head area and saw personnel were there and he told them t o put foam down. He went back t o the (bottom side) of the a i r c r a f t , pushed a cargo c a r t closer and climbed back up onto the a i r c r a f t . The captain followed the first o f f i c e r out the l e f t emergency exit. He walked back toward the t a i l section on the now horizontal l e f t side of the a i r c r a f t , opened the l e f t rear emergency door,and climbed down i n t o the a i r c r a f t . There were three male and one female passengers A l l were calm; there was no panic. The captain told them t o come to the inside of the cabin and a f l i g h t attendant a t the front of the cabin. rear exit. The three male passengers climbed out by themselves. The f i r s t officer then escorted each passenger back t o the baggage c a r t and a i r c r a f t began to r o l l over had injured one of her hands. The f l i g h t they climbed down. The woman who had been on the a i r s t a i r when the attendant was attempting t o give f i r s t aid and the captain began t o a s s i s t ; however, a f t e r looking a t the injuries briefly they assisted her i n leaving the a i r c r a f t . The f l i g h t attendant then deplaned followed by the captain. t o Madison Avenue and 43rd Street f o r a "jumper" 21 who h i t a pedestrian. Then a detective unit and a f i r e department unit arrived, a t which time a c a l l over the radio said that a helicopter had h i t the Pan American blade a t the Madison Avenue location. He then walked t o the Pan American Building. A detective said he saw a body and a 6-foot length of rotor Build2hg and went up an elevator with some firemen. About 4 minutes elapsed from the i n i t i a l response u n t i l the detective was on the elevator.

The New York Police Department (NYPD) received a c a l l t o respond

21 A person who had committed suicide by jumping from a building.

r

• 9 -

When the detective and the firemen arrived at the 50th floor, the elevator went back down to the bottom. The Fire Department key was then used to take command of the elevators. When the detective arrived at the top s,ome other fireman were already there. getting to the roof because the elevators remained in automatic operation operated the elevators manually with the fire service keys until building immediately after the accident. When the fire service arrived they personnel arrived to operate the manual controls. The NYPD personnel stated that initial confusion existed in At 1738, the New York Fire Department (NYFD) received a special call to send the rescue unit to the Pan American Building. This was immediately followed by a call for a full response--all units from the with the automatic elevator operation, foam was not applied until 1745 fire battalion--to that location. Because of the difficulty encountered or 1750 when the first fire department units arrived on the roof. The crash/fire/rescue (CFR) procedures outlined for the heliport were contained in the heliport operations manual. The procedures were were not completely familiar with the contents of the CFR portion of the valid and clearly stated for each employee. Some of the station personnel manual. However, the primary firefighters, which were the two cargo handlers, were aware of their CFR duties and performed their duties as dictated by the manual. One cargo handler had received no formal CFR training. The foam hoses were deployed immediately and most of the emergency procedures went into effect. The most significant shortcomings of the CFR activities were: (1) The alarm box to the City/Building fire alarm system was not activated. applied. (3) There was no NYA employee who immediately took charge of (2) Foam was not applied to the aircraft immediately although C02 was the accident site to insure the CFR emergency plan was implemented properly. 1.16 Tests and Research forward main landing gear tube assembly (P/N 56125-50338-2) 21 and the right aft inboard main landing gear fitting with a portion of the tube. Examination of the right forward main landing gear P/N S6125- The Safety Board's metallurgical laboratory examined the right 50333-22 fitting showed that it fractured near where the end of the tube was near the bottom of a 1.498/1.500-inch diameter hole which is drilled assembly is located within the fitting (See figure 2, Appendix F). This in the fitting to accommodate the tube. Fractography of the fractured features indicated that a fatigue crack had begun along the 0.12-inch radius near the bottom of the hole where the hole changes from a cylindrical

to a conical shaped section. (See figure 4 , Appendix F.)

31 The S6125-50338-2 tube assembly includes the S6125-50333-22 fitting,

1

• 10 -

Examination of the fracture using a scanning electron microscope (SEM) disclosed fracture features typical of h' from these origin areas. Fatigue had propagat2down and through the rycle fatiaue p r o p a m n bottom of the fitting and out. (See Figure 4 , Appendix F.) Approximately 40 percent of the fractured cross sectional area of the fitting appeared cracked. The remaining sections of fracture away from this fatigue region were typical of overload separations. ~ ~ ~ ~~~~ - ~~ Some areas were missing along the fracture line that corresponded to the overload portion of the separation. These missing areas suggested that the fitting opposite the fatigue region and near its forward side had broken in compression since compression breaks tend to fragment the fracture. mating fracture halves and noting that the fracture on the inboard half The missing area on the forward side was seen by comparing the went through the small hole used to locate the tube in the fitting while on the outboard half the fracture in the same area progressed through the bolt hole. (See Figure 3, Appendix F.) Detailed examination of the fracture origin area disclosed two origin sites, both of which appeared to be at discontinuities in the planes of fatigue fracture slightly offset from one another. The two radius (See Figures 5 and 6, Appendix F). The two origins produced two fatigue cracks grew into one large crack a short distance out from the radius. Because of the extent and symmetry of the crack arrest markings and the locations of the origins with respect to a ratchet mark (step- was considered secondary and the other was considered the main origin. like portion of the fracture connecting the fatigue planes), one origin A substance was found which completely filled the discontinuity at the secondary origin and partially filled the discontinuity at the main origin. (See Figures 5 and 6, Appendix F.) Energy dispersive X-ray normally associated with the fitting alloy system along with an appreciable analysis of the substance at the main origin area disclosed elements are foreign elements. The silicon energy peak was strong indicating amount of sulfur and small amounts of calcium and potassium all of which silicon as a primary element of the substance; the fitting alloy normally contains less than 0.4 by percent weight of silicon. The radius in the origin area was mostly covered by an adhesive adhesive material indicated that it was high in aluminum and silicon (EC-2214) used during fabrication of the assembly. Analysis of this with some sulfur, chlorine, potassium and calcium. fitting gave values averaging Rockwell "B" 83 and 40 percent International Annealed Copper Standard, respectively. These measurements, as well as the microstructural characteristics, appeared normal for 7075 aluminum alloy heat treated to the T73 condition (specified material and heat treatment). Hardness and electrical conductivity measurements of the

• 11 -

and tube assembly showed fractures that were all typical of an overload separation. No evidence of fatigue or other type of pre-existent cracking was found on this assembly. 1.17 Additional Information 1.17.1 History of Heliport Operation Examination of the right-hand aft main landing gear fitting Heliport operations began in 1965 from the Pan Am Building with New York Airways operating Boeing Vertol 107 equipment. There was public pressure against the NYA petition because of noise and safety reasons. Hearings were held and the operation was approved. A 5-year permit from the NYC Planning Commission was issued for the period 1964 Air Facility Permit for 1 year, which was later renewed for another 1- through 1969. The NYC Department of Marine and Aviation then issued an year term. In February 1968, NYA ceased operations from the heliport because of a contractual disagreement between Pan American World Airways and Trans World Airlines. During the disagreement, the facility permit a renewal. The Department of Marine and Aviation refused to renew the for the heliport expired. Shortly before the expiration date NYA requested permit because (1) NYA was not operating onto the roof heliport currently, at a set date, (3) public pressure was such that a hearing should be (2) NYA presented no plans in the renewal petition to begin operations held. Since NYA was not operating to the roof, the city determined that there was no point in renewing the permit at that time. No further petitions were presented, and in 1969 the NYC Planning Commission permit expired. On November 24, 1976, the New York City Planning Commission held a public hearing to consider the application of New York Airways, Inc., for a resumption of scheduled helicopter operations from the roof top heliport on the Pan American Building. Before the hearing, local community planning boards 5 and 6, representing the neighborhoods most directly affected by the proposed operation, gave their approval of the granting of an operational permit after an extensive review of the facility. The operation was then approved by the New York City Board of Aviation Administration. Estimate, the Department of Marine and Aviation, and by the Federal It The resolution by the Board of Estimate, City of New York, to grant a permit to operate the Pan American Building Heliport was approved December 6, 1976, and adopted January 20, 1977. The special permit was for a 3-year period. 1

• 12 -

Department of Marine and Aviation for an Air Facility License for the On January 27, 1977, New York Airways, Inc., applied to the operation of a heliport on the roof of the Pan American Building. This on February 1, 1977, and were conducted without incident until this license was granted on January 31, 1977, for 1 year. Operations began accident. During this period New York Airways conducted 7,240 helicopter operations from the rooftop heliport. 1.17.2 History of S-61L Forward Lower Landing Gear to Fuselage Attachment Fitting Failures attachment fitting failed when a Los Angeles Airways S-61L, N300Y, was parked with rotors turning at the American Airlines gate area, Los Angeles International Airport. While ground personnel loaded mail aboard the aircraft, a snapping noise was heard, and the helicopter of the five main rotor blades contacted the ramp surface and separated. tipped to the right and rolled over on its right side. Outboard sections building were broken. One person on the ground was injured and windows in the airline terminal On July 15, 1963, a forward lower landing gear to fuselage Investigation revealed that forward lower landing gear fitting, P/N S6125-50312-22, had failed in fatigue and had separated, allowing the right main landing gear to collapse. This part had a total time of 1912:43 hours. the forward and aft fittings, both left and right, as follows: As a result of this occurrence, the manufacturer redesigned 1. Forging material was changed from 7079T6 aluminum alloy to 7075T73 aluminum alloy. 2. Wall thickness of the tube portion of the fitting was increased from .120 to .160 inches. 3. The internally machined radius was increased to .12 inches. models (four at that time) per Sikorsky Service Bulletin 61 B25-1 dated The redesigned fittings were installed on all existing S-61L requiring installation of the improved fittings. (PN's 6125-50333-21-22 September 18, 1963. Appropriate engineering drawings were changed and PN's 4125-50334-21-22). Subsequently, all S-61L model aircraft, including those purchased by New York Airways, Inc., had the improved fittings installed. This had been installed. accident resulted from the first failure since the redesigned fittings

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1. 17.3

Normal Helicopter Operating Procedures Experience has shown t h a t the overall safety of helicopter operations is enhanced by operating the engines and rotor system during operations. Dynamic components of a helicopter's main rotor system a r e the frequent passenger enplaning and deplaning of normal scheduled would shorten the service l i f e of these components which are critical t o not designed f o r frequent stops; therefore, rotor shutdown at each stop safety of f l i g h t and would increase the p o s s i b i l i t y of component fatigue. blades are turning during high and variable wind conditions. Also, The s t a b i l i t y of a helicopter is increased when the rotor blade flapping a t low rotor RPM during such wind conditions increased the possibility of blade damage t o the a i r c r a f t ' s airframe. 1.18 New Investigation Techniques None

ANALYSIS t o applicable regulations. The a i r c r a f t ' s powerplants and systems were not factors i n the accident. The gross weight and c.g. were within prescribed limits. The flightcrew was properly c e r t i f i c a t e d and each crewmember had received the training and off-duty time prescribed by applicable regulations. The a i r c r a f t was c e r t i f i c a t e d , equipped, and maintained according the landing on the heliport was gentle. The a i r c r a f t was taxied t o the According t o the flightcrew, passengers, and other witnesses, normal position without incident, and approved procedures were followed f o r passenger operations. The f a c t t h a t the engines were operating, and the rotor was turning had no bearing on the f a i l u r e of the landing gear. No control input was made which could have overloaded the p a r t which failed. The captain s t a t e d t h a t he had h i s hands on the controls, and t h a t the collective was bottomed, which would produce minimum torque on cyclic was i n the neutral position according t o the captain and the the engines. This s e t t i n g was verified by the f i r s t officer. The r o l l , he saw the blade t i p path r o t a t e with the a i r c r a f t and remain f i r s t officer. The f i r s t o f f i c e r s t a t e d t h a t as the a i r c r a f t began t o constant i n the windshield i n relation, t o the fuselage. The constant relatlonship shows t h a t no cyclic input was induced which in turn would have t i l t e d the rotorhead and the blade t i p path plane. the f i r s t sound of f a i l u r e u n t i l the blades struck the heliport surface,, were correct. The location of the a i r c r a f t and the number of people \, and concluded t h a t the actions taken by the crew--to close the ESC's--' The Safety Board reviewed the actions taken by the crew from 7 14 - around the helicopter, coupled with an unexpected noise from an area \ initially believed by the captain to be the rotor system, dictated that \ the engines be shut down immediately. The fact that both ESC's were shut down so quickly probably prevented further damage and injury and ! possibly prevented a fire. The pilot's reaction of not applying the rotor brake was also correct. The rotor brake is not designed to stop a rotor head turning NR is below 40 percent. For an emergency shutdown the lever may be at 100 percent NR quickly. It is designed to stop the rotor blades once forced forward into the full on position, after closing the engine W M control with a delay time of 5 seconds. Since the captain barely had time to close the ESC's before the blades struck the ground, the Safety Board concludes that he could not have used the rotor brake for an emergency stop of the rotor blades. At 100 percent NR, the application of the rotor brake will cause the brake to heat up and possibly burn out, thereby creating a fire hazard. The Safety Board, therefore, concludes that the failure of the gear was not the result of a pilot input. The fracture of the right hand landing gear forward fitting, P/N S6125-5033-22, stemmed from a fatigue crack through 40 percent of the cross section. The crack location in the bottom portion of the fitting and placed tension on the bottom, had caused the fracture to begin and suggested that bending stresses, which compressed the top of the fitting propagate. Planar orientation of the crack was diagonally downward and inboard through the support rib between the fuselage and lower diagonal tube attachment. Since fatigue cracks tend to propagate in a plane perpendicular to the direction of principle tension stress, a tension force along the diagonal tube may also have contributed to the crack propagation. The material properties of the fitting, including the chemical composition, were considered normal for 7075-T73. Originally the fitting with stress corrosion cracking warranted changing the material to 7075- was designed using the alloy 7079-T6 (P/N S6125-50312). However, problems T73 (T73 condition is highly resistant to stress corrosion). The radius showed no appreciable attack from corrosion, indicating this area vas adequately protected against it. There was no indication of stress corrosion on the fracture surface although pitting of the fracture was noted. This pitting, however, was much more intense in the latter stages of fatigue propagation, indicating that the corrosion medium may have entered when the crack opened to the atmosphere (breaking through the support rib and lower portion of the fitting).

15 - These holes were located along the inboard edge of the adhesive just inboard of the tube end and were open between the external and internal radius of the fitting. An access, therefore, existed for water or other mediums to penetrate into the interior and collect along the lower portion of the radius. If the adhesive in the radius area contained minute holes through its thickness, then corrosion attack would have been highly localized, and would have produced discontinuities such as those found on the failed fitting. Two holes, however, did enter into the interior of the tube. The discontinuities found could also have been produced by normal microconstituent particles or phases in the material which were exposed to the surface. The sizes of the discontinuities, however, were much larger than the compound phases or particles found in the microsections which would mean that the discontinuities would have to be unusually large particles or groupings of second phase particles. The substance found in the cavities of the discontinuities is believed to be the adhesive used in the assembly. It is not known whether the adhesive entered the cavity before or after the fracture. The Safety Board, therefore, concludes that the fracture of the right main landing gear was the result of fatigue originating from a small surface pit of undetermined source. Although, in this case, the rotating main rotor blades resulted in fatalities when the right landing gear failed, there is a good possi- bility that similar fatalities could have occurred if gear failure had occurred during shutdown or starting procedures. In considering all of deplaning operations versus frequent rotor shutdowns, the Safety Board the safety aspects of continued rotor rotation during enplaning and most cases, safer. This conclusion is based on the fact that, (1) concludes that continued rotor rotation during such operations is, in and the engine by introducing more fatigue cycles thereby reducing the frequent rotor shutdowns shorten the service life of the rotor components brake fires, engine acceleration malfunctions, and main blade to fuselage overall safety of operations, (2) potential safety hazards such as rotor repeated rotor brake applications, and (3) the stability of the helicopter contact due to excessive flapping at low rotor RPM are introduced by blades. Continued rotation is especially important for safety during is increased due to the gyroscopic effects resulting from the rotating variable, high wind conditions.

The heliport was certificated properly under 14 CFR 139. All criteria was met or exceeded. The personnel requirements, as stated in the equipment which was required to meet the crash fire rescue (CFR) the heliport manual, were met or exceeded.

16 - existed and some misunderstanding of CFR responsibilities were apparent, the CFR activities were effective for the situation. The Safety Board also concludes that, although some confusion the aircraft remain open. Helicopters operated under 14 CFR 127 are The Safety Board recommends that the cockpit cabin door of not required to have the cockpit door closed and locked as are aircraft operated under 14 CFR 121. Since the door is not usually used in normal become an obstruction between the cockpit and cabin during emergency operations, the Safety Board believes that it is unnecessary and could conditions.

• CONCLUSIONS

1. 1

Findings

The aircraft was certificated and maintained according to approved procedures.

All crewmembers were certificated and qualified for the flight.

The airport was properly certificated under 14 CFR 139, without exemptions. 4 . The fracture of the right main landing gear forward fitting resulted from a fatigue crack.

The fatigue crack had initiated along the 0.12 inch internal radius near the bottom of one of the two loca- tion holes where the hole changes from a cylindrical to a conical shape.

Fracture features were typical of high cycle fatigue propagation from the origin areas and propagation down and through the bottom of the fitting.

All fractures outside the vicinity of the fatigue origin regions resulted from overload separations.

Hardness and electrical conductivity measurements of the failed fitting gave values normal for 7075 aluminum alloy 1 heat treated to the T 7 3 condition.

The failure of the landing gear did not result from any pilot inputs or operational overloads.

The flightcrew's decision to close the EX'S after a malfunction was suspected was proper.

• 17 -

The rotor brake could not have been used effectively to halt the rotor system in the short time interval between failure of the landing gear and rotor blade impact. The CFR procedures for the heliport were adequate for the emergency. New York Airways personnel accomplished effectively the CFR duties, although there was some confusion concerning overall supervision of specific duties. 3.2 Probable Cause probable cause of the accident was the fatigue failure of the upper right forward fitting of the right main landing gear tube assembly. Fatigue originated from a small surface pit of undetermined source. All fatalities were caused by the operating rotor blades as the result of the collapse of the landing gear. The National Transportation Safety Board determines that the 4 . SAFETY RECOMMENDATIONS As a result of this accident, on May 18, 1977, the National Transportation Safety Board issued the following recommendations to the Federal Aviation Administration: “Issue an Airworthiness Directive to require an immediate one-time inspection by an approved method on both the forward and aft main landing gear attachment fittings, right and left, on all Sikorsky Model 61L series helicopters having similar installations. (Class I - Urgent Followup) (A-77-32) Reevaluate the current inspection interval and issue a , requirements for more frequent periodic inspections if necessary to insure continued safe operation. The inspection interval could be based on a set number of operating cycles instead of an established operating time. (Class I1 - Priority Followup) (A-77-33)” Upon receipt of these recommendations, the Federal Aviation Administration issued a telegraphic airworthiness directive which: ’. (1) Required, prior to next flight, a fluorescent penetrant j inspection of the forward and aft main landing gear attachment fittings, right and left, on all affected ~. visual inspection was required prior to the first flight Sikorsky Model 61 series helicopters. In addition, a of each day. 18 - (2) Required the reevaluation of the current inspection interval and issue requirements for more frequent periodic inspections if necessary to insure continued safe operation. The inspection interval could be based on a set number of operating cycles instead of an established operating time . As a result of the cockpit door of the S-61L sliding almost closed and jamming, on July 13, 1977, the Safety Board subsequently recommended that the Federal Aviation Administration: "Require that the sliding cockpit door on the Sikorsky S-61L helicopter be removed or retained open so that it cannot obstruct the entrance from the cockpit to the cabin area. (Class 11-Priority Followup) (A-77-51) BY THE NATIONAL TRANSPORTATION SAFETY BOARD / s / KAY BAILEY Acting Chairman / s / FRANCIS H. McADAMS Member /s/ PHILIP A. HOGUE Member /s/ WILLIAM R. HALEY Member October 13, 1977

19 - APPENDIX A INVESTIGATION AND HEARING

Investigation May 16, 1977. The investigation team went immediately to the scene. Working groups were established for operations/weather/airports/air traffic control, human factors, witnesses, structures/systems, powerplantsl maintenance records, and cockpit voice recorder. The Safety Board was notified of the accident about 1745 on Participants in the on-scene investigation included representa- tives of the Federal Aviation Administration, Sikorsky Aircraft, New York Airways, Inc., New York City Transportation Department, Air Lines Pilots Association, and Association of Flight Attendants.

Hearing A public hearing was not held. 20 - APPENDIX B PERSONNEL INFORMATION Captain Lee G. Richmond 1964, as a first officer. He was qualified initially in the S61N on March 22, 1964, and upgraded to Captain on November 17, 1970. His initial Category-A Edge qualification was on April 23, 1971. Captain Lee G. Richmond, 46, was employed by NYA on February 24, Captain Richmond's last line check was on June 28, 1976. He had completed proficiency checks/recurrent training on January 12, 1977, and July 13, 1976. He received an Edge Procedure Checkout and Line Check on February 1, 1977. This period also included a 1 hour ground school on edge procedures. No. 644892 dated November 11, 1970, with the following ratings: Rotorcraft - Captain Richmond holds Airlines Transport Pilot Certificate Helicopter BV-107-11 (VFR only) SK-61; Commercial Privileges airplane single-engine, land and sea; airplane multi-engine land, glider, instruments. It had no limitations. His first-class medical certificate was dated April 21, 1977. at the time of the accident, 9,000 of which were in helicopters. He had about 2,200 hours in S61 helicopters. In the previous 30 days he had recorded 50:30 hours as a S61 helicopter captain and 9:20 hours other helicopter time. Captain Richmond had about 11,721 total hours of flight'time rotor time as an S61 captain. First Officer John F. Flanagan In the 24-hours before the accident he had recorded 3:48 hours First Officer (F/O) John F. Flanagan, 31, was hired by New York Airways on April 8, 1977. His initial 561 qualifications was on April 16, 1977, and his Edge Procedure Qualification was completed on April 15, 1977. First Officer Flanagan holds Commercial Certificate No. 1987361 with the foJlowing ratings: Airplane single-engine land, rotorcraft- helicopter instruments including helicopter. The date of his certificate was January 6, 1970. His second-class medical certificate was dated August 26, 1976, and had no limitations.

21 - APPENDIX B First Officer Flanagan had a total of 1,768.4 hours of flying time, with 1,339.2 hours recorded in helicopters. His total 561 time was 61 hours, all flown in the 30 days prior to the accident. He had recorded 3:48 hours rotor time in the 24 hours before the accident. each pilot had flown. On the first day of this sequence they did not The day of the accident was the fourth consecutive day that fly together. However, they flew together on the second and third days, and the day of the accident. They reported for duty at JFK at 1402 on the day of the accident. Each had been off duty since 2117 the previous day. At the time of the accident each pilot had been on duty 3:33 hours. Flight Attendant Lammie Chevalier Flight Attendant Chevalier was employed by New York Airways in

• She was current and qualified to perform her prescribed duties.
• 22 -

APPENDIX C AIRCRAFT INFORMATION Sikorsky S-61L, N619PA (SIN 61427) was manufactured in June

• It was owned by the General Electric Credit Corporation of Georgia

and operated by New York Airways, Inc. It was certificated and maintained according to procedures approved by the FAA. At the time of the accident the aircraft had accumulated about 6,913:15 flight hours and 7:22 flight hours since its last major inspection. engines. Engine serial numbers and times are as follows: The aircraft was equipped with two General Electric CT58-140-2 Position Serial No. Total Time 1 2 295063C 295069C 7,201:44 6,517:52 I E 47 E 46 z L I L E 45 7 E 4 4 E 42 UNION CARBIDE BUILDING CHEMICAL BANK BLDG I I I U I ST

@

HOTEL BILTMORE ‘331 I MADISON I AV ST AMERICAN BRAND! BLDG NEWYORK 2 GENERAL BUILDING

E P, 0 466 LEXINGTON Q BLDG p y - ACCIDENT GRAND CENTRAL TERMINAL POST OFFICE GRAYBAI BUILDIN( I Site Co-ordinates: Long. 73O 58’ West Lat. 40° 45‘ North

I FERICAN BRANDS BLDG c I POST @ OFFICE 8 A I I I GRAYBAR BUILDING CENTRAL TERMINAL I I I APPENDIX ' 0 LEGEND

1. C-5" Outboard Section - Main Blade Spar
2. 4'4" Spar Section - Outboard End Tip
3. C-1'' Spar Section - Outboad End Tip
4. 4-0" Spar Section - Outboard End Tip
5. 0-11'' Spar Section - Outboard End Tip
6. 2-3" Spar Section - Outboard End Tip
7. C-2" Outboard Section - Main Blade Spar
8. 2 Twelve Inch Wide Trailing Edge PoCketO
9. 10-6" Center Section - Main Blade Spar

IPenetrated Window of Office 36th Floor)

1. 2-4" Outboard Section - Main Blade Spar
2. 1 Twelve Inch Wide Trailing Edge Pocket
3. 3'W Outboard Section - Main Blade Spar
4. 4"Z Outboard Section - Main Blade Spar

[Outside Room 369-466 Lexington Ave.1

1. 1 9 - 2 Center Section - Main Blade Spar

Ion Heliport Just Forward of Aircraft Nose)

1. Miscellaneous Blade Parts - PocketO.

Leading Edge Counterweights 111 Locations) Ion Heliportl e Helicopter Location NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. Wreckage Distribution Chart Sikorsky S61L N619PA New York Airways Inc. Pan Am Building Rooftop Heliport Manhattan, New York May 16.1977 1

• 25 -

APPENDIX E FIGURE 1 APPENDIX E FIGURE 2

• 26 -

ENERGY ABSORBING STRUT 6125-50301 AFT Flll'lNG 6125-50334-12 I I I / / / / FITTING ASSEMBLY L CLY 6125-50317-3 OLEO STRUT 6125-50302 \ \ FWD S-61L MAIN LANDING GEAR

• 27 -

APPENDIX F Figure 1. Overall view of the components, as received. 1.) Forward main landing gear fitting and tube assembly. 2.) Aft main landing gear inboard fitting with portion of tube. Figure 2. Right hand main landing gear fitting (P/N placed relative to each other as if intact. Inboard 56125-50333-2) with the fractures (arrows "a" figure 1) attachment bolt was removed from the hole. APPENDIX F

• 28 -

Looking Inboard Looking Outboard Figure 3. Mating fracture surfaces on the P/N S6125-50333-2 fitting. Both photographs approximately X1 1 / 4 Figure 4 . Portion of inboard fracture surface removed for detailed fractographic examination. Arrow "0" denotes main origin and arrow "S" locates secondary origin while dashed lines indicate approximate extent of fatigue propagation from these origins.

• 29 -

APPENDIX F . Figure 5. SEM photograph showing secondary origin bracket S (see arrow "S" in figure 4 for location). Fracture heads depict fatigue propagation direction. X100 surface is above origin and hole radius is below. Arrow- ,, ,e Figure 6. SEM photograph of main fatigue origin area (see arrow "0" figure 4 for location). Arrowheads indicate fatigue propagation directions. X90 APPENDIX F

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~ i I \ \ Figure 7 Main o r i g i n area shown i n f i g u r e 6 a f t e r extensive cleaning by replication. X300 Figure 8. Longitudinal metallographic microsection through the main origin area showing the discontinuity i n profile. Arrows "R" and "F" indicate the radius and fracture p r o f i l e respectively. 9x375 Kellers etch

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, APIJENDIX F Figure 9. Longitudinal section through.the fitting radius at a location diametrically opposite the fatigue origin. X10 unetched Figure 10. Longitudinal section through the main depicted by arrow "0" in figure 8. X10 nital etched fatigue origin area. Arrow "0" indicates same area

FD06968 ｜ 1979_美国_AAR7907.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1979 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

NATKDNAL AIRCRAm ACCIDENT REPORT

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NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 Page 15 , Sectic’:: 1.16.1, link2 5: c:‘1.3:1gt’ “Cause” to “caust2d .‘I Page 25, second f u! 1 paragrapll, 1 ir,e 9: c h ,‘. n g e “first office-r” to “flir:ht engineer.” UNITED STATES GOVERNMENT

UNITED AIRLINES, INC. MCDONNELL-DOUGLAS, DC-8-61, N8082U PORTLAND, OREGON DECEMBER 28,19!8 NTSB-AAR-79-7 .

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4 . T i t l e a n d S u b t i t l e TECHNICAL' REPORT DOCUMENTATION PAGE 2.Covernment Accession No. 3.Recipient’s Catalog NO. 1 -5.Report D a t e Aircraft Accident Report - United Airlines, Inc., McDonnell-Douglas DC-8-61, N8082U, Portland, 8

• 1979

rforming Organization Code 8.Performing Organization Report No.

• Performing Organization Name and Address

lO.Work U n i t N o . National Transportation Safety Board Bureau of Accident Investigation Washington, D.C. 20594 Period Covered 12.Sponsoring Agency Name and Address NAT IONAL TRAKSPORTAT I ON SAFETY BOARD W a s h i n g t o n , 0. C . 20504 IS.Supplenentary f;oles 16.Abstract About 1815 Pacific standard time on December 28, 1978, United Airlines, Inc., Flight 173 crashed into a wooded, populated area of suburban Portland, Oregon, during an approach to the Portland International Airport. a1 a low altitude for about 1 hour The aircraft had delayed southeast of the airport while the flightcrew coped with a landing gear malfunction and prepared the passengers for the possibility of a landing gear failure upon landing. The plane crashed about 6 nmi southeast of the airport. The aircraft was destroyed; there was no fire. Of the 181 passengers and 8 crPwmembers aboard, 8 passengers, the flight engineer, and a flight attendant were killed and 21 passengers and 2 crewmembers were injured seriously. The National Transportation Safety Board determined that the probable cause of the accident was the failure of the captain to monitor properly the aircraft’s fuel state and to properly respond to the low fuel state and the crewmember’s advisories regarding fuel state. This resulted in fuel exhaustion to all engines. His inattention resulted from preoccupation with a landing gear malfunction and preparations for a possible landing emergency. :I ?ither Contributing to the accident was the failure of the other two flight &wmembers to fully comprehend the criticality of the fuel state or to successfully communicate their concern to the captain.

• Key Words

1. Oistribution Statement

?uel exhaustion, fuel state, preoccupation, landing rear malfunction, yaw, retract cylinder assembly, fuel Iages, to talker. This document is available through the National Technical Information dentifier: McDonnell-Douglas DC-a-61 Accident Service, Springfield, VA 22151 I Y.Security Classification 1 20.Security Classification 2l.No. of Pages 122.Price ( o f t h i s r e p o r t ) (of this page) UNCLASSIFIED UNCLASSIFIED ‘KSB Form 1765.2 (Rev. 9/74) ( 62 1 j

! 1 i i 1. 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 1.10 1.11 1.12 1.13 1.14 1.15 1.16

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. . . . . . . . . . . . . . . 3. Cone Ius ions . . . . . . . . . . . . . . . . 3.1 Findings . . . . . . . . . . . . . . . . . . 3.2 Probable quse . . . . . . . . . . . . . . . 4. Safety Reborn.mendations . . . . . . . . . . . . 5. ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ Appendixes. . . . . . . . . . . . . . . . . . . . . . . . . . Appendix .. - Investigation and Hearmg . . . . . . . . . . . . Appendix B - Personnel Information. . . . . . . . . . . . . . Appendix C - Aircraft Information . . Appendix D - Cockpit Voice Recorder Transcript . . . . . . . . . . . . . . . . . . . . i i 1 2 2 8 8 8 8 8 10 10 10 10 11 11 12 13 13 14 14 15 15 16 17 18 18 18 18 20 20 21 21 22 27 27 28 29 30 30 31 33 34

NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT Adopted: June 7, 1979 UNITED AIR LINES, INC. MCDONNELL-DOUGLAS DC-8-61, N8082U PORTLAND, OREGON : DECEMBER 28, 1978 SYNOPSIS About 1815 Pacific standard time on December 28, 1978, United Airlines, Inc., Flight 173 crashed into e wooded, populated area of suburban Portland, Oregon, during an approach to the Portland International Airport. The aircraft had delayed southeast of the airport at a low altitude for about 1 hour while the flightcrew coped with a landing gear malfunction and prepared the passengers for a possible emergency landing. The plane crashed about 6 nmi southeast of the airport. The aircraft was destroyed; there was no fire. Of the 181 passengers end 8 crewmembers aboard, 8 passengers, the flight engineer, end a flight attendant were killed and 21 passengers and 2 crewmembers were injured seriously.

• The National Transportation Safety Board determined that the probable cause

of the accident was the failure of the captain to monitor properly the aircraft’s fuel state and to properly respond to the low fuel state and the crewmember’s advisories regarding fuel state. This resulted in fuel exhaustion to all engines.’ tiis inattention resulted from preo&upation with a landing gear malfunction end preparations for a possible landing emergency. Contributing to the accident was the failure of the other two flight crewmembers either to fully comprehend the criticality of the fuel state or to successfully communicate their concern to the captain. . .

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1. FACTUAL INFORMATION
2. 1

History of the Flight IiI’ !. On December 28, 1978, United Airlines, Inc., Flight 173, a McDon- nell-Douglas DC-8-61 (N8082U), was a scheduled flight from John F. Kennedy International Airport, New York, to Portland International Airport, Portland, Oregon, with an en route stop at Denver, Colorado. l/ Flight 173 departed from Denver about 1447- with 189 persons on board, including 6 infants, and 8 crewmembers. The flight was cleared to Portland on an instrument flight rules (IFR) flight plan. The planned time en route was 2 hrs 26 min. The planned arrival time at Portland was 1713. 21 x According to the automatic flight plan and monitoring system- the total amount of fuel required for the flight to Portland was’31,900 lbs. There was 46,700 lbs of fuel on board the aircraft when it departed the ga te at Denver. This fuel included the Federal Aviation Regulation requirement for fuel to destination plus 45 min and the company contin- gency fuel of about 20 min. During a postaccident interview, the captain stated that he was very close to his predicted fuel for the entire flight to Portland ‘I... or there would have been some discussion of it.” The captain also explained that his flight from Denver to Portland wes normal. ’ I’ At 1705:47, Flight 173 celled Portland .\pproech end advised that its altitude was lO!OOO ft 3/ end its airspeed was being reduced. Portland responded and told the fGght to maintain its heeding for e visual approach to runway 28’. Flight 173 ecknowledged the approach instructions and stated, “. . . we have the field in sight.” At 1707:55, Portland Approach instructed the flight to descend and maintain 8,000 ft. Flight 173 acknowledged the instructions end advised that it wes “leaving ten.” At 1709:40, Flight 173 received and acknowlec@ed a clearance to continue its descent to 6,000 ft. During e postaccident interview, the captain stated that, when Flight 173 was descending through about 8,000 ft, the first officer, who was flying the aircraft, requested the wing flaps be extended to 15’, then asked that the landing gear be lowered. The captain stated that he complied with both requests. However, he further-stated that, as the landing gear extended, ‘I. . . it was noticeably unusual and (I) feel it seemed to go down more rapidly. As (it is) my recollection, it was a thump, thump in sound end feel. I don’t recall getting the red and transient gear door light. The thump was much out of the ordinary for this airplane. It was noticeably different and we got the nose gear green l&W times herein are Pacific standard, based on the 24-hour clock. j/ A computer printout which predicted the amount of fuel that would be used between several identifiable en route points. The flightcrew was able to check the actual fuel used against the predicted fuel use at each of these points. 3/ All altitudes are mean sea level unless otherwise indicated. . . . . _ . . . . . r‘.’ _ . . . . -. . -.

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-3- light but no other lights.” The captain also said the first officer remarked that the aircraft “yawed to the right. . . .‘I Flight attendant and passenger statements also indicate that there was a loud noise and a severe jolt when the landing gear was lowered. d At 1712:20, Portland Approach requested, “United one seven three ‘heavy, contact the tower (Portland), one one eight point seven.” The flight responded, “negative, well stay with you. Well stay at’ five. Well maintain about a hundred and seventy knots. We got a gear problem. Well let you know.” This was the first indication to anyone on the ground that Flight 173 had a problem. At 1712:28, Portland Approach replied, “United one seventy-three heavy roger, maintain five thousand. Turn left heading two zero zero.” The flight acknowleged the instructions. . _ At 1714:43, Portland Approach advised, “United one seventy three heavy, turn left heading, one zero zero and I’ll just orbit you out there“ti1 you get your problem.” Flight 173 acknowledged the instructions. For the next 23 min, while Portland Approach was vectoring the aircraft in a holding pattern south and east of the airport, the flightcrew discussed and accomplished all of the emergency and precautionary actions available to them to assure the locked in the full down position. The indicators on top of both wings, -3 l,yF3tJt$&l landing gear leas cer checked the visual which’ ex?end ‘above the wing surface when the landing ge,ar is down-and-locked. The captain stated that during this same time period, the first flight attendant came forward and he discussed the situation with her. He told her that after they ran a few more checks, he would let her know ivhat he intended to do. 3 About 1738, Flight 173 contacted the United Airlines Systems Line Maintenance Control Center in San Francisco, California, through Aero- nautical Radio, Inc. 4/ According to recordings, at 1740:47 the captain explained to company dispatch and maintenance personnel the landing gear problem and what the flightcrew had done to assure that the.landing gear was fully extended. He reported about 7,000 lbs of fuel on board and stated his intention to hold for another 15 or 20 minutes. He stated that he was going to have the flight attendants prepare the passengers for emergency evacuation. At 1744:03, United San Francisco asked, “okay, United one seventy three . . . You estimate that you’ll make a landing about five minutes past the hour. Is that okay?” The captain responded, “Ya, that’s good ball park. I’m not gonna hurry the girls. We got about a hundred sixty five people on board and we . . .want to . . .take our time and get everybody ready and then we’ll go. It’s clear as a bell and no problem.” s/ Aeronautical Radio, Inc., an air-to-ground radio service which provides a communication system for commercial aircraft.

The aircraft continued to circle under the direction of Portland Approach in a triangular pattern southeast of the airport at 5,000 ft. The pattern kept that aircraft within about 20 nmi of the airport. (See Figure 1.1 #a From about 1744:30 until about 1745:23, the cockpit voice recorder (CVR) contained conversation between the captain and the first flight attendant concerning passenger preparation, crash landing procedures, and evacuation procedures. During his initial interview, the captain indicated that he neither designated a time limit to the flight attendant, nor asked her how long it would take to prepare the cabin. He stated that he assumed 10 or 15 minutes would be reasonable and that some preparations could be made on the final approach to the airport. -c At 1746:52, the first officer asked the flight engineer,“‘How much fuel we got . . . ?” The flight engineer responded, “Five thousand.” The first officer acknowledged the response. At 1748:38, Portland Approach advised Flight 173 that there was another aircraft in its vicinity. The first officer edvised Portland Approach that he had the aircraft in sight. % At 1748:54, the first officer asked the captain, “. . .what’s the fuel show now . . . ?I’ The captain replied, “Five.” The first officer repeated, “Five.” .-It 1749, after a partially unintelligible comment by the flight engineer concerning fuel pump lights, the captain stated, “That’s about right, the feed pumps are starting to blink.” According lo data received from the manufacturer, the total usable fuel remaining ivhen the inboard feed pump lights illuminate is 5,000 Ibs. .?t this time, according to flight data recorder (FDR) and air traffic control data, the nircraft was about 13 nmi south of the airport on a west south;qesterly heading. From just after 1749 until 17-19:15, the flightcrew engaged in further conversation about the status of the landing gear. This conversa- tion was interrupted by a heading change from Portland Approach and was followed by a traffic advisory from Portland Approach. b About 1750:20, the captain asked the flight engineer to “Give us a current card on yeight. Figure about another fiftee.n minutes.” The first officer responded, “Fifteen minutes?” To which the captain replied, “Yeah, give us three or four thousand pounds on top of zero fuel weight.” The flight engineer then said, “Not enough. Fifteen minutes is gonna- really run us low on fuel here.” At 1750:47, the flight engineer gave the following information for the landing data card: “...Okay. Take three thousands pounds, two hundred and four.” At this time the aircraft was about 18 nmi south of the airport in a turn to the,northeast. 9 At 1751:35, the captain instructed the flight engineer to contact the company representative at Portland and apprise him of the situation and tell him that Flight 173 would land with about 4,000 lbs of fuel. From ‘. * ---_ _ . --~.

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‘V’ \ -_ ’ ’ -- _. . , 1752:17 until about 1753:30, the flight engineer talked to Portland and discussed the aircraft’s fuel state, the number of persons on board the aircraft, and the emergency landing preparations at the airport. At 1753:30, because of an inquiry from the company representative at Portland, the flight engineer told the captain, “He wants to know if we’ll be landing about five after.” The captain replied, 1’Yes.ff The flight engineer relayed the captain’s reply to the company representative. At this time the aircraft was about 17 nmi south of the airport heading northeast. -r At 1755:04, the flight engineer reported the “...approach descent check is complete.” At 1756:53, the first officer asked, “How much fuel you got now?” The flight engineer responded that 3,000 lbs remained, 1,000 lbs in each tank. At 1757:21, the captain sent the flight engineer to the cabin to “...kinda see how things are going. . . .” From 1757:30 until 1800:50, the captain and the first officer engaged in a conversation which included discussions of-giving..the flight attendants ample time to prepare for the ..__ emergency, cockpit procedures in -c’---the event of an evacuation after landing, whether the brakes would have antiskid protection after landing, and the procedures the captain would be using during the approach and landing. At 1801:12bPortland Approach requested that the flight turn left to a heading of 195 . The first oifice; acknowledged and complied ;vith the request. At 1801:34, the flight engineer returned to the cockpit and reported that the cabin would be ready in “another Iv.*o or three minutes.” The aircraft was about 5 nmi southeast of the airport turning to a south\Acest- erly heading. Until about 1802:10, the captain and the flight engineer discussed the passengers and their attitudes toward the emergency. .-,‘1 At 1802:22, the flight engineer advised, “We got about three on the fuel and that’s it.” The aircraft was then about 5 nmi south of the airport on a southwest heading. The captain responded, “Okay. On touchdown, if the gear folds or something really jumps the track, get those boost pumps off so that. . .you might even get the valves open.” At 1802344, Portland Approach asked Flight 173 for a status report. The first officer replied, “Yeah, we have indication our gear is abnormal. It’ll be our intention, in about five minutes, to land on two eight left. We would like the equipment standing by. Our indications are the gear is down and locked. We’ve got our people prepared for an evacuation in the event that should become necessary.” At 1803:14 Portland Approach asked that Flight 173 advise them when the approach would begin. The captain responded, I’. . . They’ve about finished in the cabin. I’d guess about another three, four, five

-7 - minutes.” At this time the aircraft was about 8 nmi south of the airport on a southwesterly heading. )rr At 1803:23, Portland Approach asked Flight 173 for the number of persons on board and the amount of fuel remaining.- The captain replied, “. . . about four thousand, well, make it three thousand, pounds of fuel,” and “you can add to that one-seventy-two plus six laps- infants.” From 1803:38 until 1806:10, the flightcrew engaged in a conversa- tion which concerned (1) checking the landing gear warning horn as further evidence that the landing gear was fully down and locked and (2) whether automatic spoilers and antiskid would operate normally with the landing gear circuit breakers out, . . gr) At 1806:19, the first flight attendant entered the cockpit. The captain asked, “How you doing?” She responded, “Nell, I think we’re ready.” At this time the aircraft was about 17 nmi south of the airport on a southwesterly heading. The conversation between the first flight attendant and the captain continued until about 1806:40 when the captain said, “Okay. \$e’re going to go in noIf*. \‘e should be landing in about five minutes.” Almost simultaneous with this comment, the first officer said, “I think you just lost number four . . . ,” followed immediately by advice to the flight engineer, “. . . better get some crossfeeds open there or something.” ,& At 1806:46, the first officer told the captain, “We’re going to lose an engine. . . .‘I The captain replied, “\t’hy?” At 1806:49, the first officer again stated, “We’re losing an engine.” Again the captain asked, ” 1% hy .3” The first officer responded, “Fuel.” p Between 1806:52 and 1807:06, the CVR revealed conflicting and confusing conversation between flight crewmembers as to the aircraft’s fuel state. At 1807106, the first officer said, “it’s flamed out.” At 1807:12, the captain called Portland Approach and requested, II. . . would like clearance for an approach into two eight left, nowl” The aircraft was about 19 nmi south southwest of the airport and-turning left. This was the first request for an approach clearance from Flight 173 since the landing gear problem began. Port land Approach immediately gave the flight vectors for a visual approach to runway 28L. The flight turned toward the vector heading of 010’. 4 F r o m 1807:27 until 1809:16, the following intracockpit conversation took place: 1807:27 - Flight Engineer: “We’re going to lose number three in a minute, too.” 1807:31 - Flight Engineer: “It’s showing zero.” Captain: “You got a thousand pounds. You got to.”

N -. ’ 0 .. . , Flight Engineer: “Five thousand in there . . .but we lost it.” Captain: “Alrigh t.” 1807:38 - Flight Engineer: “Are you getting it back?” 1807~40 - First Officer: “No number four. You got that crossfeed open?” 1807:41 - Flight Engineer: “No, I haven’t got it open. Which one?” 1807:42 - Captain: “Open ‘em both--get some fuel in there. Got some fuel pressure?” Flight Engineer: “Yes, sir.” 1807:48 - Captain: “Rotation. Now she’s coming.” 1807:52 - Captain: “Okay, watch one and two. We’re showing down to zero or a thousand.” Flight Engineer: “Yeah” Captain: “On number one?” Flight Engineer: “Righx” 1808:08 - First Officer: “Still not getting it.” 1808:ll - Captain: “\i’ell, open aII four crossfeeds.” Flight Engineer: “All four?” Captain: “Yeah.” 1808:14 - First Officer: “.Alright, no1.i it’s coming.” 1808:19 - First Officer: “It’s going to be --on approach though.” Unknown Voice: “Yeah.” 1808:42 - Captain: “You gotta keep ‘em running. . . .” Flight Engineer: “Yes, sir.” 1808:45 - First Officer: “Get this. . .on the ground.” Flight Engineer: “Y’cah. It’s sho\*ing not L’ery much more fueL” 1809:16 - Flight Engineer: “i\‘e’re do;vn to one on the totalizer. [dumber two is erzpty.” rit 1809:21, the captain advised Portland Approach, “United, seven three is going to turn to\‘ard the airport and come on in.” ..I f t e r confirming Flight 173’s intentions, PortIand :Jpproach cleared the flight for the visual approach to runii’ay 281,. At 1810:17, the captain requested that the flight engineer “reset that circuit breaker momentarily. See if we get gear lights.” The flight engineer complied with the request. At 1810:47, the captain requested the flight’s distance from the airport. Portland approach responded, “I’d calI it eighteen flying miles.” At 1812:42, the captain made another request for distance. Portland Approach responded, “Twelve flying miles.” The flight was then cleared to contact Portland tower. At 1813:21, the flight engineer stated, “We’ve lost two engines, guys.” At 1813:25, he stated, “We just lost two engines - one and two,” At 1813:38, the captain said, “They’re all going. We can’t make Troutdale.” 5/ The first officer said, “We can’t make anything.” 5/ A small airport on the final approach path to runway 28L.

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. ’ _ -. . . At 1813:46, the captain told the first officer, “Okay. Declare a mayday.” At 1813:50, the first officer called Portland International Airport tower and declared, “Portland tower, United one seventy three heavy, Mayday. We’re--the engines are flaming out. ,We’re going down. We’re not going to be able to make the airport.” This was the last radio transmission from Flight 173. About 1815, the aircraft crashed into a wooded set tion of a populated area of suburban Portland about 6 nmi east southeast of the airport. There was no fire. The wreckage path was about 1,554 ft long and about 130 ft wide. The accident occurred during the hours of darkness at latitude 45’31’21”N and longitude 122’29’59”W. The elevation of the accident site was 285 ft. 1.2 Injuries to Persons Injuries Crew Passengers Others 1.3 Fatal 2 Serious 2 lMinor/None 4 . Damage to Aircraft The aircraft was destroyed. 8 21 152 I ; 1.4 Other Damase 0 0 0 Two unoccupied homes were destroyed. Telephone lines were cut and high-tension electrical powerlines were damaged. 1.5 Personnel In for ma tion The crewmembers were properly certificated and qualified for the flight. (See Appendix B.) 1.6 K Aircraft Information . . The aircraft was certificated and maintained in accordance with Federal Aviation Administration (FAA) requirements. The gross weight and center of gravity were within prescribed limits for the approach and landing. There was no usable fuel in the aircraft when it crashed. The figures below illustrate the aircraft’s approximate takeoff gross weight, approximate landing weight, and the approximate pounds of fuel remaining upon arrival in the vicinity of the Portland International Airport; these figures are based on normal operations.

Zero fuel weight from weight manifest Total fuel on board from fuel service form Aircraft weight before departure from gate at Denver Fuel consumption on taxi Takeoff gross weight Fuel consumption en route to Portland, based on flight plan Landing weight at Portland lbs 200 27 +46,7 00 248,627

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247,6 27 -31,900 215,727 Zero fuel weight from weight manifest -2oi,927 Fuel remaining at Portland 13,800 /9 fl Throughout the landing delay, slight 173 remained at 5,000 ft with landing gear down and flaps set at 15 . Under these conditions, the Safety Board estimated that the flight would have been burning fuel at the rate of about 13,209 lb.spe,r-hour--220 lbs per min. At the beginning of the landing delay,?here were about 13,332 lbs-df fuel on board. X new type of fuel quantity indicating system was retrofitted to this aircraft on Slav 12, 1978. Authorization ko. 2-1849. The retrofit was authorized by Change Order \iith the new system installed, there are eight individual tank quantity gages. Each of these gages has three digits which are seven-segment incandescent lamps. On these individual tank gages, the digital reading is multiplied by 100 to obtain the total amount of fuel in the tank. The totalizer gage receives input from each individual tank gage and displays the total fuel available on three digital readouts. However, this digital reading must be multiplied by 1,000 to obtain the value of the total amount of fuel on board. The smallest increment of change that can be indicated on the individual tank gages is 100 lbs. The smallest increment of change on the totalizer is 1,000 lbs. Before the implementation of the change order, each individual tank gage displayed five digits which were read directly to obtain the amount of fuel in each tank. The change order also replaced the flight engineer’s totalizer gage, which had displayed six digits read directly for total fuel on board. - According to United Airlines, the primary purposes of installing the fuel quantity indicating system were (1) to reduce erroneous system indications because of stray pickup of 400 Hz signals in the fuel quantity indicating system wiring, and (2) to reduce indication errors from current leaks across the elements of the capacitive probes and compensators. After the accident, United Airlines determined that the aircraft was burning fuel in accordance with the automatic flight plan and monitoring system. In October 1978, fuel burnoff examination indicated that the aircraft was not consuming fuel as fast as predicted; it was 1.04 percent

-=a -110 .’ __. ,. less than predicted. In addition, another method for determining burnout was begun by United engineers. Each trip’s total burnout was divided by total time. For December 1978 these aggregate values verified that this aircraft’s fuel consumption was within 1 percent of the plan. The aircraft was also engine which displayed, in being used by the engine. forward engine instrument tzeges. equipped with a fuel flow indicator for each ; hundreds of pounds, the hourly rate of fuel{ These indicators were located on the pilot’s/ panel along with other engine monitoring: 1.7 Meteorological Information Surface weather observations taken before and after the accident at Portland International Airport by National Weather Service personnel were: 1655 - 4,500 ft scattered; visibiljty - 30 mi; temperature - 30’F; dewpoint - 13’F; wind - 340 at 8 kns; altimeter setting - 30.16 inHg. 17z5 - Clear; visitoility - 15 mi; temperature - 29’F; dewpoint-- 13 F; wind - 010 at 11 kns; altimeter setting - 30.17 inHg. 1829 Local - Clear; visibility - 15 mi; temperature - 28’F; dewpoint--12’F; wind - 35O’at 11 kns; altimeter setting - 30.19 inHg; AIRCRAFT MISHAP. 1.8 Aids to Navipation During his deposit ion, the captain stated that he had set the Portland VORTAC, which is located 9.2 nmi north-northeast of Portland International Airport, in both of his VOR receivers. He stated also that he was receiving distance measuring equipment information. 1.9 Communications No communications difficulties were reported. . . 1.10 Aerodrome Infor mat ion Runway 28L at Portland International Airport is hard surfaced and is 11, 014 ft long and 150 ft wide. The published touchdown zone elevation and field elevation are 19 ft and 26 ft, respectively. The runway is equipped with high intensity runway edge lights, centerline lights, and visual approach slope’indicator lights. The airport has two other runways. Runway lOL/28R, which is parallel to runway 28L, is 8,004 ft long and 150 ft wide. It is the primary instrument runway. Runway 02/20 is 7,000 ft long and 150 ft wide. It is used mainly as a crosswind runway. The airport is located near the south shore of the Columbia River /fm-Y&&fo Portland. The terrain southeast of the airport is characteri- zed by low.rolling hills, which rise from the river valley.

’ I ___ . ( 1.11 Flight Recorders N8082U was equipped with a Fairchild model 5424 flight data recorder (FDR), serial No. 6043. The recorder showed no outward evidence of damage. The foil recording mediu.m was not damaged; all parameter and binary traces were present and active with no evidence of recorder malfunction or recording abnormalities. Electrical power to the recorder was terminated about 44 set before the aircraft crashed. A readout was made of the final 15 min 44.7 set of the recorded traces. This readout covers the 15 min of flight before all parameter traces - altitude, airspeed, magnetic heading, and vertical acceleration - ceased to be recorded and continues for an additional 44.7 set where all binary traces became atypical. N8082U was also equipped with a Sundstrand model V557 CVR, serial No. 1427. The recorder was removed from the aircraft and the entire tape was transcribed. The quality of the recording. was good. (See Appendix D.) 1.12 Wreckage and Impact In for ma tion The aircraft first struck two trees about 100 ft above the ground. These trees were about 1,554 ft from the point where the wreckage came to rest. 345’, About 541 ft farther along the flightpath on a heading of about the aircraft struck two trees about 85 ft above the ground. rIbout 400 ft farther, the right wing struck a tree about 45 it above the ground. About 225 ft beyond that point, the left outer wing struck a tree about 8 ft above the ground. The aircraft then struck and destroyed an unoccu- pied house which was located about 1,230 ft from the first tree. Pieces of the aircraft’s left wing structure were located just beyond the house. The two main landing gear and the nose section of the aircraft first struck a 5-ft embankment next to a city street about 1,275 ft from the first tree. TheRircraft continued across the street and came to rest on a heading of 330 between some trees and on top of another unoccupied house. The tail of the aircraft came to rest about 1,350 ft from the first tree. Just after crossing the street, the verticle stabilizer struck a series of high tension cables, which ran parallel to the street. The fuselage, from about the fifth row of passenger seats forward, sustained severe, extensive impact damage in a generally rearward direction. The cockpit upper structure, which included the cockpit forward windows, had separated and was found to the right of the fuselage just forward of the inboard end of the right wing. The cockpit floor structure, which included portions of the crew seats, sections of the instrument panel, and the nose tunnel structure with the nose gear assembly partially attached, had separated and rotated to the right and aft; This structure was in a partially inverted position. All portions of the fuselage structure were accounted for and all of the structural damage was caused by impact with the ground and the numerous large trees in the immediate area.

r + .- , . _-- ; -130 The lower left side of the fuselage, between the fourth and sixth rows of passenger seats and below window level, had been torn away. The remainder of the underside of the fuselage sustained heavy damage from contact with several large trees and tree stumps. The passenger cabin interior, from row 6 to the aft bulkhead, was relatively intact. At several points along the fuselage, windows were smashed and the fuselage had been dented by large trees and separated portions of the main landing gear. The empennage showed moderate impact damage. The vertical stabilizer leading edge had been damaged by high tension cables at three points just forward of the upper three rudder-tostabilizer hinge points. The left wing had separated from the fuselage about 3 ft outboard from the fuselage attachment point. The No. 2 engine had separated from its pylon and was located adjacent to the wing trailing edge. The No. 1 engine remained attached to a section of left wing structure. A 7-ft-long section of the left wingtip had been sheared off and was found near the first house. The right wing separated about 5 ft from the fuselage. x Z-it opening was evident between the fuselage and wing leading edge struc- ture. The wing leading edge, from a point about 5 ft outboard from the leading edge inboard end, was cut and torn aft to the front spar assembly. A large section of right wing leading edge structure had separated during the impact sequence and was also found near the first house. A section of right wing with the So. 3 engine was located just forward of the right horizontal stabil wing set tion, which included the No. 4 engine, was fuselage. and pylon attached izer. The outboard to the right of the ! capable of opera- All four engines were inspected and found to be tion. None showed signs of rotation at impact. Both main landing gear were fully extended but were torn from their mounting strut tures. They were located near main wreckage. Inspection of the right main landing gear retraction mechanism showed corrosion in the threads of an attachment eyebolt. The eyebolt was pulled out of the actuator cylinder piston. The nose landing gear was fully extended and remained attached to the nose tunnel structure. 1.13 Jj’ Medical and Pathological Information A review of the flightcrew’s medical records revealed no evidence of medical problems that might have affected their performance. AThe 10 persons who were killed in the crash died from impact trauma. Toxicological analyses showed no acidic, neutral, or basic drugs or ethanol in the blood taken from the flight engineer and first flight at tendant.

1. 14

Fire There was no fire. 1.15 Survival Aspects The accident was partially survivable. The 10 occupants killed in the crash were located between the flight engineer’s station in the cockpit and row 5 in the passenger cabin. All of the passengers who were killed had been located on the right side of the cabin. That section of the aircraft was destroyed during the accident sequence. The most seriously injured passengers were seated in the right forward portion of the cabin near an area of the fuselage which appeared to have been penetrated by a large tree. These persons were s2ated near those passengers who were injured fatally. Some seriously injured passengers were seated in the rear cabin near the trailing- edge of the wings. The fuselage in this area had been penetrated and the floor and seats had been disrupted. Some passengers sustained serious injuries during the evacuation. Two passengers sustained fractut-es and others sustained lacerations and abrasions when they either fell from exits or as they climbed through debris outside the aircraft in order to reach the ground. As a result of the accident, 22 persons were admitted to hospitals with serious injuries ranging from multiple fractures of extremities and fractures of cervical vertebrae, to observations for possible injuries. J& The plane crashed in the jurisdiction of Multnomah County Rural Fire Protection District No. 10. Three fire departments sent personnel and equipment to the scene: The Port of Portland (Airport) Fire Depart men t; Jlultnomah RFPD No. 10, and the City of Portland Fire Bureau. A total of 39 fire units and 108 on-duty fire personnel responded to the scene. Numerous off-duty fire personnel from all fire departments also responded to the scene. Because there was no fire, the basic fire service functions were search and rescue, extrication, triage, emergency medical care, precautionary foaming of some aircraft parts and surround- ing area, laying standby firefighting water supply lines, transporting or assisting ambulatory.victims to a nearby church, setting.up area lighting, providing some interagency radio communications, and setting up the on- scene command post. Although there were many occupied houses and apartment complexes in the immediate vicinity of the accident, there were no ground casualties and no postcrash fire. Injured persons were transported to nearby hospitals by helicopter and ambulance. The aircraft was equipped with 10 floor level exits, each provided with automatically inflatable emergency escape slides. h addition to slides at the boarding doors (1L and 5L) and at the two galley service

doors (2R and 5R), slides were located at the six “‘jet escape” floor level exits (lR, 2L, 3L, 3R, 4L, 4R). The ‘Ijet escape” doors were hinged at the bottom and were designed to swing down and outward when opened. Movement of the door actuated the automatic inflation of the escape slide. The slide from exit 1L was found wrapped around a tree at the left wing. The slides from exits 3L and 3R were found packed and uninflated. These exits were reportedly blocked by debris outside the aircraft. The slide at exit 1R reportedly inflated inside the cabin and extended across the aisle and lodged against seat 8C. l The door was prevented from opening fully because of cockpit and forward cabin debris outside the aircraft. The slide at exit 2R also reportedly inflated inside the cabin and blocked the cabin aisle. The exit door was displaced inward when the plane hit a tree. The slide at exit 4R reportedly inflated inside the cabin when the door was opened by a passenger. The slide inflated upward and partially blocked the exit opening. Because of debris outside the fuselage, the exit door was prevented from opening fully. The passenger who opened the door reported that about 10 persons used this exit before the slide was pushed out the exit and onto debris. The remaining escape slides reportedly deployed outside the aircraft and inflated but were punctured or torn by debris during the evacuation. The escape slides were removed from the accident site and were examined on January 3, and on January 9, 1979. No discrepancies were found in the installation, maintenance, manufacture, or design of the escape slides. The evacuation was completed in about 2 min. Except for seats at rows 20 through 22 which were torn loose from the floor attachments, there was only minor disruption of the cabin furnishings aft of row 6. The emergency lights provided adequate illumination during the evacuation. 1 . 1 6 Tests and Research -. 1.16.1 Retract Cylinder Assembly The Safety Board examined the piston rod and the mating end from the right main landing gear retract cylinder assembly at its metallurgical labora tory in Washington, D.C. The examination showed that the primary cause of the se aration of the rod end from the piston rod was severe corrosion causJby moisture on to the mating threads of both components. As a result of the corrosion, the joint was weakened to such an extent that only a comparatively low tensile load was required to pull the rod end out of the piston rod. The pattern of mechanical damage indicated that all of the rod threads had been engaged and that the rod end had been pulled straight out of the piston rod without any significant rotation.

‘LO’

. ’ . -.__ ’ , 1.16.2 Fuel Control Test Functional testing of the fuel controllers from each of the four engines was conducted at the company’s maintenance base. No discrepan- cies or out-of’tolerance conditions were found. 1.16.3 Aircraft Systems Examinations * During the week of January 8, 1979, the following examinations were conducted at the company’s maintenance facility: (1) Fuel Flow Indiiators The shop examinations confirmed that the four indicators were indicating zero fuel flow. The front face, case, and electrical connections were all damaged and none could be opera ted or testeb before being repaired. After minor repairs to the electrical connections only the flow meter for the No. 2 engine became operable, and it met the linearity specifications. (2) Fuel Quantity Gages During the wreckage salvage, the eight fuel quantity gages were recovered. All units were damaged and repairs were attempted on each. Three gages could be repaired sufficiently to allow functional testing. The No. 4 main tank gage was given a lamp check, segment check, and self-test check and all were within specification. In addition, a linearity check was made at full, at 1,000 lbs, at 500 lbs, and at ernpt;;. The results were within specifications. The No. 4 alternate tank gage and the No. 2 main tank gage were tested in the same manner, and the results were within specifications. The other tank gages were not operable because of damage and, therefore, could not be tested. (3) Totalizer Gage The glass face was broken, the electrical connector bent, and the case punt tured. The damage was too extensive to enable repair for testing. (4) No. 1 Nlain Fuel Tank Capacitance Probes The five capacitance probes from the No. 1 main fuel tank were examined according to company specification. All units were within specification except probe No. MR 28062, serial No. 525856-31X. This unit did not meet resistance tolerance specification when wet. --Y- . . . s ./.. ,.-1__-.. ----r-----.--.7-,-

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k -17- (5) Tank Reference Capacitors ’ ’ .- * , One of these units is located in each main tank. All four units were recovered and, when tested, met specifications. Y ) (6 Right Main Landing Gear Down-Lock Switch This switch is activated when the gear reaches a down-and- locked position. A similar switch was installed on the left main landing gear. A comparison of the damage to the two switch cases showed that the switch from the right landing gear had been damaged apparently by an internal part that pushed the case outward and had distorted it. Electri- cal tests of the switch and attached wiring indicated an intermittent short’ circuit when the switch was shaken. X-rays of the switch showed that’s large spring had become free of its mounts within the switch case. Normally this spring returns the down-lock switch to the gear-not:-down posit ion when the landing gear is retracted. The switch case was cut open and several coils of the spring \vere found spread apart When the spring and switch case damages were matched, one end of the spring fit into the distorted portion of the case. The other end of the spring touched wiring terminal No. 8 of the nicroyV.itch and marks indicative of electrical arcing were found on the spring where it contacted terminal No. 8. (7) Left Main Landing Gear Down-Lock Switch The spring of the left main landing gear down lock switch was free of its mounts. The coils of this spring were not bent and no marks similar to electrical arcing were found. (8) Landing Gear Warning and Interlock Circuit Breaker When examined in the field, this circuit breaker appeared to be mechanically extended or electrically open. There was some mechani- cal damage. Later, shop tests verified that the circuit breaker was open. It could be operated mechanically and it opened and closed the electrical circuit properly. (9) Distance Measuring Equipment -. Two distance measuring equipment units, Collins Model 860E- 2, serial No. 3954 (No. 1) and serial No. 617 (No. 2), were opened in the company maintenance shops and the distance modules were removed. When connected to a test panel, the mileage readouts were 16.05 nmi for the No. 1 unit and 16.0 nmi for the No. 2 unit. Both units were selected to channel 113X, which corresponds to a VOR frequency of 116.66 MHz. 1.16.4 Fuel Quantity System Error Upon request, United Airlines provided the Safety Board with an error analysis of the fuel quantity indicating system for the accident aircraft. Analyses were prepared for three different assumptions The

-A.” \ .- ’ ’ _.-. , * first analysis asumed that all errors were at their limits and in the same direction. The second analysis assumed that all errors were at their limits but were distributed randomly with respect to sign (rootsum-square analysis). The third analysis was a probable error analysis. All errors in this analysis were those asociated with empty or near empty tanks. These analyses indicated the following: Sum of Indicators Totalizer Analysis Method High Error Low Error High Error Low Error lbs. lbs. lbs. lbs. , Worst-Case Error 2,283 High 1,482 Low 3,961 High 3,606 Low Root-Square-Sum Error 828 High 28 Low 1,312 High, I 957 Low Probable Error 685 High 185 High 1,239 High 885 Low 1.16.5 Fuel Burn Time History At the request of the Safety Board, Douglas Aircraft Company and United Airlines studied fuel burn performance for the accident flight. Ln both studies, the fuel on board at the gate in Denver was 46,700 lbs. The fuel remaining at cruise at 35,000 ft was almost identical in both studies. United’s calculations of fuel burn rate for the descent from 35,000 ft to the 5,000-ft holding altitude were 13 percent lower than Douglas’. IIowever, United’s fuel burn rate while in the holding pattern was 1-I percent higher than Douglas’. This disparity was a result of different interpretations of meteorological and FDR data which resulted in differing math values. Both studies had similar fuel remaining values when both flight recorders ceased operation; Douglas had calculated 178 lbs and United had calculated 73 lbs. Both studies compared favorably to the fuel burn time history computed by the Safety Board using information from the automatic flight plan and monitoring system and CVR data. A correlation of CVR information with both fuel burn studies shows the observed and calculated fuel remaining values to be in Agreement. The CVR transcript indicated an observed fuel remaining value of 5,000 lbs about 1749. The Douglas figure for that time was 5,250 lbs and United’s was about 6,000 Ibs. if the totalizer accumulated probable error of 885 lbs was applied, the calculated and observed fuel remaining values would be in agreement. In addition, the two studies indicated that the accident aircraft’s fuel consumption was normal during the accident flight. Although both studies had similar fuel remaining values when the aircraft lost its engine power, the Safety Board believes that the Douglas’ study more closely approximates the fuel burn during the 5,000-ft hold period. Therefore, fuel remaining computations for this period are predicated on the manufacturer’s figures of a calculated fuel burn of 13,209 lbs per hour (220 lbs per min). According to the manufacturer’s study, the aircraft entered into the hold with about 13,334 lbs of fueL ,

-- -19. I ’ _. -. , . 1.17 Other Information $\1.17.1 Responsibility of the Crew Excerpt from United Airlines Flight Operations Manual, paragraph 6.2, June 30, 1978: “16. Except as otherwise specifically directed by the captain, all crew members noting a departure from prescribed procedures and safe practices should immediately advise the captain so that he is aware of and understands the particular situation and may take appropriate action.” 1.17.2 United Airlines Flight Operations Bulletin 22-76, Fuel Policy Domestic FAR 45 Minute and Overwater/International 30 Minute Reserve Fuel. “FAR 121.639 (C) does not specify in detail how the aforementioned requirements are to be calculated. United Airlines has established the following criteria for computing required fuel. a. \Veight - The operating weight empty of the airplane plus maximum structural payload or maximum space payload, whichever is smaller, plus the weight of the 45 minutes of reserve fuel. b. Speed - Long range cruise speed. C. Altitude - 25,000 Feet. d. The ability to loiter at 5,000-feet at clean holding speed for 45 I m inu tes.” "From the aforementioned criteria is derived the following DC-8-61 fuel requirements. 1. Fuel required for 45 minutes cruising at long range cruise at 25,000 feet is 8,300 pounds. 2. Fuel required for 45 minutes holding clean at 5,000 feet is 7,800 pounds. 3. FAR 45 minute reserve: 8,400 pounds.” . . Excerpts From United Airlines DC-8 Flight Manual “Landing Gear Lever Down and Gear Unsafe Light On If the visual down-lock indicators indicate the gear is down then a landing can be made at the captain’s discretion.” (Dated January 1, 1974, pg. I-44.) “Landing Gear Apparently But Not Conclusively Down If possible, have tower visually check. If there is reasonable indica- tion that the gear is down then the landing can be made asuming gear is down. Do not taxi the airplane until gear locks have been installed.” (Dated January 2, 1974, pg I-44-59.)

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“Preparation For Evacuation .’_-- , ’ 1. 2. 3. 4. 5. 6. 7. a. 9. 10. 11. 12. 13. Notify ground station of emergency. Advise the First Flight Attendant as to: a. nature of emergency and expected landing conditions, b. time available for preparation, c. signal for taking protective position, d. signal to be used if evacuation is not necessary, e. other special instructions. Determine from the First Flight Attendant: :. :: the passenger load, number of infants, invalids, and other passengers who would be given -special consideration. Direct all nonessential cockpit members to move to the cabin and assist Flight Attendants as requested. Review the EVACL’XTION Emergency procedure. slake an announcement to the passengers as appropriate. Accomplish the CABIN INSPECTIOS CHECKLIST below when advised by the First Flight Attendant that cabin preparations are completed. Depressurize the airplane when below 10,000 feet. Insure that the emergency exit lights switch is in the armed posit ion. Avoid landing, if possible, until emergency equipment and crews are standing by. Advise the First Flight Attendant when approximately five minutes . . from landing. Advise the passengers and Flight Attendants when to assume the protective posit ion. If evacuation is necessary, accomplish the EVACUATION Emergency Procedure.” (Dated September 27, 1975, page I-19.) “Cabin Inspect ion Checklist 1. All Flight Attendants briefed on station, duties, and signals. 2. Passengers reseated as required and seats to be used by crew vacated.

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-21- I . --. ,a 3. 4. 5. 6. 7. a. 9. Helper passengers briefed on station, duties, and exit operation. Passengers briefed on: a. Protective position and signal to assume position. b. Seat belts tight and low. c. How to unfasten seat belts. d. Assigned exits and when and how to leave the airplane. Passengers’ glasses, dentures, high heels, and other possible hazar- dous items removed and stowed. Loose objects stowed in secure stowage areas. Internal doors and curtains secured open. Meal service furnishings in appropriate secure area. Seat backs upright and tables stowed. Pillows and blankets distributed for impact protection.” (Dated September 27, 1975, page I-20) 1.17.4 ExcerDts From United Airlines Maintenance/Overhaul blanual “Fuel Quantity Indicator System - Tolerance a. All tanks at empty, + 150 pounds. b. Tank at full #l & $4 Main + 400 pounds

1 6r #4 Alt f 225 pounds

#2 &. #3 Main + 400 pounds #2 & #3 Alt + 250 pounds” (Dated January 19, 1976, page 201.) 1.17.5 hlain Landing Gear Retract Cylinder Assembly Although the purpose of the main landing gear retract cylinder ._ assembly is to raise the landing gear during the retract cycle, the hydraulic action of the cylinder acts as a buffer during the extend cycle to moderate the rate of extension and prohibit the landing gear from free falling to the down-and-locked position. McDonnell-Douglas Corporation issued an AR-Operator Letter, AOL 8-141, in July 1967, Main Landing Gear Retract Cylinder Assemblies, DC- 8 Aircraft. The letter advised all DC-8 operators that several cylinder end fittings had been found with fractures in the thread roots. To alleviate this condition, the eyebolt threads were changed from machined to rolled-type threads. The letter also recommended sealing the threads with a corrosion resistant compound.

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1. ANALYSIS

The flightcrew was properly certificated and each crewmember had received the training and the off-duty time prescribed by applicable regulations. There was no evidence of medical problems that might have affected their performance. 4 The aircraft was certificated and maintained according to applicable regula- t ions. The gross weight and c.g. were within prescribed limits. Except for the failure of the piston rod on the right main landing gear retrac_t cylinder assembly and the failure of the landing gear position indicating system, the aircraft’s airframe, systems, structures, and powerplants were not factors in this accident. A The investigation revealed that fuel was burned at a normal rate between Denver and Portland, The aircraft arrived in the Portland area with the preplanned 13,800 lbs of fuel and began its delay at 5,000 ft with about 13,334 lbs. The first problem which faced the captain of Flight 173 was the unsafe landing gear indication during the initial approach to Portland international Airport. This unsafe indication followed a loud thump, an abnormal vibration, and an abnormal aircraft yaw as the landing gear was loksered. The Safety Board’s * investbation revealed that the l~ing._gear_prob!e-~-is.as ca_used by severe corrosion in the matmg threadswhere theright main landing gear retract cylinder _---- --. 9sse mbly~as-connec&zd -.-- t o the rod end. The c-Grosion -low the two parts to pull apart and the right main landing gear to fall free when the flightcrew lowered the landing gear. This rapid fall disabled the microswitch for the right main landing gear which completes an electrical clrcult to the gear-- Qosition indicators in the cockpit. The XIterence between lhmfinem.-for the right maln landing gear to free fall and the time it took for the the left main landing gear to extend normally, probably created a difference in aerodynamic drag for a short time. This difference in drag produced a transient yaw as the landing gear dropped. Although the landing gear malfunction precipitated a series of events which culminated in the accident, the established company procedures for dealing with landing gear system failure(s) on the DC-8-61 are adequate to permit the safest possible operation and landing of the aircraft. Training procedures, including ground school, flight training, and proficiency and recurrent training, direct the fligh’tcrew to the Irregular Procedures section of the DC-8 Flight--Manual, which must be in the possession of crewmembers while in flight. The Irregular Procedures section instructed the crew to determine the position of both the main and nose landing gear visual indicators. “If the visual indicators indicate the gear is down, then a landing can be made at the captain’s discretion.” The flight engineer’s check of the visual indicators for both main landing gear showed that they were down and locked. A visual check of the nose landing gear could not be made because the light which would have illuminated that down-and-locked visual indicator was not operating. However, unlike the main landing gear cockpit indicators, the cockpit indicator for the nose gear gave the proper “green gear- down” indication.

Admittedly, the abnormal gear extension was cause for concern and a flightcrew should asses the situation before communic’ating with the dispatch or maintenance personnel, However, aside from the crew’s discussing the problem and adhering to the DC-8 Flight Manual, the only remaining step was to contact company dispatch and line maintenance. From the time the captain informed Portland Approach of the gear problem until contact with company dispatch and line maintenance, about 28 min had elapsed. The irregular gear check procedures contained in their manual were brief, the weather was good, the area was void of heavy traffic, and there were no additional problems experienced by the flight that would have delayed-the captain’s communicating with the company. The company maintenance staff verified that everything possible had been done to assure the integrity of the landing gear. Therefore, upon termination of corn municationstith- company dispatch and maintenance personnel, whi$h was about 30 min before-the crash, the captain could have mad&%%6gttemp~. TJe SafeZ&&a&bf&zs that Hlght 173 C~!il!!-.---.. ----. rIXI~~!on. --.--

ave landed-saf.ely..+thin 30 to 40 min after th&&ing.gear

Upon completing communications with company line maintenance and dispatch, the captain called the first flight attendant to the cockpit to instruct her to prepare the cabin for a possible abnormal landing. During the ensuing dmUseraptain did not assign the first flight attend&t a specified t.lm’e within Irhichta_prepareth~a~i~-~eequirbby-the-fiightm~~~TTTn~e *Such timP cQfst .----. -__ _ raint. the first fli& attendant was p&ably-left- with the --_ -_- . - impression that time efficiency was-not net.essarily as important asthe assurance -----_. .- .- ----- of thorough pre$%&on. _ _ The Safety Board believes that any time a flight deviates from a flight plan, the flightcrew should evaluate the potential effect of such deviation on the aircraft fuel status. This flightcrew knew that the evaluation of the landing gear problem and preparation for an emergency landing would require extended holding before landing. The flightcrew should have been aware that there were 46,700 lbs of fuel aboard the aircraft when it left Denver at 1433 and that there was about 45,650 lbs at takeoff at 1447. Regardless of whether they were aware of the actual fuel quantities, they certainly should have been aware that the initial fuel load was predicated on fuel consumption for the planned 2 hr 26 min en route flight, plus a reserve which includes sufficient -fuel for 45 min at normal cruise and a contin- gency margin of about 20 min.additional flight. ‘QTherefore, the crew should have known and should have been concerned that fuel could become critical after holding. Proper crew management includes i constant awareness of fuel remaining as it relates to time. In fat t, the Safety Board believes that proper planning would provide for enough fuel on landing for a ,) go-around should it become necessary. Such planning should also consider possible ’ fuel-quantity indication inaccuracies. < This would necessitate establishing a dead- line time for initiating the approach and constant monitoring of time, as well as 4: the aircraft’s position relative to the active runway. Such procedures

I a’ _-- ,*

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a- l should be routine for all flightcrews. However, based on available evidence, this flightcrew did not adhere to such procedures. On the contrary, the ssx9q-k period of ku9ding. The other two flight crewmembers, although they made several hg time to fuel exhaustion would have been voiced. However, there was none until after the aircraft was already in a position from which recovery was not possib$ In analyzing the flightcrew’s actions, the Safety Board considered that the crew could have been misled by inaccuracies within the fuel-quantity meatiiing system. However, those intracockpit comments and radio transmissions in which fuel quantity was’mentioned indicate that the fuel-quantity indicating system wa.s a c c u r a t e . A A Had the flightcrew reld&my 91. thc>$--&el qk_an_tit&s-.to fuel flow, -they

should have been aware_that fuel exhaustion wouldxcur at oa~~t.l815f Other p-”

- evidence that the captain had failed to assess the effect of continued holding on fuel state was provided by his stated intentions to land about 1805 with 4,000 Ibs of fuel on board. Just minutes earlier, at 1748:56, he was made aware that only 5,000 lhs remained. During the 16 min between the observation of 5,000 lbs and 1805, the aircraft would consume at least 3,000 Ibs of fuel. Further evidence of .the flightcrew’s lack of concern or aivareness was provided when observations of 4,000 lbs remaining about 17 min before the crash, the left the cockpit at the captain’s request to check on the cabin evacuation preparations. Upon his return, about 4 min later, he gave the captain an estimate of another 2 or 3 min for the completion of the cabin preparation. At this time;‘.the aircraft was in the general vicinity of the airport. In the initial interview with the captain, he stated that he felt the cabin preparatmd be ea m rrom IO-0 mm and fiat the “taiIXiaafif’~could‘be accomplish;;d roach to the airport. Certain1 eCK prdc nd r ecom mended byminv- li a . 7e.e med and had alerted t h e n Portlw1 of probleing.

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CUnder these.qircumstances, there appears to have been no valid reamn not ts,-. discontinue their heading previb%l$ ‘ksti&k&d &tiding ‘.tim&$. the airport in order to make theii: accepted a’nd the”‘&$tiin“did n&t q However, about ‘15101:12, the first officqr don a vet t$ heading which would take them > away-.from-thecairpdtit -kind de@‘*their landing time.eppreciably. Moreover, after the’;turn’;-w~Sti~~,~le’t~d “non4 df the. flightcrew suggested turning toward the airport.fihus, it was at this time that the crew’s continuing preoccupation with the

1 landing g&r -@+oblem ad i&&g ‘preparations: t&a&$ ‘crucial and an accident became’ ~eyitabl&~S y i :.

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’ . -. _ . . The Safety Board also considerzthe possibility that the captain was aware of the fuel quantity on board, but failed to relate the fuel state to time and distance from the airport and intentionally extended. the flight to reduce the fuel load in order to reduce the potential of fire should the landing gear fail upon landing. The Safety Board could find no evidence, however, to support such a theory and believes that ,had he so intended, the captain would have advised the first officer and the flight engineer. Therefore, the Safety Board can only conclude that the flightcrew failed to relate the fuel remaining and the rate of fuel flow to the time and distance from the airport, because their attention was directed almost entirely toward diagnosing the landing gear problem. Although on two occasions the captain confirmed with the company that he intended to land about 1805 and that he would be landing with about 4,000 lbs of fuel, this estimated time of arrival and landing fuel load were not adhered to, nor was the expected approach time given to Portland Approach. This failure to adhere to the estimated time of arrival and landing fuel loads strengthens the Board’s belief that the landing gear problem had a seemingly disorganizing effect on the flightcrew’s per for mance. Evidence indicates that their scan of the instruments probably narrowed as their thinking fixed on the gear. After the So. A engine had flamed out and with the fuel totalizer indicating 1,000 lbs, the captain was still involved in resetting circuit breakers to recheck landing gear light indications. It \vas not until after it became apparent to the crew that tolli engine flame out is’as imminent that the captain was concerned and, in fact, mny have been confused as to the amount of fuel which actually remained. About G min before all engines stopped, the captain stated that there was 1,000 lbs of fuel in the So. 1 main tank, and the flight engineer agreed with him. .4t this same time, the captain began to describe the gage indication as changing from 1,000 ibs to zero 15s. Since the No. 1 main tank gage does not change its indication from 1,000 105 to zero ibs directly, but decreases in increments of 100 lbs, the captain must have read the gage indication incorrectly. Actually, the action he described was ttrrt of a gage changing from 100 Ibs to zero lbs. The company had recently changed the fuel quantity gpzcs 01 t!lls n~rcmft from a direct reading digital-type to a three-figure indicator tturt hrtd to be multiplied by a factor of 100 to get the actual individual tank vnlucs. In nddit ion, the new totalizer gage, of the same three-figure presentation as the indivldunl tank gages, had to be multiplied by a factor of 1,000 to get the actual totol fuel. During the stressed situation, the captain and the flight engineer may have mixed up these multipliers and used 1,000 when reading the individual.tank glgees instead of 100. However, there is no evidence from previous comments that such a mistake was made: By the .time such confusion was indicated;- the nccident was inevitable. The Safety Board believes that this accident exemplifies a recurring problem --a breakdown in cockpit management and teamwork during a situation involving malfunctions of aircraft systems in flight. To combat this problem, responsibilities must be divided among members of the flightcrew while a malfunc- tion is being resolved. In this case, apparently no one was specifically delegated the responsibility of monitoring fuel state. --.----_- -. Although the captain is in command and responsible for the performance of his crew, the actions or inactions of the other two flight crewmembers must be analyzed. Admittedly, the stature of a captain and his management style may exert subtle pressure on his crew to conform to his way of thinking. It may hinder .-$! interaction and adequate monitoring and force another crewmember to yield his right to express an opinion. _c -e.. - -.. _.-. - ..-.. __ The first officer’s main responsibiIity is to monitor the captain. In particular, he provides feedback for the captain. If the captain infers from the first officer’s actions or inactions that his judgment is correct, the captain could receive reinforcement for an error or poor judgment. Although the first officer did, in- fact, make several subtle comments questioning or discussing the aircraft’s fuel state, it was not until after the No. 4 engine flamed out that he expressed a direct view, “Get this . . . on the ground.” Before that time, the comments were not given in a positive or direct tone. If the first officer recognized the criticality of the situation, he failed to convey these thoughts to the captain in a timely manner. The flight engineer’s responsibility, aside from management of the aircraft systems, is to monitor the captain’s and first officer’s actions as they pertain to the performance of the aircraft, that is, takeoff, landing, holding speeds, and range of the aircraft considering time and fuel flow. Although he informed the captain at 1750:30 that an additional “fifteen minutes is really gonna run us low on fuel here,” there is no indication that he took affirmative action to insure that the captain was fully aware of the time to fuel exhaustion. Neither is there an indication that, upon returning to the cockpit at 1801:39, he relayed any concern about the aircraft’s fuel state to the captain. Although he commented that 3,000 lbs of fuel remained, he failed to indicate time remaining or his views regarding the need to expedite the landing. The first officer’s and the flight engineer’s inputs on the flight deck are important because they provide redundancy. The Safety Board believes that, in training of all airline cockpit and cabin crewmembers, assertiveness training should be a part of the standard curricula, including the need for individual initiative and _ .- .. effecti-v-e. expression of concern.

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In order to determine.’ whether the captain had received all available assistance during the emergency, the Safety Board evaluated the actions of the company dispatcher and his role relative to the accident sequence. According to the tape of the conversation between the captain, the company dispatcher, and company line maintenance personnel, the captain had advised the dispatcher that he had 7,000 lbs of fuel aboard and that he intended to land in 15 or 20 min. The dispatcher then checked with the captain to ascertain a specific time for the landing and the captain agreed that 1805 was Ita good ballpark.” The dispatcher, according to his interview after the accident, then relayed this landing time and the aircraft’s status to the company personnel in Portland. He also stated that his assessment of the situation was that of the fuel remaining upon landing would be low but the landing could be made successfully at 1805. The Safety Board believes that, with the information given to him by the captain, the dispatcher acted properly and in accordance with company procedures.

P

1. CONCLUSIONS

3 .l Findings 1. 2. 3. 4. 5. 6. 7. a. 9. 10. 11. 12. 13. 14. Except for the failure of the piston rod on the right main landing gear retract cylinder assembly, with the resulting damage to the landing gear position indicating system switch, there was no evidence of a failure or malfunction of the aircraft’s structure, powerplants, flight controls, or systems. : The aircraft departed Denver with the required fuel aboard of 2 hrs 26 min for the en route flight and with the required E:.4R and company contingency fuel aboard of about 1 hr. The aircraft began holding about 1712 at 5,000 ft N ith its gear doivn; this was about 2 hrs 24 min after it departed Denver. The flightcrew was properly certificated and qualified for the flight. The aircraft was certificated, maintained, and dispatched in accordance with Federal Aviation Regulations and approved company procedures. The landing delay covered a period of about 1 hr 2 min. All of the aircraft’s engines flamed out because of fuel exhaustion about 1815-l hr 3 min after it entered into hold and 3 hrs 27 min after it departed Denver. Fuel exhaustion was predictable. The crew failed to equate the fuel remaining with time and distance from the airport. No pertinent malfunctions were found during examinations of the fuel- quantity measuring system. A new digital fuel-quantity indicating system was installed on this aircraft on hlay 12, 1978. This was in accordance with a DC-8 UAL flee tw ide retrofit program. Evidence indicates that the fuel quantity indicating-system accurately indicated fuel quantity to the crew. The fuel gages are readily visible to the captain and the second officer. The captain failed to make decisive timely decisions; The captain failed to relate time, distance from the airport, and,the aircraft’s fuel. state. as hisattentiqn-was directed cbmple tely to.ward the ,_.. _..- _ . ..-

-- -29- . ’ --- , - 3.2 Probable Cause The National Transportation Safety Board determined that the probable cause of the accident was the failure of the captain to monitor properly the aircraft’s fuel state and to properly respond to the low fuel state and the crew-member’s advisories regarding fuel state. This resulted in fuel exhaustion to all engine‘s. His inattention resulted from preoccupation with a landing gear malfunction and preparations for a possible landing emergency. Contributing to the accident was the failure of the other two flight crewmembers either to fully comprehend the criticality of the fuel state or to successfully communicate their concern to the captain. I ;j *30- - ’ * _.__ , , 4

1. Safety Recommendations

As a result of this accident, the Safety Board has issued the following recommendations to the Federal Aviation Administration: “Issue an .Operations Alert Bulletin to have FAA inspectors assure that crew training stresses differences in fuel-quantity measuring instruments and that crews flying with the new system are made aware of the possibility of misinterpretation of gage readings. (Class II--Priority Action) (A-79-32)” “Emphasize to engineering personnel who approve aircraft engineering changes or issuance of Supplemental Type Certificates the need to consider cockpit configuration and ” instrumentation factors which can contribute to pilot confusion, such as the use of similar-appearing instruments with different scale factors. (Class II--Priority Action) (A-79-33)” “Xudit Supplemental Type Certificate SX3357 \‘E-D for completeness, e-pecially in the area of system calibration after installation. (Class II--Priority .4ction) (X-79-33)” “Issue an operations bulletin to all air carrier operations in-spec tors directing them to u~c their assigned operators to ensure that their flightcrews are indoctrinated in principles o f f l i g h t d e c k resoume management, with particuhr emphasis on the merits of participative management for captains and assertivene.ss training for other cockpit crewmembers. (Class II, Priority diction) (X-79-17)” BY THE NXTlONXL TR.\NSPORTATlON SAFETY BOARD /S/ JAMES B. KING- Chair man /s/ ELWOOD T. DRIVER Vice Chair man .,:. ’ I June 7, 1979 /s/ FRANCIS H. McADAMS Member /s/ PHILIP A. HOGUE Member I --_-__ ~_. _

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1. APPENDIXES

APPENDIX A Investigation and Hearing 1. Investigation The Safety Board was notified of the accident about 2130 e.s.t. on December 28, 1978. The investigation team went immediately to the scene. LVorking groups were established for operations, air traffic control, witnesses, human factors, powerplants, structures, systems, maintenance records, weather, cockpit voice recorder, flight data recorder, and performance. Participants in the on-scene investigation included representatives of the Federal Aviation Administration, United Airline, Inc., Douglas Aircraft Company, Air Line Pilots Association, Professional Air Traffic Controllers Association, Association of Flight Attendants, International Association of Machinists, ~lultno- mah County Sheriff’s Office, and Port of Portland. 2. Public Hearing There was no public hearing held in conjunction with this accident investiga- tion. 3. Deposit ions The cap ta in was deposed at the Federal Aviation Administration’s Rocky Jlountain Regional Headquarters in Denver, Colorado, on March 6, 1979. Parties to the deposition included representatives of the Federal Aviation Administration, United Airline, Inc., Douglas Aircraft Company, and the Air Line Pilots Association.

I --%32-- - APPENDIX B 8 I

. . Personnel Information Captain Malburn A. McBroom Captain Malburn A. McBroom, 52, was employed by United Airline, Inc., on May 1, 1951. He was upgraded to captain on July 1, 1959. Captain McBroom had 27,638 total flight hours, 5,517 of which were as a captain in the DC-S. In the previous 90 days, 7 days, and 24 hours, he had 210, 18:04, and 3:38 flight hours, respectively. He had 14:40 hours of free time before reporting for this flight. Captain McBroom holds Airline Transport Pilot Certificate No. 1006880, issued September 28, 1971. He is type rated in the Douglas DC-8 and, the Boeing

1. His first-class medical examination was passed September 22, 1978, with the

limitation that the holder shall possess glasses for near vision while flying. Captain

lcBroom passed satisfactorily his last proficiency check

September 1, 1978, and his last en route check October 5. 1978. First Office R&rick D. Beebe First Officer Rodrick D. Beebe, 45, was employed by United Airline, Inc., on June 19, 1965. He ;vas upgraded to a DC-8 first officer on June 21, 1978. First Officer Beebe had 5,209 total flight hours, 247 of ivhich ivere as a first officer in the DC-8. In the previous 90 days, i days, and 2-1 hours, he had 182, 18:01, and 3:38 flight hours, respec timely. He had l-1:10 hours of iree time before reporting for this flight. First Officer Beebe holds Commercial Pilot Certificate No. l-131046, issued September 15, 1975. tie is rated in airplane multiengine land aircraft with instrument privileges. He also holds a rotorcraft rating. His first-class medical examination ivas pa.std October 3, 1978, with no limitations. First Officer Beebe had his last emergency training June 24, 1978. He passed satisfactorily his proficiency check June 21, 1978, as well as his initial DC-8 en route proficiency check August 1, 1978. Second Officer Forrest E. Mendenhall Second Officer Forrest E. hlendenhall, 41, was employed by United Air Lines, Inc., on December 18, 1967. He was upgraded to a DC-8 second officer on January 31, 1975. Second Officer Mendenhall had 3,895 total flight hours as a second officer, 2,263 of which were in the DC-8. In the previous 90 days, 7 days, and 24 hours, he had 179, 18:04, and 3:38 flight hours, respectively. He had 14:40 hours of free time before reporting for this flight. Second Officer Mendenhall held Flight Engineer Certificate No. 1819179, issued February 14, 1968, with a turbojet rating. He also held Commercial Pilot, Certificate No. 1632855, issued April 22, 1965. He was rated in multi- and single-

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engine land and sea with instrument privileges. His first-class medical examination was passed, with no limitations. Second Officer Mendenhall had his last emergency training August 16, 1978. He passed satisfactorily his proficiency check February 24, 1978, as well as his en route proficiency check December 14, 1978. Flight Attendants Date of Hire Date of Birth Date oi Init ial Training Date llost Recent Recurrent Emerg Tng Joan Nancy Wheeler King Sandy Bass Martha Fralick Diane woods 7/15/64 812167 10/U/67 U/67 l/26/72 10/4/42 4/16/47 g/21/46 ll/19/45 5/14/49 8/19/64 g/6/67 11/15/67 12/6/67 2/24/72 4/20/78 6/16/78 u/19/78 ll/Ll/7 8 3/T/78

I ,, -34- . -__ * APPENDIX C Aircraft Information Aircraft N8082U, a McDonnell Douglas DC-8-61, serial No. 45972, was owned and operated by United Airline, Inc. It was manufactured May 22, 1968, and delivered to United Airlines cn that date. At the time of the accident the aircraft’s operating hours and maintenance inspections were as follows: Total Hours Since Hours to Next overhaul/ Maximum Aircraft Hours 33,114:33 Overhaul 21,245:43 inqec tion I, Limits 3,754:17 -25.000 Inspection Ck 1,78 1:49 3,boo Inspection Kk 456:49 1,675 Inspection Bk 366:03 400 In-Tee tion AK 16:03 100 I j ‘! ‘t) ESGISES - Pratt A \‘hitnev JT3D-3B Date T-so Flight Installed IlOUl-S Cvcles So. 1 Engine 8-8-78 29.305: 28 11,266 S/N 669234 $0. 2 Engine 10-24-73 X.685:28 11,897 S/N 669312 So. 3 Engine 1-19-78 31,080:28 11,821 S/N 613929 So. -1 Engine 11-26-77 31,640: 28 14,540 S/N 64-1806 Hours since Installed 1,228:-A3 59T:43 2,933:33 3,367:43 ‘ -.--Y--..- _ _ . __ . ___ .-,-. . ----- ------ -. --,---.- ..~.__

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-5 -? UNK * li x 5% ( > (( 1) --- PA Cb VHF x x x PD TWR APPENDIX D TRANSCRIPT OF A SUNDSTKAND V557 COCKPIT VOICE RECORLJER SERIAL NO. 1427 REMOVED FROM THE UNITED AIRLINES DC-8 WHICH WAS INVOLVED IN AN ACCIDENT AT PORTLAND, OREGON ON DECEMBER 28,1978 THE TIME IS IN PACIFIC STANDARD TISIE LEGEND Cockpit area microphone voice or sound source Radio transmission from Voice iderltifi ed as Captain Voice identified as First Officer Voice identified as Flight Engineer Voice identified as off duty Captain Voice identified as Flight Att mdant Voice unidentifi e-d Unknown Unintelligible word Nonpertinent word Nonpertinent text Drak in continuity Questionable text Editorial insertion Pause Portland Approach Control U n i t e d C o m p a n y VHF Radio Nonpertinent aircraft or facility call Portland Departures Portland Tower

‘a -__ ‘, -36- TNE & SOUKCE INTRA-COCKPIT CONTENT t How you doing (Dory)? Ke’re ready for your announce- ment (Do) you have the signal for not evacuate also the signal for protective position. Thar’s rhe only rh:ngs I need from ycu right nou’ Okav ah, u bar u ould you do? Have you g21 any suggesr:3ns abou: u-hm !o brace? ‘Xanr to do II on :hc PA? I --- I’ll b e honncst uith hcu, I’ve ncvm had one of thee 3eiore --- .lIy firs1 you know --- l All rlghr, u,hat \;e’ll do IS u,e’ll have FrOs11e oh shout 3 couple of miflUiC5 before touchdown signal for brace posItIon APPENDIX D AIR-GROUND COMMUNICATIONS TIME dr SOURCE CONTENT XXX 17$5:flb RDO-2 Left I’*‘0 tu’cnty one seventy three heavy CA.\-5 Okay, he’ll come on rhc PA CAh4-I and then ah --- CA.\l-5 And if you don’t want Us to evacuate what’s are you gonna say 1745:09 C A M - I We’ll either use the PA or we’ll stand in the door and hollar C A M - 5 Okay, one or the other, ah we’re reseating passengers right now and all the cabin lights are full up

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- -37 - I N T R A - C O C K P I T TIME k SOURCE CAhl-I Okay CONTENT C A M - 5 W ill go take it from there C A M - I All right 1745:23 CAXl-5 We’re ready for your announce- ment any time 1745:43 CAA1-3 CAL- 3 1746:21 CAM- 3 CA.Li-? C?Al-? CAhl-? 1746:52 CAhl-2 C A M - 3 C A M - 2 1748:00 CAiM-4 C A M - 5 C A M - 4 1748:17 C A M - 4 I can see the red indicators from here, ya know but I can’t tell l l if there’s anything lincd up. Cause I only gor this thing to shine down there l l l all the way down Last guy to leave has gotta turn the battery external power switch Off You’re right l

l

How much fuel we got Frostie? Five thousand -_ Okay Gonna get us a spare flashlight Sir? ‘Conna get us a spare flashlight Less than three weeks, three weeks to retirement you better get me outta here -’ --- - ;-” -- APPENDIX D AIR-GROUND COMMUNICATIONS TIME dc SOURCE CONTENT X X X

INTRA-COCKPIT TIME & SOURCE CONTENT 1748:ll C A M - I C A M - ? CALI- 1748:21 CA.l-4 CA.\l-O 1745:33 C.?.\l-I C,A!-L C.A!-I 174s:43 CA.\-I -- CA.lI-4 CAXI-4 CAX4-I C A M - 2 Thing to remember is don’t worry What? Thing to remember is don’t worry Yeah If I might make a suggest eon --- You should put your coats on - - - Both for your protcctlon and so you’ll be noticecl so they’ll know who you are Oh that’s oka) But If it gets, 11 11 gets hot II sure is nice to not have bare ‘r::?s Yesh But if anything goes u’rong bou lust charge back there and get !‘our ass off, Okay Yaah I told, I told the gal, put mc where she wants me, I think she wants me at a wing exit Okay fine, thank you (We better turn around and head west) APPENDIX D AIR-GROUND COMh4UNICATIONS TIhlE & SOURCE CONTENT I74S:OO PA Unltcd one scvcnlj rhree heavy, traffic clcim o’clock f~\e rn~lu ror:? Sound i’FX Cod c l-.‘r,kno,~ n 171;5:45 RDO-2 Yeah, \ce’ve got sorn&oc~y out there PA me ‘Kay

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. .- N -- 0 ( .. . , I N T K A - C O C K P I T TIME & SOURCE CONTENT 1748:54 C A M - 2 1748:56 CAI\I-I C A M - 2 CA.iI-3 1749:oo CA.\-1 C/1X1-? c .A.!\ - ? CAhl-? CA.\l-? 1749:45 CAXI-? C A M - ? -39- APPENDIX D AIR-GROUND COh~MUNICATIONS TIhtE & SOURCE CONTENT Ah, what’s the fuel show now, buddy? Five Five (The lights in the fuel punlp ---1 That’s about right, the feed pumps are starting to blink xxx That lights too big to shine down there Yeoh Slaybe l l You can always get a l X X X PA United one seventy three heavy turn left heading one six zero RDO-2 Okay, left one six zero You got one seven three heavy ilain gear back there Yeah both of them appear to be down and locked 1749:50 RDO-2 That guy’s out there about nine thirty, now is that right? I N T R A - C O C K P I T TIME & SOURCE CONTENT CA&!-? l I see him I7 SO:16 CA.\i-I CAhl-I Hay, Frost le C/Ul- 3 CA.\l-I 1750:30 CA,\I-3 CAhl-I C A M - 3 1750:34 C A M - 3 C A M - ? Okay Give us 3 current card on weight figure sbou: another fifteen minutes Fifteen minutes? Yeah, give us three or four thousand pounds on. top of zero fuel weight N o t e n o u g h Fifteen minutes is gonna --- really run us low on fuel here Right -4o- APPENDIX D AIR-GROUND COI’.~L!UNICATIONS TIME & SOURCE 1749:53 PA 1749:55 RDO-2 1749:57 PA 175rJ:17 R L X - 2 xxx CONTENT Say again Ah, traf f it’s out There about nlnc thirty now.? Ah no, he’s about SIX o’clock now ihe one that I called earllc-r, now you got another 3sout nine ;Fl;rty, d:30<: five rnilcs c~rcl:r,g 1750:35 PA United one seventy three

-45. APPENDIX D I N T R A - C O C K P I T AIR-GROUND COMMUNICATIONS TIME &

• S O U R C E

CONTENT TI5IE Er SOURCE CONTENT C A M - I CAAI-I CA:\l-I CASl- 3 1754~27 CAX1-2 1754:31 CAhl-I CAhl-I 1755:04 C A M - 3 Okay Do you want to run through the approach descent, yourself? So you (don’t forget something) Yes, sir 1754:19 PA United one seventy three heavy traffic at twelve o’clock a half a mile 1754:23 RDO-2 Yeah we got it down belou He’s going to have the company call out the equipment? U’e’ll (call) dispatch In San Francisco and maintenace doaxn there will handle it that way so u’e don’t get it all over local radio The ramp here is going to back it up by getting the crash equipment. How many people and all that? When we get done back there then 1’11 tell them what we’re going to do, so we don’t end up with about a million rubber neckers out there. Okay, approach descent check is complete xxx

-46- I N T R A - C O C K P I T AIR-GROUND COMMUNICATIONS TWE & SOURCE CONTENT 1755:13 C A M - I Okay, check the new ATIS is delta TI.VE t?i SOURCE CONTENT APPENDIX D CA.!!-1 What I need is the wind, really VHF Portland International Information delta Portland u,cather four thousand f ive hundred scattered visibility three zero t ernperatur e three zero, de.& point one three urnds three !our zero degrees at s c!g.tt 3li:mete: tb,:ce zero one SIX 175S:Sl CASI-3 17)5:55 CA.\-1 CA.\t- I 1756:S3 CAhI-2 C A U - 3 CAM- 2 1757:21 C A M - I Wind is three forty at eight Okay You want to be sure the flight Sgs and all that // are stowed l l l fastened, why don’t you put all you: books in your bag over there, ROC. .x x x How much fuel you got now? Four, four --- thousand --- in each --- pounds Okay l You might --- you might just take a walk back through the cabin and kinda see how things are going Okay? 1757:02 PA ., One seventy three heavy turn left two eight five 1757:06 RDO-2 Two eight five one seventy three heavy

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. ’ __-- ( . 1 APPENDIX D -470 INTIIA-COCKPIT TIME & SOUHCE CONTENT 1757:30 CAhj-I CA.jI-3 1758:lS CAXI-2 1755:28 CA.!-2 1755:3s CA\-t CA.\-1 1758:45 CAh-2 CA.\-] CAL-I 1800:15 CAL-2 1800:24 C A M - I I don’t want to, 1 don’t want to hurry, em but I’d like to do it in another oh, ten minutes (or so) Yeah, 1’11 see if its, --- get us ready If u*e do indeed --- have IO evacuafe assuming that none of us are inca- pacitated. You’re going 10 take care of the shutdou.n, right. Parking brakes, spoilers a”d flaps, fuel shut off levels, fire handles, battery switch and all thqt l l AIR-GROUND COMMUNICATIONS T I M E 6: SOURCE GONTENT You just haul ass back rhere and do whatever needs doing 1 think that Jones is a pretty level headed gal, and Pardon? I think that “A” Stew is a pretty level headed gal, and sounds like she knows what she’s doing and l l been around for a while, I’m sure Duke will help out We’re not gonna have any antiskid protection, either xxx Well, I think the antiskid is working, it’s just the lights that ain’t working

\ -’ * ’ _. -. , . I N T R A - C O C K P I T 4 8 - APPENDIX D AIR-GROUND COMh9UNICATIONS TIME & TI.VE 6( SOURCE CONTENT SOURCE CONTENT 1800:33 C A M - 2 C A M - I C A M - 2 CAM-J CA,\-2 ISOO:42 CA.!!-I 1800:50 CAhI-2 CA,:- I 1801:34 C A M - 3 C A M - I 1801:39 C A M - 3 That light go off when you push the circuit breaker in? Yeah Oh, it did Yeah Oh I won’t use much breaking we’ll just let it roll out easy l l You plan to land as slow as you can with the power on? Ah, I think about ref or there abouts try and hold the nose wheel off, I’m, I’m tempted to turn off the automatic spoilers to keep it from pitching down, but lets try and catch it (You’ve got) another two or three minutes O k a y - - - How are the people Well, they’re pretty calm and cool a h - - - some of em are obviously nervous, ah --- but for the most part they’re taking it in stride --- t h e y - - - X X X ISr,I:l2 P:I United one seventy three heavy turn left heading one niner five 1501:15 R D O - 2 Left one niner five . . one seven three heavy

-49- I N T R A - C O C K P I T i I TIME & SOURCE CAlI- 3 1802:OS CA,\l-I CA.\l- 3 lSO2:22 Crl.\l- 3 lSO2:2S CA.!-I CONTENT I ah stopped and reassured a couple of them, they seemed a little bit more --- more anxious than some of the others Okay, well about two minutes before landing that will be about four miles out, just pick up the mike --- the PA and say assume the brace position Okay G’e got about three on the fuel (and ’ that’s it) Okay, on the touch down if the gear folds or something really jumps the track, get those boost pump off so that --- you might even get the valves open. TIME bc SOURCE CONTENT lSC2:44 PA 1802:49 RDO-2 1803:14 P A United one seventy three heavy did you figure anything out yet about how much longer? Yeah, we, ah, have indication our gear is abnormal it’ll be our intention in about five minutes to land on two eight left, we would like the equipment standing by, our indication are the gear is down and locked, we’ve got our people prepared for an evacuation in the event that should become necessary Seventy three heavy, okay advise when you’d like to begin your approach

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l ’ _ -_. , INTRA-COCKPIT TIME & SOURCE CONTENT 1503:29 CA\- 3 One seventy two plus, ah CA.%- 3 Plus six laps CA,%-2 CA,!-3 1803:58 CAIM-3 CAhI-3 Eight, i’sn’t it? CAM-I 1804:04 CAM-2 CAM-I CAM-? I think he wants souls on board, he wants crew members and everything Ah, that right, he does, doesn’t he? Ah, five, three, eight, nine Well, okay One eighty five There’s one check that we missed What -SO- APPENDIX D AIR-GROUND COMMUNICATIONS TIVE dr SOURCE 1803:17 R D O - I 1303:23 PA 1803:30 R D O - I PA 1803:33 R D O - I CONTENT Very well, they’ve about finished in the cabin -- - I’d guess about another three, four, five minutes

• I

United one seven three heavy, if you could, ah, give me souls on board and amount of fuel One seven two an about four thousand well, make 11 three thousand pounds of fuel Thank you Okay, and you can add to that one seventy lwo plus six laps, infants xxx

INTRA-COCKPIT TIME & SOURCE CONTENT CAhl-I CAM-? CAM-? C A M - I C A M - ? 1804:44 CAJI-I CAhl-2 CALI- C A M - 2 1804:59 CA!vI-I 1805:08 C A M - 2 C A M - 3 C A M - I C A M - I CAM-3 1805:26 CAM-3 CAM-I 1805:35 CAM-3 1805~39 CAM-l Checking the gear warning horn l right right right right How do we do that? What we gotta do is get us past flaps thirty five l Thirty five what happens when you close the throttles (any idea)? You can do that too, it’ll be one or three Yeah But we con? tell with that breaker out I guess Yeah Push the breaker momentarily Ready? Yeah Okay, pull the breaker? Yeah Okay, now we won’t have the spoiler pump automatic spoilers Yes we will APPENDIX D &R-GROUND COhlhlUNICATIONS TIhlE h SOURCE CONTENT

I N T R A - C O C K P I T -52- APPENDIX D AIR-GROUND COMMUNICATIONS TIME & TIME h SOURCE CONTENT SOURCE C A M - 3 CAhl-I CA,\l- 3 CA11-2 CA\l- 3 1sos:Yl CA.\l-I 1506:04 Ch,hl- 2 1506:lO CA,hl- I The antiskid? Well, wait a minute, I think the systems totally normal. Indications are what they are because the circuit breakers popped Yeah Right ilight Should have antiskid automatic spoilers and all that, ue may not get ground shift because of mechanical ground shift problems U’ell, ah (let’s have me) standby the boilers, spoilers anyway If we don’t get em, u hy I can - - - I think if we get the antiskid fall light is off we’ll get the automatic spo~lcrs CA,\; ((Sound of cabin door)) 1806:lV C A M - I How you doing? CA,M- 5 Well, I think we’re ready C A M - I Okay .

.

. . -. . ISC6:13 PA 1806:21 RDO-2 1806:23 PA CONTENT United one seven three heavy turn left heading zci.0 five zero Left to zero five zero, United one seventy three heavy Roger I

I N T R A - C O C K P I T -53- APPENDIX D AIR-GROUND COhlhlUNICATIONS , T I M E & TIVE dt SOURCE CONTENT SOURCE CONTENT C A M - 5 CAlI- CA,!f-5 CA’x-5 CA.Il-? 1806:34 CALI-S CA.\-? CA.Il-? CA.V-? CA.ll-I We’ve reseated, they’ve assigned helpers and showed people how to open exits and ah, Okay ‘tie have they’ve told me they’ve got able bodied men by the windows The captain’s in the very first row of coach after the galley Any invalids (* l pull out wInlows *I He’s going to take that that middle galley door its not that far from the window Yeah l l l l Okay we’re going to go in now, we should be landing in about five minutes CAL!-(3/2) I think you just lost nurnber four buddy, you --- C A M - 5 Okay, I’ll make the five minute . announce, announcement, I’ll go I’m sitting down now C A M - 2 Better get some cross feeds open there or something C A M - 3 Okay C A M - 5 All righty 1806:46 CAM-2 We’re goin to lose an engine buddy ! C A M - l Why? :

INTKA-COCKPIT TIME & SOURCE CONTENT APPENDIX D AIR-GROUND COMMUNICATIONS TIME 8 SOURCE CONTENT 1806:49 CAM-2 CALi- CA.\l-I 1506:52 CA.I-2 CA.\-2 CA!-1 We’re losing an engine l l l ((Voice fading out)) Why Fuel Open the crossfeeds, man Open the crossfeecs there or something ((sirnuitaneous *+vith above)) 1806:S5 CA.\-3 CA.\-2 CA.!-1 1 X07:00 CA.t1-2 CA.{-3 Showing iumes (Think, maybe we) Showing a thousand or better I don’t think its in there Showing three thousand isn’t it CAh!-I Okay, it, its a 1X07:06 C A M - 2 Its flamed out 1807:12 RDO-I Uniied one seven three I would like clearance for I an approach into two eight left, now 1807:17 PA United one seventy three heavy, ok, roll out heading zero one zero --- be a vector to the visual run- way two eight left and ah, you can report when you have I the airport in sight suitable for a visual approach.

\

. *_ _., . INTRA-COCKPIT APPENDIX D AIR-GROUND COMMUNICATIONS TIME & TIME & SOURCE CONTENT SOURCE CONTENT 1807:27 CAhl-3 CAL-I 1807:31 CAlI- 3 CAll- I CA.\-3 CA!-1 1507:3s CA\1-3 ISO7:?3 CA\-2 lSO7:41 CA.jl-3 1807:42 CAL-I C A M - I C A M - 3 1807:48 C A M - I 1807:52 C A M - l C A M - I ’ i : C A M - 3 U’e’re going to lose number three in a minute too Well You gor a thousand pounds, you got (0 Five rhousand in there, buddy, but we lost rf ,411 rrght Are you getting II back So, nurnbcr four, you got that crossfeec open? INO, I haven’t got it open, which one Open em both, II get some fuel in there Got some fuel pressure? Yes, sir Rotation now she’s coming Okay, watch one and two We’re showing down to zero or a thousand Yeah 35- 1807:25 RDO-I Very well

INTRA-COCKPIT TIME dr SOURCE CONTENT -560 APPENDIX D AIR-GROUND COMMUNICATIONS I TIME h SOURCE CONTENT C A M - I C A M - 3 1808: 18 CA,M-2 1808:ll CA,!-1 CA,\4-3 C.A:\l-I 150X:14 CAdit- 1 SO8:19 CA.\1-2 CA:\-? 190X:42 CA,\-1 CAL1-3 1508:45 CAV-2 CA.ti-3 CAhl-3 On number one Right Still not getting it Well, open all four crossfeeds All four? Yeah All right now, IIS coming It’s going to be D on approach though Yeah You gotta keep em running, Frostie Yes, sir Get this # on the ground Yeah It’s showing not very much more fuel xxx xxx 1808:50 RDO-I 1808:58 P A United one seven three has got the field in sight now and we’d like an ASR to ten left er two eight left Okay, United one seventy three heavy, maintain five thousand 1809:03 R D O - I hlaintain five

\

. ‘_ -., . INTRA-COCKPIT T161E 6: SOURCE CONTENT 1809:16 CAXI-3 We’re down to one on the totalizer 1309:17 CA.\-3 Number two is empty CA\-2 Yeah C A M - I Yeah ((Sound of spool down)) i 1809:51 CA,&!-2 You want the ILS on there . Buddy -57- APPENDIX D AIR-GROUND COMMUNICATIONS TIME & SOURCE CONTENT 1899: 21 RlIO-I lSO9:27 PA lSrJ9:32 RDO-I ISO9:33 PA 1909:39 RI-IO-2 1809:42 PA 1809:45 RDO-2 United ah, one seven three is goint to turn toward the airport and come on in Okay now you want to do II on a visual is that what you want? Yeah Okay United one seventy three heavy ah turn left heading three six zero and verify you do have the airport in sight W,e do have the airport in sight, one six three heavy elt one seven three heavy One seven three heavy is cleared visual approach runway two eight left Cleared visual two eight 1 e f t

.

I

,

. INTRA-COCKPIT TIME dc SOURCE CONTENT CAhl-I Well CAhl-2 It’s not going to do you any good now CAL!-1 1810:17 CAX-I 1X10:24 CA.V-I CA.%-3 CAL{-I 1X10:33 CA.\l-I CAL!- 3 C A M - I 1810:43 C A M - 3 No, we’ll get that Il warning thing if we do Ah, reset that circuit breaker momentarily, see if we get gear lights Yeah, the nose gears down O f f Yeah About the time you give Ihat brace position You say now No, no but when you do push that circuit breaker in Yes, sir APPENDIX D AIR-GROUND COh4MUNICATIONS I TIhIE dr SOURCE CONTENT x x x I X10:47 RDO-I Ho-w far you show us from the field? 1810:51 PA Ah, I’d call it eighteen flying miles 1810:54 RDO-I All right 1810:59 CAM-3 Boy, that fuel sure went to hell all of a sudden, I told you we had four

’ ’

. , TIME & SOURCE 1811:lS CAV-I 1812:03 CA.il-? I812:Ob CA’.!-1 I812:22 CA.!-2 I N T R A - C O C K P I T A I R - G R O U N D COMhlUNICATIONS CONTENT TIME & SOURCE CONTENT There’s ah, kind of an interstate high --- way type thing along that bank on the river in case we’re short Okay ihat’s Troutdale over there ZDOU~ six of one half d dozen of the other Let’s take the shortest route to the arrporr -59- APPENDIX D xxx . 1812:42 RDO-I \Vhat’s our distance now? lSI2:45 PA Twelve flying miles 1812:CS CA.\-? Well, l l 1812:52 CAhl-I About three minutes C A M - I Four CAhl-? (Yeah) 1813:21 C A M - 3 We’ve lost two engines guys C A M - 2 Sir? 1812:SO RDO-I Okay -_ xxx 1813:25 I C A M - 3 We just lost two engines, one and two

INTRA-COCKPIT -6O- APPENDIX D AIR-GROUND COMhlUNICATIONS TIME Jr TIME dr SOURCE CONTENT SOURCE 1813:28 CAM- 2 You got all the pumps on and everything CA.\4-3 Yep 1813:38 CA,\-1 They’re all going 1813:41 CAX{-I We can’t make Troutdalc 1813:43 CA.!-2 We can’t make anything 1813:46 CA.\-1 Okay, declare a maydab 18 1 WS((impact with transmission lines as derived from tower tape.)) 1813:29 PA 1513:35 RDO-2 PA , lS13:50 RDO-2 1813:58 TWR CONTENT United one ieyenty three heavy contact Porrland tower one one eight point seven, you’re about eight or niner flying miles from the airport Okay, elghtcen seven Have a good one Portland tower United one seventy three heavy hlayday we’re the engines are flaming out, we’re going down, we’re not going to be able 10 make the airport United one 1813:59 TWR ((end of tape))

FD06997 ｜ 1980_美国_AAR8002.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1980 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT THURMAN L. MUNSON CESSNA CITATION 501, N15NY NEAR CANTON, OHIO AUGUST 2,1979 UNITED STATES GOVERNMENT NTSB-AAR-80-2

. Report No. 2.Government Accession No. I. T i t l e and S u b t i t l e NTSB-AAR-80-2

Aircraft Accident Report- Thurman L. Munson Cessna Citation 501, N15NY, Near Canton, Ohio, August 2, 1979

1. Author(s)

9 . Performing Organization Name and Address National Transportation Safety Board Bureau of Accident Investigation Washington, D.C. 20594 12.Sponsoring Agency Name and Address NATIONAL TRANSPORTATION SAFETY BOARD Washington, D.C. 20594 3.Recipient's Catalog No. 5.Report Date

1. Performi ng Organ i za t ion
2. Performing Organization

April 16, 1980 Code Report No.

1. Work U n i t No.
2. Contract or Grant No.
3. Type of Report and

Period Covered August 2, 1979 29 17 Aircraft Accident Report 1 .Sponsoring Agency Code -

1. Key Words Cessna Citation 501; stall; multiengine aircraft;

undershoot; wing flap position; airspeed control; power management; approach profile; standard procedures and practices; angle-of-attack system; turbojet engines; pitch attitude; general aviation; pilot training; checklist; survivability; shoulder harness; fire Ig.Security C l a s s i f i c a t i o n 20.Security C l a s s i f i c a t i o n (of t h i s report) (of t h i s page) UNCLASSIFIED UNCLASSIFIED 15.Supplementary Notes but ion Statement This document is available to the public through the National Technical Informa- tion Service, Springfield, Virginia 22161 21.No. o f Pages 22.Price 28 16.Abstract About 1602 e.d.t., on August 2, 1979, a Cessna Citation piloted by Mr.Thurman L. Munson crashed short of runway 19 at the Akron-Canton Airport near Canton, Ohio. The pilot was practicing touch-and-go landings during a local flight with two passengers aboard. The aircraft first touched down in a relatively level, clear area about 870 f t short of the runway. The aircraft slid through a small clump of trees, hit a large stump, and came to rest on a road adjacent to the airport boundary fence. Fire erupted immediately after the aircraft came to rest. The two passengers escaped from the wreckage; the pilot was killed. The National Transportation Safety Board determines that the probable cause of the accident was the pilot's failure to recognize the need for, and to take action to maintain, sufficient airspeed to prevent a stall into the ground during an attempted landing. The pilot also failed to recognize the need for timely and sufficient power application to prevent the stall during an approach conducted inadvertently without flaps extended. Contributing to the pilot's inability to recognize the problem and to take proper action was his failure to use the appropriate checklist and his nonstandard pattern procedures which resulted in an abnormal approach profile.

This document was converted to text using Optical Character Recogntion procedures. Every effort has been made to ensure integrity; however, minor differences may exist between this and the original printed version.

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CONTENTS SYNOPSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1. FACTUAL INFORMATION . . . . . . . . . . . . . . . . . . 1 1.2 Injuries to Persons . . . . . . . . . . . . . . . . . . . . . 6 1.3 Damage to Aircraft . . . . . . . . . . . . . . . . . . . . . 6 1.4 Other Damage . . . . . . . . . . . . . . . . . . . . . . . 6 1.5 Personnel Information . . . . . . . . . . . . . . . . . . . . 6 1.6 Aircraft Information . . . . . . . . . . . . . . . . . . . . 7 1.7 Meteorological Information. . . . . . . . . . . . . . . . . . 7 1.8 Aids to Navigation . . . . . . . . . . . . . . . . . . . . . 7 1.9 Communications . . . . . . . . . . . . . . . . . . . . . . 7 1.10 Airport Information . . . . . . . . . . . . . . . . . . . . . 7 1.11 Flight Recorders . . . . . . . . . . . . . . . . . . . . . . 8 1.12 Wreckage and Impact Information . . . . . . . . . . . . . . . 8 1.13 Medical and Pathological Information . . . . . . . . . . . . . 9 1.14 Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 1.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . 10 1.16 Tests and Research . . . . . . . . . . . . . . . . . . . . . 11 1.16.1 Powerplants . . . . . . . . . . . . . . . . . . . . . . . . 11 1.16.2 Entry Door. . . . . . . . . . . . . . . . . . . . . . . . . 11 1.17 Additional Information. . . . . . . . . . . . . . . . . . . . 11 1.17.1 Aircraft Performance . . . . . . . . . . . . . . . . . . . . 11 1.17.2 Angle-of-Attack Indicator . . . . . . . . . . . . . . . . . . 12 1.17.3 Pilot Training . . . . . . . . . . . . . . . . . . . . . . . 13 1.17.4 Pattern Procedures . . . . . . . . . . . . . . . . . . . . . 14 1.17.5 Crew Seat Strength . . . . . . . . . . . . . . . . . . . . . 14 1.18 New Investigative Techniques. . . . . . . . . . . . . . . . . 14 1.1 History of the Flight . . . . . . . . . . . . . . . . . . . . 1 2. ANALYSIS. . . . . . . . . . . . . . . . . . . . . . . . . 14 3. CONCLUSIONS. . . . . . . . . . . . . . . . . . . . . . . 21 3.1 Findings.. . . . . . . . . . . . . . . . . . . . . . . . . 21 3.2 Probable Cause. . . . . . . . . . . . . . . . . . . . . . . 22 4. RECOMMENDATIONS. . . . . . . . . . . . . . . . . . . . 22 5. APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . 25 Appendix A-Investigation and Hearing. . . . . . . . . . . . 25 Appendix B-Pilot and Passenger Information . . . . . . . . . 26 Appendix C-Aircraft Information. . . . . . . . . . . . . . 27

NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT Adopted: April 16, 1980 THURMAN L. MUNSON CESSNA CITATION 501, N15NY NEAR CANTON, OHIO AUGUST 2, 1979 SY N O PSIS About 1602 e.d.t., on August 2, 1979, a Cessna Citation piloted by Mr. Thurman L. Munson crashed short of runway 19 at the Akron-Canton Airport near Canton, Ohio. The pilot was practicing touch-and-go landings during a local flight with two passengers aboard. The aircraft first touched down in a relatively level, clear area about 870 f t short of the runway. The aircraft slid through a small clump of trees, hit a large stump, and came to rest on a road adjacent to the airport boundary fence. Fire erupted immediately after the aircraft came to rest. The two passengers escaped from the wreckage; the pilot was killed. The National Transportation Safety Board determines that the probable cause of the accident was the pilot's failure to recognize the need for, and to take action to maintain, sufficient airspeed to prevent a stall into the ground during an attempted landing. The pilot also failed to recognize the need for timely and sufficient power application to prevent the stall during an approach conducted inadvertently without flaps extended Contributing to the pilot's inability to recognize the problem and to take proper action was his failure to use the appropriate checklist and his nonstandard pattern procedures which resulted in an abnormal approach profile.

1. FACTUAL INFORMATION
2. 1

History of the Flight About 1430 e.d.t., 1/ on August 2, 1979, the pilot of N15NY, a Cessna CE-501 "Citation," invited two associates to accompany him on a local flight at Akron-Canton Airport near Canton, Ohio. Both associates of the pilot were certificated pilots; however, neither had flown in turbojet-type aircraft. One of them had been the pilot's flight instructor in the Beech aircraft model BE-60. He had flown with the pilot for about 100 to 150 hrs. He boarded N15NY and sat in the right front seat next to the pilot. The other associate boarded the aircraft and sat in an aft-facing passenger seat behind the right cockpit seat. The pilot closed the cabin entry door. The passengers were not briefed regarding the location of shoulder harnesses, the operation of emergency exits, or procedures to follow in an emergency. The passenger who was seated in the cabin said that he left his seatbelt fastened loosely so he could turn to his right and face partially forward to view the cockpit. 1/ All times herein are eastern daylight based on the 24-hour clock.

-2- According to the passengers, the pilot turned on the electrical power and checked his fuel quantity, which was about 900 pounds per tank. The pilot then "referred to a little booklet" and calculated his reference speeds for landing approaches. He set the "bug" 2/ on his airspeed indicator at 93 kns. The passenger in the right cockpit seat then set the bug on the right side airspeed indicator at 93 kns. The passengers said that they were not aware of the pilot's intentions for the flight until he requested and received clearance to remain in the traffic pattern for practice landings. The pilot used a headset and a microphone button located on his control yoke for radio transmissions. The pilot started the engines, checked the ATIS, 3/ and at 1536 was cleared to taxi to runway 23. The flight was cleared for takeoff on runway 23 at 1541:36. Three touch-and-go landings were conducted on runway 23 before an approach was flown to runway 19. The following account of the sequence of events preceding the accident was supplied by the two passengers aboard Nl5NY and by other persons who witnessed the flight and the crash: The initial takeoff was normal and the aircraft was turned to enter a left traffic pattern for a touch-and-go landing on runway 23. Downwind airspeed was about 200 kns indicated airspeed (KIAS) for a short time and then the aircraft was slowed below the gear-down limit (174 KIAS). Altitude on the downwind leg was about 2,500 ft mean sea level 4/ (airport elevation was 1,217 ft). Power was reduced abeam midfield on downwind, the landing gear was lowered, and the approach flaps were extended. A normal touch-and-go landing was accomplished on runway 23. The flaps were raised to takeoff position and thrust was applied for takeoff. During the climbout, the landing gear and flaps were retracted, and then the pilot pulled the right throttle back to demonstrate the single-engine climb capability. The right throttle was then returned to normal thrust position and a left traffic pattern was flown. One passenger said that the aircraft was "as high as 3,000 ft" on downwind. The other passenger was not positive, but believed the altitude was about 2,800 ft. During the downwind leg of the second landing, the pilot advanced the throttles and demonstrated how rapidly the aircraft would accelerate. The passengers did not state what airspeed was reached during the acceleration, but they did recall that the pilot then used the speed brakes to reduce the 2/ Movable pointer which is set at the desired reference speed on the airspeed indicator. 3/ Automatic Terminal Information Service-recorded information regarding local weather and airport conditions. 4/ All altitudes herein are mean sea level unless otherwise specified.

-3- airspeed below maximum gear-lowering speed (174 KIAS). The pilot then lowered the landing gear, extended approach flaps, and retracted the speed brakes. A second normal touch-and-go landing was made, and the aircraft was flown for a third left traffic pattern for runway 23. After turning to the crosswind leg for the third pattern, the pilot invited the right seat passenger to take the control yoke and acquaint himself with the control responsiveness. The passenger turned the aircraft left to a downwind leg. The pilot then invited the passenger to fly a zero flap approach. The pilot mentioned that the aircraft would float considerably unless flaps were used during the landing. The passenger flew the aircraft at 170 KIAS on downwind leg. He said the pattern was considerably wider- than-normal to dissipate some altitude, but he did not recall what altitude was flown. He said the final approach was flat, and somewhat below the VASI. 5/ The passenger who was flying the aircraft said that the pilot did not recommend a final approach airspeed; however, he recalled that the speed flown was "considerably faster than the reference speed (bug) on the airspeed indicator." He said the pilot was handling the throttles and made a few power adjustments during the approach. The passenger flying the aircraft said he was only handling the control yoke and trim. The landing touchdown was long (about midpoint of the runway) and preparation for takeoff was begun immediately. The passenger who was flying the aircraft said the aircraft suddenly floated into the air about 5 to 10 ft. He said he was surprised until he realized that the pilot had lowered the flaps to the takeoff position causing the aircraft to "balloon." The pilot applied takeoff thrust and took control of the aircraft. During the fourth takeoff, the tower advised Nl5NY to enter a right pattern for runway 19 because of other traffic. A right downwind leg was entered at 3,500 f t and 200 KIAS. While on downwind, the pilot reduced the throttles to dissipate airspeed and altitude. The passengers recalled that the throttles were reduced to a point where the landing gear warning horn sounded and that the pilot silenced the horn. One passenger stated, " . . . I know that when we were at 3,500 ft, those throttles were pretty much all the way back." A t 1559:33, the tower controller advised N15NY to extend the down- wind leg for about 1 mile, because of traffic landing on runway 19 and departure traffic on runway 23. At 1559:55, the controller advised N15NY to begin its base turn "anytime now." The aircraft was turned immediately onto base leg. The passengers reported that they did not recall the pilot using the speed brakes and that he did not lower the landing gear or extend the flaps on downwind. 5 / Visual Approach Slope Indicator--provides visual glide slope guidance to the pilot to assist in preventing undershoots and overshoots.

-4- The passengers recalled that the turn to base leg was made with about 30° of bank and with the nose slightly low. One passenger said that about 1,000 f t of altitude was lsot in the base leg turn. The turn to final was estimated by the passengers to have been about 20° to 30° of bank with the nose still slightly low. The passenger in the right seat stated that he noticed the VASI as the turn to final was begun, and the aircraft was just about on the desired glidepath He noticed that the landing gear had not been lowered so he said, "I don't think you want to land this airplane with the gear still up." The pilot then lowered the landing gear. The aircraft had now drifted slightly left of centerline for runway 19, and it had begun to settle below the VASI glidepath. The passenger in the right seat said he recalled that the altimeter indicated 1,700 ft when he advised the pilot about the landing gear. He said that when the aircraft went below the VASI glidepath, he cautioned the pilot about being below the VASI and about possible downdrafts near the approach end of runway 19. The passenger did not recall altimeter indications after the

landing gear was lowered, because he was watching the VASI and using outside references. He said he recalled sensing that the aircraft was "settling in." He said he could "just feel it." He recalled saying to the pilot, "w e're sinking." At that point the pilot started to apply power. The aircraft was aligned with the runway centerline but was below the VASI glidepath and descending. The passenger in the cabin recalled that the power application was relatively slow because the pilot "sort of inched them (throttles) forward." The passenger in the right front seat said he noticed the angle-of-attack indicator was in t h e caution range (yellow). At that time, the sink rate was beginning to increase and power was being applied gradually. The passenger in the cabin said he did not watch the VASI, but he could "sense" the sink rate was "pretty strong." He said, "I could see in his face (the pilot's) that he felt there was something wrong of course." He also said, "I sensed the airplane sinking and I could sense through the expression in Thurman's face that the aircraft was out of control." Neither passenger could recall seeing a vertical speed indication regarding the descent rate while on base leg or on final approach. The passenger in the right front seat stated he was sure the airspeed was "nailed right on the bug" (93 KIAS) during the final approach. The passengers said they never felt a sensation of acceleration from the power application by the pilot during the last portion of the approach. The passenger in the cabin said he felt the left wing drop slightly as they were sinking and he saw the pilot suddenly push the throttles "to the firewall," that is, full forward. The passenger in the right front seat recalled feeling slight airframe buffet just before impact. He said it was not pronounced--just a shudder before impact. The other passenger said he did not recall a shudder or buffet; rather he turned around and faced rearward in his seat, because he believed the aircraft was going to crash. He said he "kept waiting for that acceleration to pull us out of what I felt . . . was pretty excessive sink rate."

-5- The passenger in the right front seat said, "I was trying to convey to him (the pilot) my discomfort with the fact that we were getting a little bit low and that I was uncomfortable with the sink rate. . . . I didn' t want to come out and say ' I don't like this approach; please add power.' I was trying to feed that information to him in that fashion because, again, I had no experience in this type of aircraft." He said the pilot seemed calm and not rushed in his activities. Neither passenger saw the pilot use a checklist during the flight. One passenger recalled the pilot saying something during the flight such as, "You have to pay attention to what you're doing, because the aircraft will descend rapidly." The passenger said, "I remember him saying, 'You have to stay on top of it--pay attention.'" Neither passenger recalled the pilot saying he was going to make a zero flap landing. The passenger in the right front seat said he just assumed the pilot was conducting a zero flap approach because he didn't follow the same sequence as before. Neither passenger saw the pilot attempt to lower the flaps during the last approach. When the aircraft touched the ground, the passengers said they felt a series of bumps and then they came to a sudden halt. The passenger in the cabin said he thought they hit a "ditch or hill or something." A passenger in an automobile traveling southeasterly on Interstate 77, 3,300 ft from the threshold of runway 19 and along the extended centerline of runway 19, stated that the aircraft crossed from left to right in front of the automobile. He first saw the aircraft to his left about 400 to 500 f t away. He then saw it about 150 to 200 f t directly in front of his automobile and 50 to 75 f t above the ground. He next saw it to his right, just skimming the trees and then disappearing from view. He then saw red flames and black smoke. The witness stated that the aircraft was in a gradual descent, extremely low, and barely clearing the tree tops. He said, "The aircraft was going very slowly, resembling the landing speed of a light small aircraft." He said he saw the right wing "wobbling" as it passed in front of his position The controller working the local control position in the Akron-Canton Tower saw the aircraft only from the time it was on short final approach until it disappeared below the level of the approach end of the runway. He sounded the crash alarm. No other controllers reported seeing the aircraft during this approach.

The aircraft touched down about 870 f t short of the runway on slightly rising terrain at an elevation of about 1,160 f t (runway touchdown zone elevation is 1,217 ft). The aircraft rolled across rough terrain and struck a 2.5-ft-deep ditch where the nose gear separated from the aircraft. It continued sliding until it passed through a clump of small trees and struck a large stump. The aircraft spun around and came to rest on a road, about 270 ft from the initial touchdown point and about 600 ft from the runway threshold. A fire erupted immediately after the aircraft came to rest.

-6- The aircraft crashed about 1602 during the hours of daylight. The coordinates of the accident site are 40°55' N and 81° 27' W at an elevation of about 1,180 ft. 1.2 1.3 1.4 Injuries to Persons Injuries Crew Passenger

0 t her

Fatal 1 0 Serious 0 2 M inor/N one 0 0 0 0 0 Damage to Aircraft The aircraft was destroyed by ground impact and postcrash fire. Other Damage A few small trees were destroyed. The asphalt surface of a roadway on which the aircraft came to rest was damaged by heat and fire. 1.5 Personnel Information The pilot, who also owned N15NY, was trained and certificated in The pilot's logbook revealed that he began flight training on accordance with current regulations. (See appendix B.) February 27, 1978, in a Cessna 150 aircraft. He continued flight training in single-engine Cessna aircraft until April 10, 1978, at which time he also began training in the Beech BE-60, "Duke," twin-engine aircraft. The pilot completed successfully his private pilot checkride on June 11, 1978, in a Cessna 172. His logbook showed that he had logged 25.0 hrs pilot-in-command and 65.2 hrs dual when his Private Pilot Certificate was issued. The pilot received his multiengine rating on June 15, 1978, in a BE-60 aircraft, He had logged 23.8 hrs in the BE-60 and had logged 97.2 hrs total flight time when he took his multiengine checkride. On February 10, 1979, at a total logged flying time of 330 hrs, the pilot purchased and began flying a Beech E-90 "King Air." His logbook revealed that he flew this aircraft until July 6, 1979, when he purchased the Cessna Citation, N15NY. His total logged flying time on July 6 was about 480 hrs, which included 428 hrs of multiengine time. His total time was broken down into 165 hrs dual and 31 5 hrs pilot -in-command. The pilot flew N15NY with a flight instructor for 10 flights before receiving his type-rating in the aircraft on July 17, 1979. He had logged 21.7 hrs and 24 landings in the aircraft before his checkride, which was 1.5 hrs long and included 8 landings. The checkride was flown in N488CC, another Cessna CE-501 Citation. In the 16 days following the type-rating checkride, the pilot logged 10.6 hrs in the Citation (N15NY). He logged 4.1 hrs of this time as pilot-in-command, single pilot. The pilot's total logged flying time at the time of the accident was 516.2 hrs, 33.8 hrs of which were logged in the CE-501 model aircraft.

-7- The passenger in the right front seat had been the pilot's flight instructor for a period of time in 1978. He had flown with the pilot in a Beech aircraft BE-60 "Duke" for about 100 to 150 hrs, during which time the pilot trained for and completed his instrument rating. The passenger was not rated in turbojet aircraft and had not flown previously in the Cessna Citation model aircraft. H e was not trained or qualified to act as the pilot's instructor for the accident flight. According to his statement, he was a friend of the pilot and was aboard the aircraft solely as an observer. The passenger in the cabin was also a certificated pilot. However, he was not rated in turbojet aircraft and had never flown in a Cessna Citation. 1.6 Aircraft Information N15NY, a Cessna CE-501 Citation, serial No. 501-0110, was certifi- cated, maintained, and equipped in accordance with current regulations. (See appendix C.) The CE-501 is a single-pilot version of the original Cessna Citation CE-500, which was certificated on September 9, 1971, with a minimum crew of a pilot and a copilot. The CE-501 was certificated on January 7, 1977. 1.7 Meteorological Information on August 2, 1979, was as follows: The surface weather observation for the Akron-Canton Airport at 1556 Sky condition -- 3,000 f t above ground level, scattered clouds, estimated 4,000 feet a.g.l. broken clouds; visibility -- 10 miles; temperature -- 76°F; dewpoint -- 62° F; wind -- 280° at 9 kns; barometric pressure -- 29.97 inHg. A special weather observation for Akron-Canton Airport taken at 1604 Sky condition -- 3,000 f t a.g.l. scattered clouds, 4,000 f t a.g.l. broken clouds, visibility -- 10 miles; temperature -- 77°F; dew- point -- 63°F; wind -- 280° at 11 kns; barometric pressure -- 29.97 inHg. on August 2, 1979, was as follows: 1.8 Aids to Navigation Not applicable. 1.9 Communications There were no reported com municat ions difficulties. The Akron-Canton Airport is served by a Federal Aviation Administration (FAA) control tower. 1.10 Airport Information surface runways; runway 19 is the longest, 6,397 ft long by 150 f t wide. The Akron-Canton Airport, elevation 1,217 ft, consists of three hard- The

-8- approach end of runway 19 had previously been extended toward the north by using fill dirt. The pierlike approach end of the runway is about 50 f t higher than the terrain immediately to the north of it. Runway 19 is equipped with a two-bar VASI to assist pilots with maintaining a 3° glide slope during Visual flight rules (VFR) operations. When the aircraft is positioned on the glide slope, the bar light closest to the aircraft displays a white indication, while the bar light farthest from the aircraft displays a red indication. When the aircraft is positioned below the glide slope, both bars display a red indication. The VASI glide slope provides for a touchdown point about 1,000 f t from the runway threshold. 1.11 Flight Recorders data recorder, and neither recorder was required. The aircraft was not equipped with a cockpit voice recorder or a flight 1.12 Wreckage and Impact Information The aircraft first touched down about 870 f t from the threshold of runway 19. Marks in the foliage and dirt revealed that the aircraft first touched on its left main landing gear and then on its right main gear about 70 f t farther. The terrain was fairly level, open, and uncultivated. The aircraft rolled on its landing gear for about 150 f t from initial contact until it struck a 2.5-ft-deep trench where the nose gear separated from the aircraft. The aircraft continued for about 70 f t before it entered a stand of small trees. It passed through the trees and hit a large tree stump 5 f t in diameter and 4 f t high. The lower portion of the nose beneath the pilot's seat and the left wing root leading edge hit the stump, and the aircraft again became airborne for a short distance. It came to rest on Greenburg Road, which is located about 8 f t above the terrain on which the trees were located. When the aircraft hit the trees and stump, it rotated clockwise 180°. The crash path was oriented southerly along the extended centerline of runway 19. The left wing root area and lower left side of the fuselage were extensively damaged by impact. The skin was buckled beneath the left windshield and the nose of the aircraft was crushed slightly downward and buckled aft about 5 ft. The right wing and the lower right side of the fuselage were damaged extensively by impact. The skin on the bottom of the fuselage was distorted and crushed upward slightly along the full length of the fuselage. Both wing fuel cells were opened during contact with the trees, and fuel stains were found on surrounding foliage. The right wing and the entire right side of the fuselage were damaged extensively by fire. The left side of the aircraft sustained moderate fire damage. The empennage was extensively burned. The engines were burned away from their attachments and were found in the debris of the empennage. Examination of the wreckage revealed that the flaps were up and the speed brakes were stowed at impact. Continuity of the flight control mechanisms was established with no evidence of preimpact malfunction or failure.

-9- The cockpit interior showed little evidence of impact damage, except for the left side. The pilot's control yoke was broken in half just above the mid- column. The instrument panel was dented and pushed forward. The floor structure beneath the pilot's seat was disrupted. About 2 f t of the floor structure, including the pilot's left seat floor track, was disrupted, crushed aft, and buckled by impact from below. Although the right floor track for the pilot's seat was relatively undamaged, the seat had become detached from the floor track and was found loose in the cockpit. The pilot's seat had sustained impact damage. The left front corner of the seat pan was bent downward about 4 in. The seat pan had contacted the seat base in this area. The seat base and other supporting structures were bent and twisted. The lap buckle was found fastened and the webbing near the left seat attach point was burned away. There was no evidence that the attach point for the shoulder harness lapbelt insert had been fastened to the lapbelt buckle. The inertia reel assembly for the pilot's single-strap diagonal shoulder harness was found with the webbing burned within the reel assembly housing. The inertia reel housing is mounted above and behind the pilot's left shoulder, and it is attached to the wall behind the pilot's seat. The right front seat was found firmly fastened to the floor with no impact damage. The cabin was severely burned. The cabin seats were in place with no evidence of impact damage. The right emergency exit door was open, and the door was inside the cabin. The main cabin door on the left side was closed and jammed. The skin on the forward lower corner of the door was found bent and curled aft and the exterior door handle was missing. 1.13 Medical and Pathological Information A postmortem examination of the pilot, performed by the Summit County Coroner's Office, revealed no evidence of preexisting pathology which would have impaired his ability to conduct the flight safely. The autopsy revealed congestion and edema in the tracheobronchial tree, and the laryngeal airway contained considerable edematous fluid. There were flecks of carbonaceous material scattered throughout the edematous fluid. The autopsy also revealed a dislocation of the atlanto-occipital and atlanto-axial joints, where the cervical spine joins the lower back part of the head. Examination of the spinal cord revealed a "severe contusion, hemorrhage and necrosis of the cervical spinal cord." This injury was beneath the area of the dislocation. The lower aft portion of the brain (cerebellar tonsillar) was displaced downward from its normal position. The coroner concluded that the pilot died from "asphyxiation due to acute laryngeal edema and due to inhalation of superheated air and toxic substances.'' The Summit County Forensic Toxicology Laboratory in Akron, Ohio, the Ohio State University Toxicology Laboratory in Columbus, Ohio, and the FAA Civil Aeromedical Institute Laboratory in Oklahoma City, Oklahoma, conducted toxicological examinations of the pilot. Levels of carbon monoxide and cyanide were insignificant. Findings for alcohol and drugs were negative.

-10- The two passengers suffered second- and third-degree burns to exposed areas of their bodies--face, neck, and hands. They did not sustain serious impact in juries. There was no evidence of in-flight fire. There were about 1,500 pounds of jet A-1 fuel aboard the aircraft when it crashed. All fuel cells were ruptured as the aircraft slid on the ground and when it hit the trees. A severe fire erupted when the aircraft came to rest. Several ignition sources were present--electrical,

hot-engine components, and friction.

1. 14 Fire

The left side of the aircraft was upwind from the smoke and fire, which was intense and concentrated on the right side of the fuselage. The passengers' only escape route was through the emergency exit on the right side of the cabin. When the emergency exit was opened, fire and smoke propagated rapidly into the cabin requiring both passengers to exit immediately. Immediately after the accident, the Green Township Fire Department and the airport fire department were notified via the Tower "hot line." Units were on scene in 8 minutes and the fire was extinguished. The first firefighters on the scene reportedly saw someone with a crowbar or tire iron near the aircraft. It was not determined if the bar was used to attempt to open the entry door. One firefighter said he attempted to open the entry door from the outside and the handle reportedly came off in his hand with little effort. 1.15 Survival Aspects Neither cockpit occupant wore his available shoulder harness. The passenger in the cabin seat did not have a shoulder harness available. After the aircraft stopped, the passenger in the right cockpit seat said he unbuckled his lapbelt and attempted to extricate the pilot from his seat. He said the pilot was pinned between his seat and the instrument panel. H e tried several times to pull the pilot out by his shoulders. The passenger in the cabin unbuckled his lapbelt and attempted to open the left entry door. He said he rotated the handle from the locked position to the horizontal position (open) and back to the stowed position but the door would not open. The other passenger then came aft and attempted to open the door. He said he kicked the door, but it would not open. By this time, black smoke was beginning to enter the cabin and the passenger, who had been riding in the cabin, looked out the right emergency door window and saw flames. He said he located the emergency exit handle and "cracked" the exit open. As flames began to enter the cabin, both passengers made a final attempt to extricate the pilot, but without success. The passenger from the cabin then returned to the emergency exit, opened it, and exited immediately. The passenger in the cockpit said he was still trying to pull the pilot out when the aircraft began to fill rapidly with smoke. He said when he turned around he could not see the emergency exit. He tried once more to extricate the pilot and then moved aft and went out the emergency exit. He attempted to open the door two times without success.

-11- Ground witnesses near the accident site said the fire propagation was rapid with heavy dense smoke. They said the heat was so severe that they could not approach the burning aircraft after they saw the two survivors run away.

1. 16

Tests and Research 1.16.1 Powerplants On August 14 and 15, 1979, Safety Board investigators examined both engines from N15NY at the manufacturer's facility--Pratt and Whitney Aircraft of Canada, Ltd., Lonqueuil, Quebec, Canada. The total time on each engine was 43.1 hrs; each engine had been operated through 45 flight cycles. Both engines had been subjected to moderate impact damage and moderate to severe fire damage. The damage precluded functional tests of the fuel control and fuel pump assemblies from both engines. Disassembly and inspection of these components revealed no evidence of preimpact failure. The fan blades were bent and twisted severely. Blade bending in both engine fan sections was opposite the direction of normal rotation. Small pieces of wood and wood ash deposits were found in both engines in various locations throughout the engine airflow areas. The disassembly and examination of both engines revealed no evidence of preimpact failure or malfunction. 1.16.2 Entry Door Examination of the entry door revealed that a linkage tube was broken in the latch mechanism. The broken tube prevented two latching pins from retracting from the door frame when the handle was rotated to the open position. The door structure adjacent to the broken tube had a compression buckle, and the two latching pins were jammed in the door sill. The broken linkage tube was examined at the Safety Board's metallur- gical laboratory to determine the mode of failure. The examination revealed that the tube failed in tension overload and that the tube material met the manufacturer's strength specifications. 1.17 Additional Inform at ion 1.17.1 Aircraft Performance The performance of N15NY during the final landing attempt was calculated using the following conditions: Field elevation - 1,217 ft Barometric pressure - 29.07 inHg Pressure altitude - 1,170 f t Temperature - 77° F Density altitude - 2,700 f t Aircraft gross weight - 8,750 pounds

-12- The gross weight was estimated to be 8,750 pounds using the aircraft basic empty weight (6,741) plus estimated passenger weights (510) and the estimated weight of fuel onboard (1,500), minus the probable amount of fuel burned during the flight (300). Using these data and the CE-501 Flight Manual Performance Charts, a normal landing configuration (full-flap) stall speed of 74 KIAS was calculated with aerodynamic buffet beginning at 79 KIAS. A reference speed (Vref) for this configuration would have been 95.5 KIAS, based on the charts. Based on the above conditions and the Flight Manual Performance Charts, a no-flap stall speed of 82 KIAS was calculated with aerodynamic buffet beginning at 92 KIAS. Vref for the no-flap configuration was calculated to be 106.6 KIAS. The CE-501 Flight Manual specifies that a no-flap approach must be conducted at the flaps-extended Vref speed + 20 kns, which would be 115.5 KIAS for the assumed conditions (Vref of 95.5 KIAS + 20 kns). The Safety Board could not determine how the pilot calculated a Vref of 93 KIAS before takeoff. Although witnesses stated that he used the CE-501 checklist quick-reference chart for his calculation, 93 KIAS is not one of the speeds printed on the chart. The quick-reference chart shows the following weights and recommended Vref speeds: (GEAR DOWN - FULL FLAPS) VREF Weight 7500 8500 9500 10000 10500 11000 11350 Speed 89 92 94 97 99 101 102 103 104 106 107 108 Using the chart, a Vref of 97 KIAS should have been selected for the fuel weight described by the passengers, if the pilot accurately estimated the aircraft gross weight. 1.17.2 Angle-of -Attack Indicator A key performance instrument available to the pilot of N15NY was the angle-of-attack indicator and its associated displays. The angle-of-attack system derives its input from a sensor which detects the direction of airflow at the side of the fuselage. The system is totally independent of the pitot-static system and displays performance information (angle-of-attack) to the pilot in three ways. First, a three-color vertical display unit, mounted on the glareshield, shows an amber, green, and red light in descending order. This unit provides a "heads-up" source of information with respect to deviation from the approach reference speed. The correct reference speed is displayed as a green light. The second angle-of-attack display is a fast-slow pointer located on the flight director, and the third display is an instrument located on the left upper portion of the instrument panel. The third display depicts "lift" information on a scale from zero (0) to one (1.0). Zero represents zero lift and 1.0 represents 100 percent lift, or stall. The display is valid for all flap positions.

-13- An angle-of-attack indication of 0.6 indicates that the aircraft is operating at the maximum lift/drag ratio and equates to 1.3 x Vso 6/ or Vref. That indication is the maximum endurance reference and is also used for maximum angle of climb. A yellow area (caution) on the angle-of-attack indicator begins adjacent to the 0.6 index and continues toward the stall warning area. Flight in the caution area is less than 1.3 Vso (Vref) and is near the prestall buffet regime. Flight in the caution zone on the angle-of-attack indicator (less than lift/drag maximum) requires more power to sustain steady flight than is required at an indication of 0.6. Similarly, any increase in angle of attack during flight in the caution zone produces proportionately more drag than lift achieved--"the area of reverse command." Considerably more power is required to overcome the additional drag produced for the relatively small amount of lift gained. 1.17.3 Pilot Training According to the staff of Flight Safety International (FSI) located at Wichita, Kansas, FSI was initially requested to provide an instructor pilot for pilot-service to fly with the new pilot/owner of N15NY. It was later requested that the pilot-service include instruction to prepare the pilot for a type-rating in the Citation. An instructor pilot employed by FSI was provided and instruction began on July 7, 1979. According to the instructor, the entire FSI ground school curriculum was completed between July 7 and July 15, 1979. He said 4 to 6 hrs per day were devoted to ground training. The instructor stated that i t was evident to him that the pilot had spent considerable time studying the aircraft before taking delivery of N15NY. This portion of the ground school training was completed in conjunction with flight training. The flight training was conducted during cross-country flights to Oakland, Seattle, Kansas City, and Wichita. Local training flights were made at Oakland and Seattle. The flight training record completed by the pilot's instructor showed five flights for a total of 11.1 hrs flight time. He stated that additional training was conducted during cross-country flights. On July 17, 1979, the pilot received 4 hrs in the Citation simulator at FSI. He reportedly conducted the simulator time as a single pilot. The instructor reported the pilot's knowledge and performance in the simulator as "above average." The instructor also stated that "from the onset to completion of training Mr. Munson displayed well above average skills and judgment as a pilot. H e was very knowledgeable of the Operators Manual and the Flight Manual." The pilot received his type-rating from an FAA-designated pilot examiner employed by FSI. He reportedly had no difficulty during the checkride. According to the records, the pilot was trained and certificated in accordance with provisions of 14 CFR 61. 6/ The stall speed or the minimum steady flight speed in the landing configuration.

-14- According to flight instructors who had flown with the pilot and who had given him instruction for his various certificates and ratings, they considered the pilot above average in operation and knowledge of the aircraft they observed him fly. 1.17.4 Pattern Procedures The FSI training material used for the pilot's training contains a diagram for recommended VFR pattern airspeeds, altitudes, and configuration. The recommended downwind airspeed was 150 KIAS at 1,500 f t a.g.l. with the flaps extended to "approach." The landing gear should be lowered opposite to the planned touchdown point. The recommended airspeed during base turn was Vref + 20 kns with approach flaps extended and landing gear down. Minimum altitude on base leg was 1,000 ft a.g.l. The recommended final approach airspeed was Vref to Vref + 10 kns and back to Vref once the landing is assured. Regulation 14 CPR 91.70 specifies that a turbine-powered aircraft must be restricted to 200 KIAS maximum in the airport traffic area, providing that the operational requirements of the aircraft permit that speed. Regulation 14 CFR 91.87 specifies that turbine-powered aircraft must maintain at least 1,500 f t a.g.l. entering the airport traffic area and while in the pattern until final descent for landing is required, at airports with an operating control tower. 1.17.5 Crew Seat Strength The Citation crew seats were designed to comply with the strength requirements of 14 CFR 25.785. That rule specifies that the seats must withstand an ultimate inertial load of 4.5 g's downward, 9.0 g's forward, and 1.5 g's sideward, as set forth in 14 CFR 25.561. Cessna personnel stated that the seat was designed and tested to withstand these ultimate inertial loads. In fact, the seat was tested to failure at a combined resultant ultimate design load of 10.5 g's (9 g's forward, 3 g's sideward, and 4.5 g's downward); the sideward load was twice that required by the FAA so that the seats would meet more stringent foreign certification requirements. This test was conducted based on a 170-lb occupant and a 32-lb seat. 1.18 New Investigative Techniques None.

1. ANALYSIS

The Accident The pilot was properly certificated and had received the training prescribed by applicable regulations. There was no evidence of preexisting medical problems which could have affected the pilot's performance.

-15- The aircraft was certificated, equipped, and maintained in accordance with applicable regulations. The aircraft gross weight and center of gravity were within prescribed limits. Meteorological conditions were not a factor in the accident. Although density altitude was higher than field elevation, it was not high enough to affect adversely the aircraft or engine performance to a point to be considered a factor in the accident. Based on the evidence, the Safety Board's investigation concentrated on three possible areas of causation: (1) flap system or pitot-static system malfunc- tion or failure, (2) engine malfunction or failure, and (3) pilot action or inaction. Flap System or Pitot-Static System Malfunction or Failure The Safety Board's investigation revealed no preimpact mechanical problems with the flap system. This finding is supported by passenger statements confirming that the pilot did not attempt to actuate the flap control switch to lower the flaps during the last landing attempt. Additionally, during the flight the pilot did not mention problems with the flap system nor did the passengers observe any difficulties with this system. Impact and fire damage precluded a functional test of the pilot's airspeed indicating system, the most critical pitot-static instrument in this case. However, the Safety Board does not suspect a problem with this system for several reasons. Three successful takeoffs and landings were accomplished with no reported difficulties. If erroneous airspeed indications were a problem during the flight, the pilot and possibly the passengers would have likely sensed low airspeed cues, such as airframe buffet and flight control unresponsiveness. In fact, if erroneous airspeed indications were a problem, they would have been more noticeable during the earlier approaches and landings where the aircraft was slightly heavier and low airspeed problems would have been more pronounced. The passengers' description of the aircraft performance during the last approach is consistent with that calculated from the aircraft performance charts. That is, the onset of aerodynamic buffet and the rapid sink rate in the configura- tion and at the airspeed being flown was normal and predictable. Finally, the angle-of-attack indicator was observed to be in the caution zone during the last approach at 93 KIAS. Since the angle-of-attack indicator receives inputs for its display from a source totally independent of the pitot-static system and since the "caution" indication on the indicator is the proper reading for the airspeed and configuration being flown, the airspeed indicator obviously was showing the proper indication. Therefore, the Safety Board concludes that neither the flap system nor the pitot-static system failed or malfunctioned. Additionally, the investigation revealed no other aircraft system or airframe problems which could have caused the accident.

-16- Engine Malfunction or Failure Disassembly and examination of the engines revealed no evidence of preimpact failure or malfunction. Additionally, both engines were found to be capable of normal operation and were developing considerable power at impact. Rotational damage to the engine fan assemblies and the presence of wood particles and burned wood residue throughout the engine interiors support this conclusion. Debris would not be distributed through the engine air passages if the engines were operating at low power. Passenger statements further support the conclusion that the engines were functioning properly before the crash. Apparently, the pilot did not advance the throttles full forward until just before impact. He gave no indication to the passengers that he was experiencing engine problems, and they did not recall sensing any visual or audible indications of engine malfunction. Pilot Action or Inaction This undershoot accident involved a high sink rate and a descent below the glidepath which continued unrecognized and unchecked until contact with the ground was unavoidable. Wing flap position, airspeed control, power management, the approach profile, and standard procedures and practices, all are important aspects in the cause of this accident. These aspects are dependent upon one another in effecting a safe, stabilized approach and landing. The Safety Board could not determine positively whether the pilot inadvertently flew the last approach without flaps, or did so intentionally but at the wrong airspeed. The Safety Board believes that the pilot most likely forgot to lower the flaps. According to the passengers, the pilot held the selected "bug" airspeed, which suggests that he was monitoring the airspeed indicator. Moreover, the airspeed indicator is a primary performance instrument and is readily in view of the pilot. Further, it is the most important cue available and used during approach and landing. The flap handle and flap position indicator are not primary flight performance cues and are checked only during the "before landing" and "landing" checklists. According to the passengers, the pilot did not refer to a checklist during the flight. The passenger in the right front seat reminded the pilot to lower the landing gear, but he did not mention the flaps because he was not totally aware of the pilot's intentions and was not familiar with the proper airspeed to be flown. Consequently, an oversight was made and the pilot forgot to lower the flaps. He flew the approach at a normal (full-flap) approach speed, about 20 kns below that required for a no-flap approach. The aircraft entered a high sink rate and continued below the glidepath without adequate and timely corrective action by the pilot. The 4-kn difference between the full-flap Vref speed (93 KIAS) selected by the pilot and the proper speed (97 KIAS) was not a major oversight. However, it does reflect adversely on the pilot's attention to detail while computing the aircraft gross weight and the proper Vref. The Safety Board could not determine why the pilot did not monitor the angle-of-attack system, which obviously would have given him a "slow" indication. Since he had not flown other aircraft equipped with this system, he may not have been fully familiar with it, or may not have developed a habit of including it in his scan during approach and landing.

-17- The pilot's management of power during the approach is also related to the cause of the accident. Passenger statements indicate that the pilot did not advance the throttles full forward until just before impact. The technique described by the passengers regarding the pilot's "inching the throttles forward" is typical of pilot technique in a propeller-driven aircraft, the type aircraft with which this pilot was more familiar. Power response in turbojet engines is generally less rapid than in propeller-driven aircraft engines, thus requiring the pilot to anticipate his power requirements with timely throttle application. Additionally, in propeller-driven aircraft, the increased air flow from the propeller(s) over the aircraft wings and control surfaces generally improves the aircraft performance. This does not occur in turbojet aircraft.

In addition, for turbojet engines, the greatest percentage of thrust available is gained in the top range of engine rpm. The power response in propeller-driven aircraft is more linear throughout the power range in relation to throttle position. Therefore, the pilot's action of "inching the throttles forward" would not have enabled him to gain appreciable added thrust until he reached the top range of engine rpm. In the accident situation, where considerable power was required to overcome the high descent rate and to avoid contacting the ground, rapid and full throttle movement was needed to attain maximum engine response. Although rapid throttle movement is not recommended as a routine practice in jet aircraft, it can be accomplished without engine damage if t h e fuel-control system is calibrated properly. The pilot's throttle technique further compounded his situation because the aircraft was flying at an airspeed below the maximum lift/drag ratio. Flight in this manner is generally referred to as "the area of reverse command." In this condition, any attempt to arrest the rate of descent by increasing pitch attitude (angle of attack) will produce proportionately more drag than lift. Therefore, additional power, beyond that required to decrease t h e descent rate, would be required to overcome the added drag. The amount of power the pilot added during the last approach may have been sufficient for previous approaches flown at the proper airspeed for the configuration. In fact, he may have added the amount to which he was accustomed on previous occasions; however, that was not sufficient for the last approach. In order to maintain the "bug" speed he selected, altitude had to be sacrificed, and as a result the rapid descent rate continued. Rapid and full throttle advancement was the only alternative available to the pilot. The Safety Board believes the pilot failed to apply sufficient power in a timely manner because he did not realize or sense that power was required. The pilot was probably bewildered by the unexpected response of the aircraft; the high sink rate and the different "feel" of control responsiveness at the low airspeed probably confused him. When he monitored his airspeed indicator, which he assumed was showing the "correct" airspeed for the conditions, the pilot probably became even more bewildered by the aircraft reaction. His bewilderment or concern was described by one of the passengers, who said he could "sense the problem" by the expression on the pilot's face. The pilot's lack of action regarding power management in a serious life-threatening situation confirms that he did not diagnose properly the problem confronting him and failed to take timely and effective action.

-18- Another matter which contributed to the pilot's confusion during the last approach involves t h e manner in which he conducted the previous patterns. Normal practice and procedure dictate certain traffic pattern criteria, such as recommended airspeeds and altitudes and setting aircraft configuration at selected phases of the pattern. These criteria aid a pilot in establishing habit patterns during approaches and landings in order to fly in a consistent manner and to create a normal approach profile so that abnormal situations will be more recognizable. The description of the accident flight, as related by the survivors and other witnesses, shows a general lack of adherence to "standard practice" regarding airspeed and altitude management on the part of the pilot. Also, he was not consistent in establishing the aircraft configuration. This failure to establish a normal flight profile set the stage for the pilot's problem when he was requested to fly a pattern to a different runway. The first three approaches were in a left-hand traffic pattern which is easier to fly in aircraft with side-by-side cockpit arrangements because the pilot has a better view of the airport. In right-hand patterns, visibility to the runway from the left seat is restricted and hinders the pilot. The right-hand pattern to runway 19 was "nonstandard" to the pilot, who had not yet flown a "normal" flight profile for a left-hand pattern to runway 23. His erratic airspeed and altitude control and the extended downwind leg put him in an unfamiliar situation. Any habit pattern he may have developed regarding gear and flap lowering was broken. Even though his former instructor reminded him about the landing gear, the situation had developed to a stage where only positive action by the right-seat passenger or by the pilot could have prevented the accident. In order to initiate the last approach, the pilot reduced power, silenced the gear warning horn, and lowered the nose. Once the descent was established and he was reminded about the landing gear, he lowered it, but the normal landing habit pattern had been broken. The added drag of the gear, the reduced power, and the reduced lift available without flaps extended, placed the aircraft in a dangerous situation. The pilot obviously did not recognize his plight because of previous nonstandard practices. The Safety Board believes there are other reasons beyond the circum- stances of the last approach which caused the pilot to forget to extend t h e flaps and to fail to recognize the need for rapid power application. General aviation flying is generally conducted under less stringent rules and procedures than commercial or corporate/executive operations. However, general aviation flying does have rules, procedures, and common practices which a pilot must follow in order to develop good habit patterns and to produce safe flight. The pilot of N15NY did not fully comply with these essentials during the accident flight. First, the pilot allowed his right-seat passenger to make a no-flap approach and landing despite the fact that the pilot was not a qualified flight instructor and the right-seat passenger was not qualified in this type aircraft. Moreover, although a certificated pilot, the right-seat passenger had not met recency of experience requirements of 14 CFR 61.57, which requires three takeoffs and landings in the 90 days preceding the flight. Further, the pilot of N15NY did not brief the right-seat passenger regarding airspeeds associated with the

-19- maneuver nor who would operate certain controls. The Safety Board does not believe the pilot's actions were prudent under any circumstances and reflect adversely on his judgment. Second, although the pilot of N15NY was certificated to carry passengers, the carriage of passengers during practice landings can expose them t o unnecessary risks, especially with a recently qualified pilot. The pilot was required by 14 CFR 91.199 to brief his passengers before takeoff on the location and usage of seatbelts and shoulder harnesses and on procedures to be followed in an emergency, including the location and means for opening the entry door and emergency exits. According to the passengers, he failed to do so. Third, the pilot did not comply with generally accepted and required traffic pattern procedures. Besides the previously mentioned benefit of developing good habit patterns and a normal pattern profile, standard patterns also provide for proper spacing and separation from other traffic. This is beneficial to all aircraft in the pattern as well as to the tower controller. None of the patterns on the accident flight were flown at the "recommended" airspeeds or altitudes. The pilot of N15NY was certainly aware of standard pattern procedures from his previous flying experience, and especially since he had been trained recently in the CE-501 and had demonstrated his ability to fly standard patterns during a checkride. Fourth, the pilot failed to use a checklist. The routine of lowering landing gear and flaps on downwind leg was followed on the first three approaches even though he did not use a checklist. However, these "natural" actions were not performed for the last approach because the habit pattern was broken. The habit pattern was broken by the changed landing pattern and a wider- and higher-than- normal base leg entry. The Safety Board believes that if the landing checklist had been followed by the pilot, the accident could have been prevented. In summary, the Safety Board concludes that the pilot's conduct of the flight set the stage far oversight and confusion. His disregard for standard practices, procedures, and regulations created an atmosphere in which he could not recognize a worsening situation. Perhaps a more experienced pilot would have recognized the dangerous situation more readily and may have taken proper and timely action. However, the pilot had received more training than the minimum specified by the Federal Aviation Regulations. Also, he recently had been certified as competent in the aircraft, reportedly was well qualified, and had demonstrated "above average" skill. He certainly would not have been certificated and described as above average if he had flown the aircraft during training and his checkride in the manner described by the passengers for the accident flight. Therefore, the Safety Board concludes that the manner in which the pilot conducted this flight was the primary factor which precipitated the accident sequence, not his training and experience. Survivability Aspects The crashworthiness of the aircraft was a significant factor in the survival of the two passengers because a livable environment for the occupants was maintained throughout the crash sequence; there was no appreciable collapse of the

-20- airframe in the occupiable areas. However, the floor structure beneath the pilot's seat was disrupted severely. The damage included the seat floor track and the floor and its substructure. This localized damage reduced the effectiveness of the

pilot's restraint system and the seat-to-floor attachments, permitting him and his seat to pitch forward into the control yoke and instrument panel during the abrupt deceleration. The other occupants' restraint systems were not compromised. Even though the pilot's seatbelt was fastened, it was ineffective because it was anchored to the seat structure rather than to airframe structure. When the seat became detached from the floor, the seatbelt was useless. This type installation is acceptable to the FAA as long as appropriate strength requirements of 14 CFR 25.785 are met. The pilot and the right front seat passenger were not wearing their available shoulder harnesses. Thus, the pilot, as a required crewmember, was in noncompliance with 14 CFR 91.7. The Safety Board believes that had the pilot been wearing his harness, his injuries may not have been as severe. With the seat free from its floor attachments, longitudinal decelerative forces could not be

transmitted through the seat structure into the floor. However, the shoulder harness, which was anchored to the aft cockpit wall, would have attenuated some of the decelerative force even though the shoulder harness might have been overloaded by the deceleration of the combined weight of the pilot and the seat. It is also possible that the single diagonal-strap shoulder harness would have acted as a pivot point about which the pilot and seat would have rotated. In this case, the pilot would have been thrown into the control column and surrounding structure producing injuries; however, the shoulder harness may have attenuated sufficient decelerative forces to have lessened the extent of the injuries. The complex crash sequence, the number of unknowns, and the number of assumptions required precluded calculations of the probable magnitude of the crash forces using the equations of motion. The damage to the pilot's seat indicates that relatively high vertical g-forces were transmitted through the airframe structure to his seat. The impact damage to the pilot's control yoke and instrument panel was indicative of relatively high longitudinal g-forces. These forces were a result of the localized impact with the tree stump and were confined to the left front seat area of the aircraft. Although the exact magnitude of the crash forces experienced by the pilot's seat could not be calculated, certain information can be derived from the known conditions. That is, in view of the manufacturer's combined loading test of the crew seats and the fact that the pilot's seat structure in the accident aircraft bent, but did not completely fail, the loads experienced by the pilot and seat were probably in the range of 3.5 g's downward and 8 g's forward. These inertial forces certainly are within the limits of human tolerance for a restrained occupant. The localized impingement of the tree trunk destroyed any load attenuation capability of the restraint system allowing the pilot to impact the aircraft structure. The damage to the control column and to the instrument panel is consistent with the level of g's believed to have been sustained by the pilot and his seat. The pilot's injuries prevented him from extricating himself. Moreover, the passengers were unable to remove the pilot before the cockpit and cabin

-21- environment became intolerable. Since the pilot's lapbelt buckle was found fastened after the accident and because of the nature of the fire damage to the lapbelt, the difficulty encountered by the passengers in attempting to pull the pilot out may be attributed to the restriction of the lapbelt and the additional weight of the seat. The pilot's injuries were the result of contact by his body and head with the control column and the instrument panel. The evidence indicates that the injuries to the pilot's head and neck were caused by the pilot's head striking the instrument panel while the neck was hyper-extended (aft). This caused the dislocation of the cervical vertebrae and consequent spinal cord damage. Postcrash fire also was a major survivability factor. The two passengers had limited time to attempt to extricate the pilot and to escape. Their efforts were further complicated by the jammed main entry door on the left side of the fuselage where the fire and smoke initially were less severe. The main entry door would not open because of impact damage and a tube in the linkage of the door latch mechanism was broken, leaving two door latching pins engaged in the door sill. The pins were jammed because of the buckling in the door structure and the structure beneath the door. Metallurgical examination of the failed linkage tube in the main entry door's latching mechanism revealed that i t failed in tension overload and that the material met Cessna's strength specifications. Impact forces and resultant damage could not have generated sufficient tensile loads to fail the tube. The only way the tube could fail in tension is from an excessive force on the door handle in an attempt to open the door. The Safety Board could not determine whether the tube was broken as a result of the passengers' or rescuers' attempts to open the door.

1. CONCLUSIONS
2. 1

Findings 2.

1. The pilot was properly certificated and trained.

The aircraft was properly certificated, equipped, and maintained. 3. There was no evidence that aircraft structure, systems, or power- plants malfunctioned or failed. 4. The pilot did not comply with recommended or standard traffic pattern altitudes and airspeeds. 5. The pilot had to be reminded to lower the landing gear during the last landing attempt. 6. The pilot forgot to extend landing flaps during the last landing attempt. 7. The pilot did not use a checklist during the flight.

-22- 8. The aircraft was flown about 24 kns below the desired no-flap reference speed during the last final approach. 9. The pilot did not add sufficient power to arrest the descent rate. 10. Although a pilot, the right-seat passenger was not qualified to assist the pilot. 11. Neither the pilot nor the right-seat passenger was wearing the available shoulder harnesses. 12. Longitudinal and vertical crash loads were estimated to be 8 and 3.5 g's, respectively. 13. The pilot's restraint system was rendered ineffective by the localized damage to the seat track and supporting floor structure. 14. A severe postcrash fire erupted when fuel was spilled during the crash sequence. 15. The pilot sustained severe traumatic injuries from contact with the control column and instrument panel. 16. The pilot died from the effects of fire. 17. The two passengers sustained no serious impact injuries, but were burned severely during evacuation. 18. The main cabin door was jammed. 19. The two passengers were not familiar with the operation of the main door and the emergency exit and had not been briefed by the pilot before takeoff. 3.2 Probable Cause The National Transportation Safety Board determines that the probable cause of the accident was the pilot's failure to recognize the need for, and to take action to maintain, sufficient airspeed to prevent a stall into the ground during an attempted landing. The pilot also failed to recognize the need for timely and sufficient power application to prevent the stall during an approach conducted inadvertently without flaps extended. Contributing to the pilot's inability to recognize the problem and to take proper action was his failure to use the appropriate checklist and his nonstandard pattern procedures which resulted in an abnormal approach profile. 4. Safety Recommendations None.

-23- BY THE NATIONAL TRANSPORTATION SAFETY BOARD /s/ JAMES B. KING Chairman /s/ ELWOOD T. DRIVER Vice Chairman /s/ PATRICIA A. GOLDMAN Member G.H. PATRICK BURSLEY, Member, did not participate. FRANCIS H. McADAMS, Member, filed the following concurring and dissenting statement: The majority concludes that the cause of the accident was the failure of the pilot to recognize the need for, and to take action to maintain, sufficient airspeed to prevent a stall, and the reason for the pilot's failure was the fact that he did not use the checklist and used nonstandard pattern procedures. This equates to 100 percent "pilot error," but the majority has made no attempt to determine why the pilot failed to take adequate action. In my opinion, the Board should have cited as a contributing factor the fact that the pilot lacked sufficient flight experience in the aircraft, and further he may have lacked adequate basic training. The Citation is a high-performance aircraft and, although the pilot had the minimum number of hours (approximately 30 hours), I believe that with more experience in the aircraft he would have arrested the high sink rate and approach to stall by immediately adding thrust. In addition, the Board report should have addressed the fact that all of the pilot's checks--private, multiengine, instrument, and type ratings--were given by designated examiners. It is interesting to note that during 1978 only 1 percent of private pilot certificates were issued by FAA inspectors; all of the remainder were by designated flight examiners. In this connection, the disapproval rate by designated flight examiners was 6 percent whereas for FAA inspectors it was 28 percent. By addressing this situation, the Board might have been able to recommend that the FAA review the procedures for designating examiners. April 16, 1980

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-25-

1. APPENDIXES

APPENDIX A INVESTIGATION AND HEARING

1. Investigation

The Safety Board was notified of the accident about 1700 c.d.t. on August 2, 1979. Investigators from the Safety Board's Chicago Field Office and Washington, D.C. headquarters were sent to the scene. Two working groups- powerplants and human factors-were established to assist the investigator - in-char ge. Participants in the investigation were the Federal Aviation Administration, Cessna Aircraft Corporation, and Pratt & Whitney Division of United Technologies Corporation.

1. Public Hearing

Public Hearing N o public hearing was held and no depositions were taken.

-26- APPENDIX B PILOT AND PASSENGER INFORMATION Pilot - Thurman L. Munson, age 32, held a Second-class Medical Certificate issued February 1, 1979, with no limitations. He possessed a Private Pilot Certificate for Airplane Single-Engine Multiengine Land with an Airplane Instrument Rating. He received a type rating in the CE-501 on July 17, 1979, which satisfies the requirements of a Biennial Flight Review. Mr. Munson was a professional baseball player and was employed by the New York Yankees Baseball Team. Right Front Seat Passenger Mr. David L. Hall, age 32, held a First-class Medical Certificate issued April 24, 1979, with no limitations. He possessed an Airline Transport Pilot Rating for Airplane-single- and multiengine land, an Airplane Instrument Rating, and a Flight Instructor Certificate for Airplane-single- and multiengine land. He also held a Ground Instructor's Rating for advanced and instrument instruction. On his last medical certificate application, dated April 24, 1979, Mr. Hall listed 6,723 total flight hrs and 512 hrs in the previous 6 months. He had no flying time in the Cessna Citation model aircraft. Cabin Passenger Mr. Jerry D. Anderson, age 31, had a medical certificate pending. He held a Private Pilot Certificate for Airplane-single-engine land.

-27- APPENDIX C AIRCRAFT INFORMATION The aircraft, a Cessna Citation Model 501, N15NY, serial No. 501-0110, was issued a Standard Certificate of Airworthiness on June 25, 1979. The pilot/owner took delivery of the aircraft on July 6, 1979. The aircraft had accumulated 43.1 hrs flight time since new. The .engines were maintained in accordance with applicable regulations and procedures. Pratt and Whitney of Canada engines, model JT-15D-1A, were installed on N15NY. Serial No. PCE 77064 was installed in the left position and PCE 11067 was installed in the right position. The engine times since new (TSN) and cycles since new (CSN) were as follows: PCE 77064 43.1 hrs 45 hrs PCE 77067 43.1 hrs 45 hrs

FD07017 ｜ 1980_美国_PAB8001.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1980 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

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I t ' ·"')! t~·:-;-.~-~·r:· .. -... ~:-~ : "! ~:"l:c· .. ~1:.·.:'"1~~:~;:'"':.'}~:,; ·.:~·:- .'·.·?~..:~T:'f{~ ... ;11 < ,;·'. t "') ....._....~-~· ) ·--..... ,., Brief Fol'llr.' \'", • er or•1ng vrg•n z•t on .. port No. • er or• nt rpn zat on ... • ress lational Transportation Safety Board Bureau af Accident lnveatiaation Wa•hington, D.C. 20594 ype o eport •n Period Cove red 12.Sponsor nt gency N1111e •nd Atdress 42 U.S. Pipeline Accident• ' occurring in 1976, 1~77, NATIONAL TRANSPORTATION SAFETY BOARD ·Wtsh1ngton, D. C. 20594 i 1978, and 1979 in Brief Format. .Sponsoring Agency ode This publication contains briefs of selected pipeline accidents, occurring during tlie calendar yeara 1976, 1977, 1978, and 1979. The brief forut preaenu basic facts, conditiona, and probable ccuae(a) in eac~ instance.+-- · Pile 1'Ullbere: DCA-76-FP-f21 DCA-77-FP-e23 DCA-77-FP-f25 DCA-78-FP-ftll FTW-78-FP-tel LAX-78-FP-ffl DCA-78-FP-fll2 PTW-78-FP-ff2 F'l'W-78-FP-ff3 DCA-78-FP-ff4 F'l'W-78-FP-H4 FTW-78-FP-•s DCA-78-FP-ff6 FTW-78-IP-H7 DCA-78-FP-H9 FTW-78-PP-"9 F'm-78-DP-flf !""!'W-78-PP-IJ:;. t'I'W-78-IP-tl2 DCA-78-PP-•13 nw-78-FP-114 FTW-79-FP-ff2 PTW-79-FP-N3 PTW-79-FP-tf4 PTW-79-FP-ff5 PTW-79-FP-N6 l>CA-79-FP-M7 PTW-79-DP-N7 PTW-79-FP-ff8 PTW-79-FP-•9 FTW-79-FP-lll PTW-79-DP-112 FTW-79-FP-el3 PTW-79-FP-f14 DCA-79-FP-917 DCA-79-FP-121f DCA- 79-FP-f21 DCA-79-FP-122 DCA-8f-FP-M2 FTW-8f-FP-M2 DCA-81-FP-·6 .Key Words External corroeion, improper operating procedure, ~utaide force damage, rapidly expanding -Circumferential fracture ... terial failure, hydrogen atreaa crac~f.ng, inadequate control devices, soil mveaent, excavation d ... ge, customer'• service line, LPG aaa, live ~andoned service line gu compreaaor • 1str1bution tateaent Thia document i• available to the public through the Rational Technical lnfor- -tion Service, Speingfield, Virgini• 22161. curity C assif i~tion (of this report) .UNCLASSIFIED 20.S.curlty assi (of this pqe) UNCLASSIFIED .No. o Pages llTSB Fora 1765.a (Rev. t/7ti • I ' ''\ --,.; ... ! I l I ---~

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I ··" ... JI ... i~' I I I I I FOREWORD The National Transportation Safety Board, in accordance with the provisions of the Independent Safety B~ard Act of 1974, has detennined the probable cause of the accidents reported herein. I This publication contains the reports' of 42 pipeline accidents arranged in chronological order., ' The enclosed briefs are the reports of the National Transportation Safety Soard and are thereby subject to the limi- tations of 49 use 1903(c): . I I "No part of any report or reports of the Board, relating to any accident or the inves,tigadon thereof, shall be acknitted as evidence or used in any suit or action for damages gro~ing out of any matter mentioned in such repor:t or reports." ! For those readers who wish more detai:led information, the original factual reports are on file in th'e Washington, D.C. office of the National Transportation Safety Boar~ and may be examined. These reports will be reproduced for a fee: covering reproduction costs and postage. Orders for materials ajre also subject to a user charge by the Board for special services, and such charges will be included in the bill. I National Transportation Safety Board ! Public Inquiries Section · Washington, D.C. 20594 II · · .. :uz;gs bt••· -

·::-p-"''~:--r~7.-'.'.'.?7:l ---··--:......----:--~-~ .. ~- -··-"····-·· -· ··------------~--·------ J'~:1.~:};,:~; ! TABLE or CONTENTS PAGE FOREliC>RD • • • • • • • • • • • • • • • • • . . . . . . ii TABLE OF CONTENTS • • • • • • • • • • • • • • • • • • iii EXPLANATORY NOTES • • • • • • • • • • • • . . . . . . 1 ALPHABETICAL LIST OF ACCIDENTS • • • • • • . . . . . . 3 REPORTS OF ACCIDENTS • • • • • • • • • • • . . . . . . 6 ) iii

... r~·-· . ---------·---·-·-·-···--·---------·--------··--·---· ----··-·--·-·-----·-----···--·-.. -· I ., 2 - I I I that: "Tran•iHion line" aun• a pipeline, other than a ,,atbering line, I (a) Tranaporu ... from • aathering line or atorage facility to a diatribution center or atorage facility; (b) Operate• at a hoop stress of 20 percent or more of SMYS: or (c) Tranaports gas within a storag~ field. Tranaportation of Gas "Transportation of Gas" means the gathering, transmission, or distribution of gas by pipeline or the storag~ of gas, in or affecting interstate or foreign cOiiilllerce. Pipeline I "Pipeline" means all parts of those physical facilities through which gas moves in transportation, including pipe, valves, and other appurtenance attached to pipe, compressor uni~s, metering stations, regulator stations, d~livery stations, holders, and fabricated assemblies. Pipeline Facility "Pipeline facility" means new and existihg pipelines, right-of-way, and any equipment, facility, or building used: in the transportation of gas or in the treatment of gas during the course of transportation. 49 CFR 195.2 Liquid "Commodity" means a hazardous material ~hat is subject to Parts 172 and 173 of this chapter, petroleUtll, Ind p2troleum products. Pipeline System "Pipeline system" or "pipeline" means ail parts of a carrier's phy~ical facilities through which commodities move in transportation that is .,,'oject to this part, including, but :not limited to line pipe, valves and other appurtenances connected to line pipe, pumping units, fabricated assemblies associated with pumping units, ~etering and delivery &t~tions and fabricated assemblies therein and carrier~controlled breakout tankage. ·

-----··--·---· ----··-·--·-·-----·-----···--·-.. -· I ., 2 - I I I that: "Tran•iHion line" aun• a pipeline, other than a ,,atbering line, I (a) Tranaporu ... from • aathering line or atorage facility to a diatribution center or atorage facility; (b) Operate• at a hoop stress of 20 percent or more of SMYS: or (c) Tranaports gas within a storag~ field. Tranaportation of Gas "Transportation of Gas" means the gathering, transmission, or distribution of gas by pipeline or the storag~ of gas, in or affecting interstate or foreign cOiiilllerce. Pipeline I "Pipeline" means all parts of those physical facilities through which gas moves in transportation, including pipe, valves, and other appurtenance attached to pipe, compressor uni~s, metering stations, regulator stations, d~livery stations, holders, and fabricated assemblies. Pipeline Facility "Pipeline facility" means new and existihg pipelines, right-of-way, and any equipment, facility, or building used: in the transportation of gas or in the treatment of gas during the course of transportation. 49 CFR 195.2 Liquid "Commodity" means a hazardous material ~hat is subject to Parts 172 and 173 of this chapter, petroleUtll, Ind p2troleum products. Pipeline System "Pipeline system" or "pipeline" means ail parts of a carrier's phy~ical facilities through which commodities move in transportation that is .,,'oject to this part, including, but :not limited to line pipe, valves and other appurtenances connected to line pipe, pumping units, fabricated assemblies associated with pumping units, ~etering and delivery &t~tions and fabricated assemblies therein and carrier~controlled breakout tankage. ·

) .;

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3 - Alphabetical List of Accidents Location Albuquerque, New Mexico Arlington, Texas Arlington, Texas Auburn, Alabama Balt:lmore, Maryland Berwick, Louisiane Chicago, Illinnis Chrisman, Illinois Conway, Kansas Enid, Oklahoma Fort Payne, Alabama Grand Island, Nebraska Greenville, North Carolina Hamden, Connecticut Hastings, Nebraska Indianapolis, Indiana Irving, Texas Lafayette, Louisiana Company Gas Company of New Mexico Lone Star Gas Co. Lona Star Gas Co. Alabama Gas Corp. Baltimore Gas and Electric Texas Pipeline Co. People's Gas Light and Coke Comp.;;:iny Central Illinois Light Company Hydrocarbon Transportation Inc. (HTI) Champlin Petroleum Co. Dekalk-Cherokee Natural Ges District Northwestern Public SerTice Company Carson Gas Company Southern Connecticut Natural Gas Co. Hastings Utilities Citizens Gas and Coke Utility Lone Star Gas Co. Central Louisiana Electric Co., Inc. I 7/25/79 5/29/78 11/27 /78 1/15/78 6/6/79 1/2/80 10/14/77 10/13/79 1/12/78 8/13/79 11/17 /79 8/28/78 6/28/77 10/18/77 2/10/79 .J/5/77 1/11/79 8/7 /78 6 7 8 9 10 11 12 13 14 15 16 17 18 19 { 20 I i 21 ! l ! i 22 " ! i 23 ! I i ~ ~ ~ i::.

. --'· ,.: .. · . . "• ·"-'· ·, .. :/_, .: . ·.': ~-----------------·---------- ------------"""·--· -~-.---~·-·---·~-! Location Lewisburg, Tennessee Lincoln, Nebraska Mountain View, California Nebraska City, Nebraaka New Orleans, Louisiana North Richland Bills, Texas Orange, Texas Padre Island, Texas Pearland, Texas Phoenix, Arizona Pierre Part, Louisiana Pittsburgh, Pennsylvania Roswell, Georgia Royal Oak, Michigan Seat Pleasant, Maryland Shreveport, Louisiana Slapout, Oklaho1118

• 4

Company Lewisburg Gas Department (Municipal) CENGAS Div. of Minnesota Gas Co. 10/31/76 11/9/77 Pacific Gas & Electric 4/19/7"9 co. Nebraska City Utilities 9/1/78 New Orleans Public 2/7/78 Service Lone Star Gas Co. 1/19/79 Ci ties Sen• ice 8/20/79 Pipeline Company Florida Gas T~ansmis~ 1/27/78 sion Company United Texas 10/24/78 Transmission Co. Arizona Public Service 6/30/78 Company Dow Chemical USA 9/4/79 The Peoples Natural 7/31/79 Gas Company Atlanta Gas Light 7/25/79 Company Consumers Power 1/16/79 Company Washington Gas 8/15/79 Light Company Arkansas-Louisiana 10/30/77 Gas Company Delhi Gas Pipeline 5/25/79 Corporation 24 25 26 27 28 29 30 31 \ ·'-- 32 33 34 35 36 37 38 39 40

,•";' t' ::-. ."·-."'".''~-~ ·-,,: .'-·•:·'-·j'-"-; .-::· -~,,'!'.,-J.-·.-;.···. j ···: 1 •. I I'

, __ , __ _ Loe~ Company Date Page Snowmass Village, Rocky Moutain Natural 3/30/79 41 Colorado Gas Co. Sterling City, Texas Mid America Pipeline System 11/8/79 42 Stoughton, Bay State Gas Company 1/25/78 43 Massachusetts Sullivan, Indiana Ohio Valley Gas Corp. 2/10/78 44 Tempe, Arizona Arizona Public 12/10/77 45 Service Company Weimar, Texas LoVace Gathering Co. 4/7 /78 46 West Lafayette, Indiana Indiana Gas Co., Inc. I 11/24/77 47 !

~' ' f;· , .. " ' * llATIOllAL TIWISPOR'l'ATIOll SAFBTlf 80AllD WASHINGTOll, D.C. 2059' Brief of Accident FTW-79-F-P011 Pipeline Accident: FY Zi.._, Qtr. • 4th Location Company '!'Jpe C~ity Date Gas Company of New Mexico Gas Distribution Natural Gas 7-25-79 Albuquerque, New Mexico Accident: LOSSES: At 5:51 p;m., m.d.t., on July 25, 1979, natural gas at 38 psig pressure escaping from a separation in a service line found at a 1-inch dresser coupling located underneath one of the apartments of a duplex house, accumulated, exploded, and ignited. Ignition occurred when one of the occupants struck a match to light a stove. The 3/4-inch steel mill-wrapped pipe was bent severely by a telephone company backhoe while working in the street to locate a telephone cable. The backhoe operator did not await the markin~ of the service line and did not know that the natural gas line was there until the excavation equipment hit it. The service line changed to 1-inch at the inlet side of the coupling and a 2-inch separation existed between the coupling and the pipe which indicated that the pipe had been pulled out. Two persons were killed, two person9 were hospitalized for burns, the duplex apartment house was destroyed, and adjacent houses were damaged. The odor of gas was detected by residents but not repo;;·ted. Pipeline Non-PipeliM Fatalitiea L.1 Reportable Injuries 2 ; DAaage $ 1,800 Dm1141e $ 30,000 Probable Causes: 1. Pipeline damaged by backhoe. 2. Excavator unaware that he had damaged pipeline. 3, Failure of excavator to wait for marking of pipeline location. 4. Failure of residents to report gas odor. --------Other-Factors:-- __ l , _____ _ 2. Probable Cau&e of caaualties: Otber Caaualty Factor&: llec0111Dendations: None

1. ·Fatalities due to burns and collapse of structure as a result of

primary loss event.

1. Injuries due to burns and collapse of structure a~ a result of

primary loss event. I ' °' .• ·~.? •'"« ·<;~ I, • ,~ -!~· ~£~- ;~: f1 . ':;~ ,··1 't~ i ?~ \ ~i ,, i;•J .-4 \ ! ·-l '1 ;;\ '·-~J, ·" ~ ., ·.~ A I

:~

1- - -;~ I . : t 1 ·.; 11 'j

.r.-::, ~-::;:1.;:;-:'~-~ ·;t·!'·-.'~"t'!);:t>!~""''l'l.';'l};:y.?'"'"""'· ~··-·~ -. .., .. ·.·-......;·~.''-''""·~·,.~··., .... _ .. -.. , "·'"' ··.~ .. ,.

,~1u·· ---l!!ll!l\'l!llma----

:~~~ .// JY .//' i.:.~~~Uo1.i'":;>:S$".r.c:;...-.-... ~--··· FTW- 78-F-Pe/~;~ Cc..,l)any Lone Star Gas Co. ._..,;------------- NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 Brief of Accident .. -- . Pipeline Accident: FY--2!.__, Qtr. 3rd ~pe Coa!IOdity Date Location Gas Distribution Natural Gas 5-29-78 Arlington, Texas Accident: At 8:45 a.m., c.d.t., on May 29, 1978, natural gas leaking from two corrosion ho~es in a 1-inch _.-· bare steel gas custow£r ysrd line operating at a pressure of 11 psig and co~ered by 17 inches of soil which had been sat.·rated by heavy rains the day before, migrated beneath a house resting on a pier and beam found"itio: ~'Id was ignited by the p:l.lot light on a gas hot water. The resulting explosion destroyed th~ one- ~tory brick house and damaged adjacent houses. There ~ere no fatalities or injuries. The bare yard lin~ was part of an unprotected gas piping system leading from the outlet side of the curb valve to the inlet side of the customer~ meter. The operator's service line was a coated and wrapped steel pipe connected to the main with an insulated coupling. There was no apparent insulated fitting between the fuel line and the uncoated yard line. As a result the yard line was anodic to the house piping, part of which was burned, and galvanic corrosion resulted. Pipeline Non-Pipeline LOSSES:

Fatalities

1 Reportable Injuries __

• __ ;

Damage $ DaaalJ• $ 100.000 Probable Causes: Othe.: Factors:

1. Corrosion due to lack of cathodic prot~ction.
4. Improper/inadequate procedures for design, installation and inspection of gas service

lines. 2. Probable Cause of Casual ties: 1. 2. J. Other Casualty Factors: 1. 2. Recaa111endati:>ns1 R-79-32 & 33 ..... ·.·:.'S . ·"~ ··~ ~1 ~ ··:i ;\ ~ "' rt -1 ~ ·~'.!.: ·0 ~~ 1: -* ·~ J . ·-~ :·:j .; .. I· -· ~ :iJ 'f! ''j ,) :'1 ~ ··~ ,;~ \1 ---1------l f .-, I .··1~ ., .. ~ 1 ~ 'l .'! {$ @ '!J 'i ·~ij \l ·-,l . ::'1 .~~') ;j

.'i..~N~-:i.:.W..'i%~·"'"~-~.$.,.~:,.t·'' .i.="',M.W,•i/i,?fliiii""._._·~e~.,.if™•.,..t .. , •• ,.tzo;..,.ifl-t;.f!..,..J!.·"·Wi'Ct~·,~.,.,...~Pl""'·nz.:ir.--.' 1'.'lt• .. 1'·,s~-~-.~~ ..... ?:;;;~'!'::;r:..,.~v,~:-'.:i."!:r::.~ .. r!;.' .. .."..>'j,'""'·'!;::_.,.:----·,;"t~·'-::·.:·~.:-~r> :ix·-~·~--·-,-~~-~t'.'.j;~ ' ' ~ ··:· ... ~~. ~ ~~::. i· .... ! .. ·~· i r -'"t. . . ~~ ~- ~ ~:- ·~ '7ft' --··-~----~--~=:=~~---~·~~~~ , .. ,. .. ,,., HATIONAL 'J'RAHSPORTATION SAFETY BOAllD WASHIHG'l'ON, D.C. 20594 Brief of Accident FTW-79-F-P002 Pipeline Accident: FY.!!, Qtr. lat Ccmpuy Type Commdity Date Location Lone Star Gas Co. Gas Distribution Natural Gas 11/27 /78 Arlington, Texas Accident: LOSSES: At 7:45 a.m., c.s.t., on November 27, 1978, natural gas leaking from a ci~cumferential fracture in a threaded, 1-inch steel nipple - part of the "swing connection," off the tap on a Rervice line - operating at a pressure of 14 psig, migrated laterally along the gas main and water line beneath and into the house where it was ignited when an electric heater was turned off. An explosion and flash fire resulted, with the fire fatally injuring one occupant and seriously injuring the other. The house suffered extensive damage from the explosion and some fire damage. Fatalities 1 Reportable Injuries 1 Pipeline Dallage ·~ ilan-Pipeline n.uve us p 000 Probable Causes:

1. Earth side/movement, moisture related causing direct damage to pipeline.

Other Factors: l . 2. Probable Cause of caaualties:

1. Fatality and injury due to fire as direct reault of primary loss event.

Other casualty ractora1 1. 2. Ra~tiona1 P-79-27, P-79-28 ... -· QI I . l f ,·:~

,<":,

:~ ~ (~ ';~ -~ ;~ •. ~ ···~ -~:~ ~~ ::t :l ·!4 ~~ ·ii ~1 ;:~

~ ·,~ 'l ~ ~1 j ., ., .. , ;' ·' :i --··- -- ~--1- ~ .J " •'j j j .'1 ·1 ·,l .,

--- -Other- -ractoras -· - --1-.- .Environment ... ..,__ temperature. change.

• Traffic vibration.

(Stresses which may have fractured weakened cast-iron pipe.) Probable Cau .. of C&•ualtiea: l.

<>the; Casualty Factoras l.

lteCClllUendationa1 None '° I I -L ! " -1 ~ 'l i ., l 1 1 .1 ' i -!- J 1 ~ • i I j ·1 l 1 i ~ j' ~ 1 ,1~ ~ ~ .. ...,,,,.,,..:.v-r;wriWP.., "bt·-:Mo-.-• ..-...--..u·~···" ~ ~ f• i'.' r L ··-•~'·•••••··-~•-•-...,....,.,.. -·-~--·--.......,.••~-... ..... ,.,.,.,,. ___ ,..,_ .. _ •. __ .,. ____ , __ .,..,... ___ ••----•·•-_...,... .. ,, .. .,.,. • ... ____ .,, __ ,....m~•-·•,.~-·--•••• ' '.l "' ~ . 1 :;~~~.;-~........__ '· . 1~.1 I l I . 1 'l ' ·• •I :~--·_ ... !. "' ... ·1 --· ; ' ····! r'ti ·~· ~; ... J ,,., .. ,.\ ·----~-~~~~~~~~-~ ~~ NATIONAL 'l'RANSPOl\'f.lTIOll SAFB'l'll' BOARD WASHIHG'l'Oll, D.C. 2059' Brief of Accident DCA-79-FP-1117 Pipeline Accidenta cc..odity " Z!.,_. Qtr • __1!!!l Ccapany Type Date l.ocation Baltimore Gas and Distribution Natural G11 06/Q6/79 klgpgre. Ian!""'- Accidents A contractor, while excavatina for a subway station, •truck a new 1 1/4-inch •t••l coated aervice line ~perating at 7 inches of water column (7" w.c.). The impact of the heavy equip19ent (backhoe bucket) upon the 12-foot-long service line caused it to bend. The force of the !apact pulled the elbow, which connected the service line to the indoor meter ri•er, approxillately 52 inche• ioto the brick wall. The break occurred on tha pipe near the elbow. Natural ga• e•caped frOll the broken ••&"Vice line and sat.arated into the basement of the three buildings and ignited from an unknown aource. The explo•io" an1I fir• totally demolished three, three-story buildings, and •everely d ... &•d adjacent buildin&•• The .. rvic• line loc.1tions in tbe area were visibly marked on the buildina• vull• with wide line• of J•llow paint. Pipeline llOn•H .. liM LOSSES: FatalitiH ' . Report.bl• lnjuri•• t , Dmll9e • 596. 00 0..V- f 120.QOO.OO Probable Cause•: l. Improper operating procedure• for heavy excavation •quip .. nt. ·--2.-------------

- 3. Other Factore: 1. Operator's contractor huaan error. 2. Failure of the gaa c011pany to have a full-tiae in•pector et th• excavation •ite. Prabable CauH of Ca11ualtie•: 1. 2. 3. Other casualty Factor•: 1. 2. ReCClllllendationas None ... 0 . ···-'-·\ I I l \ I i .· J'. :.;· :~~ -~ ;.ili '\' ~' -..-,, ;~ -~ :_: ') ~- ? ~ ·1 .; .. "\ ;" --- ------~--- ·{;;,-- ' I !i I ., I ' I t I I I 1 '1: \ !, ·'(o · J ' "> ·~ i ? ;:,,. . 1- ·. ! :~

• .. -.t

r. ,~ , f ~ t ~· 1. ~ r- ~2 f~1~. l ~;;f;~< ::~.-~·:~ -~~i·

• ;.:r.";>

~ -~; ~~ !;\' (., r r ( f . .,.~··•"r•~,.,...-..,;~•r'-.~~"'- ... 1·•~.-. ,.. .. ~.-~r .. 1'~'"¢i..'fi!'4J!Qj@,ifl!t{!i~""IP",.....,.,..~...,'h;tti'·lif.j·'··"S¥!'''h·'+4"e;iio<;:i:w>"'Yilfr~*fllli!}"il:=~·~,;.,'>'~:·~ ~--- ,,, !!!, j -· '? .,,.,,1 ..., ' ""' ~. llATIOllAL TMlllPOll'l'ATlml unTI IDUD llUlllW'Kll, D.C. JOSH 1Jder or Accident • • • FTW-80-F-PH2 Pipmline Accident• COll!IOditr Crydt OU n ..!!!.-• Qtr • ..!!!!! Date Looatim cmpuy lerviclL, Lwi•iaa The Texas Pipeline Co. Type Liquid PiHliDI 1Lill2 Accident: LOSSES: At 9:54 a.m., c.a.t., on January 2, 1980, crud• oil 11a1Lin1 fr211 a fractur1 in a 22-inch Houma-Erath pipeline at a levee croaaing at Btrvick, LA, flowed under houa•• along the lev11 and was ignited by a gaa hot water heater. The resultinA fire injured tW!> peraona, one fatally, deetroyed five frame hou•~• and one 112bile h2111. lnv1ati1ation revealed that the tie-in v.ld on the levee croaaing was reinforced by a iull-enc~rcle11ent fillet-veld al11v1 which stiffened the reinforced pipe area and providtd atr1am concentrators At 1ith1r end of the sleeve wh•r• the pipe was weakened by underbead crackinA caused by the veldina proc•••· An illp1rfecti~n in the base material, the chemical c011Po•it!on ( a hi1h carb~n and aanaan••• ~ontent), vaa a factor which increased the bardn••• of the be•t-affect1d aon• and pr090t1d underbead crackina. rataUti•• - l - 1 a.portable lnjuri•• ~ 0 - 1 l'ipeUne .,..,. • no. ooo llOn-PipeU.M Dwlte • 250 .OQO Probable cau.,•• 1. Material failure of attel pip• dut to use of full-~ncircl ... nt, f~llet-v1ld1d a1 .. v1. 2. ... ... ·; ,, j l :l l 'j :, :,l :I ~ -,~ ~i ,';', ~1 ] j .. -~ ·~ ]. -- ----- --· - -- --J- 1 Other ractores 1. laperfection in baH .. teria. 2. Probable Cau• or caaualtieas

1. Fatality due to fire •~ a direct cauae of pri .. ry lo•~ event.

]. Other casualty ractor•• 1. 2. Re~ndatlon•• ··~ ;i -~ -~ .-~...: 'l .1 ~I~ t~ .· ··,.·~ ··~ ~1 ~! !{ t~~~ ... ~ ...... .,..,. .......... --~····· .. · ·,r0j

·~· ~") :;- . f,.. v-·~""'X,--:;~··' ..... ,.,.:~.~-·.~;.c u:i+#~·t$t~•~.;~p,qiv,t. ~s·c7'·S?,·fr:-:~::":>~,.;r:~1~::~~~··t":??~If:·?{,:~ llM'ICS..L ~TIC. arm 90llD ... DG!Oll, D.C. 20514 ki•f of Accident DCA-78-PP-tfl Pipeline Accidents "--ZL.· Qtr ._1,.1.,.t __ Ccllpany Typa Cclmadity O.te Location ,et Gaa Li&ht Cbtributlon Natural GH 10/14/77 4930 w. Cortez_Street and Coke Coapany Chicaao._Illinoi• Accident: LOSSZS1 Explosion and fire de1troyed a two-f aaily houae and damaged adjacent buildings. Natural gaa had entered the dvellina through a broken service head adapter which was used to connect in1erted plastic service line• to the riaer and meter aet on the inside of t~e building. The ad&pter waa broken when a contractor, employed by the city, pulled the 1 1/4-inch plaatic~en~a•ed service line oper1t1n1 at 1/4 P•la preaaure while re.cvina atreet curbt. Source cf ignition i• unknown. The contractor did not notify the utilitiea of planned excavation• aa required by the city code. Pipeline DwcJ• • 700. 00 Non~Pipeline DllllAIJe Sl00,000.00 Fa tali u ... _...,1..__. Reportable Injurie• 3 , l"roblble Cau .. 11

1. Damaae by human non-pipeline forces due to machine operator error, unaware of pipeline

location.

1. Coordination failure, excavator made no effort to detenaine pipeline existence.

.... N r .. . ,. . I 1 ~l 4 1 .cJ i i ~ . . ·l ~ 1 ~ I i I ~ I ~ I -~ I 1 l . ~ I ~ I i i ~ i ~ ------~-' ~ I ,

I

r ·1 r~-l ----------· 3.

{.

•• 1. 2. Probable Cau .. of Ca1ualtie11 Other Casualty Factor11

1. Fatally burned.

Recomaendation11 P-78-15; P-78-16; P-78-17. /""' ..... ~ .. . :; .":": _.;.~ .. -~ :;::. . :~} ·~~

r:; I. ~­ r;· " L f' .,··v ' . / . .'

.,..... • 140,000

Probable Ca11H•1

1. Pipeline daaaged by backhoe.
2. Excavator unawara that he had daaagcd pipeline.
3. Failure of public to report ga• odor.
4. Huaan failure t? execute emergency procedures properly (reepund to leak report).

Othe~ ractora1 1. 2. Probable Ca11 .. of caaualtiea1 OtMr Casualty Pactora1 RoCOlllllendationa1 None 1. Fatality due to saoke inhalation and burns a• a result of the prillary lo•• event. 2. Injury due to burb8 and collapse of structure as a result of tho ?~illary lose event. 3. 1. 2. .... w . i ; j . i -~1 ' ~'~

• .

'! ':i ---- __ • __ J

#""~:g;tfflf;.JIJ?!,,.,_ tt.if"Cll!4£ ~!t,if."'.'t'#.f!i-l ¥"tji ~ .>'~-· :-;r-'~'"*"'i'J:r>.->l,.,.b.,, ... K,>i_,f,,,,:U:;i>L .... --.-.-.-~-.. ..--r--•·--.,....-~,~~~,,. ... ,.:..-,. i ' I r:·-r- ·-: ,, f. !:. t; f:· ~ r [ ,. " ,.. .... -· ...... P!W-7i-PP-H3 cmpuy Bxdrocarbop Jrtp1port1tiog Inc. (BTI) !'ype ·- Station Hpeline AccW.t• Camodity Date "?rpel h""M • 1112171 •than.t;propat " !!, etr·~ Looatioe ,.,,_ ~ Accidtnta A liquid puap ttation va• puaplnt product (nor9al butat and tthane-propant llix) with it• tvo unit• vhtn a .. 11iv1 11al leak occurred on one o' tht pu.,a. AutOlaftic •Jtt ... abut down both unit• in r11pon11 to 11ak1, but there vaa aufficient di1char11 of product to caute ac txploaion and fir• which in turn da .. ged cloaed valv11 and reaulted in further ltakafl and diachar11 of product. lt>th ... - driven turbine•, on• ~ump and other pipelin~ facilitiea vert dalla&ed be)'ODCI repair. .. portable Injuri•• 0 . Pipeline o..ge • 300 eOOO I 00 11an-Hpeline DaMIJI ··------- IDS&Ua ratali t111 o , Probable CaUHf I

1. Material failure of puap abaft :;eal due to above noraal deterioration wear.

2 I 3, other ractor11 1. 2 I Probable f..aUM of CU.ualtieaa 1. Non• 2. 3, Other Ctaualty l'aotor•• 1. Non• 2. =ocamendat1on11 ('"'• __ ,,,,,, .. ,, ....... -·-----,,·-·-··----- :''

~

'._'. ~ . "~~ .. , . .:J ! .... :'i f. ..::11 l' ...... ;~ I ... .-~ ,'i' I .. · •-·:. I -' I :"- l .~: :l ! . ')~ I i '• 'j ., i . ·.}. t ~ t .:~ l ·.·.J --_J __ l I t I -:-i ., ~ ~ ~ ,; ., . l 1 \ -t ' ·1 J ' 'J ' .\ ~1 ~· J -~ ._·: .:-~ .. , ,·.,.,\ ~ f ~;. [,.;. ·--"··"·"-'-- ~ ... c"" .:~;i~?~?~~i

.~ii!\@W\,.li\l'l~'\¥"'l'l&.i,M"""'"':ii#iM0f!iPJii'i.iiii!i,¥@W'i"""~"'"' •••4. :;o:;;:w&••c .. JQ$iP..zP£Z .sp;e . ""'--til<<'· "'·W ,,_,, • '·"" 4<* '"""·· ••• ,.,,, •.. ,., · • ,..., ,.,..,.,,...,.~ .. "' ,,,,.;.OF,.,.,. ·'""?:'t:!"".cf'!''~~;)~";"·~"">"m.~, WWW ~ , f.~ ~--cj t·. ~~ r:· .. :~:1 r ·»·;\·: I i·:· I I 1:1'!- 79-P-Pl12 ec.pmy Chaaplin Petroleum Coapany M'l'IOMIL 'l'IMllom&ftCll unn IDllD tlUMJmftll. o.c. 205N 'lYpe Gu llrlef af locident MpeUae AccW.ta 0ir mity n.te " !!_.~.~ LooatiGa -.!~1!11 latural Gaa 1/13/79 laid. Oltt ........ Accidents At 8:15 a.a., ~.d.t., on Auauat 13 0 1979, a ca11preaaor atation operator atood partially in front of a acraper trap cloaure while openina it and the exploaive force of rapidly expandia& natural gae, which had been confined at an ••t:laated preaaure of 100 paia, fatally injured bia after tearing the cloaure off it• hinge. He had previoualy opened the 2-inch blowdown valve 2 or 3 tiaee and had left the valve open, but failed to verify pruaure within the 10-inch acraper trap by uae of a preaeure indicator valve. The 750 pai1 li:de preaaure, introduced into the trap vitb an 8-inch polyurethane aphere vaa not coapletely relieved becauae the relatively fl~zible pi& blocked the 2-incb blowdown outlet. The operator vaa not f&lliliar vith the polyuretbana pi& aince this vaa the firat one uaed in this line. The ri&id neoprene pia, norully in uae, vu effectively prevented frOll blockina the blowdown outlet by a narrow •trip of baratock; the polyurethane pig did block the preaaure blowdown openina. Pipeline 111!8-Flpelllla LOSSBSa rataliti•• _1 __ , lleport.ule lnjuri•• 0 ' O..V- f 1,000 .,... •------ Probable CauH•s OtherPactoras

1. Failure to properly follow complete procedure ("non uae of equ:l,.eat required by

procedure•" and unneceaaary expoaure when op•ain1 cloeure). 2. 3.

1. "Syate• change ude without adequate ayatn teat"-produclna unfOreaeen canaequencH.

a. Prob.ible Ca1111e of caaualtioa1 1. Fatality due to internal injurie8, atruck by pipe cloeure. •• •• Otber ca.aitr rector•• 1. 2. None ·-~·~~·-·-~·-·-----·.-· ..... ·---------.. ---·~·-.... ·~-·~ ···--·~-·~·- .,. "' ···~·~. ... , ··~·" -•·H•~••o .,,,,_, ·--· -.. ---·-·-·M·--------~·· ,.,,,,4 "•,•••-••••> -,, '" ••-• J > .... "' I ·i~' !~ ~ :) 7J t ~ 1 ~ ~ ·j ·.1 j j ;~ ~ '-l :,.. ~ (· ' 3 '~ ~~ ·~ ~i .~ ·rj ~ ..if ·, -~.~ i 'I ., .~ ·~;.·· '.~ ~J :~

Ha1

1. Material failure of caat iron due to atrea• induced by froat action and other

indeterminate forcea. 2 • 3. Other ractora1 1. 2. Prabel• cau.. of cuualti .. 1 l. Fatality due to fire and aaphyxiation aa a reault of prt .. ry loaa event. 2. 3. ou..r ca...itr raotora1 1. a. ~Aldatlaaaa ltone ,,........t_ ,,,-- .... OI ! i t i- I I I I ! i ! . l I I { '.-} ·~l .:.r. ~;' ·~ •·"1 '.~ ~ j ·~ '1 ;1 :',1 l ~:i .j ':i .'1 •'< '~ ,, ti .. ~ -.!·,, ':) ,' i'_·:.'i~;]

;_~-. _· ·:.··-~·~,·"'J"::<·:~-r."i"""~-:0·~~~'.01"-.'l!!'""""'n'~"":"IJ::r..w· , . ...,..lf,~ .... ,.1.:~w~-ll·~'ti!\1?'?..:r'ff':''i'·'ltt~.·,~-- "'~;t.:~Prt<}~~~ ...... - '·· _;.~--,")' ·: .,: ,A ·• - .~.'I»','.·.~'-'>"' ;&fi ; \ ..... , -------------------wit.· J ·~ ,~- ~ '-""" l .f .f ,;f .'!/ ~ ..... llATIOllAL TIWiSPOJl'tATIOll SAPBTY 80UD WASHillG'l'Qll, D.C. 20594 Brief of Accident Fl'W-78-F-Pfl4 Pipeline Accidents ~ity "!! I Qtr ._4_t_h,___ __ Location Date company Northwestern Public Service Type Distribution Natural a .. 8/28/78 Grand Ialancl, Bebruka C.Ompany Accident: At 10:25 a.a., c.s.t., on August 28, 1978, natural 1as which eacapecl fro• a 2.7-inch lon1 ciruaferential fracture in a socket heat-fusion coupling on a 2-inch P.E. aain operatina at a preaaure of 40 PSIG, migrated beneath a one-story residence and was aubjected to an unknown aource of iplition. '11\e reaulting explosion and fire injured one peraon, deatroyed the houae and claaa1ed three othera. Investigation revealed that: (1) the coupling vaa aanufactured with a theraoplaa:ic aaterial which bu had a poor service history, (2) the coupling was streaaed by aubaidence related to aever construction and a subsequent main extenaion over the aewer 6 yea~• prior to the accident. LOSSES: Patalitiea____:!!:. Rfporteble Injuriea± Pipeline DaalJO $ 2.000.00 Hon-Pipeline o..;e • 189. 000. 00 Probable Cauaea:

1. Failure to execute installation procedures properly

Other Pa~tnraa

1. Imperfection in base material of plastic fitting (polyethylene couplina).

PrClbable cauae of caaualtiea1

1. Injury due to fire aa a result of priaary losa event.

Injury due to collapae of atructur• aa a reault of prillary loaa event. 3. other Casualty Pactora1 1. 2. Reccaaendationa1 P-79-12, P-79-13, P-79-14 ----·-··--· -···~------··-~---~~·,..., -·-·-· • . • .... ..... !: ,.,, .i ... '""'··~~ ··-·' •• '·'"·... '. ·'· • -~ ....... -i:.,. - -,. ~ ' ·~" .:·.~ ~. ·:i ,::·~ :>'~.~ :.,.. ~!i ., ·t ·.~ ·~

t: ~ r t~ f"· h f ' ( i ·4 .... l ...... ~ ....... " [ DCA-11-n-a2s ec.pany Caraon Gas Coapany "f":"t"'V>""·"""-" ·;,>·-.. f •. '";"•-·: ·1:·'" , DTIOML 'l'llMSllOll'fATIOM Ul'ftY IOAltD USHUG'l'Oll, D.C. 20594 Type Distribution Brief ot Accident Pipaline Accidents ~ity Vaoorhad Pr..- Su FY n..__, Qtr •. _lr .... 4 __ _ Date Location Ofa/28/77 Gr1tpyill1. 1prgh C!ero''p• Accident: Exploaion and fire destroyed a ainale family houae. A contractor, repairin1 ~ aeptic ayat .. , pulled a 3/4-inch propane gaa aervice line operating at 10-15 paig and broke the pipe at a thr•~d•d connection. The gaa entered the house under the alab foundation and through an opening where the aervice line riaer went throuah the alab flooring. A fl~•h of fire waa aeen at the baae of the hot water heater .. cond• before the exploaion. The a•• waa aupplied fr011 a 1,000 gallon propane atorage tank. The contractor, not knowina the kind of line he had pulled, ignored what poaaible d ... ge had bean done and pushed the pipe back in the ditch without checking for hazards. Pipeline Mon-Pipeline LOSSES: Fatalities 2 1 Reportable InjuriH 2 1 Dw9• $ 150.00 Dama9• f 25.000.0Q Probable Cauaeas l. Damage by human non-pipeline force• due to aachine operator error, unaware of pipeline location.

1. Excavator concealed damage to pipeline.

--3 .-Human-failure_, __ f ailu1 e_to_detect_escap_e_oJ_g1a. ____ _ Other Factors: l. 2. Probable Cause of Ca•ualties: i. Fatalities froa collapae of atructure.

1. Critically burned.

Other Casualty Factors: 1. 2. Reeo1111endationa: None .... CID I [ I I I \ . I ,,.-., /.......... l ' -~~-··•·<·" __ ,..,., .. .,.... . .,.,.~' I ~·-· ,, ____ ·-----·-·------- ------·-·····. ·.,..·! ,, ' .. ; ' ·,j '·.

feet froa a 8-unit apartment complex. The gas migrated into the corner apartment and was ignited by sone unknown source. Heavy rains and a broken drain line contributed to the eroeion of support from beneath the pipe and to the heaving and swelling of the soil around and above the pipe. Graph!tization of the pipe wall had weakene~ it at the point of failure. IDSSES: Fatalities.:: ... !..: i Reportable Injuries. ____ . Pipelin• Daaage $ 3,000 Hon-Pipeline 1>111U19e $ 80,000 Probable .:.:.:.i;.;;es:

1. Graphitization of cast-iron main.

a.) Washout from rain and/or erosion

1. Damage by natu~al forces:

b.) Earth slide/movement, moisture related. -3.- Other Factors: 1. 2. Probable CauM of CA•ualties: Other Ca•ualty Pactor•a Re~tion•a None

1. Fatally burned.

.... '° I '1' ·.l 1 ~ , ' i1 ' 'i1 .! I. ' :1 -. . --7~ ·--~Ji · ' 'i . '. -~:.;~ 'd I -~ I )~ I ,~ l ·1 l. J ' ·-~ i '~ . . i1 '.~ J ''.':~ .. i. · > .. :~~ '•:·i;i . :-':} i·;.)fa£~fr-~

?i ·:: 'r ... }~~· .. J'"•. ·j: ./ ,,)-.,, , .. :,, .. FTW-79-F-P-!6'15 Company NATIONAL TRANSPORTATION SAFETY IOAIU> WASHINGTON, D.C. 20594 Brief of Accident Pipeline Accident: Type C~ity Date FY....!:!._, Qtr ._2_nd __ _ Location Hastings Utilities Gas Distribution Natural Gas 2-10-79 Hastings, Adams Co., Accident: LOSSES: Nebraska At 2:10 a.m., c.s.t., on February 10, 1979, natural gas escapin~ from a circumferential fracture in an 8-lnch cast iron main operating at a pressure of 32 psig migrated into a commercial building where it was subjected to an unknown source of ignition. The resqlting explosion and fire destroyed three commercial buildings and damaged many others. There were no casualties. Metallurgical examination revealed that graphitization nearly pernetrated the pipe wall in the area of the fracture. And the pipe had been subjected to frost action during its 50-year service life with the frost line being lower than its 36-inch depth at the time of the accident. Pipeline Non-Pipeline Fatalities

• 0 - ;

Reportable Injuries - 0 - _; Dwge $ 29, 000 Damage $4.000.0Q.Q__ Probable Causes: l. Material failure of cast•iron pipe due to graphitization which weakened material.

1. Damage by frost action.

Other Factors: l. None 2. Probable Cause of Casualties: l. None 2. 3. Other Casualty Factors: l. None 2. RecCllllll&ndations: None ,· ' ' N 0 I ··.:,. I· .. t ., . :.: I l ·,. j,, : . J I·,,; ,. ... ~; I ", '! f . ·.' '~ .· . •."l . . :·.] I . - [. ~ ·1 I , :J I . , I «H I ' 'j ~~ .t1 i : ~-~1

...:;_

· .. ~ ,, ,j · .. ·;~P. . :~ . ·,~(! ~] ~-~ ':l ·~ ···~ .S"' .) ;~ ~~ r:~ .~ ·S•i:1

I F /' ' . < ~·'>:."i0G' j'~·f~I "l u \ ! ~ , ....... ,, .. _, ... ~·· ,,,/ · .. · -~· <~·~( .. -.··. \ ' ;: , ./ NA'l'IOML 'l'RAHSPOR'l'A'l'ION SAPB'l'Y BOARD , 7 'I WASHDlG'roN, o.c. 20594 Brief of Accident r I DCA-77-F-P023 Pipelina Accident• Company '1'ype Ccmiodi ty Citizen• Gas and Coke Utility Gas Distribution Natural Ga8 !'Y 77 Date

5/5/77

, Qtr. 3rd Location Inclianapoli•, Ind. Accident: At 6:00 a.m., c.d.t., on May 5, 1977, natural gu escaping from a 1/4" x 1/2" hole in a l l/4-inch steel service riser operating at a presure of 15 psig was subjected to an unknown source of ignition, exploded and burned, destroying three commercial buildings and damaging three others. The 1 1/4-inch service had been installed in 1956 prior to the requirements for electrical isolation, to serve an inside meter. The hole was partially enclosed in the bottom of an 8-inch concrete slab where the riser from the below-grade service entered the building and ascended to a regulator and meter which were vented to the outside. New, uncorroded metal spatter, on the exterior of the pipe only, covered rust and earth adjacent to the half-moon shaped hole. LOSSES: Fatalities - 0 - i Reportable Injuries....:.JL.: Probable Causes: l. Damage by lighting. 2. 3. Other Factors: l. 2. Probable Cause of casualties: l. None 2. 3. Other Casualty Factors: l. 2. ReC None t-ipeline Damage $ 3, 000 Non-Pipeline Damage $ 200,000 N ~ I .'! . ·~ ; ---~ \ ·: ~ .· ... :·. ~··:· "~l .. :.··~ irhJ,H',~':@''-'-!1iz:.llli~..i:~4;,iliLf_il;~~1-..... •· •· "~·- ....... ,~ .••. ' ..•. : ' ·~ ~ '':·i -~,. . · .• :·.~··.~;:'i(~.i~- .~~

;,-:; ~/ ·1: .... :y···-~ . ~':"·~·,"!~~~ ~.~!-<.~.t-:'{:....,;r..i:.;.;,~·;.. .... ~.i-~in.;L...ti --.;...h~; ••• ~ •• 1 .' .. :,:·•\···"'"·"' -. ·~···O.·,' .. :.:.~:J, ~.·.•:.,1,.;.Y,..,.:.·.!',,;,,;_ ·:.-·,, -.; .... d .t-.:, .. ~,, ............. ~· ·( ,-1..1<:><.-· :·1•.,.~ .• ,~.,..,· •. ~.-1:):i·:·i:;:;1,.;~ •. b .. -,ti ;,~ °'":·~ ~ .-.~.~-- .t.~·1 .. !Jf'..,.;t"~·:.!1\i.•ti..w.~r..j..,;:~~\ikii:!.ti.:;;;::-.ti.),i.:,,::! t,.,,~.Oi;~~i<~t1. :t,·,~ ... ·:Y .. :'i.,~'i.~¥..:.,,.;. .. ,L~'..t.:.f.i.:',.:·.~i:YfH-:4;:~-~ f:e.j -~ ~7 r ~ ~'. 1~.-'. 1 ,.- -~·- .· .. ··, !:i_·. . " ~ l ~t i . ·.'" .. ('.· , ~-~.{ . ' i• ~:~ ' • R !. -•, ~}~f1''1i'',,., ", '-·- .. ,·, .. ·.- :·1 . ·---·-· .,, ---·----·-----, ._--.- -l'J FTW-79-F-P00J Caapany Lone Star Gas Co. NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 Brief of Accident Pipeline Accident: FY ~. Qtr._2n_d __ _ Type Commodity Date Location Distribution Natural Gas 1/11/79 Irving, Texas Accident: At ~:40 p.m., c.s.t., on January 11, 1979, natural gas leaking from a circumferential opening in a 1-inch steel service line, operating at a pressure of 28 psig, migrated laterally beneath and into a house where it was subjected to an unknown source of ignition. The resulting explosion and fire fatally injured one or.cupant, critically inju~ed the other, who died 10 days later, and badly damaged the house. Leakage occurred at the 1ad!v corroded end of a bare steel nipple where it screwed into an elbow above 'che service tee. 'lne bare service line was insulated at the meter but not at the mill-~Lapped, anode-protected main, resulting in insufficient cathodic protection. LOSSES: Fatalities 2 Reportllble Injuries 0 Pipeline Daage $ 1, 000 Han-Pipeline o..t)e $ 3·., 000 ;.·obable Causes: l. External corrosion due to the lack of cathodic protection. 2. 3. Other Factors:

1. Earth movement, moisture related, causing direct damage to pipeline •

Probable Cause of casualties: l. Fatalities due to fire as a result of primary loss event. 2. J, Other Casualty Pa~tora1 1. 2. RecCllllendationa. None .~·"""· .. / N N 1 ! _, 'l ' '• l J ~ ' ' ;i :'~ ']

! J I iJ { [ 2. I ·~ l ·~ I ~ ~· ' ·1 Probable Cau .. of Ca•ualtiea1 Other Casualty ractor•• .. ~tion•• Pending 1. Injuriea were due to exploeion and fire ae a direct re•ult of the primary lose event. 2. 3. 1. 2. ·-·"-'• ,.._., .. ,....,.....,.,,....,. _ ,,..,._ ___ _,.,.,,. .... ..._.. ............. ._..· .. -~..,, .... -,.-.,,.......,.... ... ~-.. ... - .... ~ .. ,-----................ ,..-... ~., .•.. ,.""''""''~"''·""~''~•"'''"'~'-""" i ~ ' ~~ ! .·~ [ -~ I ~· l .-j I -~ l. :.:i ! ·~ 1 J 1 _j '1 ,J J

{ ::·· ·;-, 1 ,1 !; i;l ~ i' ! F ,, f ~ ~ ~ IL "ll~ t ~r · :~. -, . '· ...._ ~~--·;w-··• -.-.,.,-~,-=""''""'~.,..~-"'"'......,,,,,""""""·~""···;A,'W{m1 DCA-76-FP-"-l Cmpuy Lewiebura Gae P•p1rt91pt {Munil''inal} NATIONAL TRAllSPOllTATION SAnTY BOARD WASHillG'l'Oll, D.C. 20594 Type Brief of Accident Pipeline Accidents ec-odity DAte n ZL• Qtr.~ Location Di1tribyt,ign Magyral GM 10/31/76 720 Cr•atl.all.4_-11t~ l~iahur•~ T•nn••• .. Accident• At 6:30 c.e.t., October 31, 1976, natural aa• which had eecaped from a circuaferential break in a 2 1/2- inch caat-iron main owned by the Lewiebura Gae Depart .. nt, operating at a preeeure of 15 pei1, ai1rated beneath a one-etory houee at 720 Creetland Drive, in Lewieburg, Tenn•••••• exploded and then bunaed. U>SSBS1 The gae wae ianited by an unknown eource. 'l'Wo people were injure~ and the houee wae d5etroyed. When the gae main break w~: e:poeed, it waa revealed that the caat-iron main vae lyin1 direcely on a rock in the bottom of the trer.eb. A large truck h•uling creek gravel had been croeein1 over the pipe, creatina a downward force which broke the caet-iron main. Ten daye after the accident one of the injured person died. Pipeline Non-Pipeline rat.alitiH 1 Reportable Injuriee I DaucJ• s ,:.U2.:..Qg Dalla9• S 25.QQQ.OO Probable Cau•••• l. Inadequate ditch inepection during conetruction (no padding under main.) 2. Overetreeeina of pipeline through heavy equiFment above pipeline. 3. Other Factor•• l. 2. Probable cauee of caeualtiea1 l. Fire, oxplo~ion and injuriee from collapse of etructure. 2. 3. Other Caaualty Factor•• 1. 2. ReCClllllendttionea None N • . :·,·~ . ~1 1 ' ·J j t: \ J ·., i ... 'j ·~ ~ 1 .~ ~ i q l ~ 1 ~ ~ ~i 3 ~ ~ /~ ~ ~ 4 1 ··~~ ·~~

r ' ! -., . ..~'!'P"'~:"J'~'-• - ~· · .. ..,. ..,,.,. _,.,ir"...,...:•.·....-=-;o:-r.-..T.':";""~""··:it>·n'°-~,,.'t"°'".,...-.."l" ... ~'" - .·-."'~ ~-,,.....,. >: -~·!'" ·r'""f";"".'n:.:7f""~1~·.:•· 1 "' ,,. ·:re···,-,.,-~~ JA;C~;',·;:-."if~ 'f . '. ~ .__. ··-----·----- ------~ ·---------, FT!J-: tl··D-Pf lf -------- CCBPMY .Ja;IKi61..lU.~vi~•~iMoun~o~f----­ M inqe 1 o ta Cat Co. llATlOllAL TIWISPOllTATlCll unft IOUD llA8HlllQ'IQI, D.C. 2059' Type lrlef of Accident Pipeline Accidents ec-xllty O.te n 78 , Qtr. lat ~ ---- Loca ti OD Dbtribution Natural Gae 11/9/77 Lincoln, Rebraaka (Lancaater County) Accldenta The accident waa the reault of natural gaa leakage fro• a one-inch aill wrapped ateel aervice line which had broken at thread• entering a ninety (90) degree elbow becauae of atr••• cr•!ate~ hv inatallation mi1aliR1UM1nt. The gaa migrated froa the thread break. located 14 inches f~oa th• block foundation, then throuah the foundation into the baa .. ent where it exoloded and burned when ignited by an unknown aource. One peraon wee critically injured and later died. The house auffered aot1e atructural and fire damage. LOSSISa rataliti••-=...!...: a.portable lnjuri .. ...::..JL.: Pipeline Dm&IJ• f Unknown llDn-Pipeline 1>m119e f Unknown Probablt!J Cauaeaa

1. Failure to execute inatallatlon procedure• properly.

Other ractora 1 1. 2. Probable Cau• of caaualtiear 1. Due to fire aa a result of primary loaa event. 2. 3, Other CaHal .. y Pactona 1. a. .. ~tion•a Mone N VI " .I .··;e ., ·' -~ .. :~ ,.) ·! ..-:.'. '{ ~ ~ --q-- .·l ,j ·' ., -~ ::~ ·1 .1 . ,:; ~ :1

• ';j

i :~ :t ~ )~ ' .~ '~

m;'!#J+!'MWf.,(flb$G'),fil$'il~ll!'iNifW"'iZ,,tJ:t?..!f?f.*""+;(lli'!:'l!:'~~~-!''''"l'-\'F)""''l\i ,MJll!.iif'. ·~--.-~.....,.... ...• ···~,·~. ,lr;....,. __ _ I~ .\ t: ~­t , t I f. . . J ·, nw-79-r-Pffs CGllPUY Pacific Caa 6 Electric co. DTlOllAL 'l'UllllOnl.t'lCll unrl IDUD llAllll1111'Gm, D.C. 20594 kief of Accldut Typo Ratural Gaa Diatribution Pipeline Accldeat1 a-:dity Natural Gaa l>Ate n !!, Qtr ....... 3-.rd. __ LocatlGD 4/19/79 Mountain Vin. Santa Clara Co., California Accident• On April 19, 1979, a 12-inch atael gaa diatribution aain with a Maxiaua Allowable Operating Preaaure of 153 pai& waa atruck and ruptured by a bulldozer adjacent to a pipeline .. rker while it waa clearing and arading a fire-break and acceas road in a rock quarry near Mountain View, California. The eacaping sa• waa ignited by the bulldozer and the reaulting fire deatroyed the bulldozer and r.ritically injured the operator wh~ died 19 days later. IDSSB81 ratalltie• 1 Rasartable lnjuriH O • Pipeline U..V• • 10,000 llOll-Pipellne .,.,. t J,O QOO Probable CauH••

1. Damage by outside party excavator due to machine operator's error in judgement.

l. Other Pactora1 1. 2. Probable c.... of CUUltiH•

1. Fatally burned.

l. OtMr ca.alty reocoH1 l. 2. a.carnrrdatiana1 Hone ~ N 0\ I ... "' CJF{~1;1; 1: .·~ \ .~. ; 'f .· .. -;.~' ~ j ·,;i :j :ii .... ~ -~ ·' l -~

~"-~·':-'F .... ' M.·;1!'.:'>"'""··>i"~~-~-:"j.."!i\"'~t~Y-t· ·" ~-' [. r' l. [, t f; ~ ! f ~;, '" I / v P'rW-78-D-Pfl5 ....,..-' llATIOllAL ftAllSPORTATI<* 8ll'ftY 9DAllD WMllllG'lal, o.c. 20594 Type arief of Accident Pipeline Accidents o-xlity Date n 1978, Qtr • ...;4~th;;;._ __ Locati• '-' Compuy Nebra•ka City Utilitie• Ga• Dbtribution Natural Ga• 9-1-78

llebrHka Ci~y, lebraaka

Accidents A pickup truck, driven by a 77-year-old .. n, departed from the highway and travel~d over 300 feet to a location 35 feet aouth of the ahoulder of the road where it •truck a 4-inch gaa tran .. i••ion line which waa operating at a pre••ure of 600 paig and roae above the around to a gate valve and regulator in•tallation. The colliaion, reaulting exploaion and fire fatally injured the driver, destroyed the pickup, broke the pipeline completely in tvo, d ... 1ed the r ... inder of the inatallation, broke an electric pole and 2 guy wire•, and interrupted the aa• aervice of 55 cuatoeera. LOSSES: Patalitie• - 1 - 1 ~ ...:trtable Injuries~ Pipeline o.Age $. __ ? __ _ Probable cauHa1 l. Accidental damage - facility •truck by vehicle. 2. 3. Other ractoras l. 2. llOn•Pipeline o..ve • 2.QQQ Probable Cau .. of caa11<iea1 l. Fatality due to injuriea auatained in motor vehicle accident with fire. 2. ], Other caaualty ractores 1. 2. Rec:aimendationas None --·---···-.. ···-· ..

··---··-···-········----

-··-

N ..... :i.' ·-::.· -,~ ' il~ •' .f; :~ ~· i J.; ., J, -:<' :;:~ t. ,. ·~ -~ ~ ,, 1 ~ J i l ~ - ~ J A l ~ i j ~ ~ ~ ~ i ~ .~1 ~ . I -~ ~ ·~~ ' ~ :~ l ft .:~ -l ~'~ :~ ~ .. : . '~ ,,,,~:~]

FW~-"·' !l·.>:;!!pl~'r-'l:Y.~·"'!;;:.;:-7,(';o"~,..,..,.t;"".·'~ •• ...,._ .,. ··-~-~·>Y,•·""-~-.-.... ·-·,...,.--.. ....,.--..,J~ ... ~·~···-~· , .,4£'i. R'\t .(,¥ .. ,~.,,, .• .-,.,.,-.,r..•,.,..1".'""l,,..,,.....,.~..,....-._.., ..... :'"'>'"';·•y--. I i n ~ t· ll ~ I . i------ r'.'1 ,. 1 1 1·l f. t.·i

FTW-78-F-PlfS

other callualty ractore1

None :'.- N CID I r I I I I ~ ,, ·.·t ' ·~) ., '~ :l ,!l \'i ~ . .. ·~' \i ;i 4 ~ 1 ~t I: ~- l~ j "L . :~ . l ~ l ~ ~ t ~ ~ ~ ' I . p I ~ f t 5 ·;·,·- ....~ _,. ·---·l ··:< F'l'W-79-F-PH4 coepany lli\TlOllAL TltNISll(JaTJlTlOll unTY 9Dlm Type WMJllMG'IQI, D.C. 205H Brief of Accident Pipeline Accident• ~ity Dete n !!.., Qtr.~ Looation Gaa Diatribution Natural Ga• 1/19/79 Horth Richland Billa, Taxaa Lone Star G11 Co. Accidantz At 1:10 a.m., c,a.t., on January 19, 1979, natural gaa which had eacaped from n circuaferential fracture at the thread• of a 1-inch nipple above the aervice tap on a 6-inch aain, oparatina at a preaaure of 28 paig, migrated laterally beneath and into a houae where it vaa aubjected to ignition by a gas-fired furnace or water heater. The reaulting exploaion and fire killed one resident, critically injured the other and completely deatroyed the houae. Ga• ·odor• had been detected by the reaident• but not reported to the gas company. The operator'• "awing connection", which is no longer uaed, was deaigned to withstand the damaging effect of atre•• caused by the expansion and contraction of the clay soil aa it becaae vet and then dried. However, the threaded fitting, used contrary to induatry atandards, vaa un&ble to vithatand the aoil aov ... nt. It fractured in the thread which acted aa a &treas concentrator. lt8SJOrtable lnjur ic•t! __ 1 __ . Pipeline o..ge $ 1,000 IDSSES: ratalitiH 1 Probable Caunaz

1. Failure to comply with industry atandarda.

2, Soil stress, moisture related (expansion and contraction). 3, Failure of public (caaualtiea) to report gas odor. Other Pactoraz 1. 2. llOn-MpeU.ne .,..... • 75,000 Probable Cau .. of caaualtieaz

1. Fatality due to fire aa a result of pri .. ry lo•• event.
2. Injury due to fire as a reault of primarv loH event.

Other canalty ractoraz 1. 2. ~~tion•• P-79-27, P-79-28 N '° I ! ·;f ,.-c_, ? I -~ ·~ :1 ~ ·' i ~ ;j ~ -~ ;i ~ j -+ -~ ·-~ ~~ •. 1 ~i ·' ·t ·-.1 ~ ' . ~ ~

rict, Orana•. Te:xaa, baaan to clean a farm drainage ditch with a generally north-aouth alignment. After makin1 aavaral p .. ••• across the ditch, the operator headed the bulldozer aouth along the length of the ditch. At 2:15 P·•· the corner of the blade cut into a propane line, owned by the Cities Service Pipe Lina Co11pany, which croesed beneath the ditch in an east-weat direction. Propane at 350 paig eecapad and waa ianited within seconds. The reaulting fire killed one person and injured another, and cauaad conaidarabla property damage. Fatalitie11 1 ----· R8portabl• Injuries l . Pipeline Daaage $190,000.00 Non-Pipeline Dallaci• $99,000.00 Probable Cau11ea1

1. Damage by outside party excavator due to machine operator error, unaware of pipeline

existence. 2. w () -·~ :1 1 :.i ·~ 1 j .~~ .i 1 I ·) '.,i_;~ - -- -· - -- -- - --- ---·- -- ~· · Other Factor•: ' . ,

• 3 .•.

1. Coordination failure: No one-call notification requirement.
2. Coordination failure: Pipeline does r.c~ "~·pear on excavator's mapa •

I ·1- 1 r t. ~­ S· t. ,. t !

1. Coordination failure: Inexperienced operator did not detel"IJline pipeline exiatenca.
2. Inadequate baaic system design (regarding depth of burial which was n~t required at tiae

of initial construction). Probable Cause of Casualties:

1. Fatality and iniury due to fire as a result of priaary loss event.

Other Caaualty Factora1 Rtl~ndation•1 P-80-1. P-80-2, P-80-3-4, P-80-5 through 7 ~ .... - i ,/~-·

I t ii ' . . ·• ".·\ !· .._,. ... _.. . . ·~ r ,· ., r llATIOML 'l'llAllSiroRr&TIOll unfY 90AltD ;: I· ~·. ~;.. t· . ~---" -!--- :i: i!-r f I I ' f 1· f l L h', t 1 E ¥; ~·" ' :: & tlUllllllG'IQI, D.C. 205H arief of lccident FTW-78-F-Pff4 Pipelinca Accidents ~ity rY !!__, Qtr •...;2;..;nd-.. __ Location CClllPMY O.te Florida G~• Tranamiaaion Type Compreaaor Statiop Matural Gas 1/27 /78 Padre laltpd. Te!!f Comoamr Accident• A transmission company's remote compressor station developed a natural gas leak which was ignited by one of the engines. The engine stopped instantly when its combustion air was snuffed out. but its vital functions (oil pressure. temperature. auction and discharge pressures. etc.) continued mmaentarily. The radio alarm relay system became inoperative since it was activated by energy from the engine magneto. The fire weakened the 2-inch bypass between headers which waa then ruptured by the discharge pressure end a large volume of gas escaped. The gas volume increased as additional leaks developed. Two of the station's three units were destroyed and the third was severely damaged. Total gas loas was estimated to be 3.24 MMscf. Pipeline LOSSIS: rauliti•a._o,__ _ _. Reportable Injuries 0 , .,...... $ 500' 000 Probable cauae11 l. Lack of or inadequate automatic shutoff devices. 2. Lack of or inadequate control devices. -J. lllOn-Pipeline DIM9• •·--::.o __ _ Other Pactor11 1. Base material failure of steel length of pipe due to excesaive heat. 2 .• Prab.lbl• c... of caaualti••• 1. 2. J. OtMr cuualty ractor•• 1. 2. .. ca•1ndatiOll8• P-79-1 <-•·••···-··-·------.. -------------... ---------------.. -··-----·--·-····--·--........... . c..i ..... I :- ~ '<.'.;·:! 'l ., ~" :~· '.; ··.1 ' . -~ :!

;,i..,;"· ·, . .,, -' •,,'! ": ,;'\ llA' .'IOllAL TIWISPOR'l'ATIOll SAl'&'l'Y IOUD llAIHillG'l'Oll, D.C. 205H ldef of Accident FTW-79-F-Pllll6 Pipeline Accident• a-xiity n --1L• Qtr •.:l:o•t=---- ec.puy Type Date a.acauon United Texaa Traneaiseion Traneaieeion Hatural G11 _10/21t/78 Pearland. Texu COllDllDY Accidents At 3:00 a.a., c.e.t., on October 24, 1978, natural ga• eecapina froa a ruptured 30-inch pipeline operating at a preeeure of 560 peig w•• eubjected to an unknown eource of ignition, exploded and burned. There were 6 fatalitiea and 47 injuriee reeulting fr,,. the fire. One houee, a barn and 7 mobile hoae• were deetroyed and eeveral were daaaaed. Thirteen vehicle• were deetroyed and ~ aeveral damaged. The extent of daaage aay be related to encroachment by the trailer• on the pipeline right-rf-way with the deetroyed houee located 40 feet f~oa the point of rupture and the aobil~ hOlle park located adjacent to the 50-foot pipeline riaht-of-vay. The coneiderable delay in ehuttinl off the flow of ga• wae due to the erroneoua indication that the parallel 24-inch line had failed but the delay apparently wa• not a factor which affected the caeualtiee. Metallurai~al analyei• revealed that the failure wa• aue to hydrogen cracking (or poeeible •tr••• corroeion crackina). Pipeline llDn-Pipeli .. IOl.GBS• rataU.ti.. 6 1 .. portable InjuiH__il -~'

.,...._ I

DIMt9 •·-------- Probable C6"H81 1. The pipeline failure wae due to hydrogen etre•• crackina. 2.

-l. - -

Other Factor•• 1. 2. Prabable cauee of C&eualtie•• Otbar C&eualty rector•• None i. The fatalitie• and injurie• were due to fire ae a reeult of the prillary lo•• event. 2. lo 1. 2. ,, .. - .. . ' :~. '~-~1~:·f.?' w N I

• --1

I ' ''·~ .;~ "' ·-\l :1 ·· .. ~ 'i ~'~ j '.~ ... ~ 1 l -~ ··i ~ ·~ ·~ " ;~ J ·l 1 q '·-~ -j ~ ,j .i ti { ... 1, ; ;1 .~ 'i ~ 1 '--1- -- - I i -~ .. ; 1 i :; -~ :-1 "' .>] '~ ~,i ::3 .·:;J ;~~ ·J -;.i; ., .. , ,j \ ~~ J j " ·r1 -~j

~-~-:-~·····-····--····~--··~'=:·~·~----~-~-~-?'~'~(;.ii /;· ' MTIOllAL 'l'IWIUOll'l'A'fIC* 8Ar&ft 9DUD :'·t1 /' DSHillG!'Oll, D.C. 20594 I -':~ -" •let or Accident I :i FTW-78-n-fll Pipeline Accidents PY Z! ' Qtr •• 3.el .. ~~~ CCllfllUY Type a-dity Date l.ocatiOD Arizona Public Service Co. Diatribution Natural Ga• 6/30/78 Phoqix. Arifopa (Maric9pa County) Accidents The accident waa the reault of a natural gaa leak from a fracture caused by the iaproper inatallation of a 2-inch Acrylonitrile Butadiene Styrene plastic main in a comROn trench with a telephone cable • .Approximately 4 to S feet of the cable were overlaid by the plaatic pipe. Taaping ancr aettl .. ent of backfill material created ovality in the supported deaaent of pipe, with atre•• and tiae cauaing the fracture. Natural gaa eacaping from thi• fracture in the main, operating at a preaaure of 29 paig migrated through hi.ably permeable aoil, beneath a alab and upward• into a houae where iplition by an unknown source resulted in one fatality, five injuriea, one house deatroyed, two other• extensively d ... &ed and eleven other home• partically damaaed. U>SSBSa l'ataliti•• l , a.portable Injuries S , Probable Cauaeaa

1. Improper construction.

Pipeline Dmate • S,000 llan•H.pelU.. .,..... • 300,000 w w I :I -~ J1 1 !·; ~ -~ -~ :j ~l .,, :-i . ·l -~ . :_:~ .. ~ -~ -~~ ., ··,1 ~ .J :j ~ j ~~ --~ .:-:i . -~;t r

-t-:-:>- .... .,.:.;:,;'>-!· -- - --- -

--

• . -
• -l. --·

---·---- ~~·:+ ,. ,- ¥.~, ~-: ,. r r ~~ ~:­ L ii- lfil Other l'actoraa

• Inadequate ditch inapection during c·natruction.
• Inadequate lower-:ln inspection during construction.

Prabablo Cauae of caaualti•••

• Fatality due to injuries from collapse of structure due to pr:laary lo•• event.
• Injuries due to fire and collapae of structure due to priJl&ry lo•• event.

J. OtMr Caaualty l'actoraa

ile~tionaa None -· ~ ···-··-~ ... ". ... ,.,,..;.._.,.......,, ..... -.... .. _... ..... ..... ........ ---.. -----···--·~········· ...• - .... -:~ fl 'J ·I ''l ~i -~ . ·-·~ ·-~ ;•.3 J -~ -'~ ;'j L, •" ~. t~ k !.~:~::~t~1~·11". ... .;.,.t;;\;'.."·~~··:\•::p·~Y•:'.:,t-.W.'f'.-.?J .. -!-~ ;t.'.·-~·••'", • · ·~:'rtµ~··,~·.' · 1 ~· .,., • ...... ., .. ,,,,'.f"~!"",.-.'".'"., .... - • ., . ., .. ; "' .. "•''~.::!' ".r~:--"':>r:{'·~~,~,~·~· :•·· ., ":·.•· · , .. · ... » Y.::·· ::." . ('~"··•· •. ) NATIONAL TRAHSPORTATIOH SAFE'l'Y BOARD WASHINGTON, D.C. 2059' Brief of Accident FTW-79-'F-P014 Pipeline Accident: FY Z.2. Qtr. 4th Location CompAny Date Dow Chemical USA Type Liquid Gathering Comodity Natural Gas Liquids 9-4-79 Pierre Part, AsaU11ption Parish, Louisiana Accident: LOSSES: At 12:15 p.m., c.d.t., on September 4, 1979, the tugboat "White Fae~," towing the barge "Intercoastal 103" in Lake Verret below Pierre Part, LA, backed into and ruptured a 10-inch Dow Chemical, U.S.A. pipeline containing natural gas liquids under a pressure of 640 psig. The resulting explosion and fire were responsible for two fatalities, one injury, destruction of the tugboa·t, barge, and severe damage to the swamp-buggy backhoe on the barge. The pipeline had only 2 feet of cover and was within 5 feet of the water surface of the point of rupture, as indicated by a postaccident survey. Fatalities =...1...=. ; Reportable Injuries - 1 - ; Pipeline Damage $ 240,000 Hon-PipeliM Dmlage $ 245,000 Probable Causes:

1. Pipeline damaged by tugboat (operator error - failed to follow instructions).

Failure to comply with F·:deral regulation (inc:dequate depth of bu.cial as requh·ed by Corps of Engineers Section 10 Permit) 3. lmpr~per/inadequate pipeline construction/inspection. Other Factors: 1. 2. Probable Cause of casualties: Other Casualty Factors: ReCOlllllendations: None

1. Fatalities and injury due to fire/asphyxiation as a result of

primary loss event. 2. 3. l. 2. r~""···. /····· ' ; .,,, .... ~.,.,,,..,.......... . .... ~ . ..,··---................................ ~ ... - ... , .... ,, • .:-............. ,, ...... ... ........ ,._~--·A .......... , .. "'"'"" ... '-'-~----··• ••• < '' .,.('.:.;:: ... .... "" I .. ;~ I . ::;1 i ' J I .· .. ~ ! ... ;.\' ... -~5' l i I l . ,. I l I ... c ..... , ... l .~ 1 ·l ~ . 1 .~.i ~ .• .. 1. ~, 1 ~ :4 , ~ ~ :J ;:~ ~ ~ :~ M . J ~'I ~~ ''";:.,:;

l//U ';{ _/ v /Jr~J~~ NATIONAL TRAHSPORTATIOll SAFETY BOARD WASHIHG'l'OH, D.C. 20594 Brief of Accident DCA-79-F-P-021 Pipeline Accident: FY 79

, Qtr. 4th

Ccmpany Type C~ity Date Location The Peoples Natural Gas Co. Distribution Natural Gas 7 /31/79 Pittsburgh, Pennsylvania Accident: IDSSES: All&alJ•n~v-c~o~up,_.twy.__ ______ _ A man entering a small cellar beneath the office of a commercial greenhouse, struck a match to light his cigarette, a flash fire resulted, burning him critically and resulting in minor damage to the cellar. The man died later that night. A 12-inch,bare-9teel, 80-?&ig pressure main running from south to north, and west of the west building line was excavated 16 feet south of the south building line and 5 feet west of the west building line where two (2) corrosion-caused leaks were found and repaired the same evening. Four additional corrosion leaks and one leaking clamp were repaired later. A 4-inch hole in the greenhouse was located approximately 18 feet from the gas main. The leaking gas could have entered the greenhouse cellar through this drain hole. Fatalities~ Reportable Injuries~ Pipeline Damage $ ______ _ Non-Pi pa line DaaacJe $__.s ... o .... o __ _ Probable Causes: 1. Material failure due to corrosion. 2.

• - --3 .--

Other Factors! l.

Corrosion survey of this bare steel main had not been made to determine if active corrusion existed. Probable Cause of Casualties: l. Fu.tality due to fire.

Other Casualty Facto%&: l.

Recaaaendationsr P-79-34, P-79-35 through 37 "" V1 I !' ·:;,; ; :·~:ti -_'.\··i ,·, .. ~ . · .. ' ~:~

• .. r~

· .. -'J . .·.; .:? :·. ~ ., .·!

• -;------ ·+-

· . . ·, ~'11..:«l: .. ;; ,,,.~.~·,ti',~>{;· ·:·~'ff."!-"".·•···~· • ..•.•• • '"• •.. J .. ·:.:. '·'·' .. · """'' · ,,,.,., •. ,,.,,,, ••·"~'·'=->• •~"·'·'·'·.-; ~'"'"'"'.c·,c; ... ·i<<.,;1;,,;,.~o,,,,,,,.,"'..,,i.f,>"-~''·""•;•v:.C;.;.;r»..-:.,,·;.~,i ..... ~ .. :: . . ; .. ~.· •• ·"·· ..• ~" ,-: ·. : ....... ~ -. ' ;,,.\" . "'' .. ; . ~\ .......... ~ t ..... : .. .: ... :.:: • .., .,,·-~· ... ;.-41~'·'""''"•·1';:;!': ·i ~ ~~· ~f. ~:;· f ,l~ '~ }'.: ~ ~:-· ;(.' r· -~ :-:« . '""''·'\ :JCA-79-FP-020 Company Atlanta Gas Li&ht Company NATIONAL TRANSPORTATION SAFE'l'Y BOARD WASHINGTON, D.C. 20594 Brief of Accident Pipeline Accident: Type Ccxmnodity Date PY !!, Qtr ._4_th __ _ Location Distribution Natural Gas 07/25/79 Roswell, Georgia / Accident: At app1oximately 8:10 a.m., e.d.t., July 25, 1979, near Roswell, Georgia, a contractor was boring a 20- inch hole under a county road when the cutting head on the auger penetrated a 4-inch plastic main. Natural gas at 54 psig pressure migrated through the bore hole into the bore pit where it ignited. Ignition was from the diesel engine used to power the auger. A workman in the pit received fatal burns;-the fireman received hand and arm burns while rescuing the workman still in the pit. The two way gas flow was stopped in approximately two hours by pinching the plastic main a short distance east of the ruptue with "1 hydraulic vice, and closing a valve at the end of a 6-inch connecting section of steel pipe j~·.st we'3t of the rupture. The 4-inch plastic gas main was not marked for this specific project, nor ·.,as a request made to the gas company to mark the gas main for this specific project. LOSSES: Fatalities 1 Reportable Injuries 1 Pipeline Damage $ 600. 00 Non-Pipeline Damage $ 3, 500. 00 Probable Causes: 1. Damage by outside contractor; non-pipeline damage by failure of the contractor to make the necessary calls for utility locations. 2. 3. Other Factors: 1. None 2. Probable Cause of Casualties: 1. Fatal burns. 2. 3. Other Casualty Factors: 1. None 2. Rec011111endations : None i , .......... , , ... ">! .. ~....:.:· ~.,...,.....~ ... ~ ................. A! ........ .-... >l-•·-""'··· .......... ~ .. --.......... ..-....-.................. --.... · ......... -··--«•- .. , ' .... . .~~·.'f;>i.-:•:'l>:, .. ;;,;:.,,,:,,.,.., ... ,,.,, ....... •·:.-, • .~. ,.,.<~• ...... ~·,.., .h:'<'O< '~"'' • '1'• ·'."f.-·'-•"'""'• "-<""" ""' "" ·---1 · i .;•:, '''iij ·.i~ ,~:~ ;; j ) -~ ,:r,1 ~ ... , :·~ ! ·~~ ·~1 ,:~ " i i;-~· I i I I I ' I".•••""'-'•.,.,"":~-"·· .i.J~~

.·, ~ ···· .-~-~·····~ · :?~-f~·~··:·-·:· .. :;~:z~-~·1 '· ,, · .. f:! r#~°9,"'.(WJi;,,,,.,.,~,~ ... f("!l'FJ!>,~;,¢%l~'?':<'l""''"";'•'1r,<.,,.~""'""'l''P:',o"''''""'"''''·°'~"'-~'·•·•·•···-·· ., .. , .... ,,,., .......•.• ~ .. ··~.,.,..,,...,.~ ......... . f,: t r i f f ' • h t r .. , .. ~-. =~-· ... " ....... ~~-·-..,,,, ______ _ '-- .., -.......... " DCA-79-FP-11117 Company Consumers Power Company NATIONAL TRANSPORTATION SAFETr BOARD WASHINGTON, D.C. 20594 arief of Accident Pipeline Accident: Type CClllllOdity Date FY.....lL., Qtr .~ Location Distribution Natural Gas 01/16/79 1014 E 6th Street RmraLO.ak. Mil:hiaan Accident: At approximately 5:00 a.m., e.d.t., in January 16, 1979, a natural gas explosion and fire destroyed the re~!dce at 1014 East Sixth StrP.~C on Royal Oak. Michigan. Natural gas leaking froa the broken threads of a 2 3/8 inch steel main screwed into a 2-inch pipe coupling migrated under frost and frozen earth, entered the residence where it was ignited from an wiknown source. One peraon waa killed and two were injured; adjacent houses and several vehicles were also damaged. The investigation revealed that the accident could have been caused by improper procedures used to backfill an excavation at a threaded and coupled joint in the gas main. Frost and frozen earth at a depth of approxiaately 22 inches was a contributing factor in the migration of the gas. LOSSES: Fatalities 1 .1 Reportable Injuries_2"""---· Pipeline Damage $ 3,500.00 Hon-Pipeline Dallaqe $ 80,000.00 PX"obable Causes: 1. Improper backfill over a 2-inch threaded and coupled steel gas main. 2. Improper support under the coupling and pipe prior to backfill. 3. other l"actorsa 1. 2. Probable Cause of Casualties: l. Criticqlly burned. 2. Injuriee from burns and collapse of structure. 3. Other Casualty Factors: 1. 2. Reca:nmendatiClfta: None r..;;·~Jl",,U.~\J."·'"""··---·"•''U~•· ....... ·--- .... ,,., ....... ~ .... ,,~~ ..... ;....e-·U:~'4(4~--=-"~""'--'""""' ... ---...-----~-·-="'~"-..... "'"""' ..... ___ ...... ,.......-..... "''"'"'"""·~·--.. ~-,.,-........ - .... , ... -... -, .......... ~ ........ , ...... .,_...,. ____ _ w .., r I I t i I I I l I I I ! I - '~ ···1 ,·; ::< ·' ~ ·1) ~i ,, :J ,.'.i 'l ·· .. ~ -~ ~ :il :.ti ~ ·:i :ii ·~ ·~ .;~ ·~ ~ ,J 1 ;j j J 'J ,J ,J :i 1 '~i ------'

.+J:,:·w~*2~'3".,f.!n,'fy'Jii"r:J!!'J'Ol'i',~c:,;:~\,...~,,f",..,,..,..,.,~I":" 'i-'\"'7#1""'~r~""""'·"'?"·!'"""<,'f.'"'.''·,....,.,. -· • · · ··~· .. ....,.....~~·•r·~· . r? I ;; i .. I I DCA-79-FP-!122 CClllpany Washington Gas Light Company 111\TIONAL TRANSPORTATION SAFETY BOARD WASBING'l'OM, D.C. 20594 Brief of Accident Pipeline Accident: "'YPe coa.odity Distribution Natural Gas FY 2!, Qtr. _!!!! Date Location 8/15/79 Seat Plypnt. ~rxlapd Accident: A contractor, while excavating for an addition to the house involved, Stl'Uck a 3/4-inch steel service line, breaking it between the cut off valve and drip tee inside the house. Gas at 18 P•il pre••ure was blowing directly into the house for about 10 minutes. The contractor went into the baae .. nt of the house to see if he could cut off the flow of gas. At this point iRQition occurred fr011 an unknown source. The contractor ·is s~riously burned. The contractor did not. use the one-call •Y•t .. LOSSES: in Pri~ce Georges County for location of utilities. The gas company was unaware of construction around the gas service. Fa tali ties __ o __ ; Reportable Injuries. __ 1 __ Pipeline Damage $600.00 Non-Pipeline Dwge $ 130,000.00 Probable Causes: l. Damage by Human Exror: Non pipeline-damage by failure of contractor to use the Prince Georae'• County one-call system for line location. 2. 3. Other Factors: 1. 2. Probable Cause of Casualties: Other casualty Factors: Re~endationaa None

1. Injury was from explosion and fire

None 2. w Cll

• -j

···/t"~~·.·1 ' "7i :~ ·~ 1 -~ ~ ·j ' ·-·

r'•-.0.,'.,·•~"""'="~-~Y·"""'"'"'-"'"' .. ,, • ..,.,,.,.. ... "',,,·.,,.."'""""""""'lW"'-\i\ii@l.'!$iijC~•·•!"'-~">·%•"•"W\l"""""'""'""'.'M@t~1("1ii·"'*"""""!!h4a·'ii~'"~""""w ... /ii1?'"i'.~.~,:-,15l~;';;-''1,6!2,ll"@i;,~f<;i.'ilt')~~~ j, t [ e I~ .tt. . 'HA muz. A&&S tXIPm. ...,, ,. ~t ~ FTW-78-FP-ffl Ccapuiy Arkansas Louisiana Gaa Company '(WCI.Al NA'l'IORAL 'l'IWiSPOR'l'A'l'ION SAPE'l'Y llOARD WASBIIG'IOll, D.C. 2059' Brief of Accident Pipeline Accident: Type o:-odity n-1.!..., Otr. _!.!.! Date Location TransmiHion Natural GH 10/30/77 Shreveport, Louai&na Accident1 A city o,1lldozer was aaaiating the fire department extinguish a a110lderin1 fire at an abandoned city landfill. Its blade struck an 8-inch tranemission line carrying natural gas at a preaaure of 260 paia. The threaded an~ coupled pipe pulled apart. The escaping gas ignited, severely burning the bulldozer operator and he died 16 days later. Four others were burned and two required lengthy hospitalization. The bulldozer and lowboy were destroyed. T'~ operator'• ahutdmm interrupted aervice to 75 cuata.era. Pipeline Non-Pipeline LOSSBS1 ratalitiea __ 1.___ Repor~le Inj ... : iea_ ..... 2.___. ~· • 12,000.00 oa.&9• s ~.r , ooo !.2!!.. ProbAble Cauaea1 l. Damage by outside party excavatcr due to machine op•rator error, unaware of pipeline exiatence. 2. J • ____ Other_ f'actore 1. . 1 .• 2. Probable Cauae of Caaualtiea: l. Que to fire as a result of primary lo•• event. 2. J. Other Ca•~•lty ractora1 l. 2. Ra~ationa1 None ..... -.._ ....... ~····"........,,,,.,.__. .... -. ......... ~-·-·-·-·--·~· ·-· - "" '° ·,~ l ·; ,< .-! .. ,,

f· t;;• t t; ( ·-···. .

• -

.. - . ! :.· - . . ' J' ,,- ~· ' ' F'l'W - 79- DP- •• i Campany Delhi Gas Pipeline Corporation llATICllAL TIAllSPOITATICll SAPm IOAID VASHlMGTOlt, D.C. 20S94 lrief of Accident Pipeline Accident: Tyre C~itJ Date nzs Gas Matuu-1 OS/25Q.9 Catherina Gae • Qtr • .>.,rw4 ___ _ Locatioa Uepmag. Olsh!acee Accident: At 7:00 p.a., c.d.t., on May 2S, 1979, natural gaa under a preaaure of approx:lllately IOO P•la blew a unibolt'closure and ninged ~upport off of a 10-inch acraper launchar/reeeiver when a COllpADJ employee apparently attempted to remedy a seal leak at the couplin& by atrikina it with a 1()-pound brrr= sledgehaaaer without first blowing down the equipment to reduce the preaaure. The company ..,107 .. stood in front of the closure while striking it, and the exploaive fore~ of rapidly .xpandina natural ... at 800-psig pressure hurled him ag~inst a launcher/receiver on a 6-inch pipeline located behind hla. Injuries received by this man were fatal. LOSSES: Patalitiea 1 ; reportable lnjuriea -·---· Pipeline o ... ,. tL..Qgg, lloa-PipeUae na-1• •--- Probable Cauaea:

1. Improper·operating procedure• for a scraper trap.
2. Improper procedures for maintenance of a acraper trap.

Other Pactora: 1. 2. Probable Cauae of Caaualtiea: Other Caaualty factora:

1. Fatality due to exploaive force aa a reault of prlaary lo•• event.
4. Inadequate maintenance of acraper trap cloaure.
5. Iaproper leak repair procedure by uae of halller prior to

pressure relief. --. -~··· ., ........ - ;- ~ -·~~ ~li~:-zrf,,- j · · ;1 • 0 ~ .. . ~ ·.~ ·1 fl~ l -- -1. l ~ ~ '.j j :1 :1

.' .. 11 ' ;1 ~

r ~ ; . ·: t; r r ;, t !· I [ f r: i r i.' ·'~'f;;' ::•:'·f~, i }i;~ .' ' -1 "I ' -~-... ~ .. -. .__ ............ ..., ····~~ .,. ··- .,..... .. . ... . ~-.... ,., .,.;c~,.,-,f:~ \ I - ·-; ---- ,_,, ____ ,, '~ ·~; PTW-79-D-PH7 ec.puy Rgsiy Mpyptaip Ratural MTIOllAL TIWISPOll'l'aTIOll unn PJDUD llAlllllllGtal, D.C. 205H arief of Accidltnt Type Gae Rittribution Pipeline Accidents ~ity Matural GH O.te n!!, gtr._2..,nc1.__ __ LacaUoa 3/30/79 Spawatt! Villa&•• Al8ont Ca. , Colorado Accidents Natural &•• leaked from a fractured 2-inch plug valve on a gaa aain and a11r1ted into a buildina where it was ignited by an unknown aource, exploded and burned totally destroyin1 th• •ix-unit, three-story conda11iniua. The valve failure wa• the reault of hillaide toll moYe919nt in reaction to freezing A•i thawing. The odor was detected on the niaht before th• accident but not reported. U>Ua1 r1tal1tie1_J!__1 .. portable !njuriH 2 , Piplline o..te • 2,000 --'1 .. llM ~ • I00,000 Prablbl! CIUM!I

1. Natural force• - earth mov ... nt, temperature related (fre•ze-thav ~ycle).

Other P1ctora1 1° Failure of public to report g11 odor pro111>tly. 2. Problbl• ca.... of CUU1ltiea1

1. Injurlea fr011 fire.
2. InjurlH from collapse of structure.

Otber ca.aJ.tr raotor•a 1. 2. None I • ....

:~,"'!'.$~;~\···!%:t .. :cf.·.,qf«;'';'!~'17'-r'l"~,:.11;'1-; .... "T"!''"';?.~''~<,-~."!'": '~""N"~·..-·l"···, ...... ~ .. -·...-···.i ... :·-. .,..,.., ... ¢¥ .. !"(it/IJIJITT{*1a./\ .. ,.---:-. .. ""\I'~-·~-.·· .... ~; : l . ! . . I ' i l ! ~I L ~· .. r ' ' I [, . ! J 1 ~1 'r.1 1 ~ I 1 i ! I ! ~. 1 ~ ' t f f ~ ~· \ r • t ~ t f • ~ J .-------~--- -------·-····-·1 Fl'W-78-FP-ff2 Campany Hid America Pipeline System HATIODL TRAllSPORTATIOll SAPBTY BOUD WABHDIG'l'Oll, D.C. 20594 Type Brief of Acci~ent Pipolin• Acc14enta ec-odity Date "Z!. Gathering Line Propane 1118/79 , Qtr. -1ar. Location Sterligg <:ity. TIM' Accident: A pipeline contractor's ditching machine ruptured a 4-inch propane gathering line under a atatlc pressure of 500 psig. Three hours after the rupture, the pipeline contractor'• superintendent, who had re-entered the area and par\ed his pickup truck 650 feet fro• the break, attempted to st.art his truck. The explosion and fire critically burned the auperinteudent, who died 40 daya later. The ditching machine, truck and several acres of pasture were destroyed, and 1,530 barrel• of propane were lost. The pipeline company which engineered the line being ditched by the con- tractor did not provide maps to indicate the location of the provane line. LOSSES: Fatalitl••·l~ Reportable Injuries , Pipeline Dallll9• $18,360.00 lion-Pipeline DaUcJ• ··_;;;--;;...... __ _ Probable Causes: l. Damage by outside party excavator due to machine operator error, un8"are of pipeline existence. ··2 .- Failure-of· personnel to-de:tec t -hazardous conditions -due-to error in -j udg€.Mnt ·---- - -

1. Coordination failure, notification system failed to forward pipeline location to excavator.

Other Factor•: 1. 2. Probable Cause of casualtiea:

1. Fatally burned.

2 • J. Other Ca•ualty Factor•: l. 2. Reccmaendation•: None / -1- ~ N ! ;;_ '>·( . ·,:; ·: ,:· _·"'_1· ' ~ ' . ,•, ) "• ·~1-< J ,, ~ 4 ~ ~ '.1:. ~ ~ ' ~ .) t i ; ~ ~ ., ii ·~ '.j ' -~ 1 ~ 1 1 ; " l .. i '!! ----Tf j ~~ , ~ ·~ 1 ] .j ·1 ~ ;:} -~1 }! ~J

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t' I ~- .. .....,.,,..~·~. . .. ' . ' .... ,,,.,,.,}'.t'~ . . "·<:,.·: . --:·· .-~: .. ,·,:,. .·~~ , ~-;:J ~ 1 ---~-~·ft' -. ~ ,f.; ..._..... ::.1- DCA-78-FP-H9 Cc:apuy Bay Stote Gas Colli!anv M'l'IOllAL TIWIBPOll'l'A'l'IOll 8AnTll' IOAllD llASBI~, D.C. 20594 Brief of Accident Pipeline Accident• Type co.odity Distribution Natural Gaa nl!., Qtr._2_nd __ _ Date r.ocation 1/25/78 458 Canton Street Stou&hton. Haaaachuaett• Ac.'!cidenta Natural gas at 45 p•il leaked from a fractured 6-inch ateel .. in and aigrated under a paved atreet and frc 0zen earth into a residential dwelling. The gas was ignited by sOM unknown aource. The building was destroyed and one person killed. Excavation of the failed pipe ahowed that the rupture occurred at a 1elded joint. The pipe was installed in 1948, prior to f..cleral regulation•. A fir• continued to burn in the lawn and above tha fractured aaiu until valves were located and turned off 5 V2 hours after the explosion. One valve isolating the leak failed to seal and a valve cloaer to the leak was finally closed and it held. Thia valve was overlooked during the initial ahutdown. Pipeline Mon-Pipeline LOSSES: Fatalities __ 1 __ 1 ReporUble Injuries 2 1 Dua.ge $ 3,000.00 o.&ge s 40,000.00 Probable Causes:

1. Construction defect - failure of substandard weld.
2. Inadequate welding inspection during construction.

Other Factorr; l. 2. Probable Cause of Casualties: l. Fatally burned. 2. 3. Other Casualty Factor•: l. 2. Reccmaendations: None I "' w I ! I -- -r-- ·~ -..!, " ·!i .-> ··'I ·'t 1 f.i '1 '1 ,,~ 'J j " -~ } :-1 ~ ., --~ " ~1 •l ~ ; ~ ~ "·j l ...,. '~·~ -~ .. ..11 :! i

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PrabAbl• cau.. of caaualti••• Other ca....ity ractoraa Rec a111Pandatiana 1 None l.

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' • Due to fire, sephyxiation and injuries froa collapae of atructure. ' • ,· . i' l' I i ' ! • ! • i ~:I \'; .. I " ·~ .. ~ ~ l :s ., d ' i ~ ;1 ·4 'j -~ -'. '! i .. .. ~ .j i ~ j ,i i ' ,; j -~ ' i ' i " '•.', If' " i' i L [. " I r r ii:~ .. ·\ , i :·.T·f~Pl -:. ;,i ·----~- ·---------~------· ~- ... 1 ·- ~'.!} . . ,, '"-") ....., ';u:' ::~ . ; LAX-78-FP-~lal CCllllpany .Arizona Pyblic Service Co. HA'l'IOHAL '1'11ANSPOR'l'A'l'ION SAFETY BOARD WASHIHG'l'Oli, D.C. 2059' Brief of Accident Pipeline Accidents Type ec.odity Distribution Natural Gas PY]], Qtr •--.la ... t-.... __ Date Location 12/10/77 ,..,. • Arisooa Accidents Explosion and fire destroyed a four-unit apartment complex. Natural ga• at 38 p•i& leaked froa a crack in a 2-inch plastic Acrylonitrile Butadiene Styrene main. The ga• aigrated throuah the ground under a paved parking area and into the building 35 feet away. The gaa was ignited when an occupant lit a cigarette. The main bed 35 inches of cover and excavation revealed that th• 2-inch pipe had been damaged previously and a piece of tape had been applied to the daaaged area by non- pipeline personnel. The fire was extinguished in one hour. LOSSES: Fatalities 2 Reportable Injuries 3 Pipeline Damage $1.000.00 Hon-Pipeline DaaacJ• $98 I 000 0 00 Probable causes: i. Overstressing of pipeline through heavy equipment above pipeline.

1. Specific cause unknawn.

Other Factors: r.- ·- --· - 2. Probable Cauae of casualties:

1. Critically burned
2. Injuries from coll•pse of structure

Other c .. ualty Pactora1 l. 2. Rec:Cllll9Ddationa1 None -. ,,, ., .... ~·····--··"•"-... .. ~ ... ~ ... ..., ............. ~ .. ~---··.._ ... , .. -...... -"'"'---"·__..--........ ~ VI I " 'i ~~ ,, ·1 ' ·11 1

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,::. ~ ~ ~ • • f "" .9·~-= ~ 1 •. ,. l · t r. f '· r t i ~ ~.· ~-- i r r t !. t r t. • •' , __ •r C" • •• ·• •" ';~·C:""7• .;;-~,,<"·;:-+"C'V-U~,~,.,,.,..r.:,..,~,......,.;-~"''''-•J-';"• · • ,. . -,,.-.... . ...... ·--;·-.~-........ ~-·-:v-~"'-'"r."'"'''' ¥''"n"l"'" ........ (,""".:~"'-"...,.. .,,:-o·,;,;""'~•1'(\C'\";~""''°'W'1··· ... '~ .. ' ' lj~ :,,~~-- -, ~I I . -.' .. ~~ '·· -•. · .... '._:, --------·-··-·--- .... -·i ·., ' ~:1 llATIOllAL TMNSPOMTATIOll UFSTY IDAIU> lllA&HUIG'IQI, D.C. 20SH arief of Accident F'1W-78-I-ff7 ------- Pipeline Accident• camodity Natural Gae n..z!. Qtr. .3rd caatpuy Type O.te 4/7/18 LocatioD We tmar, Tua• (Colorado County) LgY.ca G!therin• C011panY TranaaiHion Accident a U>lla• Two aen were periorain& routine ''libration and .. intenance on a gray caat-iron, positive dlsplac..ant Mter at a town border station, while aervin& the city on bypaH, when the aeter explodied, lnjurin& both pereona ~nd interruptin& aervice to 798 cuataera. The aeter exploded at aoaethin& leH than the full inlet preaaure of 165 pal& when the downatreaa prover valve waa closed before the aeter reached line preasure and preasure on either aide of the diaphraaaa eqUGliz.cl. Met~lluraical exaalnation revealed the existence of ceatin& defecu which weakened the caae. The 49-yaar-old aeter with a vorkin& preaaure of 250 pal& had been teated at leaat once to twice ita vorkln& preasure, but had been uaed ha .. ny location• without additional atrenath teata. The c011pany aeter repair ahop had no facilities capable of teat1na aeters to aore than 100-p•i& preaaure. The bulky 900-lb aeter had been buaped and dented in handlin& and additional atreamea had been illpoaed by the tiahtenin& of ita screva each tiae it vaa 1eaHcmbled. Pi li pe ne llDn-Hpelllle rauliU•• O 1 leportel• lnjuri••~ 1 1 .,... • "! ,743 .,.,. t ----- PrabUl• Cauaeea 1. Iaproper procedure for .. int..-ance (etrenath teatina) of iroh-caee aeters. 2. Manufacturina defect• in iron-case aeter due to error in sanufocturing procedur~•· l. Material failure of iron-caae .. ter due to (poaaitile) previoua-daaaa• which weakened .. terial. Otbel' ractor•• 1. 2. Prabolbl• c..... of cuua1u ... 1. hjury froa flyin& objecta (frapenta of •eter ·i:aae) due to priury loaa event. 2. J. Otbar CUualtr ractor•• 1. 2. lee a ... u-. Mone , •• lfl, .... I • °' ·~i I 1 J J j ;l :1 ·-~ ~ i .l ··1 -~ ., d j ·1 l .5 j ! I : l l i :t \ } -i .. ~ l 1 ., -~ ~ . :J j

&-" ··- ..... ,. ., ..•..... ''""'" ' ... ,_ -·-""'·'"'""""~.--~ .. f;' ~ i\ f; t ,. .;:>v ---. -· "--~-,,,...~····--·-~---·-------.. =· ';'."'.'~:'~'l, ~ •. ·~ · ....... ~ j, i' ~ ,/' t / ,, 1" I ' I ""· ~ ,. >: 11 •• • tlA'l'IOllAL TIWISPOR'l'ATIOll SAFETY 80AllD WASHillG'l'Olt, D.C. 20594 Brief of Accident DCA-78-F-P0t4 Pipeline Accident: ec-xtity Natural Gas FY--1.!__, Qtr. lat Cm,puy Location Inoiana Gas Co., Inc. Type Distribution Date 11/24/77 West Lafayette, Indiana Accident: IDSSES: Natural gas leaking from a circumferential break in a 6-inch cast iron main (located at a depth of 26 inches) migrated about 5 feet to a perpendicular sanitary sewer, through the backfill in the sewer trench and under a house built u~10 a concrete slab. Part of the ga8 entered the house through floor heating conduits and was ii:-1ited at 2:05 a.m., e.s.t., on November 24, 1977, when an occupant attempted to light a cigarette with a lighter. An explosion and fire reRulted. The residence was damaged and both occupants were injured. One died 11 days later as a result of burns. Metallurgical analysis attributed the failure to graphitization and/or material failure. There was no suggestion of .stress other than that induced hy temperature change. Fatali ti.. 1 _1 RaportM»l• Injuries 1 , Pipeline Damage $ 3,000 llon-PipeliM .,..,... • 10,000 Prob41ble Cau .. a:

1. Material failure of cast-iron pipe due to graphitization which weakened material.

--- - ---- - - - -- - other- ra·c~ou:-- - -- -1~ - -- ---- -- 2. Prob41bl• Cau• of caaual ti••: 1. Due to fire as result of primary loss event. 2. 3, Other C&aualty ractoraa 1. 2. 11e~tiona1 None ~ ..., Hi::."t:·.utwo~:r.: .. 1:..o;'>'~.~!..·.r ... ~"·"'-.,.. • .._ ......... .., ...... ., •••• ~.-·, .. ··-· ·~- ...

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FD07038 ｜ 1981_美国_AAR8115.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1981 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

(_ ( ( NATIONAL _ ____. TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT NORTHEAST JET COMPANY GATES LEARJET 25D, N125NE GULF OF MEXICO MAY 19, 1980 NTSB-AAR-81-15 UNITED STATES GOVERNMENT

TECHNICAL REPORT DOCUMENTATIOl't PAGE J I. Report No. I 2.Government Accession.No. 3.Reclpient's Catalog No. NTSB-AAR-81-15 PBSl--'910415 \ .,\ 4. Title and Subtitle Aircraft Accident Reeort-- 5.Report Date ''¾,... Northeast Jet Company, Gates Learjet 25D, Nl25NE, Sentember 15. 1981 Gulf of Mexico, May 19, 1980 6.Performing Organization Code

1. Author\s/
2. Performing Or~anlzatlon

Report No.

1. Performing O~ganlzatlon Name and Address

JO.Work Unit No. National Transportation Safety Board 3352 Bureau of Accident Investigation II.Contrast or Grant No. Washington, D.C. 20594 .. 13.Type of Report and Period Cove red 12.Sponsorlng Agency Name and Address Aircraft Accident Report May 19, 1980 NATIONAL TRANSPORTATION SAFETY BOARD Was~ington, D. C. 20594

14.Sponsoring Agency Code

.• IS.Supplementary Notes The subject report was distributed to NTSB mailing lists: 1A, 'SA and SB. 16.Abstract At 1205 e.d.t., on May 19,·1980, N.ortheast Jet Company, Learjet 25D, Nl_25NE crashed into the Gulf of Mexico while en route to New Orleans, Louisiana, from West Palm Beach, Florida. The pilot and copilot were on board the aircraft. · .About 2 1/2 minutes after the aircraft ,,was reported at Flight Level 430. in the vicinity of the Covia Intersection on Airway J58, the Jacksonville, Florida, Air Route Traffic Control Center received an unusual staccato sound transmission over the frequency, followed 18 seconds later by a report from the copilot, "Can't get it up ••• it's in a spin •••• " About 33 seconds after the first staccato·sounds, radio and radar contact with N125NE was lost about 104 miles west of Sarasota, Florida. Floating debris was located by a search aircraft and later recovered; the flightcrew was not found. There were no known witnesses ~o the crash. · The National Transportation Safety Board determines that the probable cause of this accident was an unexpected encounter with moderate to severe clear air turbulence, the flightcrew•s improper response to the encounter, and the aircraft's marginal controllability characteristics when flown at and beyond the boundary of its high altitude speed envelope, all of which resulted in the aircraft exceeding its Mach limits and a progressive loss of :control from which recovery was not possible. Contributing to the accident was the disconnection of the Mach overspeed warning liorn with an unauthorized cut-out switch which resulted in the absence of an overspeed· warning that probably delayed the crew's response to the turbulence encounter, and the inconsistencies in aircraft flight manuals and flightcrew training programs • • ha 1u,.... ,..~ •• • A • · 1.7. Key Words Clear air turbulence-penetration, airplane ,· 18.Distribution Statement response, pilot response, 10&!1. of control, overspeed, , This document Is available to . autopilot mistrlm, disengagement, automatic flight the public through the National control system, control stick puller, mach tuck, Technical Information Service- aileron buzz/"snatch", spoilers, nosedown pitching Springfield, Virginia 22161 11!,qment, uncoordinated roll maneuver, high sp'eed.dive. (Always refer to number listed- In Item 2) ff. 19.S~curi ty Classification 20.Securlty Classification 21.No. o~_Pages 22.Price ·,\s. (of this report) (of this page) 72 ""--1 'UNCLASSIFIED UNCLASSIFIED NTSB Form 1765.2 , (Rev. 9/74)

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CONTENTS SYNOPSIS . . . . . . . FACTUAL INFORMATION . History of Flight • • Injuries to Persons Damage to. Aircraft • Other Damage • • • Personnel Information • Aircraft Information • Meteorological Information. Aids to Navigation • • Communications • • • Aerodrome Information Flight Recorders • • • Wreckage and Impact Informatio)l • Medical and Pathological Information Fire . . .. . . Survival Aspects • • Wreckage Search • • • Tests and Research • Aircraft Performance ATC Tape of Communication • Aileron Buffet • • • • • • • Additional Information. • • • • • • • • • • • • • Automatic Flight Control Stability System (AFC/SS). Stall Warning Stickshaker/Pusher System. Wheel Master Button • • • • • • • • • Overspeed Warning Horn Cut-out Switch • Gates Learjet Service News Letter • • • Special Certification Review of the Learjet ANALYSIS . .... . The Flightcrew • • • • Aircraft Airworthiness • Loss of Control • CONCLUSIONS. Findings • • • • Probable Cause • . . . RECOMMENDATIONS. APPENDIXES . . • . Appendix A-Investigation and Hearing. Appendix B-Crew Information • • • • Appendix C-Aircraft Information • • • Appendix D--Probable Ground Track • • Appendix E--Expanded ARTCC Transcript •. Appendix F--Learjet Accident and Incident History Appendix G--Airworthiness. Directives. • • • Appendix H--NTSB Safety Recommendations. Appendix 1--FAA Response Letter •••• ii • 1 1 1 4 4 4 4 4 5 6 6 6 7 7 8 8 8 8 9 9 12 12 12

13 14 14 16 17 21 21 21 22 27 27 28 29 31 31 32 34 35 36 39 44 60 69 ) ([ ,, ' ~ NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT Adopted: September 151 1981 NORTHEAST JET COMPANY GATES LEARJET 25D, N125NE GULF OP MEXICO MAY 19, 1980 SYNOPSJS At 1205 e.d.t., on May 19, 1980, Northeast Jet Company, Learjet 25D, N125NE crashed into the Gulf of Mexico while .en route to New Orleans, Louisiana, from West Palm Beach, Florida. Only the pilot and copilot were on board the aircraft. About 2 1/2 minutes after the aircraft was reported at Flight Level 430 in the vicinity of the .Covia Intersection on Airway J58, the Jacksonville, Florida, Air Route Traffic Control Center received an unusual staccato sound transmission over the frequency, followed 18 seconds later by a report from the copilot, "Can't get it up •.• it's in a spin; ••• " . About 33 seconds after the first staccato sounds, radio and radar contact with N125NE was lost about 104 miles west of Sarasota, Florida. Floating debris was located by a search aircraft and later recovered; the flightcrew was not found. There were no known witnesses to the crash. The National Transportation Safety Board determines that the probable cause of this accident was an unexpected encounter with moderate to severe clear air turbulence, the flightcrew's improper response to the encounter, and the aircraft's marginal controllability characteristics when flown at and beyond the boundary of its high altitude sp·eed envelope, all of which resulted in the aircraft exceeding its Mach limits and a progressive loss of control from which recovery was not possible. Contributing to the accident was the disconnection of the Mach overspeed warning horn with an unauthorized cut-out switch which resulted in· the absence of an· overspeed warning that probably delayed the crew's resp.onse to the turbulence encounter, and the inconsistencies in aircraft flight manuals and flightcrew training programs regarding the use of spoilers to regain control. ·

1. FACTUAL INFORMATION
2. 1

History of the Plight On May 14, 1980, N125NE was flown to West Palm Beach, Florida, on a business flight. The aircraft was fueled to near capacity and then hangared. According to the fixed-base operator, at West Palm Beach, the aircraft did not receive any further service. About 2140 1/ on May 18, the flightcrew arrived in West Palm Beach by commercial aircraft, remained overnight in a company apartment, and arrived at the airport about 0930 on May 19. Their activities between the time of their arrival on May 18 and their arrival at the airport the following morning are not known. y All times herein are eastern daylight, based on the 24-hour clock.

-2'- At 0955:15, the flightcrew of Learjet N125NE contacted the International ) Flight Service Station, Miami, Florida, obtained a weather briefing, and filed three flight plans ·ror a trip from West Palm Beach to Allentown, Pennsylvania, with en route stops at New Orleans, Louisiana, and Newark, New Jersey. The flightcrew was to deadhead to New Orleans and pick up a passenger for a charter flight to Newark, New Jersey, and then return to Allentown, the company headquarters. They planned to depart at 1230 with a . route of flight to New Orleans on Airway J-58 at Flight Level {FL) 430 at a true airspeed of 440 knots. Time en route was to be 1 hour 30 minutes with 4 hours of fuel on board. There was no forecast of turbulence in the flightcrew's weather briefing. The copilot of an unmodified Learjet 24D, N51J, stated that he saw the crew of N125NE arrive at the airport and he engaged in a conversation with them about a similiar portion of the route of flight. He said that the crew of N125NE did not have the New Orleans instrument approach chart and they had asked for and made copies of his chart. He said that when the crew boarded N125NE for departure, the pilot occupied the right seat and the copilot occupied the left seat. At 1107:06, N125NE contacted Palm Beach Clearance Delivery and received the following clearance: ", •• cleared to the New Orleans Lake Front airport radar vectors Sarasota as filed maintain five thousand expect FL 430 10 minutes after departure, departure frequency will be 124.6, squawk 3712." At 1119:14, the flightcrew received taxi clearance to runway 9, and at 1121:07, the crew received clearance for an intersection takeoff; 3 seconds later, they reported rolling. At 1122:46, the aircraft was cleared to climb and maintain 10,000 feet mean sea level {m.s.l.) !/ and to turn left to a heading·of 330°. Thirty-six seconds later, they _'1'_· ... were told to turn to 290°. At 1124:51, the aircraft was cleared direct to Sarasota and was J cleared to climb to and maintain 17,000 feet. At 1126:49, Nl25NE contacted the Miami Air Route Traffic Control Center {ARTCC) and reported, "· •• out of fifteen, five climbing to one seven thousand," and was then cleared to climb to and maintain FL 230. At 1127:30, N125NE was cleared to climb to and maintain FL 430. At 1130:56, the crew reported out of FL 260, and at 1135:16, they reported out of FL 330. At 1145:16, the aircraft reported to the Miami Center, " ••• with you level uh out of four two zero for four three zero." At 1201:42, the pilot contacted the Jacksonville ARTCC and reported level at FL 430. At 1203:56, an unusual staccato or vibration noise, was transmitted. over the ARTCC frequency. The following transcript of the radio transmissions from N125NE was prepared by the Jacksonville ARTCC: 1203:56 1204:00 1204:03 1204:13 1204:14 1204:20 1204:23 {unusual sound on frequency, three distinct bursts) (put out the spoilers) (keyed microphone with static) (keyed microphone with static) Can't get it up (pause) it's in a spin (background) noise, voice talking in background) (sporadic sounds, keying and unkeying of a microphone) • Oh jees (background noise) !/ All altitudes are mean seal level unless-otherwise noted.

.ttffi -:!i~, 1204:27 1204:30 1205:19 R-29 1208:19 R-29 1208:29 R-29. -3- We're gonna (static) November One Two Five November Echo ah reset and squawk three seven one two normal November One Two Five November Echo JAX November One Two Five November Echo Jacksonville Center At 1203:53, the Jacksonville ARTCC lost altitude information (mode C) from the aircraft and at 1204:29, the ARTCC lost radar contact with the aircraft on Airway J-58 in the vicinity of the Covia Intersection when the aircraft apparently made about a 90° left turn from the 290° radial, 104,5 miles west of the Sarasota (SRQ), Florida. The aircraft crashed at latitude 27°54' N and longitude 84°46' W. The depth of the water is about 600 feet. According to the copilot of N51J, he departed West Palm Beach about 16 minu,tes after N125NE. He and the pilot, who was flying the aircraft, received radar vectors over Lake Okeechobee during the climb-out, and about 30 miles south of Sarasota, they were cleared by the Miami ARTCC to fly direct to the Covia Intersection. The aircraft reached FL 430 well before the Covia Intersection and was cruised at Mach 0.77, indicating 210 to 220 knots with a true airspeed (TAS) of about 440 knots. The ram air temperature was -39° C. The gross weight of the aircraft was estimated at 12,000 pounds. He described the weather as essentially clear, with a very light haze at about FL 450, with some low clouds at about 2,000 feet and some cloud buildups southwest of their course. He did not note any change in ram air temperature, N51J encountered some light to moderate "chop" which presented no problem, about 50 miles west of Sarasota. In the vicinity of the Covia Intersection, the aircraft pitched up about 5°, climbed about 300 to 400' feet, pitched down about 4°, lost about 700 to 800 feet of altitude, and then abruptly pitched up at which time the autopilot disengaged. The flightcrew reengaged the autopilot, and the same sequence occurred two more times. Following the third reengagement of the autopilot, no further turbulence· disturbances occurred, The pilot of N51J, an experienced Learjet captain, gave the following account of the incident: I noticed that our Mach number suddenly rose from .77 to nearly .• 80 and simultaneously our altitude increased and I felt the most severe turbulence I have ever encountered in a Learjet. It disconnected our. autopilot and, when I reengaged it for the last time, the altitude hold was inoperative and it had to be repaired later. I reduced.power immediately. The turbulence continued for a certain time, which I cannot guess at now. Our altitude varied considerably during this interval. I did not check the. path of the jet streams that day but I am fairly certain that we must have crossed a jet stream at a fairly sharp angle and this was the cause of the rise in Mach number and the turbulence.

-4- The pilot further stated that he, "• •• had no great difficulty in maintaining . , .... control under these extreme conditions." He did not deploy the spoilers, nor did he , unintentionally disengage the autopilot and yaw damper with the wheel master button during the encounter. · Shortly after 1100, a National Aeronautics and ,Space Administration (NASA) pilot departed the Johnson Space Center, Houston, Texas. He was flying a Northrup T-38 jet aircraft from Houston to Patrick Air Force Base (AFB) near. the Kennedy Space Center, Florida. He stated that there were cloud buildups just to the south of New Orleans, with tops about FL 430. He stated that 40 to 50 miles east of New Orleans, the weather was clear and the air was smooth, with some scattered cloud layers below. He was cruising at Mach 0.89 at FL 430 on Airway J58 and attempting to attain Mach 0.90. The gross weight of the aircraft at the time was 10,500 lbs. His flight level, was changed by the Jacksonville Center and he climbed to FL 450. Shortly thereafter, he overheard a keyed microphone and voices in the background which lasted about 10 seconds. He said he was not able to determine what was stated. The aircraft overflew the accident site about 19 minutes after the accident. The pilot further stated that he did not encounter any significant turbulence. He said that in the vicinity of Covia Intersection he requested to fly direct to Patrick AFB -and-that the air traffic control (ATC) kept him at FL 450 as long as they could before he received a descent clearance to land. 1.2 1.3 1.4 Injuries to Persons Injuries Crew Passengers Fatal 2 0 Serious 0 0 Minor/None 0 0 Damage to Aircraft The aircraft was destroye~ by impact forces. Other Damage None. 1.5 Personnel Infcrmatioo Other Total ·-- 0 2 0 0 0 0 The fiightcrew was certificated and qualified for the flight •. (See appendix B.) The pilot obtained type ratings in the Learjet 23 and 24 on August 16, 1966. He acquired his type rating in the model 25 on July 8, 1968. According to Northeast Jet, he had accumulated 15,740 flight-hours, of which 6,062 hours were in the Learjet. The copilot was not rated in the Learjet. According to the company, he had accumulated 4,116 flight-hours, of which 65 hours were in the Learjet. He had also acquired 40 hours of Learjet 25 ground school. He was a former military pilot and had accumulated 2,476 flight-hours of high performance turbojet flight time before his employment with the company. 1.6 Aircraft Infcrmatioo Gates Learjet Model 25D, N12~NE, serial No. 271, was issued a standard airworthiness certificate on February 12, 1979. It was equipped with the manufacturer's Century Ill and Softfiite performance modifications to improve the slow speed and stall • •

"'" ,, ,"".{f 'f •·i -5- ' characteristics of the aircraft. It was certificated for flight up to 51,000 feet. The aircraft was purchased by Northeast Jet Company on April 30, 1979. (See appendix C.) The maintenance logs were on board the aircraft and were not recovered. A review of the company's available maintenance records did not provide an accurate evaluation of the maintenance status of.the aircraft. However, the records indicated that the required maintenance checks under the company's Approved Aircraft Inspection Program had been-conducted at the proper intervals. · Company records indicated that on. May 29, 1979, the copilot's airspeed indicator was indicating 0.02 Mach higher than the pilot's; a ground check of the indicators showed both to be reading identically. The_ cabin altitude test horn· was reported inoperative in August 1979; corrective action taken was, "slaved in aural warn control box. No help. ·Reinstalled plug on original box and system ops check okay." On December 26, 1979, a customer work record stated "Stick puller goes off at Mach .79 on captains a/s indicators." According to ,the maintenance facility that performed the 1,200-hour inspection on April 20, 1980, the Mach/overspeed warning and stick puller control systems had been tested and no discrepancies were noted. During the same inspection, the right engine oil pressure gage was indicating a below zero pressure and the left aileron cable· was reported ·bad; no corrective actions were recorded. However, a Northeast Jet representative said that the right engine qil pressure discrepancy had been corrected and the left aileron cable had been replaced on May 6, 1980. The maximum· certificated takeoff gross weight of the Learjet 25D is 15 ,ODO pounds and the center of gravity (e.g.) envelope at this weight is 17 to 30 percent mean aerodynamic chord (MAC). The total fuel capacity of N125NE was 6,144 pounds. 1r1? The addition of 580 gallons of fuel on M~y 14 would have placed the fuel load on departure• \k, \ at 5,737 ,pounds. . Postaccident weight and balance computations of the aircraft before takeoff were: 1.7 Item Zero Fuel Weight (Bow)* ·Fuel Load wings and tip tanks fuselage Total Ramp Weight The e.g. was 21.5 percent MAC. *Basic operating weight Weight (lbs) 8,709 4,837 900 14,446 Meteorological lnfcrmation ' Moment (XlOOO) 3,256.000 1,865.330 341.720 5,463.050 The 1000 West Palm Beach surface weather was: Scattered--2,000 feet and 30,000 feet; visibility--12 miles; temperature--82° F; dew point--74° F; wind 140° at 9 knots; altimeter--30.07. Based upon radar observations from the National _Weather Service (NWS) radar at Appalachicola, Florida, and photographs from the Geostationary Operation.al · Environmental Satellite (GOES), ~here was no significant thunderstorm activity over the Gulf of Mexico in the vicinity of Covia Intersection. There was, however, thunderstorm activity to the north over northern Florida, Georgia, and. Alabama.·

-6~ The 0800, 250 millibar (approximately 34,000 feet) map showed· a trough \ 1 extending south through the western plains States into western Texas. The jet stream wind maxima extended north-northeast from northeast Texas through West Virginia, The 0800, 100 millibar (approximately 53,000 feet) map showed a trough with no pronqunced · jet maxima. The 0800 winds aloft observed at Bootheville, Louisiana, Appalachicola, and Tampa, Florida, were as follows: Altitude (feet above sea level) Bootheville - 42, 797 Appalachicola - 42,988 Tampa - 43,138 Direction ( degrees true) 263 261 256 Speed (knots) 69 49 9 The maximum vertical wind shears at the approximate altitude of Nl25NE at Boothville, Appalachicola, and Tampa were 9.2, 14.6, and 6.5 knots per 1,000 feet, respectively. The maximum horizontal wind shear between Appalachicola and Tampa (a line nearly normal to the wind direction) was 37 knots per 150 miles. The parameters used by the NWS for forecasting clear air turbulence based on wind shear include: vertical wind shears exceeding 6 knots per 1,000 feet and/or horizontal wind shears exceeding 18 knots per 150 miles for moderate turbulence, and vertical wind shears exceeding 6 knots per 1,000 feet and horizontal wind shears exceeding 40 knots per 150 miles for severe turbulence. In addition to the wind shears, a shallow temperature inversion layer, possibly an upper front, was reported at Bootheville, Appalachicola, and Tampa near the flight level· of N125NE, Such an inversion layer, or upper front, is often considered an indication of clear air turbulence. There were no forecasts for clear air turbulence included in the 0900 area forecasts issued by the Forecast Offices at Miami and New Orleans. There were no convective SIGMETS or AIRMETS pertinent to the area of the accident. The following pilot report was made by N51J at 1230: Location--270° 160 miles froJ;ll St. Petersburg, Florida; altitude--43,000 feet; type of aircraft--Learjet 24; turbulence--:-severe clear air turbulence (cat). 1.8 Aids to Navigation Not applicable. 1.9 Communications There were no known communication difficulties before the last transmission from N125NE. 1.10 . Aerodrome Information Not applicable. I,

('71 ttL:-' -7- 1.11 Flight Recorders The aircraft was not equipped with a flight data recorder or a cockpit voice recorder, nor was either required ,by regulation. 1.12 Wreckage and Impact Information Recovered aircraf~. wreckage from Nl25NE consisted of a 40-inch sec'tion·' of fuselage from the aft pressure bulkhead forward (frames 18 through 22), which contained the baggage compartment; a 1.5- by 3.0-foot piece of cockpit floor structure; a landing gear emergency air bottle; an oxygen boit1e; a spare wheel; a ram air duct; the right wing fuel tip tank nose seetion, from the forward :closure bulkhead to the second bulkhead (station 46); the front section of the right engine pylon; and miscellaneous cabin interior items. Examination of the debris was concentrated on the baggage compartment floor structure and fuselage skin, the right engine pylon; and the portion of the right wing fuel tip tank. . . 0 On the l!!ft side of the fuselage , section, the frames and stringers remained attached to the baggage compartment floor structure. The floor structure was undamaged. The Nos. 5 arid 8 wing spar to 'fuselage attachment fittings were broken. The fasteners of the wing fitting ,at the No. 7 spar attachment failed in shear, leaving the wing fitting attached to the fuselage fitting. · On the right side of the fuselage section, the No. 7 wing spar fitting was broken and the remaining portion was connected to the fuselage fitting which was bent rearward. The No. 8 fuselage fitting was broken and bent rearward and outboard. The skin on the right side of the fuselage section was concaved in the open bays between the frames and stringers. The air conditioner evaporator and blower assembly, anti-ice tubing, electrical'wiring, and conduits were attached to the fuselage top skin. Two diagonal buckles were located below the level of the baggage floor at frame 21 on the left side .of the structure and progressed upward· and forward to frame 19. · · . o The housing f.or the recognition light, located forward of the closure bulkhead of the right wing tank was intact. The light ·.bulb and nose cone fairing were not recovered. All of the fastener holes for the nose cone fairing were elongated in the 'forward direction. Glass particles remained inside the light bulb retainer ring. The aft bulkhead fastener holes were . elongated forward around the top surface and rearward around the bottom surface of 'the· nose section of the tank. The tank was slightly compressed and exhibited a seciondary compression buckle in the bottom surface of the tank. 0 The -forward portion of the right engine pylon, which was separated from its engine and fuselage attachment, included the upper and lower skin,· the leading edge air inlet, and the inboard and outboard attachment flanges. All inboard

-8- attachments to the fuselage were sheared; All screws common to outboard flange attachment to the engine nacelle were pulled through. The upper skin surface exhibited diagonal buckles between the pylon liox structure which indicated downward loading of the pylon. 1.13 Medical and Pathological Information . A. review of th~ flightcrew•s flight physical examination records dii!!closed no history of disqualifying medical problems. 1.14 Fire ,-- There was no·evidence of fire damage to the recovered wreckage. L15 Survival Aspects The accident was not survivable. 1.15.1 Wreckage Search . 'I'he flightcrew of a .Fairchild F27, Nl 72C, on a company fligh~ from Houston, Texas, to Tampa, overheard the Jacksonville ARTCC calling N125NE. N172C was at FL 190. The ARTCC advised the flight~rew that contact with N125NE was lost and asked them if they would- attempt to contact the aircraft and search the water en route to Tampa. The captain of Nl 72C stated that the weather was clear and smooth. He • obtained clearance from the ARTCC to d~scend to 8,000 feet for a close~ look and circled a 20-mile area in the vicinity where radar contact with N125NE was lost. The captain spotted white floating debris around an oil slick on the 290° radial, 104.5 miles from Sarasota. At 1249, the aircraft made a low pass and determined that the debris was white styrofoam and what appeared to be an overhead liner and a nose cone .portion of a tip tank. The flightcrew of Nl 72C did not see the flightcrew of N125E. The captain stayed at the scene until a Coast Guard C-130 arrived at 1345. The C-130 flightcrew located the accident site, using a Litton 72 inertial navigation system, and contacted and directed a fishing vessel to the debris. By the time a Coast Guard helicopter from St. Petersburg arrived on-scene at about 1424, the debris and oil slick had drifted on a heading of 160° true. Except for a section of fuselage, the "debris had drifted beyond the oil slick. The helicopter crew reported the weather on-scene as clear with 15 miles visibility, wind--120° at 10 knots, and sea ·condition--3 feet from 220°. The fishing vessel recovered the debris and transported it to St. Petersburg. The Safety Board in coordination with the Gates Learjet Corporation, the Federal Aviation Administration (FAA), and Perry O,ceanographics,. Inc., of Kiveiera, Florida, participated in a two-phase effort to .recover the remainder of the wreckage. The first phase was conducted between·May 29 and June 8, 1980, using side scanning sonar and Lorah "C" navigation equipment. The sonar returns defined potential crash site locations in the area where the floating debris was recovered and added credibility to the t belief that the crash site area had been correctly identified.

,-9- ,f.' The second phase was conducted from June ~1 to Jull 2, and an attempdt was , made to identify the sonar returns, using underwater Video eqwpment transporte by a ,,__ tethered remote control vehicle. The video search proved negative as all of the sonar returns observed were from dead coral formations and lumps of mud. Further attempts to recover the wreckage were suspended. 1.16 1.16.1 Tests and Research Aircraft Perfcrmance The. two-engine climb schedule for the Learjet Model 25 is based on a climb speed profile of 300 knots indicated airspeed (KIAS) to· 24,500 feet, Mach o. 70 indicated (M1) to 45,000 feet. and o. 72M1 above FL 450. It is more common to fly the aircraft at 270 KIAS until reaching o. 70M1 (aoout 30,000 feet.) At a start climb weight of 14,000 pounds, the climb schedule chart shows that the aircraft was not climb limited to FL 430 at- standard atmospheric conditions (ISA): The temperature was about 10° warmer (ISA+ 10°) than ~andard from F,L 360 to FL 400, but from FL 410 to FL 430, the temperature was about standard. The amount of fuel used_ for taxi, takeoff, and to the. top of the climb was about 1,200 pounds, an am_ount that would normally be burned from the tip tariks before a fuel transfer fro111.the fuselage tank would be accomplished. At'this point, the aircraft's weight would have been 13,246 pounds with a e.g. of about the 20.2 percent MAC. , The following :airspeed limits and turbulent air penetration procedures were extracted from the Learjet 25D and 25F aircraft flight manual (AFM): MAXIMUM OPERATING SPEED VM0 /MMO These speeds shall not be deliberately exceeded in any flight condition except where specifically authorized for flight test or pilot training operations or in approved emergency procedures. If *V MO or MMO is inadvertently exceed,ed.

1. Thrust Lever - Idle'
2. Rotate nose up not to exceed 1.5 g's
3. Level wings if required

_ Limitations KIAS KCAS VM0S.L, to 14,000 feet 306 300 V MO above 14,000 f~et 359 350 MMO .82_ M1 .81M AFC/SS Inoperative

1. 78 M1

0, 77M NOTE: No aerodynamic changes are apparent at either VMO or MMO and the aircraft will respond normally to control movefilents. *Means maximum operating limit speed. TURBULENT AIR PENETRATION Flight, through severe turbulence should be avoided if possible. When flying at 30,000 feet or higher, it is not advisable to avoid a turbulent area by climbing over it unless it is obvious that it can be overflown well in the For turbulence of the sam'e inte,nsity, greater buffet margins are achieved by flying the recommended speeds at reduced .altitudes.

-10- A. AFC/SS - If severe turbulence is penetrated with the AFC/SS on, the altitude hold mode should be off. With AFC/SS off, yaw damper should be engaged. Remember, controllability of the aircraft in turbulence becomes more difficult with the yaw damper off. Rudder should be centered before engaging yaw damper. . B. Airspeed - Approximately 255 KIAS. Severe turbulence will cause large and often rapid variations in indicated airspeed. DO NOT CHASE THE AIRSPEED. c. Attitude - Maintain wings level and the desired pitch attitude. Use attitude indicator as the primary instrument. In extreme drafts, large altitude changes may occur. DO NOT USE SUDDEN LARGE CONTROL MOVEMENTS. D. Stabilizer - Maintain control of the airplane with the elevators. After establishing the trim setting for penetration speed, DO NOT CHANGE STABILIZER TRIM. E. Altitude - Allow altitude to vary. Large altitude variations are possible in severe turbulence. Sacrifice altitude in order to maintain .the desired attitude' and airspeed. DO NOT CHASE ALTIMETER.· F. Thrust - Engine ignition should be set to ON (refer to IGNITION SYSTEM OPERATION, this Section). Make an initial thrust setting for the target airspeed. CHANGE THRUST ONLY IN CASE OF EXTREME AIRSPEED VARIATION. , Buffet Boundaries--All aircraft in high speed flight are subject to airframe buffet caused by shock wave induced airflow separations from the aircraft's lifting surfaces. The formation of a shock wave begins as the local airflow over the wing airfoil shape reaches sonic speed. The onset of high speed buffet is influenced by the speed of the aircraft and ·sudden· changes in its angle of attack. Usually, airframe buffet also occurs at low -speeds when high angles of attack (stall) are approached because of separation of the airflow from the airfoil surfaces. The difference between the high airspeed which produces Mach buffet and the low airspeed which produces stall buffet decreases as altitude increases. At very high altitudes, the difference is substantially reduced in subsonic aircraft. Since Mach buffet and stall buffet are also dependent on the load factors produced by the wing, the aircraft's maneuverability margins at high altitudes are correspondingly reduced. The Learjet does not possess sufficient inherent prestall buffet characteristics at low speeds, to provide a pilot with a clear warning that the aircraft is. stalled before it enters a flight condition from which a normal recovery can not be accomplished. ~/ Therefore, the aircraft was equipped with a stall warning stickshaker/pusher system to artificially provide the needed stall warning. According to the AFM, the low speed buffet boundary for an aircraft with a gross weight of 13,000 pounds, at FL 430, and 1.Sg's is 192 KIAS (.71M1). The AFM does not depict the high speed buffet boundary. According to Gates Learjet, however, at 12,500 pounds and in 1-g flight, the buffet free Mach number range for the accident aircraft would have been from 0.57M1 (155 KIAS) to beyond red line of 0.82M1 (233 KIAS). "Beyond the red line, and beginning with a barely perceptible airframe buffet at about .82M, the buffet and aileron activity increase with increasing Mach No. to .86M, which is as fast as has been tested. 11 3/ FAA special condition CAR 3.120. I ! I)) )

-11- Radar Information--ARTCC recorded radar information for N125E was available from the Jacksonville Center, the Miami Center, and the Cross City radar facility north of Tampa. The radar points from the three radars were averaged into one probable ground track. {See appendix D.) Calculations of the aircraft's performance were made based on the radar data, aircraft specifications, and meteorological data. The calculations included the ·period between the latter part of the climb to FL 430 and the time of the last altitude encoded radar return from the Jacksonville radar. Because of data tolerances, the Safety Board could not conclude that the aircraft was performing precisely as calculated at each point in time that the calculations were made. The general range and trend of these . calculations, however, are representative of the aircraft's performance during the period of the flight examined. · The radar data showed that. the aircraft was cruising on assigned altitude and on course within a minute before radar information was lost. The radar information also showed that the aircraft's track turned to the right nearly 90° and the aircraft began a descent during the final minute of information. During this turn, altitude information was lost from all three radars; However, the ground position coordinates, which continued to be recorded, showed that ttie aircraft's ground track made a final turn of about 90° to the left. · Once an aircraft exceeds a rate of descent of 20,000 feet per minute, the radar computer no longer displays the altitude information from the aircraft's transponder, and when this happens, a specific code is recorded in the computer memory. If the altitude information from the aircraft's transponder is not received by the radar, then a different code is recorded in the computer memory. A readout of the recorded radar information from the accident aircraft showed that the altitude information was lost because it was not being received by the ground radar, and not because the aircraft had exceeded the 20,00~ feet per minute rate of descent parameter. A special flight check of the primary radar .coverage in the vicinity of the Covia Intersection showed satisfactory coverage from FL 430 to a minimum altitude of FL 190. · N125NE climbed to its cruising altitude of FL 430 between 220 and 250 KIAS, or between O. 75 and 0.82 Mach {M ). Between 1157:41 and 1202:41, the altitude was stabilized at.FL 431 and the averagt speed was Mach 0.77. During the next 48 seconds, between 1202:41 and 1203:29, the aircraft's altitude and vertical speed deviations were within tolerances. At 1203:46, Jacksonville radar showed the aircraft had lost 300 feet which resulted in a rate of descent of 1,500 feet per minute. At 1203:45, Cross City r_ads:r showed the aircraft had lost 800 feet which computed to about 4,000 feet per minute. No further altitude information was received by Jacksonville nor Cross City. Between 1203:29 and 1204:14, the aircraft made a right turn of nearly 90° followed ,by a left turn of about 90° in 7 seconds. Radar information was lost 8 ·seconds later at 1204:29. Learjet N51J departed West Palm Beach 16.5 minutes after N125NE and flew the same flight route in the same direction. N51J's route of flight was displaced about 12 miles south of N125NE's route of flight. Also, the NASA T-38 flew on the same airway in the opposite direction as N125NE and overflew the vicinity of the accident site about 18.5

minutes after Jacksonville Center received the last radar return from Nl25NE. Learjet

N51J was cruising at FL 430 "well before Covia Intersection" according to the pilot. The NASA T-38 was first recorded on radar, climbing from FL 430 to 450, about 120 miles west of the vicinity of the accident. According to the pilots, the NASA T-38 was cruising at Mach 0.89 lll!d the Learjet was cruising at o. 77, indicating 210 to

-12- 220 knots with TAS of 440 knots, with an indicated outside air temperature ·of -39° C f (-28° F). The calculated ram temperature rise at Mach 0.77 and -39° C indicated is about 20.5° C. This would give an outside air temperature of -59.5° C. 1.16.2 • ATC Tape of Communications An ·ATC tape of communications with N125NE was exa11,1ined in the ·safety Board's audio laboratory. The FAA ATC transcript was expanded in the area of the occurrence. (See appendix E.) Reception was marginal because of the di~tance between N125NE and the receiving station. If N125NE had been maneuvering, it is possible for the reception to have been intermittent even though the transmitter remained keyed. The unusual, very low volume signals, which were heard following· the cessation of the last decipherable transmission at 1204:27, may have been bleed-through through the receiver transistor controlling the squelch circuitry. The possibility that the low volume signals were coming from N125NE is supported by the fact that the normal transmitter ON/OF!f signature was absent from the transmission, which suggests that the aircraft's transmitter remained ON. The receiver squeich circuitry could have been responsible for the low amplitude signals. The low signals were weak voices; however, the words could not be deciphered. The "stacca tto sound" (similar to the stall warning signal as noted in the transcript) had a frequency of 18 to 1~ heavy beats per second. In some cases, the heavy beat was followed by a light beat about 20 milliseconds later. In general, the individual staccatto beats took a finite time (approximately 16 milliseconds) to build to a maximum and then drop off. The signal level between the beats did not drop to ~he normal quiescent (no signal) voltage level but ·remained up at some value until the beginning of the next cycle, which indicated ·that the carrier was continuing or that the receiver f. ) squelch was keeping the ATC receiver on. 1.16.3 Aileron Buffet The Gates Learjet Corporation investigated the staccato-type sound by comparing the frequency of primary flight control vibration with the frequency of the unusual sound. The·natural frequency of. the ailerons is 11.5 Hz. The same frequency was picked up when·the vibration was recorded in the cockpit. When the sound was recorded through the, radio in the cockpit, a frequency of 19 Hz was identified. The vibra~ion of the stickshaker was also recorded. It revealed a frequency of 30 Hz without the radio and 31 Hz -with the use of the radio as a medium. Based on the results of the tests, the manufacturer was not able to reach any conclusions about the source of the staccato sounds heard on the tape. · 1.17 1.17.1 AdditiClll81 Inflll'mation Automatic flight Control Stability System (AFC/SS) The AFC/SS primarily consists of the autopilot pit!lh axis which includes a force sensor fa combination 'with a control stick puller and an aural .overspeed Mach warning horn. Longitudinal stability of the aircraft is dependent on operation of the autopilot pitch axis when operating beyond Mach 0.78 (M1); when the autopilot is not in use, speed is restricted to o. 78 Mr When this limit is reached, a sensing switch ·in the copilot's pi tot static system energizes the O. 78 M1 speed warning •.

-13- The force sensor will signal the autopilot computer to disengaged the autopilot pitch trim once the pilot overrides the elevator with• a force in excess of 6 to 8 pounds. The force sensor also disconnects any autopilot modes selected, such as heading, altitude, or speed, and causes the autopilot to operate in the basic altitude hold mode. Once the control column pressure is decreased, the autopilot will maintain the existing pitch• attitude and will roll the wings leyel. The control stick puller is incorporated into the flight. control system to automatically prevent the aircraft from exceeding M • The puller is powered or armed by the left stall warning switch. When tlie aircraft0 reaches ,Mach 0.82 (M ), another sensing switch will sound ~he Mach warning horn and feed a nose-up signal to thl autopilot elevator servo clutch. This will cause the aircraft to climb until the overspeed condition is corrected. The stick puller exerts a force of 18 pounds. It is an M function only and will not work below 30,000 feet. The aircraft is not to be flown bW§'ond 0.74 MI if the puller is inoperative. · • , 1.17.2 Stall Warning Stickshaker/ Pusher System Because of the stall characteristics of the Learjet, an artifice! stall warning system incorporating a stickshaker and stickpusher was installed to provide a prestall warning to prevent an abrupt wing· rolloff. The system includes a stall vane on each side of the nose of the aircraft, two angle ·of attack indicators, two stall warning lights, and a computer. In flight, the stall vanes align with the local direction of the airstream. As the angle of attack of the aircraft changes, the realigned vanes signal the computer and the corresponding angle of attack is depicted on the cockpit indicators. As the critical angle of attack is approached at a point near the stall, 1. 07 Vs' the computer actuates the sticks.haker which induces a mild vibration of the control column while causing the red stall warning, lights ·to flash. If the angle of attack is further increased, an additional signal from the computer actuates the stickpusher (d.c. torquer clutch) and forces the control wheel forward with a force of 60 to 80 pounds. This applied force diminishes as the angle of attack decreases and can be overridden by the pilot. The system automatically disengages when it has decreased the angle of attack to a point less than that at which the pusher was set to • actuate. 4/ Any signals· from the autopilot are cancelled when the pusher activates. The computer also modulates the signals to compensate for various wing flap positions. In conjunction with an altitude pressure switch, the angle of attack for the shaker/pusher operation is reduced·above altitudes of about 22,500 feet. This causes the system to operate .at a higher speed than it does at lower altitudes. This feature is incorporated in only the models 24 E/R, 25 D/F, and all Century ill modified airplanes. · The· Century m modification incorporated an ,electronic computer circuit in the stall warning system. The circuit, identified as the alpha dot, system, uses the· rate of change of the angle of attack sensor vane to automatically raise the stall warning stickshaker/pusher speeds to compensate 'for accelerated entry to the ,stall. The circuit permits the stickpusher activation speed-to be set within 1 knot of the unaccelerated stall speed/wing rolloff •. Theoretically, the computer raises the stickshaker/pusher speeds at about the same rate that· the stall speed increases under accelerated stall conditions; During. an FAA special investigation of the Learjet, in cooperation with the Safety Board's study of modified Learjets, §/ it was determined that the 1-knot speed margin.between 4/ FAA Order 8110.6, Review Case No. 38 5/ "Study of Selected Performance Characteristics of Modified Learjet Aircraft," February 1979.

-14- activation and aerodynamic stall was inadequate. ·This condition was corrected by Air- worthiness Directive (AD) 79-12-05, dated June 18, 1979, which increased the pusher margin to about 3 knots and increased the AFM stall and landing approach speeds. However, with the development of the Softflite modification, the aircraft rolloff characteristics at the stall were enhanced significantly and permitted resetting of the stickpusher operation within l to 2 knots of the stall speed. 1.17.3 Wheel Master Button · 'The wheel master, button is located below the four-way trim switch on the left side of the pilot's control wheel. (See figure 1.) . In the Learjet model 25D, when depressed, it will, among ot_her .features, disconnect the autopilot and yaw damper, and interrupt any primary pitch trim. The yaw damper system is designed to prevent a coupled lateral-directional oscillation which is commonly referred ·to as a "dutch roll." Without the yaw damper operating, "dutch roll" can occur in the Learjet at altitude and high Mach number but is most severe in the landing c<>nf!guration. 1.17.4 Overspeecl Warning Horn Cut-out Switch .. Nl25NE was equipped. with an overspeed warning horn -cut-out switch, an. unauthorized modification. (See figure 2.) The Northeast Jet Company reported the existence ·or the switch when a similiar one was located. under the pilot's instrument panel in the company's other Learjet 25D, N911MG. An operational ground check of the switch installation in N911MG using battery power· disclosed that when the switch was activated the maximum operating speed Vt'f!/Mmo• cabin altitude,.and landing gear warning horn was inhibited. The stall warning, s cK snaKer/pusher system, and stickpulle~ were· not affected because the switch was installed between the aural warning control box output and the horn. With the switch in the normal position (ON), signals from the aural warning control box would activate the horn. In the OFF position, the horn was inhibited. An aneroid type pressure switch is installed in the copilot's pitot-static system to activate the overspeed warning horn if the 306-KIAS limit is exceedeq between sea level .and 14,000 feet. The speed restriction was imposed because of the windshield bird strike criteria of 14 CFR 25. 775. 6/ The Learjet Model 23, the first model produced, was certificated on May 15, 1956,. in accordance with Part 3 of the Civil Air Regulations; windshield bird strike criteria were not required. As a result, the Learjet 23 was approved to cruise up to its maximum operating speed of 358 KIAS between sea level and FL 239 without a structural speed restriction. Later Learjet models were certificated in accordance with FAR Part 25 and were required to meet the windshield bird strike criteria. A redesigned windshield was able to withstand the impact of a 4-pound bird at 300 knots. The Learjet models 24 through 24E were limited to 306 KIAS between sea level and FL 310 and the Learjet model 24F and later models were restricted to 306 KIAS until passing 14,000 feet, and to 359 KIAS above 14,000 feet. This procedure was consistent with an earlier FAA dec_ision involving the certification of another. type of turbojet. §I The windshield panes .and supporting structure directly in front of the pilots must withstand, without penetration, the impact of a 4-pound bird when the velocity of the aircraft (relative to the bird along the aircraft's flightpath) is equal to the value of its cruise velocity at sea level. ' I. I) Ji,

;( . \ .r -15- Figure 1.--Wheel master button on pilot's control wheel. The microphone switch is located on the front side of the wheel, opposite the wheel master button • Figure 2.--The unauthorized overspeed warning horn cut-out switch is identified within the circle.

-16- "· Shortly after the accident, the FAA issued a general notice alerting its field / offices of the unauthorized switch installation. A special airworthiness alert was issued later which alerted all air carrier and general a_viati operators of the unauthorized switch installation. The FAA expressed concern that all flightcrews and operators might not be aware of the existence of such a switch and that operators should have their aircraft inspected and have the switch removed, if installed. Northeast Jet Company did not disclose its reason for installing the overspeed warning cut-out switch. 1.17.5 Gates Learjet Service News Letter Gates Learjet Se~vice News Letter 49, dated May 1980, and issued immediately after the accident, requested that operators review their emergency procedures regarding potential .overspeed conditions. The manufacturer specifically urged carefu,1 review of procedures relating to emergency descent, inadvertently exceeding V m/Mmo' pitch aicjs malfunction, and normal or primary pitch trim system runaway. Regarding the overspeed condition, the letter states, in part: At. Mach No.'s in excess of M , aileron activity could be encountered, and this activity increases'1'ln amplitude as Mach No. is increased. This activity has been described as aileron "buzz" or aileron "snatch" and is a random frequency and amplitude movement of the ailerons and control wheel. Pulling "g's" in that regime flight increases ·the aileron activity, so one must not pull abruptly on the elevator C!lntrol to slow the aircraft, but must• apply a steady force of the magnitude necessary to produce. as much "g" force as possible without losing roll control. Exceeding V m in the lower Mach No. regjme produces higher recovery elevator cori'trol forces, but no aileron activity. Another phenomenon which occurs at Mach No.•s beyond the red line is "Mach Tuck." This phenomenon is cailsed by aft movement of the wing center of pressure and results in a nose-down pitching moment. The stick puller is provided as a device to · ensure no excursion beyond M • It should never be turned off during normal operation of the aiffi~aft. If, for any reason, there is a malfunction that requires turning off the stick puller, the aircraft should be operated at speeds well below Mm as prescribed in the applicable Flight Manual procedures. As in any airp?ane, speeds beyond the red line must. be avoided by maintaining the desired attitude with appropriate flight controls and by decreasing thrust while executing the prescribed Emergency Procedures. NOTE: iF. M IS INADVERTENTLY EXCEEDED TO THE POINT WHERE THE ~RPLANE SEEMS TO BE OUT OF CONTROL, LOWER THE LANDING GEAR. The landing gear doors may be lost or damaged, but the main concern is to facilitate recovery by using the extended gear to slow' the forward speed of the airplane •••.. Spoilers The use of the spoilers is not prescribed in Pitch Axis Malfunction and Runaway Tfim Emergency Procedures. The reason is that the nose down pitch change which the spoilers produce may, aggravate pitch down problems. '. '• )

( .. '· ' ... -17- Certification flight tests of the aircraft•~ high speed flight characteristics were conducted to determine compliance with the criteria set forth .in·FAR Part 25,253 (February 1, 1965). In accordance with Advisory Circular (AC) 25.253-1, dated November 24, 1965, on high speed flight characteristic testing, as -a means of· compliance, only a 1.5 g recovery procedure is used. · 1.1'1.6 Speeial Certification Review of the Learjet As a result of _several other Learjet accidents. (see appendix F), the FAA- undertook a special certification review (SCR). of the Learjet which addressed primarily several items suspected of being potential factors in the accidents. The following extracts of three specific problem areas discussed in the interim SCR report, were made available to the Safety Board on May 8, 1981: 1) This interim report will generally establish that the' Learjet airplanes do possess certain critical flight characteristics, which require compensation l:>y complex systems to insure an e,dequate level of safety. Records review indicates that approval of these compensating -systems were based. on possible inadequate rules, extensive rationalization rather than actual demonstration of adequacy, early "state-of-the-art" . engineering judgment, equivalent safety determinations, and apparent inadequate system analysis. It appears that most of the reported problem areas involve a system(s) whose proper functioning is critically required to provide an acceptable level of safety for the airplane; and these installed systems are possibly inadequate to perform their intended function. J/ High Spee_d Characteristics a. M (0.81) is limited by longitudinal stability ciMPacteristics. b. , Mach tuck (nose down pitch divergence caused ,by aft movement of center of pressure due to compressibility) begins prior to MMO. c. Gates Learjet states in. the Model 25 Type Inspection Report (TIR) that if a FAR 25.1505 8/ upset occurs at MMO' the aircraft will exceed MnF" Tins characteristic is the reason for the stick puller. n- the puller is inoperative, MMO is limited to 0.74 Indicated Mach Number. 7/ As a result of the preliminary findings, the FAA issued· AD 9·0-1&-0& on August 4, 1980, which was superseded by AD 80-19-11 on September~. 1980. (See appendix G.) y Maximum Operating Limit Speed - "V /M must be established so that it is not greater than the design cruising speed V Wftld s!P?hat it is sufficiently below VD/MD or VDF/MDF• to make it highly improbabfe that the latter, speeds will be inadvertently exceedea in operations." V0 /MD means design diving speed and v0F/MDF means demonstrated flight diving speed.

d. e. f. g. -18- Extension of the spoilers at high speed causes .a large nose down pitching moment. For the Lear 25 D/F Models, stick force required to hold airspeed with spoiler extension at V MO varies from 46 lbs. at aft e.g. to 84 lbs. at forward e.g. Aileron "buzz" onset occurs just above MM0 ; at higher Mach numbers and/or higher load factors, aileron "snatch" (rapid, large deflection aileron motion) occurs. Loose' (misrigged) aileron cables could increase the amplitude and lower the onset Mach number, since the major factor which damps this motion is control system friction. The Mach overspeed Y/'&rning and stick puller systems operate only from the copilot's pitot-,static system. If an error in. the copilot's system results in a low Mach reading for any reason, the overspeed warning will occur beyond MMO" Dur_ing STC approvals on , three diff~rent aircraft (one Model 2,5D and two Model 35s), it was noted in• a dive to M with a separate trailing cone calibrated .static system tft'a1t the pilot's Machmeter stopped increasing at approximately 0.80-.81 Mach number and remained at this reading out to a true Mach number of 0.86. On the recovery, the pilot's Mach indicator began working again at .805 Mach. Changing the Machmeter did not eliminate this characteristic. The copilot's Machmeter indicated correctly on the Model 25D, but both Model 35 copilot.s' Machmeters read less than the correct Mach number. The majority of the problem was traced to a production static system calibration error in a dive using a production indicator. This was not detected during original prototype testing with-a sensitive Machmeter and a trailin~ ~one. In addition, pert of the problem was possibly caused by the static sources not being flush with the surface after the airplanes were painted. The end' result of the airspeed problem was that the production airplanes were actually going .01 to .015 Mach· faster than expected. h. Lear 25 TIR data shows that the speed increase after an upset was less if the spoilers were not· used, because the heavy nose' down trim change made it harder to get the nose up to 1.5 g's for recovery. The AFM specifies spoiler deployment as the first action in an overspeed condition. If a pitch upset occurs near MM , the airplane can accelerate rapidly into a region where the flying q~ities are unacceptable. Consider, for example, any type of nose down pitch axis malfunction (such as trim runaway, pusher hardover, autopilot hardover, etc.).. In this case, ) )

-19- if the pilot restrains the control column, . the pull force can go as high as 50-60 lbs. (80 lbs • .for pusher malfunction.) Because of pilot reaction time (3 seconds according to 8110.10), 'E.f the speed will have increased beyond the limit Mach number. If the pilot follows the AFM procedure for overspeed and-deploys the spoilers (which_is instinctive), the required pull force will increase an additional 50-80 lbs. Also, because of the pitch instability due to. Mach tuck, the pull for_ce will continue to increase as speed increase~: Adding the maneuvering stick force required to pull 1.5 g, the total pilot force required for recovery can be as high as 150-200 lbs. · The stick puller was instilled to prevent Mach overspeed, but in the event of a nose down pitch axis malfunction, and/or deployment of the spoilers, its 18 lb. pull becomes insignificant. At some Mach number beyond M , the elevator effectiveness will decrease due to shock wave for;;Pafion. Additionally, stretch in the longitudinal control system at very high control forces can negate any furthei;:. elevator 'deflection in the recovery direction. At the same, time these extreme pitch forces are being generated, the pilot can h!lve a severe roll control problem due to aileron "buzz" and "snatch." An active pitch axis malfunction is not required for this scenario to take place. A passive failure on the ground to the 0.81 Mach warning/puller switch allows the system to test properly on preflight, yet be totally inoperative. , In this case, an inadvertent overspeed due to gust upset, unannunciated autopilot softover, pitot static system error, pilot inattention, fuel bumoff, flying into a colder airmass, etc., can put the airplane into an overspeed condition wit~_no warning. · If, after the pilot notices the overspeed, he deploys the spoilers, or if aileron "snatch" rolls the airplane to an excessive bank angle, it may become impossible to recover. 2) Pitch-Trim System a. The control wheel primary pitch tr_im interrupt switch installed on the control wheel of all 3.0 series and Century m 20 series Learjets is not a quick-disconnect switch as inferred in almost all Learjet TIRs and design documents. The-pitch trim interrupt switch must be held until the pitch trim selector/disengage switch is turned off. None of the control wheel switches, with the exception of pitch trim and lateral trim, are labeled as to their function. Because of these differences from model to model, different emergency procedures are 'applicable. In the event of an actual pitch, axis malfunction, the pilot cannot always immediately determine the cause of the malfunctions since it could. be caused by any of the following: stick pusher, stick puller, autopilot, secondary pitch trim or primary pitch trim. In addition, no single action by the pilot can immediately FAA_Notic~ of September 22, 1972 concerning trim malfunctions.

-20- eliminate all pitch axis faults. In order to totally i1;1olate all potential pitch axis faults, the pitch trim selector must be turned off, the autopilot turned off, both stall warnings turned off, and the AFCS pitch circuit breaker pulled. 3) Autopilot AFC/SS Characteristics a. On the 45,000 foot Model 24E/F and 25D/F autopilot malfunctions were conducted at low altitudes only with maximum specification torques on all axes. Autopilot performance was demonstrated at low altitudes only with minimum servo torques. No autopilot pitch trim runaways were conducted. b. On the 51,000 foot Model 24E/F and 25D/F autopilot functional tests were conducted at 51,000 ft utilizing minimum specification torques on all axes. Malfunction tests were 11ot conducted, but instead were "rationalized" from data obfained at 41,000 to 45,000 ft on various straight wing models of the 24, 25, and 36. c. FAA Review Case No. 57 (dated September 16, 1965) on the DC-8, on which the Learjet 24/25 AFC/SS (Mach trim) system was patterned, required the following specific_ items to be added to the existing DC-8 autopilot before it could be used as a stability device: · . o Aural warning upon any autopilot disconnect in the . clean configµration. o Adding the autopilot disconnect light to the master warning light. o Restriction of the airplane nose-down pitch command authority of the autopilot to approximately 10° (degrees). o Addition of a stabilizer'-in-motion aural warning. The items in subparagraph c were not required on the Learjet AFC/SS. d. The Mach trim function of the FC-110 AFC/SS as originally evaluated on the Model 24, required a stick force-disengage function on the· pitch axi~ to "preclude any out-of-trim problems." During required collision avoidance maneuvers, the Mach trim function was automatically disengaged with 6 lb. stick force. This force disengage function is included on all Model 24 and 25 AFC/SS systems. The function was, however,. deleted on the Model 35/36 and 28/29· models where an independent Mach trim unit is provided. ) ) )

I , ' ! -21-

1. ANALYSIS
2. 1

The Flightcrew The flightcrew was certificated and qualified to operate the aircraq. The pilot, an experienced Learjet captain, occupied _the right seat. The copilot, who occupied the left seat, was not rated in the Learjet and had limited flight time in this aircraft. It is believed that the copilot was flying the aircraft when a loss of' control occurred. There was no evidence of previous 'medical' problems of either. pilot which would have had an effect on the accident. 2.2 Aircraft Airworthiness The unavailability of the entire wreckage and most of the maintenance records for examination precluded the Safety Board from making a total assessment of the aircraft's airworthiness at the time of the accident. According to Northeast Jet, the pr11vio~ discrepancy concerning the right engine oil pressure had been cor_rected. The December, 26, 1979, remark, "stick puller goes off at Mach • 79 on captain's a/s indicators," infers that the indicator W!IS f!lulty because the Mach overspeed warning and stick pul).er system operates,,from the sensing switch (Mach switch) in the copilot's pitot-static system. .The inference is somewhat supported by the May 29, 1979, remark· that the _ copilot's indicator was believed more accurate than the pilot's, which read 0.02 Mach lower. The difference between the indicators was within tolerance; however, the pilot's indicator would have been 0.01 Mach out of tolerance with respect to the actuation of the stick puller if it operated at the prescribed speed of 0.82M . -Assuming the existence of a 0.02 Mach difference between indicators, the copilot's indfcator would have been reading 0.8i.M1 when the puller activated, and this indication was also within tolerance. The Safety Board could not conclude with certainty, however, that the copilot's . Mach · indicator was accurate based entirely on the actuation of the puller because it was not known if the Mach switch setting was within tolerances. Erroneously low airspeed indications could have, been a critical factor in the accident because the aircraft would have b~ri nearer its Mach buffet boundary and would have had less margin for maneuvering. The low airspeed indications were noted as an item of concern in the SCR interim report. The inoper!ltive cabin .altitude test horn reported in August 1979 may have been due, in part, to the installation of· the overspeed warning cut-out switch. However, the Safety Board was not able to verify that possibility. According to Northeast Jet, the left aileron cable had been replaced 13 days before the accident. · Proper maintenance of the aileron system is a critical item in the . Learjet because, as noted in the SCR interim report, control .system friction is a major _factor in damping initial Mach buffeting of the control surfaces. Because the Learjet has characteristics which could lead to critical control problems in the high Mach regime of flight and which · might not be recognized by the inadequately trained or unwary pilot, complex compensating features were incorporated into the flight control system ·to comply with current Federal aviation regulations and to provide an appropriate level of safety. In view of the integral nature of the compensating features in the aircraft, an unauthorized modification, such as ·an overspeed warning horn cut-out switch, could be· detrimental to safety. The switch also would have inhibited the cabin altitude and landing gear warning- horns. This unauthorized modification, therefore, could have insidious consequences. In some earlier Model 24 Learjets, pilots were required, according to AFM limitations, to maintain 306 KIAS between 10,000 feet and FL 310, and in some later Model 24 Learjets, pilots were required to slow to 306' KIAS at

-22- 14,000 feet during a descent to avoid actuation of the overspeed warning horn. The ) Learjet Model 25D was exempt from the 306 KIAS speed restriction above 14,000 feet, but the use of the cut-out switch would, have permitted .abuse of the speed restriction below 14,000 feet, during climbouts and descents, without activation of overspeed warning horn. Because the overspeed warning also provides a vital safety function at high Mach numbers, the Safety Board concludes that installation and use of the cut-out switch made the accident aircraft unairworthy. A preflight test of the other Northeast Jet Company Learjet disclosed that the cut-out switch did not affect the operation of the stick puller system. Based on the test and statements made by company personnel, the Safety Board concludes that the cut-out switch also would not have affected the operation of the stick puller in N125NE. 2.3 LClllS of Control Recorded comments of the flightcrew on the ATC tape indicated that control of the aircraft was lost shortly after it was leveled at FL, 430. The limited portions of the recovered wreckage prevented determining whether the aircraft was intact when it struck the water. Alth9ugh no ·firm conclusions could be made regarding the aircraft's attitude at impact, the' nature of the, damage suggested that the impact was severe. The separations of the wing attachment fittings indicated that the right wing rotated aft and the left wing rotated forward at breakup. . The top crown skin and the sidewall skin attached to the baggage floor were concaved which suggested that the aircraft struck the water inverted. However, diagonal buckles on the left side wall.skin which extended from below the baggage floor at frame_ 21 to near the top of frame 19, suggested that the aircraft may have struck the water with empennage first, in an upright, nose-high ·)· attitude. The elongation of the right wing tip tank nose section fastener holes indicated that it separated in an upward direction. Since the complete wreckage was not available for examination, the Safety Board considered several possibilities which could have caused the loss of control of the aircraft, based on the knowledge gained from previous Learjet investigations, the FAA's SCR interim report, ATC radar and tape of communications, meteorological data, and information from other pilots who were in the vicinity when the accident occurred. The Safety Board identified the following areas for evaluation: o Flight characteristics o Flight-control system and compensating features o Engine performance o Turbulence o Pilots' actions Flight Characteristics.--The flight characteristics which most probably contributed to the accident were the speed instability due to "Mach Tuck"; the minimal speed margin between MMO and MDR' resulting in the requirement for a stick puller; the high nosedown pitching moment with spoiler extension at high speed; the aileron "buzz/snatch" phenomenon which occurs slightly above MMO and which is aggravated with increased speed and load factor; and the decreased elevar-or effectiveness due to shock wave formation at Mach numbers beyond MDF' Flight Control Sfistem and Comp~sating Features;--With regard to the flight control system, control diflculty was considered because of the malfunction history of )

-23- , ,(, the electromagnetic clutches. ·However, because·the accident aircraft was equipped wit.h improved d.c. torquer clutches, the Safety Board concludes that a malfunction in this unit was not likely. The possibility of a transistor failure in the autopilot c,omputer which could have caused a trim runaway in either the noseup or nosedown direction and flight control difficulty was considered because'it is not known whether the aircraft was equipped with the Delco or ·non-Delco germanium transistors. · According to Gates Learjet, Delco transistors are more resistant to thermal runaway failures than germanium transistors built by other manufacturers; also, the transistors on the accident aircraft were likely to have been non-Delco. Their reliability, therefore, is questionable. However, in consideration of a transistor failure, ·a failure eould cause a runaway trim in either the noseup or nosedown direc_tion. The eontrol wheel pressure needed to compensate for runaway trim condition could have been low or high (10 to 80 pounds) depending ori when the pitch trim .'monitor may have diseonneeted the autopilot.· The Safety Board eannot rule out the possibility of a failure or malfunetion of an autopilot computer transistor; however, when eonsidered with.all the available.evidence, we believe that a failure or malfunction of a transitor W(IS not likely. · Engine Perfortnanee.--Engine flameout leading to a loss of eontrol was also reviewed. . The serviee history diselosed that engine flameout primarily concerned the CJ610-6 engine and not the -BA engine whieh has an improved compressor stall margin. Also, there was no evidence on ,the A TC tape indieating that the flightcrew was eonfronted with an engine power loss, and loss of thrust would not have eaused or neeessarily ha:vEHiontributed·to either a low speed or high spe.ed loss of,eontrol situation • . f-7 Therefore, the Safety Board coneludes that it is not likely that an engine flameout caused X i the loss of control. '_\ . ( -,- ,. ~ .. :.. .. Turbulence.--The Safety Board's ·examination of the weather conditions showed no active thunderstorms in the immediate vieinity where the aircraft departed its flight level. The wind in the vicinity would have been ,from 270° at 50 knots (+10° and 5 knots), and the temperature would have been -59° C (+2°). This temperature corresponds almost exactly with the· corrected ram air temperature reported by the crew of N51J. Based on.the soundings whieh indicated the ,existenee of a shallow temperature inversion layer,. an upper front was present. Sueh a frontal system is known to be condueive to the formation of clear air turbulence. Since the NWS defines a horizontal wind shear of 40 knots over 150 miles as il severe clear air turbulenee condition, the Safety Board concludes that moderate to severe clear air turbulence existed at FL 430 in the vicinity of the Covia Intersection when the aceident aircraft entered the area. The pilot's report from Learjet N51J, minutes after the accident, and his subsequent statements further eonfirm the existenee of clear air turbulence. The Safety Board believes that the accident aircraft encountered essentially the same phef!omenon as described by the pilot of N51J, and we eonclude that this ph~nomenon initiated the accident sequence of events. Furthermore, the flight characteristies of the aircraft, and the actions of the erew in response to the encounter led to the loss of control from which the flightcrew was not able to reeover. · An adequate range usually exists -at all altitu~es and weight conditions between the onset of high-speed buffet and low speed buffet, or the speed at whieh the stickshaker'would activate in 1-g flight. Increased load factors caused by manuevering, sueh as pull-ups or level banked turns, however, reduce the buffet-free speed range. The aircraft's operational envelope, therefore, becomes restricted under conditions of high·

. -24- altitude flight because of the buffet boundary limitations. This narrow area of operation ) is commonly referred to as "coffin corner." For these reasons, the buffet boundaries of an aircraft become extremely important to a pilot since they dictate the limiting margins within which the aircraft can be operated safely. · A sharp, unexpected turbulence encounter can easily cause an aircraft to exceed these margins. Since the aircraft was operating in a relatively narrow area of its flight envelope, the Safety Board considered the possibilities of a loss of control from transient conditions which might have placed the aircraft either below its low speed buffet boundary or above its high speed buffet boundary. The aircraft's 1-g_ low speed buffet boundary was 0.57M1 and its 1-g high speed boundary was about 0.82M1,-a 0.25 ,M1 margin equating to about 78 knots. A load factor increase of about 1.5 g's would have reduced the margin to between 30 and 40 knots. However, an adequate margin appears to have existed. · Pilots' Actions.--According to the ATC tape of communications, the first indication of difficulty began at 1203:40.1 (appendix E) with a short burst of static associated with a keyed microphone. The sound came from the accident aircraft since it compared with the transmitter key's signature from previous transmissions. Also, according to the probable radar ground track' plot, the first sign of significant flightpath deviation occurred about 1203:41, coincident with the keyed microphone sound, when the aircraft began turning to the right and descending from FL 431. Eight seconds after the burst of static, the calculated speed of the aircraft was Mach 0.81, a 0.04 Mach increase over that which the aircraft had been averaging about 4 seconds earlier. At 1203:56.7 (appendix E), the unusual staccato sound occurred. The Safety Board believes that the staccato sound was transmitted when the copilot keyed the microphone inadvertently because of his firm grip on the control wheel. It was noted that the signal level between the low frequency beats did not drop to the normal quiescent voltage level, but remained at the same value u,ntil the next frequency cycle began. The evidence supports the contention that the copilot had keyed the microphone continuously, which resulted in the inadvertent transmissions. Immediately after the cessation of the staccato sound, at 1204:00.7, the pilot stated, "put-out the spoilers." His statement sounded weak, as if it was in the background, possibly due to his statements being amplified through the copilot's headset microphone. At 1204:13.3, 12.6 seconds later, the copilot stated, "Can't get it up ••. its in a spin;" Four seconds later, the aircraft made about-a 90° deviation to the left in its ground track. Bas~d on information from the closest radar ·site, Cross City, .the aircraft's calculated rate of •descent at 1203:46 was about 4,000 feet per minute. The evidence indicates that the aircraft began to descend rapidly, and its speed began to increase shortly (8 to 10 seconds) before the first staccato• sounds were recorded. The high rate of descent is further supported by the radar returns which were progressively closer together during the final 30 seconds of radar contact. The returns support a conclusion that the aircraft was diving at high speed and at a progressively steeper angle. The speed of the aircraft and the short radius of the 90° left deviation in its ground track indicates that the aircraft could not have made either a steady coordinated turn or a turn resulting from a loss of control from its low speed buffet boundary to arrive at' the location of the last radar return at 1204:29. Therefore, the Safety Board concludes that , the weight. of evidence indicates t_hat the aircraft made a high speed descent from FL 431. ..,.; . .J·, The Safety Board's evaluation of the staccato sound disclosed. a heavy beat J gr freq 0 unuedncviY_borfat1 1_8 0ntso 1 09f Htzh.e Eail~teernosnivse attesttsheb 1 _yr thneataiu·rralcraff t muaennufc acpturorderucalsedo ashofwreeqduetnhcayt 0 reg y ·

1·_·_·c \ ""C..:: -25- of 19 Hz when recorded through the radio in the cockpit. The vibrations produced by aileron buffet could be felt throughout the entire aircraft, Recording of the stickshaker with or without the use of the aircraft radio as a -medium, produced 'essentially the same frequencies, but the shaker vibration cannot be felt throughout the aircraft. Therefore, the Safc:ity Board concludes that the staccato sound probably 'was associated with aileron buffeting at high Mach num~ers and that this buffeting was transmitted through the airframe and through the open radio transmitter which resulted in the recorded frequency ,of 18 to 19 Hz, rather than the natural frequency of 11 Hz. · Because the flightcrew was not alerted to the possibility of encountering clear air turbulence in the weather briefing, the altitude hold mode of the autopilot was probably engaged when the aircraft penetrated the turbulence near the Covia Intersection. According to the, AFM, the fl_ightcrew should ~ave had· this f.eature disengaged during penetration of known turbulence to prevent the possibility of a mistrim condition. · In 'a sudden upset, a pilot would reactively grab the control wheel in an attempt to maintain control of the aircraft. Under these circumstances, it would have been easy for· th_e copilot to inadvertently key the microphone. Further, with the copilot holding the control wheel·, the turbulence could have caused the 'force sensor to disconnect the altitude and heading hold functions of the autopilot, or he could have easily disengaged the pitch trim function with 6 to 8 pounds ·or force applied to .the control column. Either type of disengagement would not have been readily apparent to the flightcrew because there are no associated artifical warnings. As a result, the copilot could have been confronted with a mistrim condition and a need to exert a ·significant amount of pull force to maintain level0flight because of the possible nosedown. trim the autopilot may have used to counteract the increased airspeed caused by the turbulence. The necessary pull force would have continued to increase with an increase in speed because of the "Mach Tuck" tendency. Additionally, since the wheel master button was inside the copilot's left hand grip, opposite the microphone switch, it is probable ·that he could have accidentally disengaged the autopilot and yaw damper. The absence of these critical items under these conditions would have significantly contributed to the copilot's difficulty in controlling the aircraft. The lack of the Mach overspeed warning sound on. the ATC tape probably indicates that the warning horn was disabled because of the cut-out switch. Not until 20.4 seconds after 'the burst of static is ,there recorded-evidence that the flightcrew took action to correct the overspeed condition when the pilot gave the command to use the spoilers. However, his statement was made 12. seconds after the aircraft had already reache.d 0.81M1: Considering the computed rate of the aircraft's speed increase, the. aircraft probal>ly had substantially exceeded M before the spoilers were extended. Consequently,· extension of the spoilers would h;N~ further aggravated the situation by significantly increasing the pull force needed to restore the aircraft to level flight. The stick puller should have functioned once the overspeed occurred. However, since it exerts a relatively light force of 18 pounds against the COl!trol column, its operation could have been easily overcome and could have gone unrecognized by the flightcrew, particularly if the copilot had abruptly pushed forward on the control wheel in response to any pitchup caused by the turbulence. The lack of an overspeed warning, system would have contributed to such a reaction and to the flightcrew's failure to recognize that the stick puller was functioning.

-26- It is not known whether the crew was aware that the cut-out ·switch was on. ) According to the company, the pilot was aware of the switch installation, and its position before- the. flight could have been determined by following the preflight checklist. Therefore, since it would not have been easy to inadvertently move the switch to the ON position, because of its position underneath the instrument panel, it is l?elieved that the crew should have been aware of the, position of the switch. Nevertheless, the turbulence encounter was sudden and unexpected, and the Mach warning would have been essential in alerting the crew to the overspeed condition ·before the overspeed• limit .was substantially exceeded. · Since the aircraft's reactions would have appeared very similar in either a turbulence encounter or a control malfunction occurrence, the upset could have .been perceived as a control malfim~tion. The pilot's statement at 1204:23.6, (appendix E) "pull the circuit breaker," supports this possibility. It is believed that the pilot was referring to the AFC/SS circuit breaker which must be pulled to insure that all pitch trim operation is stopped-- .a prescribed emergency procedure. This possible inaccurate perception of the sudden upset also could have delayed the crew's correct response to the upset. ' . The copilot was military trained with experience in turbojet fighter and attack mission aircraft and would have been accustomed to abrupt control movements and high "g'' maneuvers. Consequently, since he lacked experience in the Learjet, the copilot may have been more aggressive in his, response to the upset and to a nosedown high speed departure. As indicated in the FAA's SCR report and Gates Learjet Service Letter 49, if an overspeed condition occurs, aileron "buzz" would be the first indication of encountering a high speed Mach buffet condition. The letter further states, "Ptilling "g's" in that regime of flight increases the aileron activity, so one must not pull abruptly on the elevator control to slow the airplane but must apply a steady force of the magnitude necessary to produce as much "g" force as possible without losing roll control." During certification flight tests, this recovery "g'' force was limited to 1.5 g's. The· ailerons in the Learjet are sensitive to buff etiilg at speeds beyond M and increased "g" loads. Therefore, it is conceivable that the copilot could have illHl·eased the onset and the intensity of Mach buffet by exerting more than 1.5 g's on the aircraft. Consequently, his attempts to recover the aircraft by pulling on the control wheel probably resulted in a loss of roll con_trol. The Safety Board concludes that the copilot's comment, "Can't get it up ... its in a spin," indicates that he was attempting to pull on the control wheel to recover the aircraft but that it was in an uncoordinated roll manuever from which a recovery may not have been possible. . Action by the pilot to deploy the spoilers could have been a natural'reaction to an overspeed since he had been trained initially to use such a procedure in the Learjet Model 24, and the early Model 24 AFMs specified the use of spoilers in an overspeed situation. However, the procedures for the Model 25D/F _AFM do not provide for the use of spoilers in, this situation, but require the reduction of thrust, leveling of the wings, and a slight positive "g" recovery. The ability of one flightcrew to recover from the turbulence upset and the failure· of another flightcrew to recover may be due to differences in the severity of the turbulence encountered; differences, such as the rigging of the flight controls, between the two aircraft; or to the attentiveness of the 'flightcrews .. and their perception of the upset. The pilot of N51J made an immediate thrust reduction, did not di11engage the autopilot or yaw damper, and did not deploy the spoilers. It is believed that, the primary ) reasons for the accident flightcrew's failure to recover were the lack of a timely thrust ·. \ · reduction, an inadvertent disengagement of the autopilot and yaw damper, and an inability to counteract the significant nosedown pitch forces caused by deployment of the spoilers.

( ( \,_\ -27- ·Further, it is our opinion that. the inconsistencies regarding the use of spoilers in training for an overspeed condition may·have been·responsible for the different response to the ups.et. More emphasis should be placed in training on turbulence upset procedures. Since this type of training may not be practical in· the aircraft, it could be effectively accomplished in a simulator; The tr/lining should.instill in a Learjet flightcrew a greater appreciation for. how quickly the aircraft can exceed its operating envelope, apd how quickly they must respond correctly to insure a successful recovery. It should also teach a0 crew .how to recognize and avoid situations which may lead to a loss of control. · The Safety Board recognizes that in a high altitude environment a pilot might make oitly a small .reduction in thrust because of its affect on cabin pressurization. However, considering the, marginal controllability characteristics of the aircraft at speeds beyond Mm and the marginal "g" limits allowed for recovery, a pilot is ·confronted with a very crUicl8 situation and thrust must be reduced imm,ediately to recover .the air(lraft. The Safety Bo~d investigated three accidents in which the ·overspeed warning horn was heard before the loss of control occurred. (See appendix F .) In at least two of the accidents, and possibly the· third, the spoilers were used in an unsuccessful attempt to decelerate the aircraft. In all three accidents, deployment of the spoilers probably would have aggravated the situations and prevented recovery of the aircraft. The Safety Board is aware of the FAA's efforts in response to our previous recommendations to review the certification of the aircraft and of its recent issue of Airworthiness Directive 81-16-08 to correct some of the high altitude, high speed control deficiencies. We are also aware of· the SCR -team's recommendation that the spoiler system be redesigned to reduce ·the,nosedown pitching moment so that deployment of the . spoilers at vM0 /M will not requil'.e more than 50 pounds of control force· to counter. Earlier this year, ~ recommendation was considered resolved with the required pitch axis modifications and the changes in the AFM and training procedures. However, the Safety Board believes that changes in the AFM and training procedures· will not necessarily remedy this potential problem as evidenced by the events in this accident. Currently, the spoiler system is used primarily as a speed brake and not necessarily a spoiler. Also, the aircraft's emergency descent performance is dependent upon the use of the spoiler as a drag device. It is apparent that a thorough retraining exercise must be conducted to insure that pilots do not use .the spoilers at an inappropriate time. . In response to a Safety Board recommendation, the FAA stated that it had established a team to "review the adequacy and effectiveness of Learjet crew training." 10/ As of this date, we have not received any information about its progress. Ther·etore, we encourage the FAA to take immediate action to expedite its review of training to resolve this potential problem. 3.1

1. CONCLUSIONS

Findings 1. The pilots were certificated and qualified for the flight. 2. There was no evidence· of physical impairment or incapacitation of the pilots. '107 FAA letter dat~d S~ptember 25, 1980 (see appendix I.)

-28- The aircraft was certificated and maintained according to approved procedures.

There were no thunderstorms in the immediate vicinity of the accident.

Although no severe clear air turbulence was forecast, there was moderate to severe clear air turbulence in the area where the aircraft abruptly departed its flight level.

The aircraft was at a. conservative cruise speed when it encountered moderate to severe clear air turbulence which required immediate pilot action to maintain. control of the aircraft.

The copilot, who was flying the aircraft, may have initiated abrupt control movements. during the turbulence encounter in an attempt to control, the aircraft, ·

The copilot may have accidentally disengaged the autopilot and yaw c;la:mper which· would have significantly hampered recovery, or a partial disengagement could have occurred which also could have adversely affected recovery.

The airplani:, exceeded its high speed Mach buffet boundary and its MMO limitations; .

The lack of an overspeed warning probably delayed the flightcrew's response to correct an overspeed condition.

There was no conclusive evidence of a failure or malfunction of the aircraft's systems. 'However, unauthorized installation of the overspeed warning horn cut-out switch rendered the aircraft unairworthy.

The increased speed and attempts, by the flightcrew to regain control of the aircraft by deploying the spoilers, failing to retrim, and pulling on the control wheel with excessive force resulted in the loss of pitch and roll control from which a recovery was·not possible.

The marginal controllability characteristics of the aircraf.t at and beyond M contributed to the flightcrew's difficulty in executing a recovery, arlll 0 the · extension of the spoilers probably prevented a successful recovery.·

· The inconsistencies in the AFMs and in training probably contributed to the flightcrew's use of the incorrect procedure for recovery from an over speed condition. 3.2 Probable Cause ) ' \'. I:, I 1: .. The National Transportation Safety Board determines that the probable cause of this accident was an unexpected encounter witli moderate to severe clear air turbulence, the flightcrew's improper response to the encounter, and the aircraft's marginal controllability characteristics when flown at and beyond the boundary of its high ,. , altitude speed envelope, ell of which resulted in the aircraft exceeding its Mach limits and a progressive loss of control from which recovery was not possible. Contributing to the (t "··' I ·/ r -29- accident was the disconnection of the Mach overspeed warning horn with an unauthorized cut-out switch which resulted in the absence of an overspeed warning that probably delayed the crew's response to the turbulence encounter, and the inconsistencies in aircraft flight· manuals and flightcrew training programs regarding the use of spoilers to regain control.

1. RECOMMENDATIONS

As a result of this investigation, the Safety Board issued the following recommendation to the National Oceanic and Atmospheric Administration: Define the relationship between clear air turbulence and upper fronts. as analyzed by soundings and ·develop forecasting techniques to utilize the information to improve , clear air turbulence forecasts. (Class II, Priority Action) (A-81-103) BY THE NATION:AL TRANSPORTATION SAFETY BOARD /sf JAMES B. KING Chlllrman /sf ELWOOD T. DRIVER Vice Chairman /sf PATRICIA A. GOLDMAN Member /sf G. H. PATRICK BURSLEY Member FRANCIS H. McADAMS, Member, did not participate. September 15, 1981

(( 1. Investigation -31-

1. APPENDIXES

APPENDIX A INVESTIGATION AND HEARING The Safety Board was notified of the accident about 1600 on May 19, 1980, and investigators were dispatched to St. Petersburg, Florida, and Jacksonville, Florida, to conduct an investigation. Parties to the investigation were the Federal Aviation Administration, Gates Learjet Corporation, and Northeast Jet Company. 2. Public Hearing No public hearing was held, and no'depositions were taken.

Pilot James T: Cheek -32- APPENDIX.B CREW INFORMATION Pilot Cheek, 59, held Airline Transport Pilot (ATP) Certificate No. 245834, with an aircraft multiengine land.rating and type ratings in the Lockheed Jet Star L-1329, the Desault Falcon DA-20, and the Gate Learjet Models 23, 24,· and 25. He also held a cer.tificate, issued on January 17, 1976, for commercial privileges in single engine land sea airplanes and rotorcraft-helicopters. He had held a flight instructor certificate, which expired on December 31, 1979, for single and multiengine aircraft and rotorcraft- helicopters. Pilot Cheek held .a first-class medical certificate, issued February 11, 1980, with the limitation that he shall possess correcting eye glasses for near vision while exercising th!! privileges of the airman certificate. His application for this medical · certificate showed that his uncorrected near vision in both eyes was 20/100, corrected to 20/20. His uncorrected distant vision was·20/20. · Pilot cheek had been employed as a captain by Northeast Jet on October 8, 19,78. He reported on his application that he had 14,810 hours of flight time, of which 11,790 hours were in multiengine aircraft. He also reported a total multiengine charter time of 1,750 hours in the Learjet and 390 hours in the Falcon, On a resume attached to his employment application, he reported 6,869 hours of turbojet pilot-in-command time, of which 5,898 hours were in the Learjet. His total flight time reported by the company as of May 19, 1980, was 15,740 hours, of which 6,062 hours were in the Learjet. According to the company's records pilot Cheek had flown 165 hours in the 90 days preceding the accident Between April 22 and May 17, 1980, he had flown 41 hours -- 13 hours in Nl25NE from May 5 to May 8 and 28 ·hours in N911MG, the company's other Learjet 25D. Sixteen hours were flown in N911MG between May 14 and May 17. He did not fly on May 18. Pilot Cheek's last proficiency check was a· 6-month IFR flight on April 1, 1980, conducted .by the chief pilot. Pilot Cheek had obtained his ATP certificate January 16, 1963. He had obtained type ratings in the Learjet 23 and 24 on August 16; 1966, after having accumulated a total of 568.9 hours in the.Learjet. ile had obtained a Learjet 25 rating on July 8, 1968. He had completed a pilot recurrent tr_aining course in. the Learjet models 24D/E/F and 25B/C/D/F with Flight Safety International, Wichita, Kansas, between July 31, 1978, and August 4, 1978, The course included 16 hours of ground instruction and 14 hours. of simulator instruction: He received 8 hours of initial ground training October 4; 1978, ahd 16 hours of recurrent training on August 24, 1979, with Northeast Jet. Copilot Francis J. Donnelly Copilot Donnelly, 32, held ATP Certificate No. 1840270 with aircraft multiengine, instrument, and helicopter ratings and typ_e ratings in the Cessna 500 Citation and sikorsky S-58. He also held a certific!lte, issued on February 2, 1980, for commercial privileges in single engine land aircraft and rotorcraft-hel\copters. This certificate was issued on February 2, 1980. He held a first class medical certificate issued December 7, 1979, with no limitations, . t. •iii)·. •.tJJ ' ,, ·)· ',.,, "/ .

( -33~ Copilot Donnelly had been employed by-Northeast Jet on April-11, 1980. On a resume, attached to his employment application he reported 4',051 hours of flight time, of which 2,850 hours were in single ·and_ multiengine turbojet aircraft. His total flight time reported by the company as of May 19, 1980, was 4,116 hours of which 65 hours were in the Learjet. · According to company records, copilot Donnelly had flown 65 _hours in the 90 days preceeding the accident. Between April 19 and May 13, 1980, he had flown 60.6 hours -- _33.1 hours in N125NE and 27.5_hours in N911MG. On April 21, 1980, he received an annual proficiency/qualification check of 0.6 h!)ur duration from an FAA Principal Operations Inspector At the time of the accident, copilot Donnelly was a Major and a Naval Aviator in the United States Marine Corps. He had been serving as Executive Officer of Marine Aircraft Group 49, Naval Air Station, Willow Grove, Pennsylvania. He had been scheduled to be released from active duty July 1, 1980, and had obtained a May 1 release date. He entered Naval Flight School November 7, 1966, and flew both airplanes and helicopters while on active duty. The -major portjon of his flight .experience was obtained flying helicopters (Boeing .CH-46, 755 Hours) in Vietnam and in the following turbojet airplanes: 1,250 hours in North American T-2's (instructor pilot); 800 hours in Douglas A-4's; 76 hours in Hawker-Siddley AV-8; 350· hours in·Douglas DC-~B. He also accumulated 101 hours in a reciprocating twin engine airplane. · · Copilot Donnelly had obtained his commercial' pilot certificate through a military competence examination on April 17,-1968,'at which time he had been issued the following ratings: airplane single engine land; rotorcraft-helicopter, and instrument including helicopter. On January 21, 1970, he had obtained an aircraft multiengine land rating, limited to centerline thrust, and· on February 15, 1980, he had obtained his ATP certificate and a standard multiengine land rating with a type rating in the Cessna 500 Citation. He had 6.5 hours in the Citation at the time of his flight check; Between April 14 and April 18, copilot Donnelly obtained 4.0 hours of Learjet ·25 ground school from Executive Jet Aviation, ~nc., Columbus, Ohio. He also received 5 hours of instruction concerning flight safety items .on March 19, and 8 hours an indoctrination course on March 20 fr Northeast Jet. He flew a 1.1-hour training flight on April 19 and a 1.2-hour training flight on April 20 before his 0.6-hour check flight the following day. He subseque,ntly received 22 hours of instruction while on various charter and ferry flights and accumulated a total of 27 .2 hours of pilot in command time in the Learjet.

-34- APPENDIXC AIRCRAFT INFORMATION _ ,FAA certification of the Learjet 25D was approved May 20, 1976; under 14 CFR Part 25, effective February 1, 1965, with the addition of Special Conditions. Gates Learjet 25D,'N125NE, serial number 25-271, was issued an airworthiness certificate on February 12, 1979. It was certificated for flight' up to 5i,OOO feet'. The aircraft was· equipped with the manufacturer's Century m and Soft-Flite _ performance improvement modifications. It was also equipped with two General Electric CJ610-8A turbojet engines, an FCS-110 standard autopilot with a GLC S231-2 indicator, and a· Collins FD-108 primary flight director. The Century m · modification was designed to improve the slow speed performance of the aircraft and to permit operation within shorter. field lengths. It involved increasing the radius of the wing leading edge forward of the 6 percent chord station. The new contou_r was kept constant from the wing root to the wing _ tip, in contrast to the original leading edge, and contained a change in chamber and an increase in thickness from about midspan outward to the tip. This change in the shape of_ ihe leading edge lowered the stall speed of the wing by several knots. A strake was added to the juncture of the wing tip and the tip tank to improve the effectiveness of the aileron, particularly at high angles of attack. In the cockpit, the angle of attack indicators were revised with col~red segments reflecting safe, caution (shaker), and danger (pusher) flight regimes. · The "Softflite" modification, which became effective in July 1979, was .~ ) developed to further -improve the aircraft's stall characteristics. The aerodynamic improvements included full chord wing fences, stall strips, and an extension of the gap seals at the leading edge of the ailerons to further control airflow between the upper and lower surfaces of the wing in the vicinity of the ailerons. In addition, the improvement required removal of the vortex generators on top of the wing in front of the ailerons and replacement with boundary layer energizers (small ridge devices installed at. right angles to the airflow to energize the_ boundary layer flow in order to delay the· onset of compressibility). accident. The aircraft had been flown slightly over 1,200 hours at the time of the The engine serial numbers were: Position Left Right Serial No. GE-E211 ~100A GE-21!-079A

JACKSONVILLE RADAR CROSS CITY RADAR JACKSONVILLE RADAR CROSS CITY RADAR CROS$ CITY RADAR 0 ·1204:30.3- .1 SECONDS OF STATIC 1204:27.0 - ADO - 7 "WE'RE GONNA" 1204:23.6- RDO -1. "(PULL THE CIRCUIT .BREAKER)" 1204:22.6- RDO -2 "OH JESUS (CHRIST)" 1204:20.9-.9 SECONDS OF STATIC _,,- 1204:13.3- RD0-2 "CAN'T GET IT UP. IT'S IN ASPIN", ./ RD0-1 "(VIOLENT SPINNING), (AH#)" 1204:29 1204:03.3-1.5 SECONDS OF STA.Tic 1204:21 1204:00.7- ADO· 1 "(PULL/PUT OUT/OFF/UP THE SPOILERS)" 1204:17 J--cc---1204:00.1 -1.3 SECONDS OF 18 HZ STACCATO SOUND 1204:10 1203:58.9-1 SECOND OF 18 HZ STACCATO SOUND 1203:58 1263:56,7 - .7 SECONDS OF 18 HZ STACCATO SOUND 2 3 NAUTICAL MILES RD0-1 VOICE IDENTIFIED AS CAPTAIN RD0-2 VOICE IDENTIFIED AS FIRST OFFICER ( ) QUESTIONABLE TEXT

NON-PERTINENT WORD G'c,- :g ~ ; I ... .,. ~ I ~ t::J t::J ;i > (') P'i1

-36- ,\PPENDIXE NTSB EXPANDED TRANSCIDPT OF AN ARTC CENTER TAPE R29 POSITION REEL '19/12 TRACK 2'1B, MAY 29, 1980 ·CAM RDO -1 -2 -? * It % () (( )) TIME& SOURCE 1201:42 RDO-1 1201:46 CTR CTR 496 CTR CTR LEGEND Cockpit area microphone voice or sound source Radio transmission from accident aircraft Voice identified as Captain Voice identified as First Officer Voice unidentified Unintelligible word Nonpertinent word Break in continuity Questionable text Editorial insertion Am~GROUND COMMUNICATIONS CONTENT Jacksonville Center Lear one two five november echo with you four three oh Lear one two fivenovember echo Jax Center roger flight level four three-zero ((Intercom)) ((Intercom)) ((Intercom)) Republic four ninety six, contact Atlanta Center one three ·two point eight five Four ninety six roger, good day Good day ((intercom)) NASA nine sixty two Jax ( "'" )' \ ff/' _I .,

. I ,, ' ',I TIME& SOURCE NASA CTR NASA CTR NASA 1203:40.1 RDO 1203:56.7 RDO 1203:58.9 RDO 1204:00.1 RDO 1204:00.7 RD0-1 1204:03.3 Roo· 1204:13.3 RDO RDO-2 RDO-2 RDO-? 1204:20.9 RDO -37- APPENDIX E CONTENT Yeah Jax NASA nine .ah six two is at four three zero Roger, it's gonna be necessary to move you either to forty five or, ah, forty one, what's your preference? ((Intercom)) Let me try to get up tci forty five if I might NASA nine sixty two roger, maintain flight level four five zer.o Nine six two to four five. zero ((Short bur.:st of static starts and contim~es until 1203:41.0)) ((Initial sound of stacatto beats on radio approximately 18 Hz, continues until 1203:57 .4)) ((Second sound of stacatto beats on radio approximately 18 ~z; continues until 1203:59.9)) ((Third sound of stacatto beats on radio approximately 18 Hz, continuing until 1204:01.4 and including a voice saying)) (Pull/put lout/off/up the spoilers), ((The word "stalls" was heard by one person, most heard the word "spoilers")) ((Burst of static, no particular structure involved, continues until 1204:04.8)) · ((Sound similar to cockpit background noise followed by the voice of the copilot saying)) · · Can't get it up It's in a spin (Violent spinning) (ah #) ((Sound of static, continues until 1204:21.8))

APPENDIX E TIME& SOURCE 1204:22.6 RDO-2 1204:23.6 RDO-1 1204:27.0 RDO-? 1204:30.3 RDO -38- CONTENT Oh Jesus (Christ) (Pull off the circuit breaker) ((or)) (Pull off the breaker) ((or)) (Pull off the *) ((or)) (Pull the # engine) We're gonna ((conversation ends at 1204:27 :s» ((Sound of static, continues until 1204:30.4))

'! ,1 -39- APPENDIXF LEARJET ACCIDENT AND INCIDENT IUSTORY Some recent incidents and accidents involving Learjet aircraft are discussed herein to present the background and the development of the corrective actions which have been taken before and after the Northeast Jet accident. The relevance of these accidents, incidents,· and corrective actions to the Northeast Jet accident is discussed in the analysis of this report. O,n August 31, 1974, a Colorado Flying Academy Learjet 25B, serial No. 151, crashed near Briggsdale, Colorado. The airplane departed Denver at 1331 m.d,t. on a training flight en route to. Cheyenne, Wyoming, with two passengers aboard. The last radio contact with the flight was at 1336 when the aircraft was at 17,400 feet. The sky was clear with about 40 miles visibility. The Safety Board retrieved information from the aircraft's cockpit voice recorder (CVR). Apparently, the instructor pilot, in the right seat, decided to introduce a runaway trim emergency -to the student pilot who was on his fourth lesson for his type rating. , The runaway trim maneuver followed an unusual attitude. About 1348:39, it is believed the instructor stated "runaway trim" and the student stated 2 seconds later, "okay turn it off." Three seconds later, the student · stated "the .•• spoilers" and 3 seconds later, the instructor stated, "spoilers can't do ·that." Three seconds later, at 1348:50, the landing gear and the overspeed warning' horns sounded;, the overspeed horn warning continued to the end of the recording at 1349:15.,' At 1348:56, it is believed the instructor stated, "can't pick up ••• pull." A witness estimated that the aircraft was in a 45° dive angle. The aircraft struck the ground in a wings level, 20° to 40° nosedown attitude. The instructor held ratings in the Learjet Models 23, 24, and 25. He had 9,323 hours of flight time. His total Learjet flight time was not known. He had flown the Learjet· 130 hours in the past 90 days and had accumulated 161 hours in the , Learjet Model 25. The student's flight experience was not known. Examination of the wreckage disclosed that the landing gear, wing flaps, and spoilers were retracted at the time of ground impact. The horizontal stabilizer jackscrew was found in the full nosedown position. On October 20, 1978, a Kelco Aircraft Company Learjet 25, serial No. 019, crashed 1.5 miles southeast of Vickery, Ohio. The aircraft departed the Cleveland-Hopkins Airport at 1019 e.d.t. with a pilot, copilot, and an FAA Operations Inspector on board for the purpose of giving the copilpt an "airtaxi" flight check. The flight check was to consist of some "high work" maneuvers, such as slow flight, stells (approach to shaker), steep turns, possible simulated emergencies, such as a runaway pitch trim, an engine fire, and an emergency descent; and "low work," such as landings, go-arounds, and simulated engine out maneuvers. The flight climbed to 16,500 feet and, at 1027, 'the crew advised the Cleveland ARTCC that they would be operating in the area of the Sandusky VOR. About 6 minutes into the flight, at 1032:49, a sound similar to a keyed microphone was received by the ARTCC, followed by five statements of, "Pull up" in rapid sequence; then a final, but louder, "Pull it out" was received at 1033:20. It was determined that the altitude alert had sounded at 1032:32, and 4 seconds later, the overspeed warning horn had sounded. Witnesses reported observing the aircraft in about a 60° dive angle and they stated they did not see any smoke, fire, or pieces of the aircraft separate before ground impact.

APPE.NDIX F -40- Both pilots held a type rating in the Learjet. The pilot had 150 hours and the r) copilot had 230 hours in the Learjet. Examination of the wreckage revealed that the wing ,flaps and the spoilers were retracted at impact. The position of the landing gear could not be confirmed. The horizontal stabilizer trim act.uator was positioned to a minus 2.69°. This position equated to a cruise speed of 276 KIAS, at t,he estimated gross weight and. e.g. of the accident aircraft. It was also determined that the aircraft accelerated to 306 KIAS (V m ) in 6 to 7 seconds. As a part of ·the Safety Board's May 1979 Study of Selected l'eiformance Characteristics of Modified Learjet Aircraft," flight tests showed it would have required a negative "g'.' maneuver to achieve such acceleration. Simulated·nosedown runaway trim conditions could not duplicate 'this condition. It was noted· in flight tests that, " ... extension of the spoilers is• not a viable procedure to prevent acceleration '.in a nosedown trim runaway condition. Extension of the spoilers at V with full nosedown trim required an elevator force estimated at 120 to 140 pounds tcfIBaintain level· flight. At 250 knots, the elevator force was measured' at 98 pounds with full nosedown trim and spoilers extended." The investigation of these accidents prompted research related to the following key areas: (1) Runaway pitch trim training techniques; (2) The use of spoilers in a high speed r~covery; (3) The flightcrew's background and qualifications; and (4) The flight control system--pitch servo clutch asse11,1blies, autopilot/automatic flight control system, stall warning system, and the effectiveness of the control cables, ailerons and· stabilizer/elevator system at high speeds. On March 2, 1979, the pilot of a Learjet Model 24B, serial No. 209, operated by the Syntek Corporation, reported a longitudinal control problem while e11 route from ·GreensbO!'O, North Carolina, to Nashville, Tennessee, at FL 350. The pilot stated that the stickshaker came on four times and he responded by turning the two ·stall warning switches 'off one at a time. , Each 'time he turned them back on, ·the aircraft would abruptly pitch nosedown, and the associated stall warning s\vitch circuit breakers would pop. By deactivating the stall warning system, he was able tQ isolate the problem. However, in spite of his action, he had difficulty with pitch control during the landing but was able to make a safe landing following four attempts at Greensboro. The pilot made a 10° flap landing at a higher than normal airspeed and used the stabilizer trim for pitch control. The longitudinal (lontro~ problem was traced to the pitch axis servo drive unit (electromagnetic clutch). The clutch contains ferrous powder which normally coagulates or packs into a solid mass -when a magnetic field is introduced electrically by signals from the autopilot or stall warning stickshaker/stickpusher system. The energized clutch then transmits torque to the elevator control system in the appropriate direction. The powder normally decoagulates and the clutch rotates _freely when electrical power is removed. Examination of the electromagnetic clutch of the Syntek aircraft revealed 11\ that the ferrous powder was packed without the presence of electrical power. Such a #,'.j;/ condition could produce a nosedown pitching moment with normal operation of the ' . i '

t -41- APPENDIX F autopilot which would require as much as 80 pounds of pull force on the control column to counter. Even without electrical power, the jammed clutch would affect the breakout force and the force gradient of the longitudinal control system before the elevator could be moved. Gates Learjet personnel theorized that moisture contamination caused the ferrous powder to pack and jam the clutch. During previous overhauls, Gates Learjet personnel have found various degrees of moisture contamination. The Safety Board examined the clutch in its metallurgical laboratory and found no foreign substances in the ferrous powder. However, some of the particles of the powder continued to pack into small hard lumps. The reason for this peculiarity was not determined, ~ut it was believed that some undetermined property in the 'material was causing the clutch to jam without the presence of a magnetic field. Although the Safety Board noted that Gates Learjet had discontinued use of the electromagnetic clutch which was manufactured by Je,t · Electronics (part No. 2380066), in new aircraft, 220 Learjets were equipped with the clutch unit at that time, and it was a mandatory item for flight. ·The ,clutch unit was the same type installed in ~he Kelco Aircraft Learjet.. The Greensboro, North Carolina, incident prompted concern that magnetic clutches may have been a factor in the Vickery, Ohio, accident. As a result of the incident and accidents and in view of the potential catastrophic results of control difficulties caused by jammed electromagnetic clutches; the Safety Board issued safety recommel)dations A-79-21 through -23 to the FAA on April 18, 1979. (See appendix H.) In its investigation of the Vickery, Ohio, accident, the Safety Board identified only two servo clutches which were the primary yaw units. These servo clutch units were corroded but the source of the corrosion could not be identified. Of the remaining eight servo clutch uni ts installed in the aircraft, six exhibited no evidence of packing, one was destroyed, and the other was not located. Therefore, the condition of the pitch axis electro'magnetic clutch uni ts could not be determined. As a result of the Syntek Corporation incident investigation, several actions were taken by the FAA and the Gates Learjet Corporation to correct the magnetic clutch problem. A temporary AFM supplement was issued prescribing specific emergency .. procedures to follow in the event of a pitch axis malfunction. Copies of the Safety Board's recommendations-were_ widely distributed and two operations bulletins describing the problem were issued to all FAA field offices. In its response of July 16, 1979, to the Safety Board's recommendations, the FAA stated that it believed it was not necessary to restrict.the operations of Learjets equipped with the electromagnetic clutches because of the temporary AFM change. However, these procedures only proved to be interim measures with ·respect to the clutch servo unit problem. Between .0330 and 0400, on October 3, 1980, a National Jet Industries Learjet 25, serial No. 010, experienced an upset while in cruise flight at FL 450 over Butler, Missouri. The crew was on an air taxi cargo flight from .Columbus, ·Ohio, to Pueblo, Colorado. With the autopilot and altitude· hold engaged, the aircraft· smoothly but suddenly pitched up, and it gained- more than 300 feet before the copilot pushed the primary trim switch to the nosedown position which disengaged the autopilot; the aircraft continued to deviate in a noseup attitude. Stall buffet was encountered and the left engine flamed out. Both pilots pushed full forward on the control column and the copilot selected secondary trim and also turned off the stall warning switches in an attempt to lower the nose, but to no avail. About 37,000 feet, the right engine flamed out. The aircraft began to respond to. control movements about 32,000 feet, and the engines were restarted between 24,000 and 28,000 feet •. The crew diverted to Wichita, Kansas, where they landed successfully.

APPENDIX F ,-42- .The Safety Board's meteorological examination of the weather conditions ) ~ existing in the area of the flight disclosed the existence of an upper front with wind ,;J shears greater than 10 knots per 1,000 feet. The·Safety Board believes that this condition provided the potential for gravity waves 11/ and/or turbulence at· the aircraft's flight level. The wave action or turbulence would have existed in a shallow layer, probably less than 1,000 feet thick. Based on the crew's .statements of the incident, it was considered possible that the aircraft.encountered the vertical component of a gravity wave. Inspection of· the aircraft by the FAA and the Gates Learjet Corporation disclosed that although the possibility of packed ferrous powder in the aircraft's electro- magnetic clutch could have caused the control difficulty in the incident, the possibility could not be verified during ground tests of the servo unit, but the lack of success in a ground test verification is. not unusual. It. was noted that the amount of powder and the amount of lubricant were not in.accordance with specifications. Subsequent flight tests and analysis of the findings caused engineers to conclude that the control difficulty could have been cause by a packed pitch axis electromagnetic clutch. At the conclusion of the investigation, the FAA issued Emergency AD-80-22-10 (see. appeildiic G) on October. 23, 1980, which .required deactivation of the pitch function iii the FC-110 autopilot AFCS or AFC/SS until the electromagnetic clutches had been replaced with the improved, in-production d.c. torquer clutches (motor driven) along with certain other changes. The d.c. torquer clutches have continuously been installed since the model 25B, serial no. 067. Other changes required by the' AD involved inspection of the autopilot trim coupler circuit board to assure that proper transistors were installed, and incorporation of a pitch trim monitor preflight test switch along with appropriate changes to the AFM. · Upon accomplishment of these items, the autopilot pHch axis function could be restored. Operators were given until April 1, 1981, f)))J to make the changes. In regard to the· transistors in the trim coupler board in the autopilot computer of the National Jet Industries Learjet, tests for faults were negative. The transistors installed were Delco germanium which are believed to be more resistant to thermal runaway failures than the germanium transistors· built by other. manufacturers. Such a failure could cause a disturbance in the pitch .axis of the aircraft. According to the manufacturer, this situation would normally be preceded by spurious autopil_ot .disconnects because. the trim monitor would sense an incorrect electrical phase relationship between stabilizer and eievator trim positions. ' In other words, the trim coupler would have· disconnected the autopilot if an unwanted trim motion of the stabilizer occurred. The control force required to maintain the desired flight attitude at the time of a disconnect under this condition .might range ,anywhere between l.O and 80 pounds, However, a pilot would stiµ retain elevator ,control, but it could be limited depending on the. amount of stabilizer mistrim present at, the time of the disconnect. Therefore, a pilot may receive some kind of warning of a potential significant disturbance in the autopilot before control difficulty would become substantial. In an attempt to prevent this type of failure from recurring, the FAA ordered compliance with the appropriate Jet Electronics Service Bulletins SB 4-2020-30, -32, -33, or -34, which are a part of Gates Learjet's aircraft modification kit; AMK 80-16B, mentioned in the airworthiness directive. ' ' On April 11, 1980, Thunderbird Airways, Inc., Learjet 25B, serial No. 196, was on a return flight from Vernal, Utah, to Houston; Texas,, at FL 410, after having completed an air taxi cargo flight. .About 1716 c;s.t, the Albuquerque, New Mexico, ARTCC heard:the sounds of a keyed microJ?hone and a Mach overspeed warning horn with ljJ 11/ Atmospheric gravity waves are a disturbance _in which bouyancy (or _reduced gravity) acts as the restoring force on parcels of air displaced from hydrostatic equilibrium. · ·

t -43- . APPENDIX F a lot of background noise. It was apparent that the flight was in difficulty, and that the pilot attempted to identify himself.and asked for a lower.altitude, but did not make any further discernable transmissions. The aircraft entered what was believed to be a steep, high speed descent and impacted 6 miles west of Conlon, Texas. Investigation of this accident disclosed a relatively high probability of clear air turbulence in the area at the altitude the aircraft was transiting. It was determined that at the time of impact, the landing gear and flaps were retracted, the spoilers were extended, and the stabilizer actuator jackscrew was in the full nosedowl). position. The aircraft was equipped with d.c. torquer clutches, rather than electromagnetic clutches in the autopilot system. The aircraf,t's autopilot computer was equipped with the non-Delco germanium transistors. The transistors were destroyed and ~ests for the possibility of their failing could not be performed, As a result of this possible type of failure, this accident, and the National Jet Industries incident, the trim monitor test feature was incorporated into the autopilot system as required by AD 80-22-10, which was iater superseded by AD-80-26-02. In· response to a Safety Board letter requesting flight test data for the nosedown trim runaway condition, Gates Learjet reported in a letter dated December 15, 1980: . The enclosed data was recorded ••• on a Model 25B (with the FAA aboard) on February 27, 1975. Stabilizer load flight test data ,is not available. Note that the runaway was stopped after three seconds; not allowed to·run to t_he stop. In the one case,at 300 KIAS, the trim was run to the· stop and required an 85 pound pull to hold the airspeed. There is no Model 25B flight test data .available to directly correlate the computer scenario of running the trim to the stop with a three second delay in any action by the pilot. In the . flight test when the trim was run to the stop, the test pilot did have his hands on the wheel. As a result of these accidents and incidents, the Safety Board issued recommendations A-80-53 through -55 to the FAA on June 27, 1980. (See appendix H.) In its response dated September 25, 1980, the FAA stated 'that with regard to recommendation A-80-'53, part of an evaluation had already been acm;,mplished in conjunction with the Safety Board's February 1979 "Study of Selected Performance Characteristics of Modified· Learjet Aircraft." The FAA stated that a separate investigation was initiated on June 17, 1980, to accomplish a certification review of the Learjet. In addition, th_ey stated that their Office of Flight Operations had established a separate team to "review the adequacy and effectiveness of Learjet crew training." (See appendix I.) On December 7, 1980, the flightcrew 9f Learjet 25, serial No. 054, operated by Continental Oil Company, experienced a simultaneous flameout of both engines at about 40,000 feet while the aircraft was climbing to FL 430 northeast of Childress, Texas. The engines were air started passing through 25,000 feet, and a precautionary landing was made at Childress. ·Extensive examination and testing of the CJ610-6 engines by General Electric disclosed that the flameouts were caused by reduced engine stall margin due t,o excessive blade ·tip clearance and excessive compressor case runout. As a result of its investigation of this incident, the Safety Board Issued recommendation A-81-69 to the FAA on June 29, 1981. (See appendix H.)

80-19-ll GATES Applies.to the unless noted: MODELS 23 24, 24A 24B., 24B-A -44- APPBNDIXG .AIRWORTBINJ!SS DIRECTIVBS GA TES J.EARJl!.J Airworthiness Dirccth·c Leiter \'olumc I & 11 LEARJET: Letter issued September 9, 1980. following models and serial number· airplanes, SERIAL Nt:MBERS 23-003 through 23-099 24-100 through 24-180 24-181 through 24-217 24-219 through 24-229 24C, 24D, 24D-A 24E; 24·F, 24F-A .. 25, 25A 24-218, 24-230 through 24-328 24-329 and subsequent 25~003 through 25-060 25B, 25C 25-061, 25-067 through 25-201, 25-204, 25-205 . 251>, 25F is,·29 35, 36, '35A, 36A 25-20~ and subsequent 28-001 and subsequent, 29-001 and subsequent 35-001 and subsequent,· 36-001 and subsequent COMPLIANCE: Required as indicated, unless previously - accomplished. Al . Before further flight, insert the following information in'the FAA Approved Jlirplane Flight Manual· and operate· the airplane in accordance with these insertions: , 1. In Section, 1, LIMITATIONS, adjacent to AIRSPEED LIMITS,: MAXIMUM OPE RAT IN:; SPEED VMO/MMO': · a. Delete any proce·dures rel_ative to exceeding VMO or MMO. b. Add the following limitation: WARNING: Do not extend the spoilers, or op~rate with the spoilers· deployed, at speeds above VMO/M,'1O due to the significant nose down pitching mo::ient associated with spoiler deployment. 2. In Section 1 -, LIMITATIONS, add a new limitation: TRIM SYSTEMS . .• a. To assure proper trim systems oper.ation, the BEF'ORE STARTING ENGINES tri::i system checks must be success£ully completed before each flight. ~ARNING: Failure to conduct a complete pitch trim preflight check prior to each flight increases the probability of an undetected system failure. An additional single failure in the trim system: could resul.t in a runaway. In certain critical flight conditions an unrestrained runaway could result in high speeds, severe buff~t, wing roll off, loads in exc·ess of structural limit and extreme'ly high forces necessary for recovery.

In Section 1, LIMITATiONS, adjacent to ,YAW DAMPER:" a. Delete any references to disengaging t.he yaw qamper before landing, or landing with the yaw damper engaged,. b. Add the following yaw damper requirements:· ' On landing, the ·following yaw damper disengage procedures shall apply: . (1) .. The"airplane shall be configured for landing at least_.S00_ft,AGL for normal landing: (2) The yaw damper shall be disengaged during the land~ng flare. · CAUTION: If landi11gs are attempt_ed in turbulent air conditions with the yaw damper OFF, the airplane may exhibit undesirable l~teral-directional (Dutch-Roll) characteristics. · 'l'!·-~se characteristics are improved as the wing/tip fuel is consumed, The pilot shall observe the NOTE relative to turbulence contained in the BEFORE LANDING section of Section II of the Airplane Flight Manual and increase airspeed as required,

In Section II, NORl".AL OPERATION PROCEDURES, adjacent to BEFORE STARTING ENGINES Procedures: a. Delete current preflight procedures on all tri(II syste:ms. b. Add the following new trim s~•stem preflight checks: NOTE: Some early Model incorporate a cutoff button that interrupts 23, 24 pitch, airplanes roll and raw axes. ( 1) Pitch Trim Selector Sid tch -- EMER (or SEC) , (2) ·operate EMEHGENCY (or SEC) pitch trim switch NOSE UP and NOSE DOWN and check for stabilizer movement. Stabilizer movement will be approximately one-half of the rate of primary trim. (3) Either Controi Wheel Trim Switch - Operate NOSE UP and ·NOSE DOWN, . Trim motion shall not occur·:. (4) Pitch Trim Selector Switch - OFF. (5) Actuate pilot's and copilot's Control Wheel Trim, and Trim ·Arming Switches (if applicable) and pedestal EMERGENCY (or SEC) Pitch Trim Switch. Trim motion shall not occur. (6) Pitch Trim Selector Switch - NORM (or PRI) (7) .. EMERGENCY (or SEC) Pitch . Trim Switch bperate NOSE UP and.NOSE DOWN. Trim motion shall not occur. NOTE: On all Model 23 airplanes and Mod.el- 24 (Serial Number 24-100 through 24-169) airplanes, ~xcept for those incorporating Accessory Kit. AAI, trim motion will occur. APPENDIX G -46- (8) Pilot's Control Wheel Trim Switch - Without depressing arming button (if applicable), move switch to LWD,' RWD, NOS.E UP, and . NOSE DOWN; trim motion shall not ·oc.cur. Depress arming button (if applicable); trim motion shall • not occur.' Then depress arming but'ton. (if applicable) "artd"'inove switch to.LWO, RWD, NOSE UP and NOSE DOWN; trim motion shall occur. (9). Repeat Step (Bl for Copilot's Control Wheel Tr·im Switch. (10) Trim by positioning Copilot's Control Wheel Trim Switch in one direction; then trim in opposite direction using the Pilot's Control Wheel Trim Switch. Pilot's •trim shal.l .override ··the Copilot's trim. · Repeat for all lateral and pitch trim positions. (11) Pilot's Control Wheel Trim Switch - NOSE UP. While ·trimming, depress Control Wheel Master Switch (if api;tlicable) or Cutoff Button (if · applicable); trim motion shall, stop when the -Control Wheel Master Switch is held. Re~eat• procedure for "NOSE ON condition; trim motion shall stop. . •. Repeat procedure for LWD . & .RWD iateral trim on airplanes equipped with Cutoff Button. (The procedures in ttiis paragraph are not applicable to Model 25, S.N. 2·5-003 through 25-205 and Model 24 ,. S.N. 24-170 through 24-328, except those airplanes modified by AAK76-4A). (12) Repeat Step (11) using copilot's Control Wheel Trim Switch, and. Control Wheel ~:aster Switch. (if . . applicable), or Cutoff Button· (if appli'cable). (13) YAW TRn: Switch - Operate each half separately (if installed); trim motion shall not occur. ( 14) .. YAW TRIM Switch .,. Operate both halves s~multarieously; trim motion shall .occur. On aircraft with Cutoff Button, check thrt.the Cutoff Button stops the trim. (15) Trim - Set all axes for takeoff. 6. In Section III, EMERG~NCY PROCI:DURES, add a new PITCH UP.SET (NOSE-UP or NOSE-DOWN) Emergency Procedure: A nose-up pitch axis malfunction or nose-up pitch trim system runaway can result in extremely, high pitch attitudes, heavy airframe buffet, anq ·require control forces in·excess of. 75 pounds for recovery. A nose-down pitch axis malfunction, nose-down pitch trim system runaway, or nose-down overspeed can result in extrem~ly high airspeeds an~ iequire control forces in excess of ·75 pounds for recovery. WARNING: Do not extend spoilers on any nose-down pitch upset at a,ny speed due .. to signific~nt nose-down pitching· moment associated with spoiler·deployment. NOTE: Control pressures may be heavy. Copilot assistance is recommended with this procedure. IMMEDIATELY: a; Attitude Control - As required to maintain aircraft control. '"\ i/ )' )

t 4 -47- WARNING: Do not extend spoilers nose-down pitch upset at any significant nose-down pitching with spoiler deployment. on any speed moment APPENDIX G due to associated NOTE:. Control pressures may be heavy. Copilot assistance is recommended with this procedure. IMMEDIATELY: a. Attitude Control

aircraft· control.

As required to maintain If in nose-up attitude, roll into bank or maintain existing bank until the aircraft nose passes through the horizon. If in nose-down attitude, level the wings before pulling the nose up. b. Thrust levers - As required. (If in nose-down attitude, immediately reduce thrust levers to IDLE position.) c. control Wheel Master Switch or Cutoff Button - Depress and -hold until step g. is accomplished·. ·d. PITCH TRIM Selector Switch - OFF. e. STALL WARNING Switches - OFF. WARNING: On any speed excursions beyond MMO, the elevator control must be smoothly and steadily applied to prevent encountering excessive aileron activity and airframe buffet. Beyond • 85 "M1, a ..

1. 5

g pull-up may be .sufficient to excite aileron activity and the g level must be limited to that required to maintain·la~eral control, AFTER AIRCRAFT CONTROL IS .REGAINED: f. Spoilers - Check retracted. g.' Autopilot's Pitch Circuit·B:,:eaker - Pull.· h. If control force continues, select other trim system and retrim the aircraft. i. Isolate malfunctioning system by switching systems ON one at a time. Pa~se between activating each system to determine the defective. system. 7. In Section IV, PERFORMANCE DATA, adja!=lent to the appropriate take.off charts, add the following: Increase all Chart V1 , VR and V2 speeds a. Model 23, 24, 24A, 24B, 24B-A, 24D,· 25A, 25B, 25C, with unmodified wings, plus 5 KNOTS Airspeed. by: 24D-A, 25, Indicated b. Model 23, 24, 24A, 24B, 24B-A, 24D, 24D-A, 25, 25A, 25B, 25C, with Howard/Raisbeck Mark II wings, plus 5 KNOTS Indicated Airspeed~. (Increase applies to FLAP 1 o and FLAP 20 charts, and is not applicable to FLAP 10 OVERSPEED chart.) 8. In Section IV, PERFORMANCE DATA, adjacent to each TAKEOFF DISTANCE CHART, add the following: Increase all chart takeoff distances by: a. Model 23, 24, 24A, 24B, 24B-A, 24D, 24D-A, 25, 25A, 25B, 25C, with unmodified wings, plus 10~.

APPENDIX G -48- weigbt is above 14,500 lbs. Fo.r takeoff weights above 14,000 lbs .• and below 14,500 lbs., reduce the we'ight to 14,000 lbs. Takeoff weight reduction .not applicable to FLAP 10 OVERSPEED, , o. In Section. 'Iv, PERFORMANCE DATA, adjacent; to LAt$!,DING APPROACH SPEEDS chart, add· the following: • , •· Increase all chart ,Landing Approach Speeds. by: a, Model 23, 24, 24A,, with unmodified wings, plus 8 KNOTS. Indicated Airspeed. . . b. Model 23, 24, 24A with ECR 736 (CJ'610-6 and Model 24B, 2~B-~, plus 4 KNOTS Indicated engines and increased gross weight), 24D, 24D-A, with unmodified · wings, Airspeed, . c, Model 25, 25A, with unmodified wings, plus 3 KNOTS Indicated Airspeed. . . .. d. Model 25, 25A, with unmodified wings with ECR 936 (AAK 70-5), plus 5 KNOTS·Indicated Airspeed. , e, .Model 25B,. 25C, with unmodified wings, plus 5 KNOTS Indicated Airspeed. , ,•f, Model ·23, 24, 2411, 24B, 24B-A, 24D, 24D-A, 25, 25A, ~SB, 25C, with Howard/Raisbeck Mark II wings, plus 5 KNOTS Indicated Airspeed. 11, In Section IV, PERFORMANCE DATA, adjacent to each LA!'.,DING DISTANCE CHART, add the following: Increase.all chart landing distances by: a, Model 23, 24 and 24A, 'with unmodified wings, plus 1 0%. b. Model 23 ,. 24, 24A with ECR 736 (CJ'61 0-6 e·ngines and increased gross weight) and Model 24B, 24B-A,' 24D, 24D-A, with unmodified. wings, plus 5%. · . c, Model 25, 25A, with unmodified wings, plus•4%. d, Model 25, 25A,'with unmodified wings with ECR 936, (A,AK70-5) plus 7%. e, Model 25B, 25C, with unmodified wings, plus f. Model 23, 24, 24A, 24B, 24B-A, 24D, 24D-A., 25, 25A, 25B, 25C, with Howard/Raisbeck Mark II wings, plus 7%, 12,, In Section IV, PERFORMANCE DATA, adjacent to the LA~DING WEIGHT LIMITS CHART, add the following: Reduce the Limiting Weight-Brake Energy l~nding weights as follows: · a, Model 23, 24, 24A, with unmodified wings, BOO lbs. b. Model 23, 24, 24A, with ECR 736 (CJ'610-6 ·• engines and increased gross weight)', and ·Model 24B,, 24B-A, 24D; 24D-A w1th unmodified wings, 400 lbs. c. Model 25, 25A, with unmodified wings, 300 lbs. • d, Mode.l 25., 2511, with unmodified wings with ECR 936 (A,\K70-5l, 500 lbs. e. Model 25B, · 25C, with unmodified wings, 500 25A, 25B, NOTE: paragraph duplicate f. Model 23, 24, 24A, 24B, 24B-A, 24D, 24D-A, 25, 25C, with Howard/Raisbeck Mark II wings, 500 'lbs. In order to comply with the requirements. of A of this Airworthiness Directive, this AD,'or a thereof, may be used as a temporary amendment to the 5 .·',) 'l:.,

top to stop)·. · Note the drag associated with control movement. Turn off the stall warnfng switches and repeat the rapid fore and aft movement. Note 'the decrease in drag, which is an indication that the elect-ric disconnect clutch functions properly by·disconnecting the drag of the pitch servo (torqu~r) from the control system. b. Effective on Models 23, 24, 24B, 24B-A, 24C, 25 and 25A l!-irplanes except airplanes incorporating Gat~s Learjet Kits AAK71-12 or AMKB0-3: , . · " (1) Check and adjust the pitch capstan slip clutch for proper torque in accordance with the appropriate Gates Learjet Service Manual.

APPENDIX G -50- C) On airplane Models 35, 35A, 36 and 36A, within the next 150 flight hours conduct the following inspection of the FC-'200 autopilot roll axis.to assure capability of manually overriding that axis of Automatic Flight Control Systems: • · · 1. Energize the airplane electrical system ... by applying 28 VD~ electrical power. 2, Check and adjust the roll.capstan slip clutch for proper torque in accordance with the appropriate Gates Learjet Service Manual. D) Submit a written report of any ou~ of tolerance of roll; yaw, or pitch axis capstan slip torque to the Federal Aviation Administration, Aircraft Certification Program, P.oom 238., Terminal B.uilding 2299, Mid-Continent Airport, Wichita, Kansas .67209. (Reporting approved by the Office .of Management an!i-Budget Order 0MB :No. 0II-R0174.) E) To as.$ure proper operation of the Stall Warning Accelerometer Unit, perform, within the next 25 flight hours, inspection of the Stall Warning Accelerometer in accordance · wit-h appropriate· Gates Learjet Service Bulletin SB 23, 24, 25- 301A, SB 28, 29-27-3A, or SB 35, 36-27-12A. Submit a written report on any c;J._.i.11~_rep·ancy discovered during this inspection to Federal Aviation Administration, •Aircraft Certification Program, Room 238, Terminal Building 2299, Mid-Continent Airport, Wichitc\, Kansas ·67209. (Reporting approved by Office of Management and Budget Order oi1B No. 04..-R0 17 4.) ·· NOTE: .The owner /operator is responsible for submitting reports required by this AD. F) Airplanes. may be flown in accordance with FAR 21.197 to a location where alterations and inspections required· ·by tqis directive can be· accomplished. · G) Any equivalent method of compliance with this AD must be.appr~ved_by the Chief, Aircraft ~ertification Program, FM Central Region. · ' This Emergency Airworthiness Directive (AD) letter supersedes the Emergency AD le.tter dated August 4, 1980, AD 8 0-16-06, ·on this same subject. This airworthiness directive becomes receipt. · effective upon FOR FURTHER INFORMATION CONTACT: _Larry Malir, Aircraft Certification Program, Systems and Equipment Section, Federal Aviation Administration Rc,om 238, Terminal Building 2299, Mid-Continent Airport·, Wichita; Kansas 67 2.09, telephone (316) 9112-11.281. · · 7

( ( -51- APPENDIX G GATES LEARJET Airworthiness Directive Final Cop~· of Letter \' olurnes I & JI 80-26-02 GATES LEARjET: Amendment 39-4015, Applies to 23, 24, 25, 28 and 29 series airplanes certificated in all categories. COMPLIANCE: Required as indicated, unless previously accomplished in accordance with AD 80-22-10. A) Before further flight: 1. Deactivate the pitch function of the FC-110 Automatic Flight Control System (AFCS) or Automatic Flight Control Stability System (AFC/SS), as indicated below, by pulling the AFCS Pitch DC Circuit Breaker to the off position, banding it to prevent use of this function and checking to assure this function is the only deactivated circuit or control: SERIES SERIAL NUMB:C::RS LOCATION 23 003 thru 014 Pilot's Switch Panel 015 thru 099 Pilot's Sub Panel 24 100 thru 139 Pilot's Sub Panel (except 131, 132 & 134) 131, 132 & 1:;4 Pilot's circuit breaker panel 140 thru 229 Autopilot computer rack (und~r pilot's seat) 230 and up Pilot's circuit breaker panel 25 003 thru 069 Autopilot computer rack (except 032) (under pilot's seat) 032 Pilot's Sub Panel 070 and up Pilot's circuit breaker panel 28 001 and up Pilot's circuit breaker .panel 29 001 and up Pilot's circuit breaker panel 2, Install a locally fabricated placard on or near the autopilot control head in clear view of the crew, us1ng letters at least 3/32 inch high, which reads: AUTOPILOT PITCH.AXIS INOPERATIVE OBSERVE APPROPRIATE AFM AIRSPEED LIMITATIONS FOR INOPERATIVE AUTOPI.LOT and operate the airplane in accordance with this placard, 3, Insert in the appropriate section of the existing Airplane Flight Manual (AFM) the FAA approved temporary Airplane Flight Manual Change dated October 22, 1980, pertaining to emergency procedures for pitch axis malfunction.

APPENDIX G -52- 2 B) On or before April 1, 1981, accomplish all of the following at a Gates Learjet authorized service center holding appropriate FAA repair station ratings (see attached list):

1. Visually inspect the elevator control

system to assure that Pitch Axis Servo (D,C. Torquer), P/N 6600163-( ) is installed, · a) If installed, modify the airplane by in""corporating autopilot pitch trim monitor test switch in accordance with Gates Learjet Airplane Modification Kit AMK 80-16B, Change 2. b) If not installed, modify the airplane by replacing the pitch servo actuator and capstan and incorporating autopilot pitch trim monitor test switch in accordance with Gates.Learjet Airplane Modification Kits AMK 80-3, Change 4, and-AMI< 80-16B, Change 2, respectively. 2. Insert in the appropriate sections of the existing Airplane Flight Manual (AFM) the FAA approved temporary Airplane Flight Manual changes dated October 22, 1980, for autopilot trim monitor. C) When paragraph B of this AD has been accomplished, the requirements of paragraphs A) 1 , and 2. of this AD are no longer applicable. D) Airplanes may be flown in accordance with FAR to a location where the requirements of this AD accomplished provided the autopilot is not operative that flight, . 21 • 1 97 can be during E) Any equivalent method of compliance with this AD must be approved by the Chief, Aircraft Certification Program, FAA, Central Region, Room 238,. Terminal Building No. 2299, Mid- Continent Airport, Wichita, Kansas 67209. This AO supersedes AD 80-22-1 o. · . This amendment becomes effective on January 15, 1981, to al-1 persons except those to whom it has already been made effective by an airmail letter from the FAA dated.December 11, 1980, and is identified as AD 80-26-02. FOR FURTHER INFORMATION CONTACT: Larry Malir, ACE-213, Aircraft Certification Program, FAA, Room 238, Terminal Building No. 2299, Mid-Continent Airport, Wichita, Kansas 67209; telephone (316) 942-4281.

t -53- APPENDIX G EMEBGENCY AIBWOBTHINESS l>lllECTIVE DEPARTMENT OF TRANSPORTATION . FEDERAL AVIATION ADMINISTRATION ""'~ 'PLtGNT STANO&ll:01 NATIONAL FIELD 0,FtCE a~ P.O. IOX 21012 S. OltLAHOMA CITY, 0«.LAHOMA 111.15 % • • December 11, 1980 't -~ . ~ ,,,. .. ,. 61.ijru OI • our records indicate you are the owner of one or more Gates .(.earjet. 23, 24, 25, 28 and 29 series airplanes. An emergency Airworthiness Directive (AD) letter, AD 80-22-10, dated .. October 23, 1980, was mailed by the FAA to registered owners of the aforementioned Gates Learjet aeries airplanes. The AD required, prior to further flight, deactivation of the FC-110 autopilot pitch axis and compelled the crew to observe appropriate Ai:r;plane Flight Manual (AFM) limitations for an inoperative autopilot and emergency procedures for pitch axis malfunction. The AD further required on or before January 1, 1981, modification of the airplane ·· by requiring (1) replacement of the existing pitch axis servo and capstan with a D.C. torquer, (2) inspection of the autopilot trim coupler board to assure that the proper transistors are installed and (3) incorporation of a trim monitor preflight test switch. Upon accomplishment of these three requirements, and an addition to the AFM describing the function and use of the trim monitor, the autopilot pitch axis may be reactivated. Immediate adoption and effectiveness of AD 80-22-10 was necessary to reduce the hazard created by a possible pitch axis malfunction which, if not detected, could result in a hazardous flight attitude. Subsequent to the issuance of AD 80-22-10, the manufacturer revised Airplane Modification Kits AMK 80-3 and A.IIUC 80-16. AMK 80-3 referred to in paragraph B)1.b) of the AD has been revised to include Change 4, This change incorporates a revised Jet Electronics· and Technology, Inc, (J.E.T.) Service Bulletin, a Parts Required List clarification, and footnotes to the kit instructions. AMK 80-16 referenced in paragraph B)1.al and bl of the AD has been reidentified as AMK 80-16B, Change 2. Revision B added a relay assembly to the trim preflight test circuitry and Change 2 specified an operational check of the Autopilot Pitch Trim System plus parts list changes. The temporary Airplane Flight Manual referenced in paragraph B)2 of the AD bears the date of October 21, 1980. This date is incorrect. It should reflect the date of October 22, 1980. Numerous operators and other interested persons 'ilave objected to the compliance date of January 1, 1981, Jeferenced in paragraph Bl of the AD. The basis for these objections is the insufficiency of time and work facilities for the nine service centers listed in the AD to accomplish the required modifications. The FAA has investi,ated the •ituation and has verified the accuracy of these objections. Consequently, the compliance time is being extended to April 1, 1981, Concurrently, six additional service centers are EMERGENCY AIRWORTHINESS DIRECTIVE

APPENDIX G -54- 2 being added that are authorized to accomplish the modifications. This action will prevent an undue hardship which would be caused if operators are forced to terminate operations because of service center workload and will not adversely compromise the safe operation of unmodified ai .. rplanes. Since the condition described herein is likely to exist or develop in other aircraft of the same type design, an emergency AD is being issued, superseding AD 80-22-10. This .new AD will reiterate the substance of AD 80-22-10 and, at the same time, incorporate the changes mentioned herein. The superseding AD will not require repetition of those requirements previously accomplished by AD 80-22-10. Pursuant to the authority of the Federal Aviation Act of 1958, as amended, delegated to me by the Administrator, the following .. Airworthiness Directive (AD) is effective immediately ~n receipt of this letter and reads as follows: 80-26-02 GATES LEARJET: Letter issued December 11, 1980. Applies to 23, 24, 25, 28 and 29 series airplanes certificated in all categories. COMPLIANCE: Required as indicated, unless previously ."\ ), accomplished in accordance with AD 80-22-10, -", i A) Before further flight: _J1, 1. Deactivate the pitch function of the FC-110 Automatic Flight Control System (AFCS) or Automatic Flight Control Stability System (AFC/SS), as indicated below, by pulling the AFCS Pitch DC Circuit Breaker to the off position, banding it to prevent use of this function and checking to assure this· function is the only deactivated circuit or control: SERIES SERIAL NUMBERS LOCATION 23 003 thru 014 Pilot's Switch Panel 015 thru 099 Pilot's Sub Panel 24 1 00 t.hru 139 Pilot's Sub Panel· (except 131, 132 , 134) 131 , 132 & 1311 Pilot's circuit breaker panel 140 thru 229 Autopilot computer rack 230 and up (under pilot's seat) Pilot's circuit breaker panel 25 003 thru 069 Autopilot computer rack (except 032) (under pilot's seat) 032 .Pilot's Sub Panel 070 and up Pilot's circuit breaker panel 28 001 and up Pilot's circuit breaker panel :! 9 001 and up Pilot' • circuit breaker panel )), I

( 'l -55- APPENDIX G 2. Install the autopilot control letters at least 3/32 3 a locally fabricated placard on or near head in clear view of the crew, using inch high, which reads: AUtOPILOT PITCH AXIS INOPERATIVE OBSERVE APPROPRIATE AFM AIRSPEED LIMITATIONS ·FOR INOPERATIVE AUTOPILOT and operate the airplane in accordance with this placard. 3. Insert in the appropriate •ection of the existing Airplane Flight Manual (AFM) the FAA approved temporary Airplane Flight Manual Change dated October 22, 1980, perta_ining to emergency procedures for pitch axis malfunction. B) On or before April 1, 1981, accomplish all of the following at a Gates Learjet authorized uervice center holding appropriat.e FAA ·repair station ratings (see attached list) : 1·. Visually inspect the elevator control system to assure that. Pitch Axis Servo (D.C. Torquer), P/N 6600163-() is installed. , al If installed, modify the airplane by incorporating autopilot pitch trim· monitor test switch in accordance with Gates Learjet Airplane Modification JCit AMI< 80-16B, Change 2 •. b) If not installed, modify the airplane by replacing the pitch servo actuator and capstan and incorporating autopilot pitch trim monitor test switch in accordance with Gates Learjet Airplane Modification Kits AMK 80-3, Change 4, and AMK 80-16B, Change 2, respectively. 2. Insert in the appropriate sections of the existing Airplane Flight Manual (AFM) the FAA approved temporary Airplane Flight Manual changes dated October 22, 1980, for autopilot trim monitor. C) When paragraph B of this AD has been accomplished, the requirements of paragraphs A)1. and

1. of this AD are no

longer applicable. D) Airplanes may be flown in accordance with FAR to a location where the requirements of this AD accomplished provided the autopilot is not operative that flight. 21 .197 can·be during E) Any equivalent method of compliance with this AD must be approved by the Chief, Aircraft Certification Program, FAA, Central Region, Room 238, Terminal Building No. 2299, Mid- Continent Airport, Wichita, Kansas 67209. This emergency AD supersedes AD 80-22-10 and is effective upon receipt. FOR FURTHER INFORMATION CON.TACT: Larry Malir, Aircraft Certification Program, Systems and E~u~pment Section, Federal Aviation Ad~inistration~ Room 238, Terminal Building 2299, Mid-Continent A:i.rport, Wichita, Kansas 67209; Telephone (316) 942-4281.

APPENDIX G -56- GATES LEARJET Airworthiness Directive Volume I & II 81-16-08 GATES LEARJET: Amendment 39-4184. Applies to the following models and serial number airplanes certificated in any category: MODELS 24E, 24F 25D, 25F SERIAL NUMBERS 350, 352, 353, 354, 356, and subsequent 206 thru 336 338 thru 341 LEARJET AFM DESIGNATION 24-350, 24-352, 24-353, 24-354, 24-35.6 and subsequent 25-206 thru 25-336, 25-338 thru 25-341 COMPLIANCE: Required as indicated, unless previously accomplished. To assure that the crew is•provided with limitations for the safe operation of the airplane and to reduce the possibility of an unsafe condition resulting from a system's malfunction, accomplish the following: A) Before further flight, insert the following information in the FAA Approved Airplane Flight Manual and operate the airplane in accordance with these limitations: 1. In Section 1, LIMITATIONS, adjacent to MAXIMUM OPERATING ALTITUDE: a. Delete any procedures relative to maximum operation altitudes of 51,000 feet. b. Add the following limitation for Model 25D/F: Aircraft 25-230 and subsequent: "The maximum operating,altitude is 45,000 feet. This is the highest altitude for which acceptable flight characteristics and systems operation have been demonstrated." c. Add the following limitation for Model 24E: 355: Aircraft 24-350, 24-352 and subsequent, except 24- "The maximum operating altitude is 45,000 feet. This is the highest altitude for which. acceptable flight characteristics and systems operation have been demonstrated." d. Add the following limitation for Model 24F: Aircraft 24-350 and subsequent when CJ610-BA engines are installed: "The maximum operating altitude is 45,000 feet. This is the highest altitude for which acceptable flight characteristics and systems operation have been demonstrated." B) In order to comply with the requirements of paragraph A) of this Airworthiness Directive, this AD, or a duplicate thereof, may be used as a temporary amendment to the Airplane Flight Manual and c_arried in the aircraft as part of the Airplane Flight Manual until replaced by revisions to the -Airplane Flight Manual provided by the manufacturer and approved by the FAA. The Airplane Flight ~anual changes

C 2 C -57- APPENDIX G required by paragraph A) of this AD may be accomplished by the holder of at le.ast a private pilot certificate issued under Part 61 of the Federal Aviation Regulations on any airplane owned or operated by that person who must make the prescribed entry in the Airplane 'Maintenance Records indicating compliance with paragraph A) 'of this AD. , . C) Prior to accomplishing the modification required by paragraph D) of this AD, contact th~ FAA office noted in paragraph F) if any modification or alteration has been performed on the affected airplane for further instruction relative to the compatibility of the modification of this AD. D) On or before February 28, 1982, accomplish the following at an FAA certificated maintenance, repair agency utilizing qualified technicians who must have ·recent accessory overhaul 'experience performing the overhaul test of the Gates Learjet Horizontal Stabilizer Trim Actuator with the nec.essary shop equipment (Attachment I hereto) as referenced in Learjet Repair Manual Number 1711-9, or the equivalent equipment, in accprdance with modification, inspection and installation instruction of the following Learjet Modification Kits, AMR 81-7, Change 1, AMK 81-8 and AMR 80-13, Change 3. 1. Modify Learjet. Model 25D and 25F flight control systems, stall w~rning system and control wheel in accordance with Gates Learjet Airplane Modification Kits .AMK 81-7, Change 1, AMK 81-8 and AMK 80-13, Change 3, respectively. 2. Insert in the appropriate-sections of the existing Airplane Flight Manual ·(AFM) the FAA-approved temporary Airplane Flight Manual Change dated June 8, 1981, pertaining to procedures required as a result of the modification of flight control system in accordance with Airplane Modification Kit A~1K 81-7, Change 1. E) Airplanes may be flown in accordance with FAR 21.197 to a location where modifications required·by this AD can be accomplished. · F) Any equivalent method of compliance with this AD be approved by· the Chief, Aircraft Certification Program, Central Region, Room 238, Terminal Building No. 2299, Continent Airport, Wichita, Kansas 67209. This amendment becomes effective on July 31, 1981. FOR FURTHER INFORMATION CONTACT: must FAA, Mid- Larry Malir, ACE-213, Aircraft Certification Program, FAA, ,Room 238, Terminal Building No~ 2299, Mid-Continent Airport, Wichita, Kansas 672091 telephone (316) 942-4281.

APPENDIX G ,-58- AD 81-16-08 ATTACHMENT I The stabilizer actuator test.stand (P/N ST-00463) is used to functionally test the stabilizer actuator after overhaul. The physical structure of the' test stand must be capable of withstanding a minimum load of 2500 lbs. without any bending or deformation. The s,tabilizer actuator is vertically mounted on the test stand with one end stationary and the other end movable through a hydraulic actuator. The test stand consists of the following components: a. Hydraulic Actuator - The hydraulic actuator is capable of applying a regqlated load of Oto 2500 lbs. on the stabilizer actuator during the entire extend or retract cycles. b. Hydraulic Pressur.e Regulator - The pressure · regulator is used to select hydraulic pressures applied to the stabilizer actuator during the functional.test. c.

Hydraulic Pressure Gauge

The hydraulic pressure . gauge is used to monitor hydraulic pressure applied to the stabilizer actuator. The gauge must be certified at least monthly. d. Digital Position Readout. - .The digital position readout indicator is used to monitor the travel of the stabilizer actuator. Signals to the indicator are picked up from a rigid mounted linear potentiometer and .movable wiper attached to the hydraulic actuator. The digital readout is accurate· to 1/1000th of an inch. e. Linear Scale - A lii;iear scale, graduated in 100th of an inch, is permanently mounted on the test stand to verify the digital readout. A tool of known length is used to verify the linear· scale and digital readout before the stabilizer, actuator functional test is performed. The tool length must be certified at least yearly. ) ) f. La1;>se Timer - A lapse timer is coupled to _the control switches and the stabilizer ac,tuator to monitor travel time during the extend and retract cycles. The lapse timer must measure seconds and be accurate to 1/100th ), of a second. ·

r ·. \ t ( -59- APPENDIX G g. Tr.im Controller - The trim controller is used to simulate two-speed input to the stabilizer actuator primar.y motor. The trim controller part number is EM 2.079-6 • h. . Pre-Select Timer check stabilizer amperage inputs . test.

• The pre-select timer is used to

actuator travel vs.• time, voltage and in accordance with the functional i. Power Supply - The power supply is variable through 0- 30 volts DC and 0-30 amperes DC. ! j • k. DC Voltmet.er - The DC voltmeter must be capable of measuring 0-30 volts DC and. must be certified at least yearly·. The voltmefer is used to monitor the voltage inputs to the stabilizer actuator in accordance with the· functional test. DC Ammeter - The DC ammeter must be capable of measuring 0-30 amperes DC and must be certified ·at least yearly. The ammeter is used to monitor the amperes inputs to the stabilizer actuator in accordance with the functional test.

1. Millivolt Meter -

The millivolt meter is used to monitor the stabilizer actuator linear potentiometer for .a smooth and steady signal output. The meter is 0-50 vol~s graduated in 1oo·mv increments. m. Switches - Necessary switches installed to operate the stabilizer actuator primary and secondary motors to extend or retract. n. A digital or,Simpson 260 meter, not a !?art of the test stand, . is used to verify the resistance of the stabilizer actuator linear potentiometer. The digital or Simpson 260 meter must be certified at least every 90 working days. AD 81-16-08 2

-60- APPENDIXH NTSB SAFETY RECOMMENDATIONS NATIONAL TRANSPORTATION SAFETY BOARD

WASHINGTON, O.C.

Forwarded to: Honorable Langhorne M. Bond Administrator Federal Aviation Administration Washington, D.C.

20591

ISSUED: April 18, 1979 SAFETY RECOHHENDATION(S) A-79-21 tbrPYib -24 The National Transportation Safety Board has recently investigated an incident which caused concern about the continued safe operation of certain L~arjet aircraft. The pilot of a Learjet Model 24B, Nl4BC, reported' longitudinal control problems on March 9, 1979, while en route from Greensboro, North Carolina, to Nashville, Tennessee. While cruising at altitude, the aircraft abruptly' pitched nosedown. The pilot regained control,and deactivated the aircraft's stall warning system and automatic flight control system. After the airi::raf,t was configured for !anding, during an instrument approach to Nashville, 'it became longi- tudinally unstable. The pilot,: who was unable ,to control the pitching oscillation, aborted the approach. As 'airspeed was increased, the aircraft became controllable. The pilot declared an emergency and returned to Greensboro where better weather' existed., Similar problems were encountered while attempting to land at Greensboro.. Three approaches were aborted before the aircraft was landed. The fourth approach was conducted. without flaps, at a higher-than- normal airspeed, and with'stabilizer trim for.pitch control. Postflight examination of the aircraft disclosed a resistance to motion of the longitudinal control system which was traced to the pitch axis servo drive unit. The unit was replaced and the aircraft was test flown without the control problems. 2631 ) ly ))

( -61- APPENDIX H

• 2 -

The National Transportation Safety Board took custody of the malfunctioning servo drive unit, and it was examined at the Gates Learjet plant in Wichita, Kansas. This unit consists of an electric motor which runs continuously in one direction when either the automatic pilot or_ the stall warning stickpusher system is energized. The output shaft of the motor drives a pair of electromag~etic friction drive clutches. These clutches rotate in opposite directions and their output shafts. are connected to a conunon output, which in turn drives the elevator control surface. The clutches contain ferrous powder. Normally, this ferrous powder coagulates into a solid mass only when a magnetic field is introduced electrically by inputs from the autopilot or stall warning stickpusher system. The clutch, which is energized, will transmit torque to the elevator control system in the appropriate dire.c'tion. The powder normally decoagulates and the clutch rotates freely when electrical power is removed. llxamination of the servo drive unit removed fr.om Nl4BC revealed that the ferrous powder in• the clutch which trans- mitted motion in the elevator trailing edge down direction was solid, although there was no e1ectrical input. With the aircraft's autopilot or stall warning ·system activated, this condition would produce a nosedown pitching moment which could require as much as 80 pounds force on the control wheel to counter. With power removed from the servo motor, the jammed clutch would still affect the breakout force and. force gradient of the longitudinal control system, The other clutch of the servo was examined and it was. free to rotate. Gates Learjet personnel theorized that ·the powder coagulated and caused the clutch to jam because of moisture contamination. Reportedly, various degrees of moisture contamination and clutch engagement have been found on other servos that have been overhauled at Gates Learjet in the past. The ferrous material of both clutches of the servo was later-examined at the Safety Board's metallurgical labora- tories; 110 foreign substance was found. The materia_l in · both clutches was determined to be of the same approximate .chemical composition. However, some of the particles ·of the ferrous powder from the jammed clutch continued to coagulate into small hard lumps, The reason for this is unknown and indicates that some undetermined property of the ferrous clutch material is causing the clutch to jam without the magnetic field.

APPENDIX H

-62-

3 - The Safety Board was informed. by the operator that the same aircraft experienced a lateral control problem on March 29, 1979. This time the aileron servo drive unit, identical to the pitch servo, was found to have a defective clutch. This unit has not yet been disassembled for detailed examination. The Safety Board is aware that Gates Learjet has dis- continued the use of this JET Electronic' s par.t No. 2380066 in new aircraft. However, we have been informed that there are approximately 220 Learjet aircraft equipped with these servo drive units in operation. Furthermore, the pitch servo drive unit is a mandatory item for flight since it is an integral part of the stall warning stick·pusher system which was required by the certification of the aircraft. Two recent fatal accidents involved loss of''control of Learjet model 25 aircraft which were equipped with the same type of servo drive.units. These accidents are still under investigation. Additionally, a review of our accident files indicates fo us that 10 other accidents·since 1964 involving Learjet aircraft, ·which we believe were'equipped with these servo dTive units,. may have been_ caused by control problems. However, the lack'of postaccident evidence precluded identi- fication of such a problem. Our investigation into this matter is ~ontinuing• In view of, the potential catastrophic results nl' control difficulties caused ~y jammed servo drive unit clutches, the Safety Board is extremely concerned and believes expedited action is justified. Therefore, the National Transportation Safety Board recomm~nds that the Federal Aviation Administration: Initiate a program immediatel~ to expedite the determination of cause for the clutch malfunction •in JET Electronic part No; 2380066, servo drive unit, d.evise a means to detect potential problems, and define corrective action. (Class !--Urgent Action) (A-79-21) If defining and implementing the corrective action described above will require prolonged effort, restrict the operation of all Learjet aircraft equipped with this servo drive. unit. (Class I-- Urgent Action) (A-79-22) I ; . /

( ( -63- APPENDIX H

• 4 -

Issue immediately an Operations Alert Bulletin to FAA inspectors and notify operators of Learjet aircraft equipped with this type of servo drive unit to advise the pilots of these aircraft of the possible control difficulties which can be en- countered as a result of clutch malfunction. (Class !--Urgent Action) (A-79-23) Determine whether other model aircraft use the same servo drive unit clutches and take appropriate action to advise the operators of those aircraft of the potential problem. (Class !--Urgent Action) (A-79-24) KING, Chairman, DRIVER, Vice Chairman, McADAMS, and HOGUE, Members, concurred in the above recommendations. ~~Ve ., V Chairman

APPENDIX H -64- NATIONAL TRANSPORTATION SAFETY BOARD

WASHINGTON, D.C.

Forwarded to: Honorable Langhorne M. Bond Administrator Federal Aviation Administration

Washington, D,C, 20591

ISSUED: June 27, 1980 SAFETY RECDMMENDATIDN(S) A-80-S3 through -55 . On May 6, 19go, a Learjet model 23 aireraft crashed while attempting a night landing on runway 33 Qt BYl"d Field, Richmond, Virginia. The skies were cle~r, visibility was 10 mi, and the wind was calm. Although the Learjet was slighUy high on the approach, it descended normally in a landing attitude. But before touching down, the aircraft yawed and· rolled, and first the right wingtip fuel tank and then the left tiptank struck the runway. Thereafter, the- nose of the aircraft pitched up, the engine thrust increased, the aircraft rolled to the right, and it crashed in a nearly inverted attitude. A fire erupted after impact, and· both pilots, the only persons .aboard, were killed, The aircraft had been manufactured in 1964. Available optiOnal slow-flight modifications installed on many Learjets had not been installed on this aircraft. During the past 2 years, the Safety Bqard has investigated several Learjet accidents in which the aircraft while on the landing approach exhibited similar roll and yaw, maneuvers followed by a loss of control and a crash. The other Learjets involved were models 24, and 25 aircraft, with the Century m and Raisbeck slow-flight modifications. The investigation revealed that in each landing accident, the aircraft apparently was flown, as specified, with the yaw damper disengaged, although the altitude at which the yaw damper was disengaged could not be verified. The accident records indicate that turbulence, crosswinds, wing icing, pilot technique, or other conditions had disturbed the aircraft's equilibrium during a flare or go--around· maneuver and that erratic roll and yaw maneuvers and a loss of aircraft ccintrol ensued. Subsequent flight tests indicated that an increase in engine thrust during an attempt to recover the aircraft may cause roll oscillations to become more pronounced and may reduce the likelihood of recovery. In February 1979, the National Transportation Safety Board, the Federal Aviation Administration, the Gates Learjet Corporation, the National Aeronautics and Space Administration, and other interested parties participated in· a "Study of Selected Performance Characteristics of Modified Learjet Aircraft." The objectives of the_ study were to examine the operation of the stall warning system, to determine the most probable effect of small amounts of_ ice on· stall characteristics, and to study the low- speed handling qualities of the modified aircraft in a landing configuration. The study found some limitations in the effectiveness of the anti-ice system and potential problems with premature ice-induced stalls.· · 2999

( i / . -65- APPENDIX H -2- Although Icing conditions and turbulence were not evident in the Richmond accident, the Influences of turbulence and ground effect may have been significant fact~rs in some of the Learjet accidents. Since the·· accident history of the aircraft indicates that the flight behavior may i;,e .unpredictable under certain conditions and loss of control may occur unexpectedly, the. Safety Board is concerned that the 1979 study may not have Identified all of the factors which can lead .to erratic rolling of the Learjet in the landing phase, We also believe that the reasons for the ensuing loss of control have not yet been fully explored. The Safety Board Is also investigating three Learjet accidents which have involved loss of control at high altitude and which terminated in high-speed descents 'into the ground, One aircraft was on a training flight at 17,000 ft, and another aircraft was cruising en route at 41,000 ft, Both aircraft departed from level flight and entered steep descents from which the crews did not recover, The descents apparently were .unexpected and occurred without warning. In .the training accident, we believe that the pilots may have .been practicing en emergency procedure for runaway stabilizer trim when the aircraft became uncontrollable. In the third accident, which, occurred on May 19, 1980, a Learjet crashed Into the Gulf of Mexico following an unplanned departure and high-speed descent from the aircraft's cruise altitude of 43,000 ft. The preliminary investigation .of this accident disclosed 'that a cutout ·switch had been Installed which could be used to silence the Mach overspeed warning horn. Similar horn warning cutout switch Installa- tions were found In other Learjet aircraft during inspections required following the May 19; 1980, accident. · · In the high altitude loss of control situations, the possibilities under consideration are that a malfunction in the flight control system, turbulence, aerodynamic characteris- tics, or flightcrew action could lead to an upset and further loss of control. Accident records indicate that once high speeds and steep descents have been established, complete loss of control may result and recovery may be Impossible. For the foregoing reasons, we believe that the the flight characteristics of the Learjet aircraft In both the low-speed landing environment and the high-speed, high- altitude cruise ·environment should be thoroughly, examined to gain a better understanding of the aerodynamic factors associated with these accidents. Without this information, we believe that measures to assure safe flight cannot .be developed. In addition, the Board Is aware that Gates Learjet Service Issued News Letter 49 · dated May 19110 pertaining to procedures to be followed If the aircraft inadvertently exceeds V /M . These procedures specify that the spoilers should not be, extended if a pitch axis'Hi'limlH8tion or a runaway trim situation is apparent. The reason stated is that the· nosedown pitch change that the spoilers produce may aggravate a nosedown pitch problem, The Board Is concerned that this Information Is not Included in the aircraft fiight manual and that operators may not be aware of the consequences of spoiler extension In these situations, Furthermore, the procedures for slowing the aircraft from excess speed, as specified in the newsletter, Include the extension of the landing gear. It Is 'the Board's understanding that this procedure has not been evaluated during actual flight conditions. The B08l'd believes that it would be appropriate for the FAA to evaluate these procedures and If they ere deemed to be effective they should be lnccrp immediately In the aircraft flight manual.

APPENDIX H -66- -3- Accordingly, the National' Transportation Safety Board recommends that the Federal A via ti on Administration: · Convene a Multiple Expert Opinion Team to evaluate the'flight characteristics and: handling qualities, of Series 20 Learjet aircraft, with end without slow flight modification, at both low- and high-speed extremes of the operational flight envelope under· the most critical conditions of weight and balance (and other variable factors) and to establish the acceptability of the control and airspeed margins of the aircraft at thes!'d extremes. (Class I, Urgent Action) (A-80-53) • ' • t Advise ell Learjet operators of the circumstances of recent accidents and emphasize the prudence of rigid adherence to the specified operational iimits , and recommended operational procedures. ,(Class I, Urgent Action) (A-80-54) Evaluate information contained, in the Gates Learjet Service News Letter 49 dated May 1980 pertaining to procedures to ,be followed If the aircraft · inadvertenU:y exceeds V m.JMmo and, based on this evaluation, require appro=- priate revisions to the lUrcrart flight manual. (Class I, Urgent Action) (A-80-55) KING, Chairman, ,DRIVER, Vice Chairman, McADAMS and concurred in these recommendations. GOLDMAN, M ber, did no Members, ) '

(I . -67- NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. ISSUED:

June 29, 1981

Forwarded to: APPENDIX H Honorable J, Lynn Helms Administrator Federal Aviation Administration Washington, D. C, 20591 SAFETY REC0MMENDATI0N(S) A.-81-69

· On December 7, 1980, both engines of a Continental Oil Company Lear Model 25 named out at about 40,000 feet while the aircraft was climbing to 43,000 feet northwest of Childress, Texas. An emergency descent was made through heavy rain, turbulence, , and lightning, during which airstart attempts were · not successful. However,. after passing through 25,000'feet, the engines were restarted and the aircraft made a precautionary landing 'at Childress. No one was injured, and' the aircraft was not damaged, An investigation into the cause of the fiameouts was conducted by the Safety Board with the assistance and cooperation of the Federal A via.ti on Administr&tion's New England Region Engineering and Manufacturing Branch and the General Electric Co., the engine manufacturer. Extensive testing and a teardown examination of the General Electric CJ610-6 engines determined that, the flameouts were caused by reduced engine stall margin due to excessive compressor blade tip clearance and excessive compressor case rtinout. Although both engines had been overhauled shortly before the incident, no evidence was found to confirm that the problem could have originated at overhaul. The manufacturer could not explain the cause of the case runout and, tip rub that led to ·increased clearances. A review of the service history between 1976 and 1980 of General Electric CJ610-6 engine-equipped Lear aircraft revealed at least 30 other instances of engine name at' eltitude, although the December 7,1980, incident was the only reported instance of the loss of both engines. Sixteen of the reported flameouts were · attributed to excessive compressor clearances. Nearly all of the flameouts occurred at altitudes near or above 40,000 feet. Some other: aircraft ere equipped with CJ610-6 engines, but those aircraft are generally operated at lower eltitudes than the Lear aircraft. The service history of those aircraft has been reviewed and only two incidents of flameout were reported during the same period. 3279

APPENDIX H - -68- -2- The Safety Board is aware that the engine and aircraft manufacturers are conducting a test and research program to develop a solution to the -loss of engine stall margiri. However, we are concerned that until a method is developed for ret;overing or preventing reduction of stall margin, the potential for an accident exists, Because the engine maintenance and overhaul manuals provide a method for determining loss of stall margin, the Safety Board believes It should be used periodically to check engines for decreased stall margin and that appropriate operating restrictions should be applied to those engines so Identified. The manufacturer has proposed a one-time altitude stall .and acceleration .ch.eek to identify engines for which a stall margin recovery fix would be necessary. However, those engines which pass this check may later develop a reduced altitude stall margin, For this reason, the Safety Board believes the check should be required- periodically to identify engines which might be susceptible to altitude fiameout. Therefore, the National Transportation Safety Board recommends that the Federal A vlatlon Administration: Issue an Airworthiness Directive to: (I) require, at appropriate periodic Intervals, the performance of the altitude acceleration and stall check procedure defined In the CJ610·6 overhaul manual on Lear aircraft with General, Electric CJ&l0-6 engines installed; and (2) restrict the maximum operating altitude of those engines shown by· the test procedure to have a reduced altitude stall margin until the manufacturer has developed a satisfactory method for recovering stall margin and it is

Incorporated in those engines. (Class n, Priority Action) (A-81-69)

KING, Chairman, DRIVER, Vice Chairman, McADAMS, GOLDMAN, and BURSLEY, Members, concurred in this,recommendation. ) ) _)

( ( -69- APPENDIX I FAA RESPONSE LETTER DEPARTMENT OF TRANSPORTATION FEDERAL AVIATION ADMINISTRATION WASHI-, D.C. 20591 September 25 1 1980 OFflC[ OF The Honorable James B. King Chairman, National Transportation Safety Board THE ADMINISTRATOA 800 Independence Avenue Washington, D.C. 20594 Dear Mi:• Chaim&~: This acknowledges receipt of NTSB Safety Recommendations A-80-53 through 55, delivered by the Board on Friday, June i1, 1980, at 5:40 p.m., after close of official business. These recommendations were based on,the Board's investigations of accidents involving Series 20 Learjet aircraft in the low-speed l&nding configuration and high-speed, high-altitude cruise environment. The Federal Aviation Administration (FAA) is aware of the facts cited by the Board in its June 27 transmittal letter and has aggressively pursued corrective actions. relative to these problems., A review of the accident data pertaining to these aircraft was initiated immediately following ihe May 6 accident at Richmond. On June 9, 1980, the Safety Analysis Division, Office of Aviation Safety submitted an analysis of Learjet accidents and Service Difficulty Reports to the Air Transportation Diviaion1 Office of Flight Operations. The analysis indicated a need for reevaluation of Learjet systems and subsystems concerning stick pusher and shaker, autopilot pitch end roll, elevator, aileron and throttle cables. The analysis' determined that aircrafC,contrQl was involved in approximately 30 percent of the 49 accidents used in the analysis. Aircraft control involved overshoot, undershoot, runway alignment, and flying speed; but pilot flight-hour· experience did not appear to be a factor. Based upon the analysis and the informatiori presen~ly available through the accident inVeetigation, we have initiated actions which address the subject of the recommendations as follows. A-80-53. Convene a Multiple Expert Opinion Team to evaluate the flight characteristics and handling qualities of Series 20 Learjet aircraft, with and without slow flight modification, at both low- and high-speed extremes of the operational flight envelope under the most critical conditions of weight and balance (and other variable factors) and to establish the,acceptability of the control and airspeed margins of the aircraft at these extremes. Comment. This recommendation has already been encompassed in an earlier investigation involving all Learjets, including the Series 20. This 1nveatigetion was a followup to the February 1979 "Study of Selected Performance Characteristics of Modified Lear Jet Aircraft" in

APPENDIX I -70- 2 which the NTSB, FAA, Learjet Corporation, National Aeronautics ~nd Space Administration, and other interested parties participated. As a result of the investigation, Airworthiness Directive (AD) 79-12-05 was issued (copy enclosed). Also, a separate investigation was initiated by the FAA on June 17, 1980, to accomplish a certification review which will also'include other areas not specifically ·addressed in the Board's recommendations. Although this review is-'still in its initial stages, Preliminary information developed as a result of joint FAA and Gates Learjet Corporation flight evaluations has evidenced characteristics· at the limits of their operating envelope which in combination with presently approved operating procedures could adversely affect safety of flight. In light of the-foregoing, on August l, the FAA Central Region issued by airmail letter an emergency airworthiness directiv~ (c_opy enclosed) to Learjet aircraft owners. Since our investigation and review is incomplete, we will make Our findingS available to the Board when we complete our research. A-80-S4. Advise all Learjet operators of the circumstances of recent accidents.and emphasize the prudence of rigid -adherence to the specified operational- limits and recommended operationa_l procedures. Comment. :immediately upon receipt of NTSB Safety Recommendation A-80-54, a notice, which included -the Board's entire transmission (copy enclosed), was Sent to all Learjet operators. In addition, a GENOT was telegraphed to all FAA General Aviation District Offices (GADO's), Flight Standards District Offices (FSDO'.s) and Air Carrier District Offices (ACD01s), directing that all Learjet Part 91, i21, and 135 operators be contacted to verify that the operators received the notice and were fully aware. of the contents of NTSB Safety· Recommendation A-80-54. A-80-S5. Evaluate information contained in the Gates Learjet Service News Letter 49 dated May 1980 pertaining to procedures to be followed if the aircraft inadvertently exceeds VmolMm.0 and, based on this evaluation, require appropriate revisions to the aircraft flight manual. Comment. This recommendation is included in FAA's investigation described above in our comments relative to NTSB Safety Recommendation A-80-S3. Also, FAA's Office of' Flight Operations has established a separate team to review the adequacy and effectiveness of Learjet crew training. In addition tO these actions which are ·being taken in direct response to NTSB Safety Recommendations A-80~53 .through SS, a GENOT (copy. enclosed) was also distributed on May 22, 1980, .to all GADO's, FSDO's. and ACDO's. This GENOT requested the immediate inspection of all Learjet aircraft for installation of mach warning cut-out switches. To date we have noted seven instances of ai?'craft with unapproved cu't-out switch installations, and· these all ·have now been removed. ) I

'1~ / \ ' ' -71- 3 Finally, on June 2, 1980, a special issue ·of General ~viation Airworthiness Alerts was published (copy enclosed). This alert addressed the subject of unapproved alterations •·ot' speed warning systems in both.air carrier and general aviation aircraft. We will continue to keep the Board informed of our findings as the investigation progresses. ~~7?£ Administrator 4 .Enclosures APPENDIX I *u.s. GOVERNMENT PRINTING OFFICE1 19Bl-0-J61-828/82

FD07073 ｜ 1982_美国_PAB8201.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1982 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

'. , . . , PB82-916901 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 PIPELINE ACCIDENT REPORTS BRIEF FORMAT SUMMARY .FORMAT ISSUE NUMBER 1 -- 1982 NTSB-PAB-82-1 UNITED STATES GOVERNMENT REPRODUCED BY NATIONAL TECHNICAL INFORMATION SERVICE U.S. OEPARTllEllT Of COMMERCE SPRlllGFIElD, VA 22161

TECHNICAL REPOP.i DOCUMENTATION PAGE 1 • Report No. J 2.Government Accession No. 3.Recipient's Catalog No. NTSB-PAB-82-1 PB82-916901 ~. Title and Subtitle 5.Report Dat~ Pipeline Accident Report - Summary Format, January ?.2. 1982 IMue Number 1 1982 6.Performing Organization Code

1. Author{s)
2. Performing Organization

Report No.

1. Performing Organization Name and Address
2. Work Unit No.

National Transportation Safety Board 3388A 11.Contract or Grant No. Bureau of Accident Investigation Washington, D.C. 20594 13.Type of Report end Period Covered )~.Sponsoring Agency Nam~ and Address 22 u .s. Pipeline Accidents occurring in 1978, i9'l9, NATIONAL TRANSPORTATION SAFETY BOARD 1980, and 1981 in Summary Format. Washington, D. c. 20594 14.Sponsoring Agency Code IS.Supplementary Notes '. 16.Abstract This publication contains summary reports of selected pipeline accidents, occurring during calendar years of 1978, 1979, 1980, and 1981. The summary reports present basic facts, conditions, circumstances, and probable cause(s) in each instance. File Numbers: FTW-78-FP-008 FTW-79-FP-002 FTW-80-FP-001 FTW-81-FP-002 DCA-79-FP-016 DCA-80-FP-007 FTW-81-FP-003 DCA-79-FP-024 ATL-80-FP-001 FTW-81-FP-004 FTW-80-FP-004 FTW-81-FP-005 FTW-80-FP-005 DCA-81-FP-007 FTW-80-FP-006 FTW-81-FP- 1 <~!1 FTW-80-FP-007 FTW-81-FP-007 FTW-80-FP-008 FTW-81-FP-008 FTW-81-FP-009 FTW-81-FP-010 17.Key Words excavation damage, odor report, 18.Distribution Statement control line, torch-cut flaw, hydraulic overpressure, This document is available emergency shutdown, butane, migration, circumferential through the National fracture, anhydrous ammonia, one-call system", asphyxiation, Technical Information breathing equipment, unrestrained pipe, compres.gion Service, Springfield, coupling, bypass, proplylene, slide gate. Virginia 22161. 19.Security Classification 20.Security Classification 21.No. of Pages 22.Price (of this report) (of this page) as UNCLASSIFIED UNCLASSIFIED NTS3 Form 1765.2 (Rev. 9/74)

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,, ' r· ~ 1.:.''. , ·.· i ~. ·, '. f ~-~ ~; ~t ff0 ',> ~· ' FOREWORD TABLE OF CONTENTS EXPLANATORY NOTF.S TABLE OF CONTENTS ALPHABETICAL LIST OF ACCIDENTS REPORTS OF ACCIDENTS iii PAGE ii iii 1 3 5

.·;. I EXPLANATORY NOTFJ:I The accidents included herein arti those occurrences incidental to pipeline operations which fall within the scope of Section 304 of the Independent Safety Board Act of 1974, as amended. As provided in this Section, the Board shall investigate and determine facts, conditions, circumstances, and the probable cause of any pipeline accident in which there is a fatality, or substantial property damage. Fatality "Fatality" means the death of a person either at the time a pipeline accident occurs or within 60 days thereafter. Substantial Damage "Substantial damage" means damage of 150,000 or more to pipeline and non-pipeline property. The following definitions, as set forth in Title 49 of the Code of Federal Regulations, Parts 192 and 195, are applicable: 49 CFR 192.3 Gas "Gas" means natural gas, fiammable gas, or gas which is toxic or corrosive. Main "Main" means a distribution line that serves as a common source of supply for more than one service line. Service Line ''Service line" means a distribution line that transports gas from a common source of supply to (a) a customer meter or the connection to a customer's piping, whichever is farther downstream, or (b) the connection to a customer's piping if there is no customer meter. A customer meter is the meter that measures the transfer of gas from an operator to a consumer.

-2- Transmission Line "Transmission line" means a pipeline, other than a gathering line, that: (a) Transports gas from a gathering line or storage facility to a distribution center or storage facility; (b) Operates at a hoop stress of 20 percent or more of SMYS: or (c) Transports gas within a storage field. Transportation of Gas "Transportation of Gas" means the gathering, transmission, or distribution of gas by pipeline or the storage of gas, in or affecting interstate or foreign commerce. Pipeline "Pipeline" means all parts of those physical facilities through which gas moves in transportation, including pipe, valves, and other appurtenances attached to pipe, compressor units, metering stations, regulator stations, delivery stations, holders, and fabricated assemblies. Pipeline Facility "Pipeline facility" means new and existing pipelines, rights-of-way, and any equipment, facility, or building used in the transportation of gas or in the treatment of gas during the course of transportation. 49 CFR 195.2 Liguid "Commodity" means a hazardous material that is subject to Parts 172 and 173 of this chapter, petroleum, and petroleum products. Pipeline System "Pipeline system" or "pipeline" means all parts of a carrier's physical facilities through which commodities move in transportation that is subject to this part, including, but not limited to line pipe, valves and other appurtenances connected to line pipe, pumping units, fabricated assemblies associated with pumping units, metering and delivery stations and fabricated assemblies therein and carrier-controlled breakout tankage.

-3- ALPHABETICAL LIST OP ACCIDENTS Location Company Date Albem.vle County, City of Virginia Charlottsville 12/17/79 5 Bernalillo County, Gas Company of New Mexico New Mexico 12/2/79 8 Beggs, Oklahoma Phillip's Petroleum Company 10/30/78 11 .son Weir, Texas Trunkline Gas Company 10/23/80 13 Borger, Texas Phillip's Pipe Line Company 2/2/81 16 Canton, Texas Lone Star Gas Company 5/16/81 18 Cartwright, Louisiana Gulf Central Pipeline Company 5/27/80 20 Cicero, Indiana Indiana Gas Company, Inc. 9/30/80 22 Dearborn, Michigan Michigan Consolidated Gas Company 1/11/81 24 Detroit, Michigan Michigan Consolidated Gas Company 6/5/79 26 Dexter, Georgia Dublin Georgia Natural Gas System 5/2/80 28 East Helena, Montana Montana Power Company 10/1/79 30 Elizabeth, New Jersey Elizabethtown Gas Company 7/31/80 33 Eugene Island Block 295 Natural Gas Pipeline Gulf of Mexico Company of America 1/27/81 37 Homewood, Alabama Alabama Gas Corporation 3/3/81 39 Keller, Texas Lone Star Gas Company 9/28/80 41 Mexico, Missouri Missouri Power & Light Company 1/8/81 44 Oklahoma City, Oklahoma Natural Gas Oklahoma Company 4/24/78 46

";• ·::;,·-·'"!····. -4- Location Company Date !!I! Reading, Ohio Cincinnati Gas & Electric Company 12/17/80 48 San Ysidro, Texas-New Mexico New Mexico Pipeline Company 10/22/80 51 Sulphur, Louisiana Enterprise Products Company 9/2/80 53 Tyler, Texas Entex, Inc. 7/3/80 56

P.~;::j;j'!flf_,,,(l!i,.~~•-·,.:~"!G,,•~--··:~:~::._~:r i ' ---- -- -- - - ·----- .. _ ,.. ___________ . ,_ ......... . ;>: .. , -5- NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 Pipeline Accident No. Company Location of Accident Time Date Property Damage Injuries Probable cause Pipeline Summary Report DCA-80-FP-007 City of Charlottesville, Gas Division-Department of Public Works Hydraulic Road and Solomon Road (Berkshire Apartments), Albemarle County, Virginia. 2:38 p.m., e.s.t. December 17, 1979 $1,000,000 (estimated) 0 Fatal 7 Nonfatal The National Transportation Safety Board determines that the probable cause of the accident was the ignition by an undetermined source of uncontrolled high pressure natural gas which had flowed through mains into an apartment complex as a result of the rupture of a regulator control line by excavating equipment. Description of Accident On December 17, 1979, at 2:38 p.m., e.s.t., a backhoe being used by the City of Charlottesville, Gas Division (gas company), severed a 1/2-inch steel regulator control line. The regulator opened and the downstream pressure increased rapidly from 10 inches of water column (W .C.) to 90-psig pressure. The uncontrolled high pressure natural gas flowed through mains and master meters and into 71 apartments where an undetermined source ignited the gas and started a fire. As a rssult of this fire, seven firemen were injured. The City of Charlottesville was in the process of updating its gas distribution system, which serves 10,000 customers, in order to bring it into conformance with the U.S. Department of Transportation regulations, 49 CPR, Part 192. On the morning of the accident, the gas company had connected a section of the Ber·kshire Apartments to a newly installed pressure regulator station, located approximately 1 1/2 blocks from the accident site. After lunch on the day of the accident, gas company employees were digging with hand tools to expose the main downstream of the regulator and connect this line to a temporary low-pressure bypass plastic line. After digging approximately 4 feet, they exposed the main. In order to make more working room, gas company employees decided to use a backhoe to enlarge the excavated hole. The backhoe bucket hit and broke the regult1tor's control line. The gas company's job supervisor immediately jumped into the regulator man hole and closed the downstream and upstream valves. Shortly thereafter, smoke and fire were observed coming from nearby apartments. Without delay, a valve located upstream of the regulator on Hydraulic Road and Solomon Road was also closed. Closing the valves affected approximately 431 customers.

rr~~~~ lo'. l' ~- -6- After the accident, the gas company completed updating its system by eliminating the master meter system serving the 71 apartments. This involved replacement of the 2-, 3-, 4-, and 6-inch mains with 2-inch pipe. (Figure 1 shows preaccident conditions.) Gas was then supplied by the new regulator station, and a customer meter was set at each apartment with a service regulator and internal relief valve. At the time of the accident, the gas company was in violation of 49 CFR 192.195(a), Protection against accidental overpressuring. This section in part states: " •••• each pipeline that is connected to a gas source so that the maximum allowable operating pressure could be exceeded as the result of f allure, must have pressure relieving or pressure limiting devices •••• ". The excavation was being performed, however, to update the distribution system and to bring the old system into compliance with the existing Federal regulations including 49 CFR 192.195(a). ,. I '.: ' )

J:r~-= ,,~~-- i.~ -6- After the accident, the gas company completed updating its system by eliminating the master meter system serving the 71 apartments. This involved replacemf::nt i>f the 2-, 3-, 4-, and 6-inch mains with 2-inch pipe. (Figure 1 shows preaccident conditions.} Gas was then supplied by the new regulator station, and a customer. meter was set at each apartment with a service regulator and internal relief yalve. At the time of the accident, the gas company was in violation of 49 CFR 192.195(a), Protection against accidental overpressuring. This section in part states: " •••• each pipeline that is connected to a gas source so that the maximum allowable operating pressure could be exceeded as the result of failure, must have pressure relieving or pressure Um.ting devices •••• ". The ~xcavation was being performed, however, to update the distribution system and to bring the old system into compliance with the existing Federal regulations including 49 CFR 192.195(a).

----~"~~-•. ~ •. ~, '!lii.'.~;.;:-.;lll\1~1,,,.~tf;..~.\·.tJ!f\'--:~:~-!'1-., ~~~~~-·-~'i;~2~:~~~~~~~;~-'~;~r·t'~~~~~:~ -- ... ---· -·····-· -·--·---··--·· ... ---.--------- -~·---- -··· --·--. ____ ., ___ ---· __ , _______ ........._ __ ~·-----~----------· - . ···- -- ..... -. . .. 4 APTS. 4 APTS. 4 APTS. 4 APTS. 4 APTS. JD 4 .. -7- BERKSHIRE APARTMENTS FIELD REGULATOR VALVE 11 APTS. 1•• R EGULATOR BENNINGTON WOODS REGULATOR STATION a. FENCE 4 .. G.L;'fP.E.J 2" H.P.G.L. fSTEELJ ~ ~ 2 .,, APTS • (;) 2 r- APTS. ..._FLOW f10" W.C.J 4 METER 3 .. APTS. N METER 4 APTS. 4 APTS. 4 APTS. 4 APTS. 4 APTS. 4 APTS. 4 ~~PTS. 4 A:PTS. t CONTROL LINE BREAK Figure 1. Plan View of Ac<:ident Site ---- ·- --------:-;;----------- ··-···--.

.-;, l I I .; ~ • ' • '· g " ./ ~ ~~ ~ '· -8- NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 Pipeline Accident No. Company Location of Accident Time Date Property Damage Injuries Probable cause Pipeline Summary Report FTW-80-FP-001 Gas Company of New Mexico 807 Sunset Road, S.W., Bernalillo County, New Mexico 8:58 a.m., m.d.t. December 2, 1979 $85,000 (estimated) 1 Fatal 1 Nonfatal The National Transportation Safety Board determines that the probable cause of the accident was the ignition by an undetermined source of an accumulation of natural gas which had leaked from a crack in a steel gas main ond migrated into a building. Contributing to the accident was the downward forces resulting from changes in ground temperature and unusually I'aeavy vehicular traffic over the gas main which caused the already deformed steel main to crack circumferentially. Also contributing to the accident was the failure of sevetal persons, including the fatality, to make a timely report of gas odors to the company which might have led to action to prevent the accident. Description of Accident At 8:58 a.m., m.d.t., on December 2, 1979, the Ohlson Clinic at 807 Sunset Road, S.W., Bernalillo County, New Mexico exploded and burned. (See figure 1.) Natural gas at 38-psig pressure had escaped from a break on a 2 3/8-inch-outside-diameter, steel coated and wrapped gas main, located 18 feet from the destroyed house. The natural gas migrated into a crawl space under the clinic and residence and spread into the living areas. Gas accumulated, for med a combustible mixture, and exploded when it was ignited by an undetermined source. The gas company dispatch center received a call concerning the accident at 9:03 a.m., and the gas company emergency units began arriving at the site at 9:25 a.m. The crews proceeded to probe the immediate area for underground gas leaks and found readings of BO-percent gas around the corner of Sunset Road and Airway Drive. Excavation to expose the main and stop the leak did not begin until approximately 11:50 a.m. because fire officials, still looking for a missing person, would not permit the gas company to move their equipment into the area. The gas company crew used a hydraulic squeezer to pinch the 2-inch gas main and stop the flow of gas. They cut out a short piece of the 2-inch main and capped the main to prevent leakage past the squeezer. The ground fire fed by natural gas stopped when the leak was finally contained at about 12:15 p.m. At approximately 3:00 p.m., the fire department still had one fire hose drenching the smouldering ruins of the destroyed house. Fire department rescue personnel were still searching for the missing person. At approximately 4:10 p.m., the gas company requested permission from the fire department to install a 2-inch plastic temporary bypass because / .............................................. lllllil~-- .........

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F"':~==~,~,, ... ,,.~"",~~""""~ f: f.'· -10- the gas company was concerned for the welfare and comfort of 16 residents whose service had been cut off because of the leakage. Permission was granted at app1·oximately 4:15 p.m. and service was restored at 6:00 a.m., on December 3, 1981. Inspection of the area around the pipeline break indicated no noticeable discoloration of vegetation, but the soil was dry in an 18-inch deep and 22-inch wide cross sectional area around the break. Metallurgical examination of the damaged pipe showed that the origin point of the failure was an area of mechanical damage to the outside surface of the pipe, where it appeared to have been struck by construction equipment such as a backhoe because the bottom of the pipe showed evidence of dents and gouges in the metal surfe<>e and the pipe was bent upward. The pavement in the accident area, however, did not show any signs that any recent excavation had been done. All known excavetions and related work done in the accident aree. since H7 4 had been done by one construction company. The construction company recorc; and maps for the sewer system on Airway Drive showed that in 1977 an 8-inch sewer main was installed down the middle of the road at a depth of 6 feet. The width of the trench was 10 feet at road level and sloped to the center. The equipment used for the excavation would not have gotten close enough to hit the natural gas line on Airway Drive. The Safety Board's investigation of this accident also revealed that the gas company had conducted special leak surveys on November 20 and 21, 1978, in the area of Sunset Road and Airway Drive following completion of the sanitary sewer project. The area was surveyed again on March 29, 1979, and was scheduled to be routinely surveyed again for leaks in December of 1979. The results of all the surveys were negative. Although there was no evidence to indicate exactly when the pipe had been damaged or when the transverse crack had occurred in the pipe, the damage previously described involved a great force which caused the permanent deformation of the metal and created excessive stress concentration within a small area. The same force lifted the pipe causing it to bend and initiated tensile stresses. The downward force which precipitated the failure probably resulted from changes in ground temperature and unusually heavy street traffic. The break in the pipe was at a noticeable bend on a section of the gas main which was buried under approximately 31 inches of cover. The break in the pipe was paper thin and extended about 5 centimeters around the pipe circumference. Failure occurred on a plane perpendicular to the longitudinal axis of the pipe. Because the dent area was bare, clean metal and showed no evidence of corrosion and because the metallic grain in the break was clean and crystalline, the break probably occurred recently. The residential part of the clinic was occupied by a doctor and his wife, who was fatally burned. She had complained to her husband about gas odors on the evenir1g and morning before the accident. Her husband, however, did not smell the gas because his sense of smell had been reduced due to a nasal operation. The nurses and staff of the Ohlson Clinic indicated that they did not smell natural gas during work on Saturday morning, the day before the accident. A woman who had driven by the house on the morning before the accident said later that she had smelled gas, and neighbors said that they also had smelled gas. No one, however, had notified the gas company or the fire department of tht! odor. Some residents stated that they did not know who or where to call to report the odor of natural gas. The gas company has a continuing program for public awareness of how to recognize and report natural gas odors. If someone had notified the gas company when the odor was first detected, this accident could have been prevented.

:!;!!?~'!S¥:'l'~!~~~i1:~~1fi~'!:;~~?~v'='~!:'~~.·"'.:~'~·,. .. '?~!F~!1~ I I I I I ~ I I I ~ -11- lfA'ftONAL TRAlfSPORTA'ftON SAPETY BOARD WASHINGTON, D.C. 20594 Pipeline Accident No.: Company: Location of Accident: Time: Date: Property Damage: Injuries: Probable cause Pipeline Summary Report FTW 79-FP-002 Phillips Petroleum Company Beggs, Oklahoma 8:20 p.m., c.d.t. October 30, 19'18 2 fatal 1 nonfatal The National Transportation Safety Board determines that the probable cause of the accident was the ignition, by sparks from the engine of a passing pickup truck, of gas escaping from a 6-inch natural gas gathering line which failed at a pressure of 900 psig at a stress position induced by a torch-cut fiaw intentionally introduced during construction of the line 26 months before. Deseriptian of the Aeeident At 8:20 p.m., c.d.t., on October 30, 1978, about 3 1/2 miles southeast of Beggs, Oklahoma, a 6-inch natural gas gathering line operating at 900 psig ruptured. At 8:30 p.m., escaping natural gas was ignited by a pickup truck which was passing through a depression along a dirt road 400 feet from the leak. Of the three occupants of the truck, two were killed, and the third was injured. The Phillips Petroleum Company (Phillips) field operations fore man heard the explosion from his home near Beggs, and saw the resulting fire. The foreman radioed the Creek Gas Plant at Glenpool to notify them of the problem and called two field coordinators to request that the Wadsworth and Taylor Boosters be checked. The rupture had occurred in the 6-inch line between the two boosters. He then drove 6 miles to the location where the 6-inch line fed into an 8-inch main line, closed the 6-inch line gate valve, and opened the vent valve. At 8:35 p.m., monitoring equipment at the Creek Gas Plant showed that the Wadsworth Booster was shut down. While the shutdown was coincidents with the rupture, the WadDworth Booster was downstream of the rupture and had responded to a high-pressure shutdown device set at 950 psig which was activated when a large downstream customer stopped accepting delivery of gas. The Taylor Booster which was upstream of the rupture was shut down manually at 9:00 p.m., thus isolating the break. The 6 5/8-inch O.D. X 0.156 W.T. APl5L pipeline was installed by Cimarron Pie>eline Construction, Inc. and hydrostatically tested at a pressure of 1,580 psig for 24 hours in June 19'16. The test was the basis for a maximum allowable operating pressure (MAOP) rating of 1,436 psig. The pipeline was placed in service on August 10, 1976, as part of Phillips Creek Gas Gathering System. '

-12- After the accident, the failed pipeline was excavated and examined. The metallurgical report stated, "The failure apparently initiated along an 8-inch long flaw, or gouge, located on the external surface" on the bottom of the pipe. ''The failure propagated in both directions from this fiaw in a helical fashion around the pipe for approximately two revolutions. • • About 2 1/2 feet of pipe length was involved in the failure, and the curved fracture surface was about 88 inches long." The metallurgical report further stated that the fiaw had been "Intentionally introduced in the field during or immediately after assembly of the pipeline, appal'~ntly by means of an oxyacetylene torch or similar device. This determination was made by experiments involving the possible alternatives: (1) melting or cutting by gas or electric welding equipment, (2) mechanical gouging or grinding, and (3) localized corrosive attack. Location of the fiaw 2 1/2 feet from the nearest girth weld eliminated accidental creation. The fiaw was sufficiently shallow that the pipeline passed the field hydrostatic test, but subsequently grew to a critical size as a result of cyclic pressures occurring during the operation of the pipeline." ~- __ L ............................. -~.-.... --.-........... --..........

~·· I ' t I 0 !> r i I .. ' ~- i I ~'. I f ,.,. I ., If it ~~ ~· I, ~ ~ .r b -13- NA'DONAL TRANSPORTA'DON SAFETY BOARD WASWNGTON, D.C. 20594 Pipeline Accident No.: Company: Location of Accident: Time: Date: Property Damage: Injuries: Probable cause Pipeline Summary Report FTW 81-FP-003 Trunldine Gas Company Quicksand Creek Gas Field, BonWier, Texas 11:35 a.m., c.d. t. October 23, 1980 1 fatal 1 nonfatal The National Transportation Safety Board determines that the probable cause of the accident was the hydraulic overpressuring of a valve due to an improper lubrication procedure. Description of the Accident At 11:35 a.m., on October 23, 1980, a gate valve on a gathering line in the Quicksand Creek Gas Field near Bon Weir, Texas ruptured during a valve inspection, injuring the two-man Cl'ew, one fatally. The Safety Board investigation disclosed the following circumstances ieading up to the accident. The accident involved a 6-inch, ASA 600, W-K-M, WExFE, rising stem handwheel-operated gate valve (See figure 1) installed on a gathering line at the Quicksand Creek Gas Field near Bon Weir, Texas. Located 30 inches below ground level in a 4-foot-deep, 4 1/2-foot-diameter corrugated metal canopy, 1/ the valve was just downstream of the Trunkline Gas Company's Duer Wagner-Quicksand Measuring Station. At 11:30 a.m. on October 23, two crewmembers arrived at the Duer Wagner Measuring Station to perform a semiannual valve inspection, which primarily involved checking and lubricating the valve stem and seats and performing a 50 percent operation of on-stream valves. After removing the valve canopy cover, one of the crew climbed into the canopy, removed the caps from the two fittings on the valve seat lubricator, pumped five to six shots into each fitting with a grease gun rated at 15,000 psi, and replaced the caps. While the crewmember in the canopy was pumping grease, his partner removed the stem packing cap, inserted grease into the fitting, and replaced the cap. When they finished lubricating various other valve components, including the upper body grease fitting but not the lower body grease fitting which was coated with the dirt, the crewmember in the canopy tried to operate the valve but could not move the handwheel. Attempting to exert more force, he leaned back while his partner knelt over the canopy to help him turn the wheel. The crewmember in the canopy felt the valve turn, heard a pop and felt the handwheel leave his hand; he was blown out of the canopy by the force of the explosion. Valve parts blew out of the valve body and canopy and scattered about the area, fatally striking the workman kneeling over the canopy. 1/ A circular shelter or pit.

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l I l J I I I I I j f J l 1 l -15- Hydraulic pressure during lubrication overpressured the valve cavity and led to the explosive failure. The grease gun, rated at 15,000 psig, ttad more than sufficient capacity to rupture the valve. 'fhe crewmembers, for reasons unknown, lubricated the upper body grease fitting without using the safety pressure relieving tool, as specified in the W-K-M manual for ''Installation, Operation &: Maintenance of W-K-M Through-Conduit ANSI Gate Valves." The pressure relieving tool was found in the truck; dirt covered the lower body grease fitting of the valve where the tool would have been applied if proper procedure had been followed. The W-K-M manual also contains a troubleshooting chart of problems that may be encountered when working with W-K-M valves. The trouble th~ men encountered with the Quicksand Creek valve, "will not open or close," has cited as a probable reason "pressure locked," which is defined as a "condition which exits in any double sealing expanding gate valve when the body pressure exceeds the line pressure by an excessive amount ••• " and as a remedy, "drain • .>dy pressure ••• " The attempt to turn the handwheel without first relieving the body pressure provided the additional force needed to precipitate the explosive failure. The fatally ·'njured workman had more than 15 years of maintenance experience and should have been familiar with the appropriate lubricating procedure. In <.Sontrast, his partner had less than 6 months of service with the Trunkline Gas Company. -------~--...... ~-"' ........... -"".-..-...................... ~-----... -· ... ---·"------ ----·--- ii.,..~~.:=:.',-.....~ ... ··-~·-.~ ..•• -... .... __ .. .-

-16- lfA'DONAL TRANSPORTA'DON SAPBTY BOARD WASmNGTON, D.C. 20594 Pipeline Accident No.: Company: Location of Accident: Time: Date: Property Damage: Injuries: Probable Cause PIPELINE SUMMARY REPORT FTW 81-FP-007 Phillips Pipe Line Company Borger, Texas 4:10 p.m., c.s.t. February 2, 1981 $300,000 1 fatal I The National Transportation Safety Board determines that the probable cause of the accident was the ignition by an undetermined source of vaporized liquid butane which had leaked into a pump room because of improper valve alignments and a blocked drain •• Description of the Accident On February 2, 1981, about 4:10 p.m., an accumulation of butane vapors in a pump room at the Phillips Pipe Line Company's Borger Products Station in Borger, Texas ignited. The resulting explosion killed one employee working in the pump room and destroyed all controls and instruments for two pumping stations within the Borger complex, as well as control rooms, meter runs, pumps and a header. The Safety Board investigation disclosed the following circumstances leading up to the accident. Pumping equipment at the Borger Products Station moves various products from the Borger Refinery to Chicago, Illinois; Denver, Colorado; and Amarillo, Texas. That portion of the Borger complex that pumps to Chicago is called the Borger-Chicago Station; to Denver and Amarillo, the Rocky Station. About noon, on February 2, 1981, the Borger-Chicago Station was shut down to make tie-ins on certain pipelines. Before work could begin, product had to be drained from part of the system. The drain system, which is used to ~~eek for leaking valves in the header as well as to drain the pumps, is open to the atmosphere in the header area and drains to a receiving tank. To drain the system some valves had to be opened and some closed to isolate the pipe to be tied in. By 3:45 p.m., the connections were completed, closed valves opened, opened valves closed and pumping resumed on the two lines shut down at noon. After pumping was restarted, an engineer returned to the pump room in the Bor~er-Chicago Station. Seeing liquid butane fiowing under the door of the sample room and backing up through the drain in the sample vat, he closed the drain valve to tJtem the flow of butane. Subsequently, the engineers terminal superintendent and dehydrator operator conducted cursory visual inspections of pipes in the pump room and header and dehydrator areas to ensure valves were correctly aligned. They found nothing amiss. At 4:05 p.m., however, when the dehydrator operator checked the receiving tank, though it ws.s full, liquid was not fiowing from the open drain above, indicating the drain was plugged.

I ~ -17- At 4:10 p.m., as the engineer and dehydrator operator walked toward the Rocky Station control room, they saw the Rocky Station pump and control rooms explode. Liquid butane, which had leaked under the header and meter run, had vaporized and been ignited by some undertermined source. The drain valve on pump 4A in the Borger-Chicago Station, which earlier was opened for tie-in work and should have been closed before pumping resumed, inadvertently was left open. This permitted liquid butane to fiow into the open drain system. A blockage in the drain system then caused butane to overflow from the open drains. The cursory line-of-sight valve examination was inadequate to assure valves were in the proper positions.

'f'~c~"'!:O"~i'TY'''E!'"',,.,,-~'."'"~,- I I -18- NA'l10NAL TRAN'JPORTA'l10N SAPBTY BOARD WASmNGTON, D.C. 20594 Pipeline Accident No.: Company: Location of Accident: Time: Date: Property Damage: Injuries: Probable Cause Pipeline Swnmary Report FTW 81-FP-009 Lone Star Gas Company Canton, Texas 4:00 a.m., c.d.t. May 16, 1981 $100,000 11 Nonfatal The National Transportation Safety Board determines that the probable cause of the accident was the ignition, by an undetermined source, of gas which had migrated into the house through a sewer tile after leaking from a circumferential break in a gas service line at its threaded connection with an elbow. The natural gas escaping at 10 psig was impeded from venting to the atmosphere by the blacktopped driveway above the leak. Description of Accident At 4:00 a.m., c.d.t., on May 16, 1981, in Canton, Texas, natural gas at a pressure of 10 psig leaked from a circumferential fracture in the threads at an elbow on a 11/4-inch bar~ gteel yard line. The gas migrated into a house 25 feet away where it was ignited by an undetermined source. The resulting explosion and fire destroyed the brick house and 1 vehicle, and injured the 11 occupants. Nine of the occupants were hospitalized, several in serious condition; the other two were released after treatment. After debris was removed from the meter set, which was adjacent to the side of the house near the front corner, the gas was shut off. A test on the service line failed to hold pressure. Because torrential rainfall during and after the accident made bar hole tests and other excavation impractical, further investigation was postponed until May 18, 1981. At that time, bar hole tests made through a blacktopped driveway which covered most of the service line revealed the presence of natural gas. Gas was also found around the slab of the house, predominantly across the front and on the side where the meter was located. Sixty hours after the explosion, a combustible gas indicator revealed a 7-percent reading in the open sewer drainpipe at slab level. The odorant level was adequate, as determined by smell and odorometer tests after the accident. However, one of the occupants stated that he had not detected any odor before the explosion and none of the other occupants had mentioned any unusual odors. One person who had been digging .alongside the house about 20 feet from the service riser several months before the accident described the soil there as having a "pig-pen" odor. Cover ever the yard line ranged from 6 to 18 inches.

-19- The leak was found by pr~ssurizing the line. A circumferential fracture extended from about the one o'clock to the five o'clock position (looking upstream) at the entry of threads into a 120-degree elbow, where stress was concentrated in the thread immediately short of make-up in the elbow. The elbow was located 25 feet from the service riser and 6 feet from an abandoned sewer tile crossing. Two other leaks were found at collars but were not significant. Gas readings were obtained in the side yard septic field served by this sewer line as well as in the new septic field to the rear-side of the house and the sewer drainpipe. The threaded and coupled, 11/4-inch bare steel yard line was insulated at its

·11.tt1~{~$t#~·?1:t;;~~~~~~~~~~~'.5-·=:~='=7;~=·:~.~~ ~·~---n~·-=-~=~---~-=--~~ :-·~ ·- -. ---- ~· -~· . -~,- u • ·r:... ____ ,_:..:. __ ... ---·---------·--·-- ·------~-· -20- NA110NAL TRANSPORTA110M SAPBTY BOARD WASHllfGTOM, D.C. 20594 Pipeline Accident No.: Company: Location of'Accident: Time: Date: Property Damage: Injuries: Probable Cause Pipeline Summary Report FTW 81-FP-010 Gulf Central Pipeline Company Cartwright, Louisiana 12:15 p.m., c.d.t. May 2'1, 1981 $50,000 to $100,000 14 Nonfatal The National Transportation Safety Board determines that the probable cause of the accident was the puncture of a 10-inch steel anhydrous ammonia pipeline by the blade of a bulldozer working at a well drilling location. Deac!ription of Accident At 12:15 p.m., c.d.t., on May 2'1, 1981, near Cartwright, Louisiana, a bulldozer :working at a well drilling location punctured a Gulf Central Pipeline Company 10-inch steel anhydrous ammonia pipeline. Anhydrous ammonia under a pressure of 550 psig sprayed into the air. At least 14 people required medical treatment as a result of the accident, and approximately 100 persons wet'e evacuated within a 2-mile radius of the accident site. The construction company bulldozer was clearing a well site and excavating a trash pit for Mitchell Energy and Paramont Drilling Company. The pit was located over the pipeline at a location 275 feet south of where the pipeline intersected a road. Pipeline markers were located on both sides of the road. Gulf Central was not notified of L -a excavation work, and the bulldozing operation had not commenced at the time that the last pipeline aerial patrol was flown. The State of Louisiana has a voluntary one-call system to assist excavaters in obtaining the locations of underground facilities. The Louisiana State Police received notification of the accident at 12:21 p.m. and dispatched its two nearest units. The Louisiana State Police then notified Gulf Central's pipeline dispatcher in Tulsa, Oklahoma, of the accident at 12:25 p.m., 10 minutes after the puncture occurred. The Louisiana State Police also notified the National Response Center. After assessing the hazards involved, the Louisiana State Police and the Jackson Parish Sheriff's Office began an evacuation of the area within a 2-mile radius of the accident site. This evacuation was completed by 1:00 p.m. Fourteen St1ite Police units were eventually in service, assisted by units from the Jackson Parish Sherifts Office, Lincoln Parish Sheriff's Office, and the Quachita Parish Sheriff's Office. Movement of the ammonia cloud was monitored from the ground and air by the State Police, the Louisiana Forestry Commission, and Gulf Central. Some 27 hours after the accident, following a survey of the general area, some of the people evacuated were permitted to return and the evacuation area was reduced to a 1-mile radius of the accident site.

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' , I I c r t ·-,_ r i t -21- When the Louisiana State Police notified Gulf Central of the accident, Gulf Central stopped pumping immediately and dispatched two of its operations personnel; a five-man repair crew was Jispatched an hour later. The break was isolated by closing automatic and manual block valves within 4 hours of the accident. The 10 3/4-inch O.D x 0.250-inch W.T., X-42 pipe was operating at a pressure of 550 psig when it was punctured. Its maximum allowable operating pressure was 1,406 psig. Maximum pump capacity was 271 tons of anhydrous ammonia per hour, but the actual rate was 35 tons per hour. Loss of anhydrous ammonia totaled 613 tons from the 10-mile segment of pipeline that was isolated. After pumping was stopped, the further loss of the liquid anhydrous ammonia from the isolated segment of the pipeline through the 1-inch by 4-inch puncture was slow. About 2 feet of liquid ammonia settled in a pool over the break. Efforts to dig a ditch to drain the liquid away from the break were unsuccessful because the ground was frozen for a distance of up to 30 feet due to the rapid evaporation of the ammonia. After the liquid had drained away and line pressure had subsided to 55-60 psig, 48 hours after the accident, a repair crew attempted to place a sleeve valve on the ruptured pipeline. They were not successful because the pressure was still too high. The Louisiana State Police flew over the area in a helicopter 48 hours after the pipeline was punctured. They observed damage to trees aiad vegetation for up to 11/2 miles from the site. There were no reported deaths to livestock or domestic animals; however, a large fish kill occurred in a private pond one-half mile from the accident site. Gulf Central surveys indicated that an area 2 miles in diameter around the leak was affected by ammonia vapor migration. Gulf Central helped limit the area of vapor migration by using propane in two pits to burn the ammonia. Seventy-two hours after the accident occurred, temporary repairs were completed and the line was placed back in operation. At this time, the remaining 50 people that had been evacuated were allowed to return to their homes. Permanent repairs were made 11 days later by replacing a 10-foot section of the pipe.

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.. !......._ ___________ ··-··-···· ··--·--·--···-··------··---------·-------········----------·····-······-·· ········------··· .. -------------········· - . -··-·····-·· -22- RA'l10NAL TRANSPOllTA'l10N SAPBTY BOARD WASBIROTON, D.C. 20594 Pipeline Accident No.: Company: Location of Accident: Time: Date: Property Damage: Injuries: Probable cause PIPBUNESUMMAllYllBPOllT FTW 80-FP-008 Indiana Gas Company, Inc. State Highway 19, one mile north of Cicero, Indiana 11:35 a.m., c.d.t. September 30, 1980 $500,000 2 Nonfatal The National Transportation Safety Board determines that the probable cause of the accident was the ignition by a pilot light of an accumulation of natural gas in a church basement. The gas had leaked from a broken threaded fitting on a 3/4-inch service line which had been caught and pulled by a trenching machine being operated outside the church. Contributing to the accident was the contractor's failure to notify the gas company about the proposed excavation to allow the gas service line to be located and worked before excavation was begun. Deaeriptian of the Accident In 1960, a 135-foot, 3/4-inch coated and wrapped steel gas service line was installed by a pipeline contractor for the Seventh Day Adventist Church. The service line entered the north side of the church basement below grade, through a sleeve in the cement block foundation at a depth of 24 inches. The meter set assembly, which was installed below the service line in the church basement, terminated in a lockwing shut-off valve, and then elbowed down to a pressure regulator and meter. A vent line for the regulator was installed through a sleeve in the wall adjacent to the service entry. In September, 1980, a private contractor was hired to trench around the exterior of the church to provide drainage and alleviate moisture problems in the basement. The contractor walked around the church twice looking for a gas meter before beginning to trench but he did not enter the church basement in his search. Neither he nor the church contacted the gas company to request that they stake the location of the gas service. No "one-call" system or requirement for excavators to consult with or notify the operators of underground facilities was in effect in the State of Indiana. On the morning of September 30, 1980, the contractor was operating his small "Ditch Witch" trencher moving eastward at a distance of 7 1/2-f eet from the north wall of the church. While trenching at a depth of 28 inches, the trencher momentarily snagged the 3/4-inch gas service line. The contractor was not aware that he had struck the service line and continued trenching eastward. The service line, which was bent 10 1/2 inches out of alignment, was pulled sufficiently to break a threaded elbow at the lockwing shutoff valve within the church basement. Gas escaped into the basement at a pressure of 35 psig.

ftll~!$WWM#.i#l':~::.'~~~~~=:'.~-:~·=:'. '!'""''·-~," ···,~~-·····-···· - ~}~· l i ~ -23- The gas-air mixture was ignited at 11:35 a.m. when it reached the pilot lig~! either on the furnace or the water heater. The resulting explosion and fire destroyed the church. The trenching machine operator was injured, treated at the hospital, and then released. The pastor and secretary of the church were working in the basement office 50 feet from the broken elbow but were not hurt. One fireman was later treated for smake inhalation. There were no other injuries. The Cicero Fire Department responded promptly and arrived within 5 minutes, and the Jackson Township Fire Department was at the scene within 10 minutes. Six other fire departments also assisted. The Indiana Gas Company was notified by telephone 8 minutes after the explosion, and gas company personnel first reached the site 7 minutes later. Nine employees in all were dispatched to participate in the emergency operations and included pipe fitters, welders, servicemen, foreman and supervisors. Since there was no readily accessible shutoff valve on the service line, information as to the location of the service line was requested by radio from the gas company's office; however, the gas company's service department was unable to promptly locate a record with that information. Therefore, at 12:35 p.m., the gas company squeezed off a section of 2-inch polyethylene main about 200 feet upstream from the service tap. As a result, gas flow to the church was shut off and service to two other customers was interrupted. Service was restored about 24 hours later.

.... -.-..--~--- ---------------· -~ - .. "[.·-

,, r------·- - . l I i -24- RA1101!1AL TRAl!ISPORTA110R SAPBTY BOARD WA8BDIGTOl!I, D.C. 10514 Pipeline Accident No.: Company: Location of Accident: Time: Date: Property Damage: Injuries: Pipeline SUmmary Report DCA-81-PP-007 Michigan C~nsolidated Gas Company Dearborn, Michigan 12:05 p.m., e.s.t. January 11, 1981 $800 1 Fatal. 1 Nonfatal The National Transportation Safety Board determines that the probable cause of the accident was a break in a regulator control line located in an underground vault from undetermined causes. Contributing to the severity of the accident was the failure of the two repairmen who entered the underground vault to control the leak and to utilize proper safety equipment. Deacriptim of Aeeident At 9:40 a.m., January 11, 1981, the Michigan Consolidated Gas Company (gas company) Customer Service received a leak report from a motorist who detected an odor of gas while driving by Southfield Road and Michigan Avenue, De&1'born, Michigan. At 9:43 a.m., the gas company dispatched an employee to determine the source of leaking natural gas. At 10:03 a.m., the employee reported that there was natural gas blowing out from one of the gas companY's manholes. At the same time, he requested that personnel from the companY's distribution department be dispatched; the distribution department requested that a pressure crew also be dispatched to the scene. At 12:05 p.m., on Sunday afternoon, the pressure crew consisting of a foreman and a workman arrived on the scene after having been summoned from their homes. They immediately proceeded to remove the cover from the manhole. The crew foreman descended into the vault, followed by the workman. Both employees were overcome by the high concentration of natural gas. Air breathing equipment was available but was not used by either employee. At 12:12 p.m., one of the distribution department employees reported to the gas company that the two pressure crewmen had passed out in the vault and requested assistance from the fire department. At 12:27 p.m., the fire department rescue squad arrived and was able to revive the workman but was unable to revive the supervisor. At 12:38 p.m., the two gas company employees were taken to a hospital by the rescue squad. The foreman was pronounced dead at 1:35 p.m., on January 11, 1981.

-25- The reinforced concrete vault at the accident site was built in 1956 and cc;,ntained two regulators in series which reduced the pressure from approximately 250 psig to 85 psig in two steps. Investigation revealed that the upstream control line was broken off at the shoulder of the 45-degree flare nut which connected the control line to the regulator. The cause of the break was not determined. When the rupture occurred, the inlet pressure of approximately 250 psig blew from the full open end of the broken line. The seven-day pressure chart for the Michigan/Southfield area read after the accident indicates that the control line broke about 11:00 p.m., January 10, 1981. The gas company conducted an annual inspection of the vault on September 9 and 10, 1980; the condition of the control lines was recorded as satisfactory at that time. The pressure crew foreman entered the underground vault when it was unsafe to do so, even though the gas company's established procedures required that vaults be tested for natural gas and oxygen prior to entry. In this accident, the opened manhole, the odor, and the loud noise of th~ blowing natural gas under high pressure should have been sufficient to alert an experienced gas company employee that it was not safe to enter the underground vault without air breathing equipment. The pressure crew fore man had 20 years of experience in gas regulator installation and maintenance; the workman had 2 years of experience. Gas company records indicated that both employees had attended safety meetings within 30 days of the accident. Those meetings included the use of air breathing equipment. '

-26- NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 Pipeline Accident No. Company Location of Accident Time Date Property Damage Injuries Probable came Pipeline Summary Report DCA-79-FP-016 Michigan Consolidated Gas Company 14039 Ardmore Avenue, Detroit, Michigan 2:15 a.m., e.s.t. June 5, 1979 $50,000 (estimated) 1 Fatal 2 Nonfatal The National Transportation Safety Board determines that the probable cause of the accident was the ignition by an undetermined source of an accumulation of natural gas which had leaked from an unauthorized connection of an indoor garden hose to a gas meter valve. Deac!ription of Accident On June 5, 1979, at approximately 2:15 a.m., e.s.t., a natural gas explosion and fire destroyed a house and extensively damaged four adjacent houses in Detroit, Michigan. (See figure 1.) A garden hose which had been connected to a gas meter valve failed and allowed natural gas to escape until an explosive mixture of gas in air was reached. As a result of the accident, one infant was fatally burned and two other persons injured. The house which was destroyed had two meters located in the basement, one for the first fioor and the other for the second floor. On March 20, 1978, the Michigan Consolidated Gas Company (gas company) disconnected the gas meter for the second floor from active use because of nonpayment of charges. The shutoff valve in the meter bar was closed with a locking device in order to prevent the valve from being opened by unauthorized persons. Eight months later, on November 8, 1978, the gas company discovered that the lock had been removed and unauthorized use of natural gas had occurred. The gas company, therefore, removed the gas meter and again locked the meter bar valve in the off position. Investigation on June 5, 1979, of the explosion and fire revealed that the shutoff valve in the meter bar had been turned on by breaking the locking device. Since the shutoff valve on the first floor gas meter was also in the open position, it appears that the piece of garden hose had been connected to the upstream side of the first floor gas meter to illegally obtain natural gas for consumption. The garden hose failed and natural gas leaked into the building. Ignition of the accumulated gas by an undetermined source resulted in the explosion and fire. ' Although the occupants of the house stated that unauthorized use of the natural gas had started only after the meter was removed on November 8, 1978, it is most likely that use had been occurring since the gas company disconnected the meter in March because the occupants also stated that they had never been without heat, hot water, or cooking gas.

• Plan View of Accident Site

I N ..... I I I i '~; .. ' ·l ·l ·1 ~ ' 1 .. -;.~ . ' -28- MA"110MAL TRAMSPORTA"110N SAPBTY BOARD WASWNGTON, D.C. 20594 Pipeline Accident No.: Company: Location of Accident: Time: Date: Property Damage: Injuries: Probable Cause Pipeline Summary Report ATL-80-FP-001 Dublin, Georgia Natural Gas System Dexter, Georgia 8:01 p.m., e.d.t. May 2, 1980 Minimal 3 fatal 4 nonfatal The National Transportation Safety Board determines that the probable cause of the accident was the ignition by a propane torch of natural gas which was released under 300 psig when a poorly restrained length of 8-inch pipe pulled out of a compression coupling. Description of the Accident On May 2, 1980, about 8:01 p.m., a natural gas explosion and fire at a construction site near Dexter, Georgia killed three and injured four workmen. The Safety Board investigation disclosed the following circumstances leading up to the accident. On the day of the accident a pipeline construction company hired by the city of Dublin, Georgia, was engaged in replacing and relocating a section of 8-inch gas pipeline installed in 1968 alongside a bridge over Rocky Creek. Upstream of the bridge crossing, the 8-inch pipeline entered an underground brick vault which contained an 8-inch gate valve and a style 38-type Dresser coupling y downstream of the valve. This in-line coupling, as originally installed, was secured against pullout forces. The relocation was effected, without consideration of the coupling, by the construction of an 8-inch bypass parallel to the bridga-crossing section to be abandoned. The bypass was. tied into the existing pipeline on either side of the bridge, with the upstream tie-in located 12 feet downstream of the coupling. Here a 90-degtee elbow was welded downward from the existing line to a 2-f oot pipe section and then to another 90 degree elbow which was welded to the bypass at a 45-degree angle from the existing pipeline. This diagonal section of the bypass was partially i>ackfilled only about 14 feet from the tie-in. At the time of the accident, the task of relocating the pipeline was almost complete. Three of the contract workmen were in an 8-f oot trench at the upstream connection of the newly installed pipe. They were using a propane torch to soften the tar adhesive on wrapping tape. Three other workmen were similarly engaged in a trench cm the downstream side of the bridge where the new pipeline joined the existing line. Once the pipe was wrapped, it would remain only to backfill the trenches. 1/ Dresser Co•!plin~ ..:. A gasketed fitting used to join pipe ends by compression.

~;! ' I I • I I I ' -29- About 7:30 p.m., the assistant superintendent from the Dublin, Georgia Natural Gas System opened the gate velve in the underground brick vault to allow gas to flow into the newly installed line. The new pipeline operated close to its normal pressure of 300 psig for about 30 minutes. However, at 8:01 p.m., the underground vault exploded and flames erupted. The nearby trench was engulfed in flames, fatally injuring the three workmen taping pipe there and injuring two who were standing at the lip of the trench. Two of the three men in the trench across the creek also were burned when earthen plugs blew out of the abandoned pipeline. The gas company's assistant superintendent radioed workmen manning the upstream and downstream control valves to close both valves. Gas flow was stopped 4 1/2 minutes after the accident, and property damage was minimal. Postaccident investigation revealed that the pipeline was disengaged from the Dresser coupling, ai.d that the downstream end moved 21 inches out of alignment because it was inadequately restrained. Further investigation revealed that the construction specifications called for a 45 degree elbow rather than the 90-degree elbows that were used; correct elbows would have provided an additional degree of restraint. It also appeared that the engineering drawing was in error; it showed the Dresser coupling upstream of the gate valve. Further cold wrap, had been specified rather than the hot wrap which was used and thereby required use of a propane torch which served as the source of ignition of the natural gas. Finally, the abandoned section of pipeline was plugged with earth rather than capped as specified; use of the latter measure, would have prevented two injuries.

under the relief valve in order to reseat it. After this operation, the company employees proceeded to put the station into service without any further checking.

,.r-' MAOP&OOPSI t TRANS. LINE ·-· -·---·-·----------- ,., FOURTH ST. ~ N ii Im POSITION OF EXPLOSION • POSITION OF PERSONNEL BOX FENCE DOWN 4" BYPASS UNE CPERMANENTJ FLOW ~ HEATER VALVE~ ·1-----, 9 ~ I. 4" VICKERS •·FLOW-+ 10'' 3'' FIRST STAGE REGULATORS , UNJUREDI \ ' UNJUREDI 2" PLASTIC FLOW-+ I ------~----~------J (TEMPORARY BYPASS) Figure 1. Plan View of Accident Site i! ,i I ~ !" •1•

• cl L> 3DP81

~-PSI. r· BOULDER UNE I ..., ... I l .~ I ~ 1 ; . .. ' " . ' I 1 [ i I ., i -; i ~ , l \ '·) ·~~ :.: .i ~ '~ .,-.;: ¥ :j .) ·~ .~ :~ ·~~ .~ ;t ~' ~ :t' ' ~ . •. I ·~ " ,!.t 'i~ . . ~ ,.,'

;::. ;} .. ··--_.::..____:,.:..... __ ..:...... ____ .... l I I I j l I I I I I l ' -32- One employee began openhig a valve on the upstream side of one of the first stage regulators, and pressure began to increase. The relief valve inside the gate station vented and at this point its pressure gauge indicated 60 psig; however, the pressure gauge on the header downstream of the first stage regulators showed only 30 psig (this gauge which continued to read 30 psig after the accident was later found to be defective). The pressure continued to increase and after one of the employees noticed a pressure of over 80 psig, the entire top portion of the meter blew off killing one employee while he was looking at the recording gauge located on top of the meter. No other property was damaged as a result of this blowout. The East Helena gas distribution system was at no time overpressured and no customers were without service. There was no fire. After the accident, it was found that the 1/4-inch supply valve on the control line to the first stage regulators was closed. This prevented the regulator from controlling the pressure. Capacity of the first stage relief valve was not adequate to relieve transmission line pressure, and pressure increased to more than 100 psig, as indicated on the recording chart on the pressure volume gauge on the meter. Because the gas company employees failed to open the supply valve on the control line to the first stage regulators, after purging the line the regulators were isolateci from the line and a rapid increase in pressure occurred. This triggered the venting of the relief valve located inside the gate station and downstream of the first stage regulator. During a postaccident test, the relief valve functioned at 73 psig, close to its set pressure of 75 psig, but its capacity was not sufficient to prevent the pressure buildup which blew out the meter. Had a gas employee, when the pressure reached 80 psig, closed the inlet valves to the first stage regulators, this accident could have been avoided. Investigation of this accident revealed that the gas company personnel were not familiar with the facilities located at the gate station. Because of a lack of training and because of the lack of written procedures in the operation of the gate station, gas company personnel inadequately performed their duties, especially when the pressure reached a critical point. Proper training and well-defined procedures in the operation of the gate station could prevent similar accidents from occurring. The company prepared written procedures for the operation of its gate stations after the accident. These procedures have been followed during the on-site training given gas company personnel, which is repeated periodically. --····-·---··-··· ··--·····----,-· l -~ i I 9 I I i {. ! . '

I f'.. ;.~ ~-; tc : . ·! ~~- I "' ~ ~ ~ i ., 1:. ~ .~. il ~ .,/;' ~ I M ~ ~ ~ " R '.~ •j •' I •' 1· ~i ~ ::;; c ' • 'Ii " .f. ~ ~~ ~ l n ~ r: ·t -33- NA'l10NAL TRANSPORTA'l10N SAPBTY BOARD WASHINGTON, D.C. 20594 Accident No.: Company: Location of Accident: Time: Date: Property Damage: Injuries: Probable came Pipeline Summary Report FTW 80-FP-004 Elizabethtown Gas Company Trenton A venue at Elizabeth River Bridge Overpass, Elizabeth, New Jersey 9:10 a.m., e.d.t. July 31, 1980 $300 (estimated) 1 fatal The National Transportation Safety Board determines that the probable cause of the accident was the ignition by a workman's tools of an accumulation of natural gas in a bellhole. Description oi the Accident On July 31, 1980, about 9:10 a.m., an accumulation of natural gas ignited at a construction site on the Elizabeth River Bridge Overpass in Elizabeth, New Jersey. One worker was burned by the resulting fire and died 11 days later. The Saf~ty Board investigation disclosed the following circumstances leading up to the accident. In order that the Army Corps of Enginers could raise the Trenton A venue Bridge over the Elizabeth River, the Elizabethtown Gas Company had to temporarily abandon a 2,000-foot section of 12-inch steel gas main. (See figure 1.) On July 29 and 30, a section of the main, which normally operated at 23 psig, was isolated by closing 12-inch valves on both sides of the bridge. Gas was then vented to the atmosphere. On July 31, a three-man crew consisting of a fore man and two workers from a firm contracted by the Elizabethtown Gas Company to work on the abandonment project was at work on the Trenton Avenue Bridge. Shortly after 9:00 a.m., after a brief visit by an Elizabethtown Gas Company inspector, the foreman instructed the two workmen in the crew to loosen the 8-bolt Dresser coupling 1/ on the 12-inch main, which coupling was located at a depth of 32 inches in a bellhole. (See figure 2.) Upon smelling gas, however, the foreman ordered the workers to leave the ditch. Before leaving the worksite, the foreman instructed the workers to let the remaining gas, which was near atmospheric pressure, dissipate before going back into the trench. . Soon after the fore man left, both men reentered the open trench, but one returned to the service truck to get a tool. At this time, seven of the eight nuts and bolts on the Dresser coupling had been removed. As the workman who remained in the trench tried to remove the eighth nut and bolt with a hammer and chisel, the natural gas ignited, sparks from the hammer and chisel apparently were the source of the ignition. The workman in the trench was burned critically. He died 11 days later • y Dresser Coupling - a gasketed fitting used to join pipe ends by compression.

f1·~ •.. :·::~·;:~.: .. ~.~;···~~.•;.:~.·.· ..• ~-.:.:::~.'-~f::[r"0~.i-2i"'f.:.~.Y'"'-·;'.';~"-·:_:_0~·::·!·,.:r.T('j~1(1 1 9?'i' 1 f0~21~fr~~'.~1,;;,4tt~Yf1'1~==:'.!c~:~-~,~:~o:~~"·~"Jlft·-!~,\il:¥f¥t+¥??":'.f~!ht~

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- ~ -- -·-- -- ___________________ __: ________ .. ___________________________ .. .-·-·---¥···-···-- -····· i I I I I I I I I l I ' i i ! \ ' ...( TRENTON DOYLE ST. '~­'; ,~ SITE -34- BRIDGE SIDEWALK ELIZABETH RIVER AVE. FIGURE 1. PLAN VIEW OF ACCIDENT SITE ELIZABETH, NEW JERSEY

. ·?: '-~=: ~:=::'.::·-."~"'~'~- '.:~-~-~':: :'""'"· ' '''+ffl;C''""'··-"'"~""' :" 'T"-':'•cr·-.• ''"'''1'" .e;'.'"""'" """' ilF'W'""<''?'·'?'" e ""' ~:•""'-"''' """"''.P~'""'"'l"''~"'':'l'''l':'.iJ .. -·- -------------· ----------------- ----------------- -----··--··-----·---------- ------! ~ / r :~ ., . ,,.I I 3'/z' -35- CONCRETE WALL • 0 01 RAILING lo ol \ 'I CONCRETE SIDEWALK DRESSER COUPLING + fr ~ -------------?\ 12" ·S. {<.' I ' ~ "-~ ---- - -------------' TOP VIEW SCALE 1/2" = 1 FT. DRESSER COUPLING * CONCRETE CURB ROADWAY RAILING CONCRETE WALi. CONCRETE SIDEWALK _...,.......- ---- ~:~:-,,,";,1:. _)' CONCRETE CURB

.. ~ FIGURE 2. VIEWS OF BELLHOLE ELIZABETH, NEW JERSEY 1 d I J;1 I I I ! I ' i i I I I I I I ! I I I

...•. , . .. ~ . -36- The configuration of the hellhole -- partially enclosed by an undercut sidewalk and a trench over 4 feet deep - provided an enalosed space in which the explosive gas-air mixture accumulated. Although near-atmospheric pressure existed in the 12-inch main, sufficient gas escaped from the loosened Dresser coupling to reach a critical level within the confined trench. The fore man recognized this, but the workmen, for reasons unknown, ignored his instructions to stay out of thie trench while gas fumes were detectable. Inadequate safety procedures, including the lack of gas monitoring equipment,· the failure to take measures to avoid ignition and the lack of proper supervision, were factors that contributed to the severity of the accident. The company's postaccident conclusion to possibly require "all bolts on a coupling be loosened before any bolts are removed," ie much too limited a countermeasure~ for it addresses only a single factor involved in this particular accident. ._. ... •.' ... , .. ··-·~

f ! ' -37- NA'l10NAL TRAllSPORTA'ftON SAPBTY BOARD WASBDIGTON, D.C. 20594 Pipeline Accident No.: Company: Location of Accident: Time: Date: Property Damage: Injuries: Pipeline Summary Report FTW 81-FP-006 Natural Gas Pipeline Company of America Eugene Island Block 295-Gulf of Mexico 4:45 p.m., c.s.t. January 27, 1981 $953,859 None The National Transportation Safety Board determineti that the probable cause of the accident was the rupture by the net of the shrimper GULF KING of a 2-inch bypass line on a 16-inch natural gas transmission pipeline. Deserfptian of the Aeeldent On January 27, 1980, the rupture of a bypass line that was part of a subsea tie-in unit owned, operated and maintained by the Natural Gas Pipeline Company of America (Natural) near the Exxon Company USA (Exxon) Eugene Island Block 295 platform in the Gulf of Mexico leaked about 44,454 Mcf of natural gas at 980 psig into the surrounding water, resulted in almost $1 million in property damage. The Safety Board investigation disclosed the following circumstances leading up to the accident. On January 27, 1980, about 4:45 p.m., the net of the shrimper GULF KING, which was trawling in 210 feet of water near Exxon's Block 295 platform, snagged the 2-inch valve on a bypass assembly on Natural's subsea tie-in. The horizontal bypass piping bent upward at an angle of 90 degrees, and the weldolet between the 2-inch and a 12-inch pipe cracked. Escaping gas created a 400-foot surface boil. The GULF KING operator reported the leak to personnel on the Exxon's 295 platform. They, in turn, notified the United Gas Pipeline Company (United), operator of the Sea Robin Pipeline, and Natural. Natural's 16-inch pipeline ties into the Sea Robin Pipeline in Eugene Island Block 295. Insf:alled in 1978 with a fabricated tie-in as.~embly, the pipeline reduces from 16 to 12 inches with a check valve and a ball valve. The 12-inch line then teed in~~ a 12-inch side tap unit on top of the 24-inch Sea Robin Pipeline. The 2-inch bypass around the check valve which was damaged was parallel to the 12-inch pipe to which it is joined by weldolets 4 feet off the bottom of the Gulf. Because the water depth was greater than 200 feet, burial of the installation was not required. Located on Bureau of Land Management right-of-way, the installation was designed and constructed in accordance with the requirements of Title 49 CFR Part 192. Upon notification of the leak, Natural shut in or diverted production on all platforms in the Sea Robin Pipeline system. About 46 hours after the accident, United, ~hich had sent divers to inspect the line, informed Natural that the leak was in the Sea Robin 16-inch line and that they had it isolated by closing the subsea valve • Consequently, Natural reopened its production lines feeding the 16-inch pipeline. The leak age resumed, so once again Natural shut in its production. Finally, more than 48 hours after the accident, United divers discovered the break in the 2-inch bypass around Natural's check valve. ...

f ,...~-,-·-·· ~··-·-'""'' ---·--· ,.,. .. , ·.- ·: . . . ~­ t' !, .'. ....... . t I ~ ~ ' ' l -38- The 2-inch bypass assembly was the only part of Natural's subsea tie-in unit exposed and thus vulnerable to damage. Normally, shrimpers do not trawl in water depths of 210 feet. In fact, burial of pipeline is not required in water depths greater than 200 feet. However, to preclude any similar occurrence, sand bags were placed over the bypass assembly when the sidetap unit was replaced. The loss of the estimated 44, 454 Mcf of natural gas was due to the size of the break, operating pressure of 980 psig and the time involved in shutting down the system, which time itself was a function of the difficulty in pinpointing the leak in inclement weather. Much of the high cost of the repair was due to the offshore location of th·e break which necessitated additonal expenditures for the use of a lay barge, divers, helicopter service and marine surveyors.

-39- NATIONAL TB.AMSPORTA'l10N SAPBTY BOARD 1f ASBIMGTON, D.C. 205M Pipeline Accident No.: Company: Location of Accident: Time: Date: Property Damage: Injuries: PrabUle C&Ule PIPBLINBSUKllARYREPORT FTW 81-FP-008 Alabama Gas Corporation Homewood, Alabama 1:50 p.m., c.s.t. March 3, 1981 $147,000 0 The National Transportation Safety Board determines that the probable cause of the accident was the ignition by a pilot light of natural gas escaping at 11 psig pressure from a 11/4-inch steel service line. Contributing to the accident was the failure of the contractor to request the gas company to locate its facilities before grading operations were begun. Deaeriptioa of the Accident On March 3, 1981, about 2:10 p.m., a natural gas explosion leveled a private residence in Homewood, Alabama, a suburb of Birmingham, Alabama. No injuries resulted directly from the explosion. The Safety Board investigation disclosed the following circumstances leading up to the accident. The owner of a private residence in Homewood, Alabama contracted with a construction company to install a driveway on his property. On the afternoon of March 3, an employee of the construction company was grading the area to be paved with a backhoe-loader. According to the homeowner, any trees to be removed were to be sawed off at ground level and the stumps paved over. However, during the grading operation, about 1:50 p.m., the backhoe operator toppled a 15-inch diameter pine tree. As the tree was uprooted, a 11/4-inch bare steel service line, which passed through the tree's root system was pulled from its threaded connection in a service cock in the basement wall; the meter set assembly dropped to the basement floor, and natural gas began leaking into the basement at 11 psig. The service line also separated partially at the point the tree was uprooted, so natural gas also began leaking to the environment. Smelling the gas odor near the uprooted tree, the backhoe operator notified the Alabama Gas Corporation at 1:58 p.m. that the service was "leaking pretty bad •. " At 2:04 p.m., gas company personnel were dispatched to the scene to repair the leak; however, before they arrived 10 minutes later, the gas in the house ignited and exploded at 2:10 p.m. Gas buildup in the basement had reached the explosive level over a 20-minute period and had been ignited by the pilot light of either the gas furnace or gas water heater.

w~·!ffti.!'l:~:.~::·r"'r...-.'lY~,'~;.,1;~,/1Y~··t" .... ,.~ ,..,.,,,,,........ •. 7'~''' • ,.-,,-.-...::·:rl"~•,1.;r ""I;"'"~·:.-,;·";',"'. ~ ::'!'~..,,.,-- > ..f !;lq~J"t'"'('""',~T","',l'?f'""IJ~..,...:r.•- "'";:<• "!! "":·'"' ':':F;":",l':r'XP''l!."!":",,;~.~.:'"r'""':"'"cf ! ·~f";"'1fr>rr•,.,, ,,........-...-·-;.·~,.-.-_ . .,...,,,..f.'~·~·-(··W}l"1-'.":!/'J'.'.V'!'f'.~~ I . , ~-. r· -40- The service line was installed in 1948, and entered the basement 18 inches below ground level where it was connected to a valve and a meter set assembly. The regulator was vented to the outside with a 1/2-inch line, which was hard to discern. Construction company personnel had made no attempt to locate the gas facilities before begining the driveway construction, although the City of Birmingham, of which Homewood is a suburb, has a voluntary one-call system to provide information to those who might encounter utility facilities. More readily visible gas facilities, such as an outside meter set assembly, or construction company coordination with the Alabama Gas Corporation to locate gas facilities could have prevented the accident.

<:~ ~ ", " I· " ,. f; I t· ' ; I ? ; t~ !• I, I !; ,. I I ! * •/ ~ Accident No. Company: Location: Time: Date: Damage: Injuries: Probable Came -41- NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 Pipeline Summary Report FTW 80-FP-007 Lone Star Gas Company Keller, Texas 9:56 p.m., c.d.t. September 28, 1980 $41,000 1 fatal The National Transportation Safety Board determines that the probable cause of the accident was the ignition by an undetermined source of natural gas from a leaking standard compression coupling on a 1-inch steel service loosened by soil movement. Delleription of Accident At 9:56 p.m., c.d.t., on September 28, 1980, a natural gas explosion in Keller, Texas, destroyed one private residence and fatally injured the lone occupant. (See figure t.) The Safety Board investigation disclosed the following circumstances leading up to the accident. In September 1950, Lone Star Gas Company installed a long-side 1-inch steel service line 40 inches beneath Price Street in Keller, Texas to provide service to a private residence. About 20 years later, when that residence was razed,the service was abandoned at the stub end of the line. Service was not abandoned at the main to allow for any future need for gas service. It was at this connection with the main that the leak developed. The service line was attached to the service tap with a 90° elbow, a street elbow, a short nipple and a 1-inch by 5 1/2 inch standard compression coupling. Gas leaked at 15 psig from the inlet side of the coupling which had pulled loose from the nipple. The standard compressions coupling was not designed to prev~r.t pullout. However, only since 1974 has the manufacturer cautioned use~::; to properly anchor the pipe where the possibility of pipe movement exists. The service line beneath Price Street was not anchored. A long period of near-record drought followed by sustained, heavy rain preceded the accident. The clay soil in which the pipe was buried contracts when dry and expands when wet. This soil movem'!!nt subjected the underground piping to stress and resulted in the loosened coupling. Ttct?. Lone Star Gas Company reported 5 additional accidents in the general area within e. two-week period, in all of which the pipe and fitting were stressed by soil movement. Besides contributing to loosening the coupling, the wet clay also kept the natural gas escaping from the coupling from migrating upward. As a result, the gas moved laterally, beneath and then upward !nto the nearby house, where it ignited by an undetermined source. -.. --·- ____ ... ......,.._ .. _:: _____ '.-~.....:-

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fY~·'7-"~·f"T ... 7"!'~ ·->--.-,::-'.''.'~-'''('..1,:- l'•~:·r"::~"!.~.--~"~,,..·-:· ...... ~-?1"'~"..t?';·'\;";;:-P';F~V • .,~ ... v.'l'?-:~?'f.i;~·~{~~~~~J::~r~-:~tf~~~~- 1'.f,.,f .. J$!f·W-,f,.-{if.1f~4RJtt:~w--.:~1!{~%Np~ It' . .-:...__ •• _ ............. ~ ... ~-...... ..... -~ ..... --··-··.. • • . -- ~-~-·· - •• - ·-· - . - ··-. ····--·-~~······ _ ••• .,,. ••. -· • •· - •• _..... ... ,.,..,......,.-...~ ... -· • .,,.. .. __ ..,., ______ ~-·--·- ~-.... -~. ··------·~-- "----·····--· --··· ··-- ---·-· -····- • ' I I -43- Had the service line been abandoned at the main when it became apparent no future need for service would arise, the hazard would have been eliminated. Similarly, pipe installation with proper anchorage would have reduced the possibility of a loosened coupling and concomitant gas leak. The Safety Board, as a result of Its investigation of a similar accident, !.frecommended that the Research and Special Programs AdministMttorv Initiate rulemaking to prescribe a time limit when an inactive service line would be required to be abandoned and physically discoMected from the main. (Class D Priority Action) ( P-80-74) The status of this recommendation is open, pending response from the R.JSearah and Special Programs Administration. 1/ Pipeline Accident Reports -- Brief Format, Issue 11-1980, page 23 -- Central Lotdsiana Electric Company, Inc., Lafayette, Louisiana, August 7, 1978.

r.~ .. .,, :.=-':=,~:~~·.~· .. --- -· ·-. . . , ~'.: -44- MA110MAL TRAMSPORTA110M SAPBTY BOARD WASWMGTOM, D.C. 20594 I Pipeline Accident No.: Company: Location of Accident: Time: Date: Property Damage: Injuries: Probable cause Pipeline Summary Report FTW 81-FP-005 Missouri Power & Light Company Mexico, Missouri 10:15 p.m., c.s.t. January 8, 1981 $200,000 3 nonfatal The National Transportation Safety Board determines that the probable cause of the accident was the ignition by an undetermined source of an accumulation of natural gas which migrated into a building from a leak at a standard compression coupling which had been pulled loose but not separated by thermal contraction of unrestrained polyethylene pipe. Deseription of the Accident At 10:15 p.m., c.s.t., on January 8, 1981, a 2-inch plastic gas main pulled loose in a compression coupling under an alley in downtown Mexico, Missouri. Natural gas at 43 psig pressure escaped from the main and migrated through a sanitary sewer system into a nearby buHding where it was ignited by an undetermined source at 10:25 p.m. The resulting explosion and fire destroyed a commercial building, severely damaged an adjacent building, broke nearby windows, and damaged several motor vehicles. The fire was confined to the area. There were no fatalities; however, three firemen were injured while fighting the blaze. At 10:33 p.m., the Mexico Department of Public Safety notified the Missouri Power & Light Company dispatcher in Moberly, Missouri, of the accident. Utility company personnel were dispatched to the scene. When the assistant superintendent arrived at the accident site, he saw flames rising in the alle~1 behind the burning buildings. At 11:15 p.m., he closed a valve through a curb-box some 200 feet upstream of the leak which shut off the gas now on the one-way feed. Excavation of the leak area began at midnight. Repairs were completed by 3:00 a.m., and service was restored by 4:00 a.m. After the accident, the main was exposed in a bell hole to the transition connection of 4-inch steel pipe and 2-inch polyethylene pipe which had been made with two compression couplings and a 10-inch-long segment of 2-inch plastic pipe. Th~ leak was found at the upstream end of the downstream coupling had been loosened by pullout forces that the coupling had not been designed to restrain. In the mid-1950's the Missouri Power & Light Company had extended a 4-inch, cast-iron main in the alley to serve a laundry. Sometime later a section of the cast-iron main was replaced with a 4-inch steel pipe. In 1974, the gas company began using polyethylene pipe and its personnel were trained and tested by the pipe manufacturer in the fusion of the plastic and other procedures involving its installation. In February 1975, ~-••. ,!.,, ____ ~---:.·~----···--: • .. ,

1··:~ --··-·-··:..;:.;,:-.: . ..==~=:=.--:-::~::-·..:.~==~.:====--===-='.:.~--~::·::'=:'.'.':~:.~:~==~::'.".~:·::~:1'.:~:~:•:-~-~·::·::_:~::':':A'.:":7~ ' f ~ -45- ,. f L. r- 2-inch polyethylene plastic pipe was inserted into the remaining 170 feet of cast-iron

pipe. The length of the plastic pipe was misjudged and an additional 10-inch piece of

plastic pipe and two standard, short-barreled compression couplings with smooth liners were used for the connection. More recently all high-presure installations have been made with "Posi-Hold" couplings, but previously their use had been limited in the gas company's Mexico district because only one set of equipment was available for such installations. The Safety Board has investigated two similar accidents 1/ involving transition couplings joining polyethylene plastic pipe to steel pipe. In both accidents, over 100 feet of unrestrained polyethylene pipe had been inserted in an abandoned main and had been joined to the steel pipe with a standard, short-barreled compression coupling with a smooth metal insert. The failures were caused by thermal contraction of the polyethylene pipe which exerted pullout forces on the compression couplings which they were not designed to resist. The city of Mexico is served by Panhandle Eastern Pipe Line Company's single city gate station with dual orifice meter runs. The increased rate of now which occurred when the coupling failed was apparent on the telemeter charts--which show proportional now--in the Mexico Service Center which is unmanned after normal working hours. A decreased rate of now was also evident when the valve was closed 45 minutes after the accident. The event was also recorded on a pressure chart at a regulator station 4,500 feet from the leak. Comparable data elsewhere in its system has been u.4Jed by Missouri Power &: Light to detect leaks, which assured their timely repair. As a result of its investigation of this accident, the National Transportation Safety Board issued the following recommendations on August 3, 1981, to the Missouri Power &: Light Company: Review company records and maps to identify locations where compression couplings have been installed on unrestrained plastic pipe of sufficient length that thermal contraction could cause separation from the couplings and take corrective action as necessary to prevent such separations. (Class n, Priority Action) (P-81-21) Install alarms on the existing gas pressure and gas now telemetering equipment to promptly alert operators to emergency conditions such as linebreaks which are evidenced by abnormally high gas now rates or pressure reductions. (Class Il, Priority Action) (P-81-22) The status of thefo,~ recommendations is open, awaiting response, as of March 3, 1982. !} Pipeline Accident Report--"Nebraska Natural Gas Company, ~ath?inder Hotel Explosion and Fire, Fremont, Nebraska, January 10, 1976" (NTSB-PAR-76-6);-and Pipeline Accident Report--"Kansas Public Service Company, Inc., Explosion and Fire, Lawrenee, Kansas, December 15, 1977" (NTSB-PAR-78-4).

-46- NA'l10NAL TRANSPORTA'110N SAPBTY BOARD WASBOfOTON, D.C. 20594 Pipeline Accident No.: Company: Location of Accident: Time: Date: Property Damage: Injuries: Probable CeUBe Pipeline Summary Report PTW 78-PP-008 Oklahoma Natural Gas Company Oklahoma City, Oklahoma 3:50 p.m., c.s.t. April 24, 1978 None • Fatal The National Transportation Safety Board determines that the probable cause o·, the accident was the displacement of air from a regulator vault by natural gas escaping from a discomected servfoe line, which resulted in an oxygen-deficient atmosphere, and the fatal asphyxiation of four men. Working in the confined vault without stopping the now of gas and attempting rescue operations without the use of safety devices and following proper safety procedures contributed to this accident. Delcrlptim of Aeeident On March 29, 1978, Oklahoma Natural Gas Company (ONG) dispatched a two-man crew to shut off gas service to a shopping center in Oklahoma City at a regulator vault in order to repair customer service lines. Because the crew was unable to close a valve that was under water inside the vault upstream of the regulator, they disconnected the line on the low-pressure side of the regulator at a 2-inch union and plugged the line without first stopping the finw of gas. Another valve was located outside the vault, but because it was paved over with asphalt, the crew did not attempt to uncover it. On April 24, 1978, ONG assigned a different crew to restore gas service to the shopping center. This two-man crew was not able to cloge the valve inside the vault because it was still under water, and they did not try to uAtcover the valve outside the vault. Instead, the crew removed the plug and stuffed the line with a rag to stop the gas now. When the crew removed the rag, they were unable to immediately align the union to start the threads, and gas began escaping at a pressure of 9 inches W .c. The escaping gas filled the 3- by 4- by 6-foot vault and within minutes the two men were asphyxiated. Three other ONG employees entered the vault through the 19-inch opening to rescue the men. Shortly thereafter, one man was pulled out of the vault by other ONG workers and was revived at the scene; however, the other four men died of asphyxiation. The crew did not have a respirator at the job site. A mainline valve finally was turned off, and rescue persomel with air packs arrived and removed the aspyxiated men from the vault. The five men in the vault had been employed by ONG an average of 20 years; three of the men were supervisors. Although ONG has trained its men in the use of air-breathing masks, ventilators, and lifebelts, the company does not have written instructions about where this safety equipment should be used.

" ~" ! r!S: it ~J· "'~ ·{~, I'~~ ,;; :~, .. ,. ,,:· ,. ··\· ' ,· l, I ,. ~: f f ' ,: rt f' ; . f: .. I ' ' ' ~} ' i'.' ff f'; ~~ ,, t: ~; ,. t:· ~ r: ~. ' ,_ ~ r I l I i I I ! l I I I ! I ' I f I I I ' I l . l ~-----------·--·-·---------- .... ·--·-··"' -47- The ONG workmen did not stop the flow of gas before disconnecting the 2-inch union in the vault by either pumping the water out of the vault to make the valve operable, or by uncovering the valve outside the vault. The crew did not use any safety equipment during their attempt to restore gas service nor did they follow any unwritten safety procedures in their subsequent rescue attempt. Working in the confined vault without stopping the flow of gas, and attempting rescue operations without the use of safety devices and following proper safety procedures were factors contributing to this accident • The Safety Board has investigated similar accidents involving gas company employees who were overcome by gas while working in a vault, two of which are referenced. 1/ In a number of cases, senior gas men who were acquainted with the hazards of natural ga8 were involved in these accidents. The National Transportation Safety Board, as a result of its investigation of this accident, recommended that the Oklahoma Natural Gas Company: Require its employees to use valves or other means to stop the flow of gas before disconnecting or reconnecting active gas lines. (Class I, Urgent Action) (P-78-53) In training both new and long term employees, emphasize the need to have available safety equipment while performing certain hazardous work in confined spaces and the importance of testing the atmosphere, the use of safety devicest and the use of safe procedures. (Class I, Urgent Action) (P-78-54) Revise its safety manual to include written instructions on where and how to use safety equipment as an on-the-job complement to existing training activities. (Class I, Urgent Action( (P-78-55) The status of these recommendations is closed, acceptable action, as of December 19, 1978. 17 "Pipeline Accident Report--Equitable Gas Compuny, Pittsburg, Pennsylvania, November 17, 1971," (NTSB-PAR-72-2); National Fuel Gas Company accident, Buffalo, New York, March 26, 1977.

~r HA'l10NAL TRANSPORTA'l10N SAFETY BOARD WASHINGTON, D.C. 20594 Pipeline Accident No.: Company: Location of Accident: Time: Date: Property Damage: Injuries: Probable cause Pipeline Summary Report FTW 81-FP-004 Cincinnati Gas&. Electric Company 515 W. Columbia Avenue, Reading, Ohio 1:00 - 3:00 p.m., c.s.t. December 17, 1986 None 2 Fatal The National Transportation Safety Boar1 · determines that the probable cause of the accident was the use of improper fittings by the gas company crew in making a service tap which allowed the escape of natural gas and resulted in the fatal asphyxiation of two men in an oxygen-deficient atmosphere • Description of Aeeident At 9:00 a.m., c.s.t., on Wednesday, December 17, two mechanics were at a job site on the north side of the street discussing with their supervisor the fittings to be used for a gas service line renewal. The supervisor radioed for shoring material when he noted that they had none, and he instructed the senior mechanic not to enter the bellhole until the shoring was installed. The men further discussed the 12-inch main, which was steel pipe on a nearby bridge crossing, but which might be made of cast iron at the service tap. The service line was pressure tested from the curb to the meter and found to be leaking. The gas customer's son last saw the two men at 12:45 p.m. standing by the service tap bellhole. When he returned home at 3:00 p.m., he noticed gas blowing from the bellhole; he did not notify the Gas Company. Just before 1:00 p.m., a postman noticed discolored air rising from the bellhole, but saw no one there. About 1:00 p.m., after parking on the south side of the street in front of the residence served by the line being renewed, he noticed one of the Gas Company employees "standing in the excavation (across the street) with his head turned to one side and waving his arms while it appeared that he was gasping for air." The postman after observing what must have been an unsuccessful attempt by the man to escape from the hole, delivered mail to the residence and then returned to his vehicle. At this time, he saw no one. He drove around the corner and parked for 12 minutes. When he departed at 1:15 p.m., no one was visible at the excavation; he did not notify the Gas Company. At 3:10 p.m., a gas· company employee passed the location, saw the Construction and Maintenance truck (with its ladder still in place), smelled gas and heard it blowing. When he stopped to investigate, he found the two men in the bellhole. After he unsuccessfully attempted to pull one out by himself, he radioed the dispatcher. When help arrived at 3:15 p.m, the men were removed from the bellhole and taken to a hospital. Resusitation efforts commenced at the scene and continued until they were pronounced dead of asphyxiation at the hospital.

Gas Company Emergency crews were dispatched to the accident site. Pressure was reduced to 5 psig. The service tap hellhole, in which no shoring had been installed, was 31 inches by 39 in~hes and 5 feet deep. (See figure 1.) After the hellhole was enlarged with a backhoe, the main was checked with a chisel and found to be cast iron (this was also indicated on the records). Two other chisel marks were subsequently found. A 12-inch by 1-inch steel Skinner-type saddle was partially around the main over a 11/4-inch hole. The saddle bolt was loose and the rubber gasket was protruding from one side. Gas was escaping from beneath the saddle and around the gasket. The saddle was designed for use on a steel main and consequently did not fit the cast iron main properly because the outside diameter of the cast iron main was larger than that of a 12-inch steel main. After the saddle was removed, the gas now was stopped by the use of a 1 li4-inch plug which was "threaded easily into the main (approximately 2 to 3 seconds)." A saddle was not needed since the crew used a 1 1/4-inch by 1-inch brass street tee with a 1-inch brass 90° compression anti-pullout ell. The job was completed by inserting the old service line with 1-inch plastic. The employees' records indicated that both men initially sent to the site had received classroom and field training when they were first employed and at later times in preparation for promotion. They were required to pass tests upon completion of training, and their work was subsequently inspected on a number of occasions. Such training was intended to adequately prepare them to safely execute this type of job.

·\ ·' ·l '· .. Ground Level 6' 4'-9" -50- 4'-6" 12" Gas Main Section A·A Scale: % = 1 '-0" Accident Site - Bellhole at Long-Side Service Tap for 515 W. Columbia Ave., Reading, Ohio Figure 1. Note: Dimensions Are Approximate Curb 5' Street 1 % " Gas Service C.G.&E. Co. By: G. Kennedy Date: 1-1 &81 Doc. No. a ·-·~--·- ·----·-···· ···-···--....,__ _ _,_:

I ~ ' i: I ~. 1: ~' ' ;r " § ~ ~ ~ I ~ j H ~ I I " ~ ·~ -51- NA'ftONAL TRANSPORTA'ftON SAFETY BOARD WASHINGTON, D.C. 20594 Pipeline Accident No.: Company: Location of Accident: Time: Date: Property Damage: Injuries: Probable cause Pipeline Summary Report FTW 81-FP-002 Texas- New Mexico Pipe Line Company Eight Miles West of San Ysidro, New Mexico 5:30 p.m., m.d.t. October 22, 1980 $283,600 1 Fatal The National Transportation Safety Board determines that the probable cause of the accident was the ignition of escaping crude oil by a bulldozer as it punctured a 16-inch crude oil pipeline while cleaning the right-of-way after an adjacent pipeline was installed. Description of Accident At 5:30 p.m., m.d.t., on October 22, 1980, 8 miles west of San Ysidro, New Mexico, a 16-inch crude oil trunkline operating under a static pressure of 400 psig, was punctured when struck by a bulldozer. The dozer operator was fatally injured by the resulting fire which consumed over 5,000 barrels of crude oil that had leaked through the puncture. The Texas-New Mexico Pipeline Company's 16-inch steel pipeline carried crude oil from Aneth, Utah, to Jal, New Mexico, a distance of 512 miles. It shared a right-of-way (ROW) in the area of the accident with Mid-America Pipeline Company (MAPCO), whose contractor was constructing an additional liquid hydrocarbon pipeline. Although the lines generally ran parallel to each other, they did cross several times. Work on the new MAPCO line had been in progress for about 30 days over about 90 miles of parallel construction which had been completed at the time of the accident. In the immediate vicinity of the puncture, MAPCO's new pipeline had already been installed and backfilled. The bulldozer operator, consequently, should have been thoroughly aware of the existence of the Texas - New Mexico 16 -inch crude oil trunkline. Also, there was no reason for cutting below grade where the new pipline had already been installed; and the bulldozer operator had been instructed not to clear the ROW. The new line was located between the two existing lines--10 feet from MAPCO's existing line and about 35 feet from Texas-New Mexico's 16-inch pipeline. An engineer from the Aneth Station was serving as Texas-New Mexico's inspector during the construction of MAPCO's new pipeline. The accident happened at 5:30 p.m. when the pipeline contractor's bulldozer was cleaning the ROW on a steep slope below the top of a mesa on Zia Pueblo land at milepost (MP) 183.2. A corner of the dozer blade punctured the 16-inch trunkline which contained West Coast Sweet Crude Oil, with an API gravity of 36.2 degrees, under a static pressure of 400 psig. The oil ignited, burning the dozer operator and the dozer. Most of the 5,684 barrels of crude oil that escaped were consumed by fire which burned about 800 feet down the slope. The operator's body was found 35 feet from the bulldozer, which was still in contact with the pipeline although it had been shifted into second reverse in an apparent attempt to escape.

L f i . - . r t -52- At 11:35 a.m., the upstream Bisti Station (MP 8'1.5) was shut down awaiting pumping orders. The line was closed at the downstream Lynch Station (MP 4'13.49) at 1:32 p.m. The high point on the line upstream of the accident was at the Continental Divide (MP 131.5). At 5:30 p.m., the Aneth Station (MP 0.0) received a low-pressure alarm indication from a block valve at the Rio Grande River crossing (MP 208.9), downstream of the break. Six minutes later, the Aneth Station received a valve-closed alarm indication from the Rio Grande block valve. Aneth was notified of the accident by the pipeline contractor at 6:00 p.m. Shortly thereafter, the first Texas-New Mexico personnel were dispatched, and began accumulating information and developing plans. The fire had nearly burned itself out by midnight and it was apparent that there was no danger of stream pollution. A pipeline contractor, summoned by Texas-New Mexico, was on site very early the morning after the accident. Halliburton cementing trucks and equipment reached the location late that morning but were released shortly thereafter since the fire had practically burned out. The line was tapped and stoppled the following day, and a 40-foot section was cut out and replaced. The line was repaired and refilled, and the cleanup completed. The total cost incurred by Texas-New Mexico Pipeline Company, including value of product lost, was $258,602.

Accident No. Company: Location: Time: Date: Damage: Injuries: Probable ca..e MA'ftOMAL TllAMSPORTA'ftOM SAPETY BOARD WASlllMOTOM, D.C. 20594 Pipellm Summary Report FTW 80-FP-006 Enterprise Products Company Cities Service Oil Company Petrochemical Plant near Sulphur, Louisiana 3:40 p.m., c.d. t. September 2, 1980 Over $100,000 None The National Transportation Safety Board determines that the probable cause of the accident was the ignition of a fire that spread to a 4-inch steel propylene pipeline, which, when heated by oil-fed names, ruptured. De8arlptian of Accident On September 2, 1980, at 3:40 p.m., a propylene pipeline owned and operated by the Enterprise Products Company (EPC) ruptured at the Cities Service Oil Company Petrochemical Plant near Sulphur, Louisiana. More than 500 feet of the pipeline were damaged and 400 barrels of product lost. Segments of 4 other pipelines owned by Continental Oil Compnay (CONOCO) also were damaged. The Safety Board investigation disclosed the following circumstances leading up to the accident. On August 29, 1980, an oil leak was detected on one of CONCO's pipelines, 175 feet north of the subsequent EPC rupture. (See figure 1.) Clean-up was deferred until after the Labor Day weekend, so a temporary dam was created to stem the oil spread. Consequently, during the next few days the oil collected in a pond created by the dam beneath a low section of elevated pipelines. On September 2, at 2:50 p.m., a Southern Railway maintenance crew working on track about 300 feet from and perpendicular to the elevated pipelines accidentally ignited a grass fire alongside the track. A moderately strong SSE wind carried the fire into brush and trees and along a power line right-of-way which crossed the railroad and converged upon the pipelines, intersecting them abut 700 feet north of the railroad tracks. Upo., reaching the oil spill, the fire fed on the oil and intensified in two critical locations: a low spot beneath the five pipelines where they were elevated on a rack 4 feet above the ground level; and a spot about 300 feet further north, where some old utility poles had been left along the pipeline right-of-way, beneath the power lines. Fueled by the burning oil and poles, the fire reached and burned through three of the overhead power lines, causing a power failure at 3:30 p.m. As a result of the power loss, the spring-loaded actuator on the downstream block valve of the EPC's steel propylene line closed. The spring-loaded actuator WdS designed to tail closed. The block valve closure stopped the now of propylene in the 4-inch pipeline, causing pressure to increase and the pipe to heat to a point of rupture. The

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-56- lfA'ftOlfAL TllAlfSPORTA'ftOlf SAPBTY BOARD W.ASBllfGTOlf, D.C. 20594 Accident No.: Company: Location of Accident: Time: Date: Property Damage: Injuries: Pipeline Summary Report FTW 80-FP-005 Entex, Inc. Intersection of Cameron and Dulse Streets, Tyler, Texas 10:50 a.m., c.d.t. July 3, 1980 $500 (estimated) 1 fatal 3 nonfatal The National Transportation Safety Board determines that the probable cause of the accident was the ignition of natural gas escaping from a slide gate by electrical arcing when an engine was started. Description of the Aecident On July 3, 1980, about 10:50 a.m., natural gas escaping from a slide gate 1/ at a construction site in Tyler, Texas where a gas main was being replaced was ignited by electrical arcing when an engine was started. The resulting fire burned four workmen, one of whom later died. The Safety Board investigation disclosed the following circumstances leading up to the accident. As a result of a study, the East Texas Division of Entex, Inc., decided to replace 250 feet of pipeline. When construction began, the company discovered that the gas main was not 2-inch, as was shown on company maps, but 5-inch pipe. The gas company decided to remove the 5-inch gas main while maintaining service at a reduced pressure of 7 to 8 psig through a new 2-inch pipe. (See figure 1.) At 7:00 a.m., on July 3, a utility foreman and a five-man crew began isolating a section of the 5-inch gas main being replaced at the intersection of Cameron and Dulse Streets in Tyler. First they squeezed the east end of the gas main and locked the squeezers in place. Then they sawed a plate hole 2/ near the west end of the pipe to be removed and installed a slide gate. The crew then dug a 5-foot-deep hellhole at the west end of the pipe section to be removed and cut and removed a 4-foot section of pipe which was 48 inches below ground. The foreman, sitting on the backhoe, instructed the crew to remove an additional foot of pipe and reverse the bolts on a Dresser coupling 3/ being used to attach a cap on the end of the main. The coupling was being held in place by the backhoe bucket while the bolts were being tightened. !/ Slide gate is a method of stopping gas now by means of placing a rubber-lined clamp with a preformed slot on the main to permit sawing through the live main so that a slide may be inserted in the slot to stop the gas now. 2/ Plate hole -:- a slot created by sawing through a live main for the insertion of a slide gate. ~ Dresser coupling- a gasketed fitting used to join pipe ends by compression. --·--·~·-·····~·---------,~- . .j

F~"'*:"~·:~':""""~'"""":~::·:""'"""':~:!:~.r'.""~o,,.~,, ... ~,-""", ~· f: l I I l I ~ i " L1: , !(' 11 ~·· ·l ~. ! "· I ·i. 'f I J. z_ ·,:~···~,~~~ 1' I" MAIN II '-.•' •' ,, ,, ,, 11 ,, II 1' ,1 1: N II II II II II I I " SPOIL DULSE a· ~ ::.-::====-= _•;.....:-..:-..:--~-=- - -57- •• BACKHOE 5"MAIN c=:;~~ ~ ©. = - = = = i =----=-.,=-- I I TRUCK I !'\' c=J-coNSTRUCT. : d ~MAIN I z c a- in

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• PAUL HAYTER (FATAL)
• LEOPOLDO SOENZ •
• JIM POWELL •
• R. C. GLASSCOCK •

I. LLOYD JOHNSON I. EDDIE OVERHULTZ • NONFATAL INJURIES FIGURE 1. PLAN VIEW OF ACCIDENT SITE TYLER, TEXAS i t ' ! ~ ' • " I ' ~ l. n @ I ~ '1 ~ l ' ~ -58- At 10:50 a.m., the foreman started the b«tckhoe begin, in preparation for positioning the bucket. Electrical arcing from the starter ignited natural gas leaking around the slide gate at 1 to 8 psig. The three crewmen in the bellhole and the foreman suffered burn injuries from the resulting fire. One of the crew died later as a result of his injuries. Use of a slide gate to stop the gas now was not an acceptable procedure by Entex operations. Written company procedures specified the use of particular line stopping equipment. Apparently U5e of slide gates to isolate pipe sections had been a common practice of the Tyler Gas Service Company, the predecessor to the East Texas Division of Entex. Line stopping equipment designed to stop the gas now in common-size mains such as 2-inch pipe was on hand. However, the slide gate was all that was readily available as a stopper for the nonstandard size 5-inch gas main. The drawback in using a the slide gate as a line stopper is the leakage during and after installation. Nevertheless a slide gate is a commonly used device up to an upper pressure limit of 15 to 20 psig. In this instance, though the 1 to 8 psig pressure was considerably lower than the recommended upper limit of 15 to 20 psig, conditions were favorable to the accumulation of a combustible mixture of air and natural gas, leakage from the 5-inch main, 48 inches below ground level in a 5:-foot-deep hole. The wind speed of 8 to 10 knots per hour was sufficient to carry the combustible mixture to tht) source of ignition. The hazards of gas and air mixtures are addressed in the Entex "Employee Safe Work Practices Manual" which also outlines precautionary measures not followed by the work crew. It states: "· •• it is essential that all possible sources of ignition be considered and controlled... Escaping gas is extremely critical and dangerous in an enclosed space such as a trench excavation .•• where dangerous gas and air mixtures could quickly develop. When escaping gas is known to be present, instrument tests should be made to determine its concentration. If an explosive mixture is found or if measurable quantities of gas are indicated, precautions should be taken to avoid possible ignition ••• " All these elements were present at the Tyler excavation and should have alerted the crew to the need for extra caution. " U. S. GOVERNMENT PRINTING OFFICE: 1982 361-828/305

FD07114 ｜ 1985_美国_AAR8502.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1985 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

NTSB/AAR-35/02

D D b TECHNICAL REPORT DOCUPlEKTATIOn PRGE . Re ort No. . T i t Ie and Subtitle Aircraft Accident Report--Air 2.Government Accession No. 3.Recipient's Catalog No. 5.Report Date NT&B/AAR-85/02 Continental Gates Lwrjet 23 Bradley International PES5-910402 Airport Windsor Lacks. Connecticut, June 4, 1984 6.Performing organization March 5, 1985 I CoJe 1 8.Performing organization Report No. '. Author(s) 1. Performing Organization Name and Address 10.York Unit No. National Transportation Safety Board 4024-A Bureau of Accident Investigation Il.Concract or Grant No. Washington, D.C. 20594 I 1 13.Type of Report and 1 2.Sponsoring Agency H a m and Address Period Covered Aircraft Accident Report, i hATiONAL TRANSPORTATION SAFETY BOARD I June 4y Iga4 Washington, D. C. 20594 14.Sponsoring Agency Code I I 1j.Supplementary Nctes __ i 16.Abstract On June 4, 1984, Night Air 4, e Gates Learjet 23, NIOiPP, was being operat Air Continental Inc. of Syria, Ohio, on a cargo flight transporting cancelled bank checks. Night Air 4 was on final approach to runway 33 et Bradley International Airport, Wind The right roll continued until t h e bank angle was about 90' and t h e airplane collided wit Locks, Connecticut, several witnesses saw it level off over the approach iights and turn ri ground. The eirplane was destroyed by impact and postimpact fire. Both pilots and th passenger on board were killed. The National Transportation Safety Board determines thst t h e cause accident was a? uncommanded roll to t h e right which caused the airplane to roll about descend into the pound. The cause of the uncoasmanded roll was an asymmetric retractio the flight spoilers wherein the left spoiler retracted and the right spoiler did not. The Sa Board could not determine t h e reason for the right spoiler mslfunction. i

1. Key Words

/18.9istribuiion Staremen: ' This document is aveilable 1 to the public through tne 1 Springfield, Virginia 22161 I Informa- l y . ~ ~ ~ ~ ~ i t ~

classifica:ioc 22.Price 2C.Security Classification Pages .- (of this report) (of t i s page) UNCLASSIFIED UNCLASSIFIED 1 ! bTSB Form 1765.2 (Rev. 9/74)

CON- SYNOPSbS .......................... 1 1 . 1.1 1.2 1.3 1.4 1.5 1-6 1.7 1.8 1.9 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1-16.1 1.16.2 1.17 1.17.1 1.17.2 1.17.3 2 . 2.1 2.2 2.3 2.4 3 . 3.1 3.2 4 . FACTUALINFORMATION . . . . . . . . . . . . Ristory of the Flight . . . . . . . . . . . . . . Injuries to Persons . . . . . . . . . . . . . . . Damage to AirpXane . . . . . . . . . . . . . . . Other Damage . . . . . . . . . . . . . . . . . Personnel hformation . . . . . . . . . . . . . . Aircraft Mcrmation . . . . . . . . . . . . . . Aids to Navigation MeteorrjlrexaI Information Comnrunications . . . . . . . . . . . . . . . . Aerodrome Information . . . . . . . . . . . . . Flight Recorders . . . . . . . . . . . . . . . . Wreckage and Impact Information . . . . . . . . . Medical and Pathological Information . . . . . . . Fire . . . . . . . . . . . . . . . . . . . . . . Tests and Research . . . . . . . . . . . . . . . Airplane Parts Examination . . . . . . . . . . . Flight Tests . . . . . . . . . . . . . . . . . . Additional Information . . . . . . . . . . . . . . Normal Operating Procedures . . . . . . . . . . . Airplane Descent, Approach, and Landing Techniques Flight Control System MaIfunctions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . 1 . . . . . . . 1 . . . . . . . 2 . . . . . . . 2 . . . . . . . 2 . . . . . . . 2 . . . . . . . 3 . . . . . . . 4 . . . . . . . 4 . . . . . . . 4 . . . . . . . 4 . . . . . . . 4 . . . . . . . 5 . . . . . . . 7 . . . . . . . . .I . . . . . . . 7 . . . . . . . . 7 . . . . . . . 11 . . . . . . . 13 . . . . . . . 13 . . . . . . . 13 . . . . . . . 14 'I . . . . . . . ANALYSIS . . . . . . . . . . . . . . . . . . . . . . . . . . 14 General . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 The Airplaie 15 The Accident 15 Accident Analysis Based on Flight Test Data . . . . . . . . . . . 16 CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . 17 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 ProbableCause . . . . . . . . . . . . . . . . . . . . . . . . 18 APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . 19 Appendix A-- Investigation ana Hearing . . . . . . . . . . . . . 19 Apperdix B-- Personnel Information . . . . . . . . . . . . . . . 20 Appendix C-- Aircraft Information . . . . . . . . . . . . . . . 21 Appendix D-- Radar Data . . . . . . . . . . . . . . . . . . . 22 Appendix E-- Accident History . . . . . . . . . . . . . . . . . 35 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii

NATIONAL TRANSPORTATION SAFETY BOARD WASEEINGTON, DX. 20594 AIRCRAFT ACCIDENT REFORT . .

llderch 5,1985 AIR CONTINENTAL GATES LEAlUET 23 BRADLEY INTEBNATKIWLU. AIRPORT WMDSOR LOCKS, CONNECTICUT JUNE 4,1984 SYHOPSIS On June 4, 1984, Night Air 4, a Gates Learjet 23, NlOlPP, was being operated by Air Continental Inc. of Elyria, Ohio, on a cargo flight trmspwting cancelled bank checks. As Night Air 4 was on fir& approach to runway 33 at Bradley International Airport, Windsor Locks, Connecticut, several witnesses saw it level off over the approach lights and turn right. The right roll continued until the bank angle was s h u t 90° and the airplane collided with the ground. The airplane was destnyed by impact and postimpact fire. Both pilots and '&e one passenger on board were killed. The National Transpclrtation Safety Board determines that the cause of the accident was an uncommanded roll to the right which mused the airplane to roll about 90° and descend into the ground. The cause of the uncommanded roll was 8n asymmetric retraction of the flight spoilers wherein the left spoiler retracted and the right spoiler did not. The Safety Ward could not determine the reason for the right spoiler malfunction. . . 1 I. FACTTJAL INFORMATION 1.1 aistwgof #'le Flight On June 4, 1984, an unmodified I/ Gates Learjet 23, NlOlPP, was being operated by Air Continental, Inc., Elyria, Oiiio, on E regularly scheduled cargo flight transporting cancelled bank checks under 14 CFR 135. The flight departed Cleveland Hopkirrs International Airport, Ohio, as Night Air 4 at 2200 eastern daylight time. 2/ After an uneventful flight, Night Air 4 arrived at Syracuse Hancock Int&tional Airport, New York, at 2245. There was routine ground cargo handling at Syracuse, the airplane was not refueled. Night Air 4 departed Syracuse at 2311, was cleared to climb to 17,000 feet, 3/ and was handed off to Boston Air Route Traffic Control Center (Boston Center) at 2314. Boston Center cleared Night Air 4 to its requested altitude of Flight Level (FL) 290 (about 29,000 feet) and the en route portion of

the flight was uneventful.

I/ An unmodified Lesjet has winghift devices that have not been changed since manufacture. A modified Learjet (for example, Century IH and Howard/Ftaisebeck Mark n) has wingfift devices that have Seen changed since manufacture to improve airplane

performance.

Z/ All times are eastern daylight saving time, based on the 24-hour crock.

3/ AU, altitudes 8re mean sea level, except as noted.

-2- A t 2332, Night Air 4 was handed off at 16,000 feet during its descent to Bradley Internstional Airport, Windsor Locks, Connecticut Approach Control. Approach eontrol identified the airplane, cleared it for a visual approach to runway 33, and at 2336 gave Night Air 4 a turn to position the airplane on final approach at 10 miles from the airport. A t 2338:22, Night Air 4 reported that the airplane was on final approach for rllnway 33, and at 2338:25 the air traffic control tower operator cleared the flight to land. A t 2341:18, the control tower operator reported to approach control that there had been an accident at the airport. 4 Fifteen witnesses, who either heard and/or saw the accident, were interviewed, and with the exception of a few minor points, all of the witnesses described basicatly the same accident sequence. The airplane was on a normal approach to runway 33 with no apparent abnormalities. When the airplane was about 200 feet over the approach Lights, an increase in engine thrust was heard and the airplane halted its rate Of descent in what two pilot witnesses thought was an apparent attempt to go-around. immediately afterward, Night Air 4 began what appeared to be a level turn to the right. ?& the airplane went through about 90° of turn, the wings of the aircraft were i?early vertical to the ground. The airplane3 nose dropped below the horizon and the airplane descended into the ground in a nose low attitude. The witnesses stated that they saw en explosion which was foilowed by Intense ground fire. None of the witnesses reported any significant lateral or vertical changes while t:ie aircraft was on short final or during the 90° right turn prior to its descent into the gound. Many witnesses stated that they saw some iights illuminated on the aircraft but none repcrtea seeing the landing lights, bcated on the landing gear, or the landing gesr in the extended position. Witnesses reported no inflight fire, smoke, or airframe separation before the crash. The accident occurred about 2341 during hours of darkness at 41%6:N latitude and 012a41'W longitude. 1.2 Injuries to ?ersons Injuries __ Crew Passengers Others Total Fatal 2 1 0 3 Serious 0 0 0 0

XnorjNone

0

C

0

0 Totai 1 0

3

2 1.3 Damage to Airplane The airplane was destroyed by impact forces and postcrash fire. 1.4 other Demiige One tekphone polo and a portion of chain link fence were destroyed. About 3 acres of ai-?: property was burned and contaminated by debris and fuel. 1.5 Persmnel Wormation TRe fiightcrew was properly certificated and qualified for the flight. (See appen6ix 3.)

-3- The captain was employed by Air Continental, Inc. on July 29, 1983, and qualified as a Learjet captain on September 27, 1983. He had last flown on June 1, 1984, and was off duty on June 2 and 3, 1984. He was returned to duty at 2100 on June 4,1984. The first officer was employed by Air Continental, Inc. on March 23, 1984, and was assigned co-pilot duties on the Learjet. His duty schedule had been the same as the captain's since June 1, 1984. flight. The passenger was a former employer of the captain and was a guest on the 1.6 Aircraft Information The aircraft was certificated, equipped, and maintained in accordance with Federal Aviation Administration (FAA! requirements. The basic empty airplane weight and center of gravity information for weight and balance calculations were obtained from Air Continental. The pilot, co-pilot, and passenger weights were obtained from pilot medical certificates. Before departing Cleveland Hopkins Airport, 568 gallons (3,806 pounds) of Jet A fuel was added to t h e airplane. To stay within the required maximum gross weight limitations, the airplane departed Cleveland with full wing and full tip tank fuel end minimum to zero fuel in the fuselage tank. Refueling was to be conducted at Bradley International Airport by Combs Gates. Typical fuel loads for Night Air 4 at Eraaey on three previous trips were 410, 415, and 442 gallons. These quantities were consistent with fuel in the wing and tip tanks only upon leaving Cleveland. i The following computations reflect the most probable loading of the airplane at Cleveland and at the time of the accident. Cieveland Bradley (pounds) (pounds) Empty Weight 6,939 Crew/Passenger 449 FreightBaggage 490 Fuel 4,718 6,939 449 360 1,518 Total W-eight 12,596 9,266 Center of gravity 26.5% 24.1% Maximum takeoff weight is 12,499 pomds. Center of gravity limits 16% - 31.5% MAC A second loading configuration, which placed all cargo and baggage in the baggage compartment to achieve the most aft possible center of gravity, also was computed. This configuration also was within weight and center of gravity limitations. A weight of 9,266 pounds for landing at Bradley was used to compute the landing approach speed of about 120 knots and was consistent with the airspeed indicator %ug' f l l 8 knots) found on the airspeed indicator in the wreckage. The approach landing speed actually flown by Night Air 4, as computed from radar data, was about 128 knots.

-4- X.? The surface weather observation for Bradley International Airport at 2250 (2150 e.s.t.) was: 1.8 No ceiling, 4,000 feet scattered clouds; visibility--20 miles; temperat~re--S5~ F; dewpoint--4Z0 F; wind--290° at 4 knots; altimeter setting--29.93 inHg. The 2350 (2250 e.s.t.1 observation was: No ceiling, 4,000 feet scattered clouds; visibility--20 miles; temperature--65' F; dewp0int--43~ F; wind--280° at 8 knots; altimeter setting--29.94 inHg. At 2333, approach control gave Night Air 4 the altimeter setting of 29.94 in Hg., and at 2338 the tower controllers gave the final approach winds as 290° at 6 knots. Aids to Navi@tion A previously seheduled FAA flight check of the visual and navigational aids was conducted the day after the accident. All systems, including radio communications, were reported as being satisfactory. A maintenance certification check of the ground facilities by local airway facilities personnel indicated all systems were functioning satisfactorily. 1.9 Communications A review of the recorded radio transmissions between approach control, t h e control tower, and the Crew of Night Air 4 revealed normal, routine handling by air traffic control ( A X ) with no discrepancies noted. The co-pilot's voice, which was identified by company personnel, was calm, and his radio transmissions were routine in nature. Air Continenta:'s policy requires that non-flying crewmember handle the radios. 1.10 Aerodrome Information Bradley International Airport is served by three runways. Runway 33/15 is 5,845 feet long, and 220 feet wide; runway 33 has a magnetic bearing of 3289 The touchdown zone elevation is 172 feet. Runway 33 has an instrument landing system (ILS) instrument approach, runway visual approach slope indicator (VASI), and a medium intensity, or simplified short approach lighting system, 1,400 feet in length. Information supplied by tower personnel indicatd that all approach and runway light systems were on low intensity seitings and were operationel a: the time of the accident. The sequence flashing lights in the approaci. light system were off during the approach of Night Air 4. 1-11 Flight Recorders The aircraft was not equipped with a cockpit voice rxorder or a flight dats reco;der, and neither p;as required.

-5- 1.112 Wreckage and Impact Information The initial impact point was located approximately 1,200 feet to the right of the threshold of runway 33. The airplane had disintegrated and scattered ove? a pattern about 400 feet long and 200 feet wide on a heading of 035O magnetic. The ground terrain was a flat, open area on the airpart property. The wreckage area was scorched from heet and fire. The airplane's initial impact damaged a chain link fence which had one post knocked down, and the cement footirg of the post was pulled from the ground. About 2 feet beyond the fence post hole, there was a 5- by 3-foot gouge in t3e ground which contained Pisces of the right airplane tip tank structure. A second gouge nark, about 18 by 10 feet in size, was located along a heading of about 035O magnetic and about 15 to 20 feet beyond the first gouge mark. Pieces of the airplane's right wing tip structure, the outboard end of the right elevator, engine blades, pieces of the cockpit windshield frame, and the encoding altimeter were recovered from within and around the second gouge mark area. Pieces of the airplane fuselage were scattered throughout the wreckage srea. X section of the fuselage right side was recovered along the wreckage path. The largest intact portion of fuselage structure which was recovered was the tail section aft of the rear pressure buRhead; it was heavily damaged by fire and was crushed on the left side which was upright against a telephone pole. The left wing structure was recovered in an inverted position just beyond the aft fuselage structure and was heavily burned. The left forward side of the fuselage from the main door frame forward toward the nose, including the control column, the rudder pedal assembly, the nose gear assembly, cockpit seat tracks, t h e throttle assembly, the nose gear door, and the lower hinge of the cabin main door, and pieces cf the cockpit windshield frame lower area were attached to the wing. Located about 30 feet left of the wing structure was a portion of the left fuselage frame and ?kin, the left cabin window, and the upper and lower halves of the cabin main door. The lower i.3lf of the right crew seat, which was located beyond the wing st-ucture, was crushed toward an inboard direction. D The left wing was recovered in one piece with the aileron partially attached, the spoiler and flap attached, and the mid area of the left tip tank attached. The wing structure was relatively intact, except at the outboard trailing edge, which was crushed forward and burned, and the leading edge, which was crushed aft and burned. The left flap was relatively intact and retracted. The leading edge and inboard area of the left flap upper surface was sooted. A line of discontinuity in the soot deposit ran in a spanwise direction forward of the skin splice line dong the spar upper cap. Aligning the discontinuity line with the wing upper surface trailing edge would correspond to a flap position of 7.5O. Tfre left flap push-pull rod was intact and attached between the flap and the flap sector in the wing. There was no apparent bending or elongation in the rod or distortion in the rod attachment holes. The left flap retraction cable was unbroken between the left wing sector and the center sector assemblies. The extension cable was broken approximately 4 inches from the attachment end on the left wing sector. The remaining extersion cable was continuous to the flap center sector assembly.

-6- The center sector assembly was intact and connected to the flap actuator which also was intact on the wing structure. The actuator ?od extension rmmired 2.25 inches from the face of the actuator housing to the centerline of the attachment bolt at the end of the rod, which corresponds to about 34' of flap extension. Full flap extension is 40'. The left aileron trim tab was attached; the actuator motor and linkages were intact through the aileron. The trim tab deflection angle between the aileron and tab lower surfaces was about 16' trim tab trailing edge down. The alignment index between the actuator motor shaft and housing was measured at about 26O, which corresponds to go of trim tab deflection for left wing down. The left spoiler was intact and attached to the wing structure and spoiler actuator linkage. The spoiler was in the retracted position. The right wing was recovered adjacent to the left wing; however, the right wing was broken apart and was damaged heavily bv fire. The right flap, spoiler, and a portion of the right aileron were recovered in the vicinity of the right wing. The right flap structure was in one piece; however, it was scorched, discolored, and partially burned away at the outboard end. The flap tracks were still attached to the right flap. The outboard flap track support assembly was separated from the wirg and remained with the flap track. The position of the track support was 6.5 inches from the centerline of the aft roller on the track support to the centerline of the attachment bolt for the flap track, corresponding to a flap positian of 6.5' extension. The right flap sector was atieched to the sector brackets in the wing structure and was free to rotate. The right flap retract cable was broken about 5 inches inboard of the sector. Tne right flap extend cable was broken about 34 inches inboard of the sector. The remaining right flap cable was in one piece and was routed around the flap center sector b u t was not within the sector cable tracks. The right wing spoiler was battered and partially burned away but still was attached to a remaining portion of wing structure with its hydraulic actuator attached. The actuator was intact but discolored by heat. Tt,e spoiler ectuator rod was extended 1.97 inches between the face of the actuator housing and the bottom of the lock nut on the end of the extension rod. This measurement corresponded to about 39' of spoiler extension. The actuator rod could not be respositioned manually. The actuator and spoiler were recovered from an area of extensive fire damage. The spoiler actuator hydraulic lines, which were attached to the actuator, were burned in an area adjacent to the actuator and were broken where they were routed through the wing rear spar. The right aileron was broken into two sections with the inboard section still attached to the wing structure. The right aileron control cables were attached to the outboard puUy assembly and were continuous up to the aileron and rudder interconnect instellation. The outboard section of t h e right aileron was recovered several hundred feet to the left of the remaining right wing structure. The balance tab was still attached to i the outboard section of the aileron. The empennage was broken into two major sections consisting of the horizontal stabilizer with the ele5stors attached and the vertical stabilizer with the rudder attached. The horizontal stabilizer, which was recovered in one piece, had separated from the top of the vertical stabilizer. The right outboerd end of the horizontal stabilizer was crushed aft, and the entire right leading edge was separated from the front spar. The horizonw stabilizer actuator, which was in place, exhibited impact damage. 39th the electrical drive motors were broken from their mounts. The actuator measured 14.5 inches from the center of the attachment points, which corresponds to about 6.9' airplane nose-up; full nose-up is 'io.

-7- The vmcical stabilizer was relatively intact and was attached to the taiI section. The rudder was relatively undamaged and was attached with the rudder trh tab intact to the vertical stabilizer. The rddder trim tab was in the faired position, and the tab push pull tube, which appeared straight and still, was attached between the tab and trim motor. The rudder cables were attached on the rudder sector and were continuous up to where the fuselage was broken apart. The elevator cables in the tail area were continuous from the sector forward to where the fuselage was broken apart. Both main landin? gear were relativiely intact and were partially attached to the wiag structure. Both maln landing gear actuators were irr the extended position. The nose gear structure, which was broken apart, had separated from fuselage structure. The nose gear actuator was broken apart, but the down lock balls were recovered in the down and lock position.

1.13

Medical and Pathological Information Postmortem examinations of both pilots and the passenger were performed by the Office of the Chief Medical Examiner, State of Connecticut. The examinations showed that the occupants died of multiple traumatic injuries. Injury patterns on the bodies indicated that both crewmembers were seated in their assigned seats and that the passenger was seated in the cabin. Toxicological specimens were screened for elcohol, drugs, and carbon monoxide, and the results were negative. There was no evidence of any disease or physical condition that would have affected the pilots in the performance of their duties. The airplane exploded on impact and was involved in an inten .e postaccident ground fire. 1.15 survival Aspects The accident was not survivable because impact forces exceeded human tolerances. The accident site was adjacent to the Bradley International Airport Fire Department station. The accident caused a power outage to the electrical gate controlling access to the site, however, the Deputy Fire Chief, who had witnessed the accident, opened the gate manually, and crash/fire/rescue (CFR) response was immediate. Five pieces of equipment manned by eight men responded to the accident. They were joined by eight off-duty firemen and by units from adjacent mutual aid fire departments. The initial fire was knocked down and controlled using aqueous film forming foam. 1-16 Tests and Research 1.16.1 Airplane Parts Examination An extensive technical schedule was established to examine the powerplants and other parts of the airplane removed from the accident site.

-8- Powerpiants.--Both airplane engines were sent to an overhaul facility in Dallas, Texas, for teardown examination and analysis. The examination was performed On July 19-20, 1984, under the supervision of a Safety Board field investigator. The examiners indicated that there was no evidence of preaccident malfunction or discyapancy on either and estimated that both engines where operating at 90 to 92 percent rpm at the time of the accident. Light Bulbs.--A number of lightbulbs from the airplane warning panel and exterior navigation lighting system were sent to the Canadian Aviation Safety Board, Ottawa, Ontario for examination &qd analysis. In a report, dated October 3, 1984, the Canadian Aviation Safety Board indicated that the filaments of the right fuel pressure light and left fuel pressure light, which had been removed from the warning panel, were stretched and appeared to have been on at impact. Both empennage navigation lights and the top rotating beacon gave the appearance of having been in operation at impact. All other light bulbs, including the spoiler warning lignt, were damaged consistent with cold filaments subjected to impact. Under normal operating conditions, the spoiler warning light is on when one or both of the spoilers are extended. System Components--The following components were examined at the manufacturer's facilities in Wichita, Kansas, on July 18-19, 1984, under Safety Board supervision. l.* 2.* 3.* 4.* 5.* 6. 7.* 8. 9. 10. 11.* 12. 13. 14. 15. 16. 17. 18. 19. Component Spoiler Control Valve Left Spoiler Restrictor Filter Right Spoiler Restrictor Filter Left Spoiler Actuator Right Spoiler Actuator Spoiler Position Switch Flap Control Valve Flap Restrictor Filter Flap Relief Valve Flap Relief Valve Flap Hydraulic Actuator Aileron Trim Actuator Pitch Trim Actuator Roll Autopilot Servo Pitch/Yaw Autopilot Servo Stall Warning Vibrator Fuselage Fuel Pump Left Fuel Boost Pump Right Fuel Boost Pump Serial Number 240 383 None 202 None None 184 48 251 None 94 047 128 384 0580-49AA 177 B6932 B1746 B4481 *Component x-rayed before examination and/or testing. No discrepancies, other than noted in the following descriptions, were cnmvered by the examinations. An X-ray of the spoiler control valve revealed no evidence of internal operating distress. The valve exhibited fire damage. The valve was tested and found operational, although it functioned slowly.

-9- An X-ray of the right spoiler restrictor filter revealed a small %-3" sized droplet Of solder in the inlet end of the filter on the retraction side. The restrictor unit 4; W a s composed of an orifice with filters on each side. The metal ban was found on the retraction side of the orifice and outside the filter screen. The hydraulic line attached to the retraction side of the orifice was partially burned away. The restrictor filter exhibited fire damage. The O-rings seals on both sides of the restrictor were replaced before testing. The restrictor filter then was tested and found to function satisfactorily. The retraction side of the filter was removed, and foreign material was extracted and submitted to €he Safety Board's labmatory where it was identified by spectral analysis as composed of tin and lead (components of solder). An X-ray of the left spoiler restrictor filter revealed no evidence of internal operating distress. The restrictor filter did not exhibit any damage. The restrictor filter was tested and found to function satisfactorily. The right spoiler actuator exhibited severe fire damage; however, there was no impact damage. The actuator was extended 1.97 inches which corresponds to 3S0 of spoiler extension (full extension of the spoilers is 45.59. The actuator was tested and retracted at about 700 psi and extended at 500 psi. During the test, the actuator bypassed hydraulic pressure internally. Disassembly and examination of the actuator revealed that O-rings, the backup ring, and the felt wiper had been damaged by the heat of the ground fire. The right spoiler position switch was fire damaged and could not be tested eiectrically. The left spoiler actuator was not damaged. The actuator was tested and B found to function satisfactorily. The aileron trim actuator was not damaged. It was tested and found to function satisfactorilv. The pitch trim actuator exhibited imDact damwe. The orimarv and secondary drive- motors- were tested and found to function satGfactorili. Th;. actuator was near the airplane full nose-up position. The stall warning vibrator, which exhibited impact damage, was tested electrically and found to function satisfactorily. The left and right spoiler actuators were split in half lengthwise and examined by ar! engineering firm to determine if a materials trace pattern could be identified to indicate the position of the spoilers at impact or during the ground fire. (See figure 1.) The left spoiler actuator was not damaged by the ground fire; however, traces of rubber specks were found on the inside walls of the actuator, and a faint Sand was found on the actuator walls, corresponding to the piston O-ring in the extended and the retracted positions. The retract end of the left spoiler actuator barrel assembly was faintly scored; the circular scoring v;as aligned with the end of the piston rod. (See figure 2.) The right spoiler actuator was damaged by ground fire; heat decomposed rubber specks were found on the actuator walls and a heavy band of dark color was found on the actuator wall corresponding to the piston being in the extended position. The retract end of the barrel assembly was scored; the circular scoring was aligned with the end of the piston rod. A new spoiler actuator with the piston it. the retracted pos.tior, was subjected to 400° F heat to determine if the heat would cause the piston to extend. The actuator piston did not extend, however, and the test was inconclusive since the duration and intensity of the postaccident fire could not be reproduced in the laboratory. D 41 The restrictor unit restricts hydraulic flo* to the actuator so that the spoilers move at a reasonable rate during extension and retraction.

-1 0- Left Pistons in barrel Right Pistons out of barrel. Figure 1.

, .

. .

. . . . . . . . . .

. .

. . ~. . . . . . , . . . . . . . .

. . :. .. . I .. . .

.. . . . .

• .

. . .

. . . . . .

. . : . .. . . . . . . .

-1 2- A second flight test was conducted by the Safety Board's aircraft performance group and the FAA pilot member of the operations group. An unmodified Gates Learjet 23, N7200K, was flown at Bradley International Airport on October 17, 1984, to obtain radar data from the ,same facilities as the data for the accident aircraft. The radar data from the test airplane flight profiles and the radar data from the accident flight were obtained from Bradley Approach Controi and compared. (See appendix D.) The aircraft instrument and engine panels were videotaped to further document the flight test. Th&' purpose of the first tR.0 profiles was to obtain the vertical Velocity performance of the airplane during the first half of the descent in spoilers extended/retracted configurations at airspeeds similar to those flown by the accident airplane as obtained from processed radar data. The difference in the vertical speeds between ;ne spoilers extended/retracted configurations was noted and compared to the vertical speed calculated for the accident aircraft. The profiles were flown and recorded from FL200 td10,OOO feet. Since engine power settings were not known, the throttle was at idle (appro%mately 55 to 60 percent engine rpm) for the two descents except that a slight amountr'of power (5 to 10 percent) was added to maintain cabin pressurization between FL200 and 15,000 feet. There was a marked difference in descent rates between the spoilers extendedketracted configurations. With the power at idle, spoilers retracted, and maintaining the airspeeds of the accident aircraft as closely as possibie, e 4,000 to 4,200 feet per minute descent rete resulted. However, with spoilers extended, t h e vertical speed indicator was pegged at 6,000 feet per minute. The calculated descent rate was about 6,500 feet per minute, which compares to a descmt rate of 3,500 to 3:800 feet per minute for the accident airplane (throttle setting unknown) The third and fourth profiles were flown frorn the downwind position (runway 33 at Bradley) to approximately 700 feet. Since the rada: data indicated that the accident airplane was about 2.5 miles abeam the radar site &t 12,000 fee? at about 285 knots indicated airspeed (KIAS), these values were selected as the initial point for the profiles. The engine power was kept at idle throughout, and indicated airspeeds as predicted froM radar data for the accident airplane were maintained. The flaps and landing gear were extended at the normal scheduled speeds, i.e., 200 KIAS for gear extension, 170 KIAS for approach flaps, 140 KIAS for full flaps. The third profile, flown with spoilers retracted, was similar tc the accident airplane profile ir, ground track. Passing altitudes were higher when compared to the passing altitudes of the accident airplane. Th6 fourth profile was flown in a similar manner as the third profile except that the spoilers were deployed at 7,000 feet since this was the only point in the descent of the accidefrt airplane where the descent rate was higher than that of the descent rate of the test aiwlane with spoilers retracted. The fourth profile required a steep descent after the fin& turn to maintain the desired airspeeds and track since engine power was maintained ateidle. Under normal operational technique, power would be added as the landing gear &d flaps were lowered to minimize changes in airplane attitude, descent rates, and aigpeed. After the airplane was levelled at 1,100 feet, it required about 90 percent rph to maintain thc desired airspeed in the gear and flaps down, spoilers extended conf:guratiori.

-13- I 1.17 Additional Information 1.17.1 Normal (3peratina procedures The FAA Approved Airplane Flight Manual of the Learjet 23, Section E, Normal Operating Procedures Checklist states: Taxiing --- E. Spoilers-Check operation, then retract. 1.17.2 Descent, Approach, and Lending Techniques The Gates Learjn? Flight Training Manual describes standardized procedwes and maneuvers for pilots transitioning into Learjet series 20 aircraft. Those portions of the manual devoted to descent, approach, and landing state, in part; Descent . . .Both a power and pitch change is usually required when transitioning to the lower altitudes. To level off from the descent, lead the desired altitude by about 10-20 percent of vertical speed to avoid overshoot and for passenger comfort. If levelling at descent airspeed, smoothly add power while changing to level flight attitude. When levelling at a slower speed smoothly change pitch attitude to level flight and as the airspeed appmaches within about 10 knots of that desired, smoothly advance power to maintain desired airspeed. The wing spoilers are a convenient means of expediting a descent rate and/or to quickly reduce speed. Deploying the spoilers will cause a slight pitch down tendency. With a little practice, this can be anticipated, elevator pressure held against it and relieved with trim. The nose up tendency when the spoilers are retracted, may be handled in like manr?er. A slight buffeting will be noticed with the spoilers extended. Good planning will usually preclude the need for frequent spoiler use in flight; however, if circlimstances dictate, do not hesitate to use them. Remember that the stall speed is increased with spoilers extended. Remember too, spoilers and flaps should not be used simultaneously because of the probable fatigue damage to the flap surface. . . .After level off in the traffic pattern, the initial target power setting ir? clean configuretion to Vref plus 40 KiAS is spproximately 78 percent rpm. Lowering the flaps to 8 O and mawtaining Vref plus 30 KIAS requires very little change of power (78 percei.t rpm), Lowering flaps to 20° along with extending the gear and maintairting Vref plus 20 KIAS requires an additional 4 percent (82 percent rpmi. Lowering full flaps and maintaining Vref will require additional 5 percent (87 percent rmp). These power settings are for straight and level flight and are approximate. Generally in the Learjet in a stabilized conditio>, I percent rpm power change will e q m 1 appzoximately 5 knots in airspeed. In t h e landing configuration at Vrei ispeed stable), reducing the rpm 1 percent will result in approximately 100 feet per minute rate

of descent.

-1 4-

Normal Approach for Landing Several factors influence the requirement for utilizing a smootfi, shallow power-on approach. Two of the basic factors are: First, if an approach angle is relatively shallow, airspeed control is generally improved. Secondly, by using a relatively shallow approach with adequate power, the rate of descent is held to an acceptable value. The final one-half mile of the final approach should approximate an ILS glide slope with a rate of de!.tent of approximately 600 feet per minute. A t idle or low power in a high rate descent (steep glide slope), the airplane on flare will only rotate; however rate of descent will not appreciably change. Another advantage of a shallow approach is that the high power required places the engines in the best acceleration range. . . . Landing Jet aircraft in general have certain landing characteristics. Deceleration is not rapid whert power is reduced to idle. While in idle, the engines still produce forward thrust. In ground effect, the jet aircraft can "float" for a long <:stance. The Gates Learjet in landing configuration at Vref is in a near landing attitude. Constantly trim pitch to neutral. n2aintain Vref until within a few feet of the runway surface. . . . The Operations group FAA pilot member and other Learjet pilots stated that near fuli nose up horizontal stabilizer trim is normal for most landings. I A review of Service Difficulty Reports (SDR) since 1979 involving flight control systems on Lear 20 series airplanes disclosed three reports concerning the spoiler system: one report indicated a leaking hydraulic line due to corrosion, and the other two concerned worn and broken attachment brackets on the actuator. All three discrepancies were discovered during maintenance inspections. None of the reports indicated if spoiler operation had been affected in flight. Of the three discrepancies noted, thne most likely to cause an asymmetric position between the left and right spoiler actuators would be a leaking or broken hydraulic line. Due to impact and fire damage, the preimpact integrity of the spoiler hydraulic lines of the accident airplane could not be evaluated.

1. ANALYSIS
2. 1

G e n d The airplane was properly certificated and had been maintained in accordance with approved procedures. There xas no evidence of preaccident failure or malfunction of *he aircraft structure or powerplants. The flightcrew of Night Air 4 were certificated and qualified for the scheduled cargo flight. The flightcrew had current medical certificates. Both crewmembers were seated in their assigned seats and the pilot was flying the airplane. Weather was not a factor; the accident occurred on a dark night, with scattered clouds, 20 miles visibility, and light winds. I

-1 5- 1 2.2 m e Accident Fifteen witnesses who either heard a?d/or saw tine accident described basically the same accident sequence. Night Air 4 was on final approach to runway 33 at Bradley International Airport over the approach lights in a stabilized attitude configured for landing. The nose of the airplane rose and a right turn was initiated as if the pilot had decided to go-around. However, the right turn continued and the airplane descended until it struck the ground in a nose down attitude with a bank angle of 90' or more. The Safety Board has investigated a number of Gates-Learjet takeoff and landing accidents which had similar characteristics. (See appendix E.) Certain flight maneuvers were common to all of the accidents: (1) each aircraft experienced steep banking with high roll rates immediately before the loss of control, (2) none of the flightcrews was able to recover the airplane after the rolling started, and (3) the addition of engine thrust appears to have aggravated the severity of bank attitude. During its investigatims of the accidents, the Safety Board concluded that a number of factors could create a situation causing the wing roll and subsequent control loss: ice/snow accumulation on control surfaces and other aircraft structures, gusty winds, wake vortex turbuience, mistrimmed flight control surfaces, cockpit flight control interference, asymmetrical thrust application, and flightcrew failure to maintain airspeed and attitude. None of these factors, however, appear to have been present in the June 4, 1984 accident. Analysis of the radar data indicates that the airplane's speed on final approach was about 8 knots above the Vref speed of 120 knots. Witnesses stated that the airplane's speed and attitude looked normal for landing. The flightcrew was rested, highly-qualified, and familiar with the airport. While this accident may have similarities to the other Learjet accidents investigated by the Safety Board, the causal factors found in the other accidents do not appear likely explanatiors in this accident. 2.3 The Airplane Examination of the wreckage disclosed no evidence of an inflight fire, explosion, or component separation. The landing gears were recovered in a fully down position. Soot patterns and impact marks on the left and right flap surfaces indicated that the flaps were partially extended :;.hen exposed to postimpact fire. Examination of the flap control cables disclosed tension overload failures typical of crssh damage indicating that the flaps were extended. The flap actuator was recovered in a position corresponding to about 34'of flap extension. Full flap extension is 40'. The exact flap extension before irpact could not be determined; however, the flaps most likely were extended at least 34'. During the postaccident inspection, the horizontal stabilizer actuator was measured and found trimmed nearly to the full airplane nose-up position. Based on statements by pilots who fly the Learjet and Gates Learjet personnel, this is not an abnormal position for landing since it relieves back pressure on the control wheel and elows for a smooth roundout and flare for touchdown. This aiso is indicative of inflight spoiler deployment since extension of spoilers causes a nose-down pitching moment. The right wing spoiler actuator rod was recovered in the extended position, and the left wing spoiler actuator rod in the retracted position. Because spoilers are programmed to operate in unison and because pilots are cautioned not to use them in the air when the flaps are down in order to prevent fatigue damage to the flaps, the position of the right sDoilers found during the postaccident inspection was unusual.

-16- A laboratory inspection of the right spoiler actuator revealed a heavy band of discolored metal on the interior wall that corresponded to the piston being in t h e extended position, indicating that the spoiler was in the extended position whi?e exposed to the postaccident ground fire. Although circular scoring marks were found on the retract end of the spoiler actuator barrel assembly, examination of the marks was not conclusive in determining whether the scoring was caused by inservice use or by impact damage. The left spoiler actuator barrel assembly had faint scoring marks. Based upon the weight of the physical evidence and the reactions of the airplane during tne last part of the flight, the Safety Board concludes that the spoilers were asymmetrical at impact. The Gleron trim actuator was recovered in a position toward full travel for left wing down which points to the possibility of a lateral control prcblem and indicates that the pilot attemptea' to counteract an uncommanded airplane roll to the right by using aileron trim. Other components of the airplane spoilers, flaps, aileron trim, and automatic flight control systems that were recovered from the wreckage and examined at the Lear facility in Wichita did not indicate any potential source of flight control malfunctions in flight. The only discrepancy noted was a small aB-BTT sized droplet of solder found in the flow restrictor of the hydraulic line for the right spoiler actuator. If the metal droplet hac; impeded hydraulic flow through the restrictor, the effect would have been a slightly reduced retraction capability of the right spoiler. However, flow rates through the restrfctor measured during both the retraction and extension cycles were not affected by the presence of the solder. Examination of the spoiler warning light bulbs indicated tha? the filaments were no? stretched at impact indicating a cold filament (bulb off) condition. Cnder no?mE! conditions. if one or both of the spoilers had been extended, the bulbs would have been illuminated. However, since the right wing struck the ground first, it is possible that the impact sequence caused an electrical interruption and extinguished the light, or that the k*&s or wiring mag have been defective and that the system was not operative. If the sys?en was inoperative, it would further explain why the flightcrew did not notice the extended spoilers on the f i i approach. Other light bulb examination evidence indicates the right and !eft fuel pressure warning lights were illuminated at impact. The Safety BoaFd attributes this to the rolling maneuver of the airplane before impact during which t h e fuel pumps probably were uncovered in the tanks, causing the warning lights to illuminete. The Safety Board could not determine the reason for the postulated malfunction of the spoiler system. There is no maintenance history of spoiler failure in Getes Learjets, and the flightcrew did not report a malfunction before flight when they wouid have checked the spoilers as part of the normal operating procedures checklist. Fiight tests in an unmodified Lear 23 indicated that an asymmetrical spoiler condition is controllable if prompt end correct rudder and aileror. control inputs are made. ::owever, the fiight tests were made under controlled conditions at altitude with Lorewerning of :be conditions. !f an wymetrical spoiler condition were to occur at night on f i m i apmoech. airplane rol! rates might develop to a degree that delayed recovery inputs by an unwary pilot would not be sufficient to stop the roll. -. r The flight tests performed at Bradky to evaluate Lear 23 flight characteristics indicate that the first portion of the approach (from FL200 to 10,000 feet) %'as ?Prforrned xith the Tpoiiers retracted. The flight tests also indicated that the coxbination of descent rate an2 acceleration which the accident airplane achieved as it

-17- 1 descended through 7,000 feet was achievable only with the spoilers extended. The Safety Board concludes that the spoilers were used to increase the rate of descent during the turn to final since the descent rate shown by the radar data of the accident flight was 'nigher than the descent rate shown by the radar data for the test flight with the spoilers retracted and was similar to the descent rate of the test flight with the spoilers extended. were lowered at about 200 KIAS, the flaps were extended at about 170 KIAS, and the After the airplane rolled out on final approach, nost likely the landing gears power was increased to maintain airspeed, attitude, and rate of descent. However, the Safety Board believes that the spoilers were still extended. It was noted during the flight test that there is little difference in cockpit ::tal background noise level with spoilers either extended or retracted when the gear and flaps are down to alert the pilot that the spoilers are extended. The fourth profile of the test flight flown at Bradley International revealed that it took about 90 percent of power to maintain level flight with the gear and flaps down with spoilers extended. The engine teardown revealed that engines were operating at about 90 to 92 percent rpm at impact. Power required to maintain Level flight with spoilers retracted is about 87 percent. Consequently, the spoilers extended configuration only requires 3 percent more power than retracted configuration and a pilot could overlook the difference in power particularly if the spoiler warning lights were not lit. It is postillated that as the airplane passed over the approach lights, the pilot realized that the spoilers were extended and retracted them. The nose of the aircraft would have risen slightly due to spoiler retraction, but since the right spoiler did not retract the aimlane started a slow roE to the right. While the pilot sdded power, he apparently did not use enough aileron and rudder control input to arrest the roll, srd the airplane rolled inverted and crashed. b

1. CONCLUSIONS

me airplane was properly certificeted and had been maintained in accordance wit'n approved procedures. fiere was no evidence of preaccident failure or malfunction of the sirplane's structure or powerpiants. The flightcress of Sight Air 3 was certificated and qualified for the scheduled cargo flight. The flightcrew of S$ht Air 3 held current medica! certificates. 30th crewmembers were seaiec! in their assigned seats and the pilot was Eying ?he airplane. '.\eat%er was not a facto? in this accident. Thore was no evidence of sn ir.%ght explosion, fire, or componeni sepsrstion. The landing gears were iuil? extended at impae:. The 5:iiips were extended: the actus1 extended position before irnpect eorllZ 7ot oe determined but most likely was at ieast 349

-1 8- The aileron trim actuator was recovered in a position toward full left wing down. The horizontal stabilizer actuator was in the near full airplane noseup position. The right spoiler actuator w a s recovered in an extended position, and the left actuator in a retracted position. The right spoiler actuator was in the extended position when evosed to the postaccident ground fire. There is no maintenance history of spoiler problems in Gates-Learjets. Flight tests indicate that an asymmetrical spoiler condition in a Gates- Learjet 23 is controllable if prompt and correct rudder and aileron control inputs are applied. If input is not correct or applied won enough, uncontrollable roll rates may deveiop. The initial pert of Night Air 4's descent was made in a clean configuration. The pilot of Night Air 4 extended spoilers during the turn to the final approach and inadvertentiy did not retract them until over the approach lights. The spoilers did not retract spmrr,etrically causing the airplane to roU t o the right. The pilot apparent:?; did not detect the roll before the roll rate developed to the extent that the aimlane could not be Controlled before it impacted the groune. 10. 11. 12. 13. 14. 15. 16. 17. 18. f 9. =le cause The Nationa! Trarqwrtation Safety Board determines that the cause of the acciCeni was en unconmanded roi: to the right which caused the airpl8r.c to roil about SOo and descend into the F o m d . The cause of the unsornmanded roll was an asymmetric yetraction af the flight swiiers wherein the left spoiier retracted and the right spoiler did ;x*.. The %fet!;v Boerd cortld not 6etermine the reason for the right spoiler malfunction. 3Y 'I'HE NATlONAL TRANSPORTATION SAFETY WARD

-1 9-

1. APPENDIXES

APPENDIX A INVPSTIGATION AND REARMG 1. Investigation The Safety Board was notified of the accident about 0030, June 5, 1984. A partial team was dispatched from the Washington, D.C., headquarters and arrived on scene about 0530. Working groups were established for operatimslair traffic control/ witnesses, structures, systems/powerplants, and maintenanre recorits. Parties to the investigation were the Federal Aviation Administration, Air Continental, Gates Learjet Corporation, General Electric, and the State af Connecticut. 2. Public Hearing A public hearing was not held. Depositions were not taken.

-20- APPENDIX B PBBsOwNEL INFORMA~ON pilot Charles Rrtssel Huffman Mr. Huffman, 52, held Airlirle Transport Pilot Certificate No. 1359790, issued On April 5, 1982. He had a singic? ancl multiengine rating with a Learjet type certificate. As of June I, 1984, his total flykg time was about 11,039 hours with approximately 1,130.4 hours in Learjets. He tad flown 713.4 hours while an employee with Air continental. Mr. Huffman had an FAR Part 135 proficiency check ride on April 29, 1984. He was assigned duty BS a Captain by Air Continental on September 27, 1983. Mr. Hdfman had a first class medical certificate dated March 28,1984, vith a Iimitation that stated, "Holder shafl posses correcting g&sses for new vision while exercising the privileges of his airman certificate." A ~ c ~ m E n g to company records, Mr. Huffman had 99.3 hours in the last 30 days and 281-9 h0W in the past 90 days He had flown into the Bradley International Airport 18 times during the Iast 90 days before the accident Mr. Dulay, 26, held an Airline Transport Pilot No. 199388678, issued on October 29, 1982, with a single and mdtiengine aircraft rating. He held a first class medical certificate dated Jure 30,1983, with a limitation that stated, "Holder must wear corrective lerses while exercising the privileges of his airmen certificate." His total flight time was 5,263.6 hours with 189-3 hours in Learjet, all of which was with Air continental. His Last proficier,cy check. which was on March 23, 1984, was administered by the company's president He was assigned duties as Air Continental copilot in March 1984. Psswnger EIdridge Monroe Sheetz Mr. SheeU, 71, a passenger, was the holder of a Commercial Pilot's Certificate No. 244571. His Seeond class medical certificate was issued on December 10, 1975, and it had expired.

-21- APPENDIX C rpsXCBAFT INFORMATION The accident aircr.a:t was a Gates Learjet model 23A, Serial No. 23-085, Registration No. NlOlPP. Tjne Grcraft was owned and operated by Air Continental, Inc., of Elq-ria, Ohio. The aircraft was equipped with two General Electric C3610-4 engines, each ;.at& at 2,850 pounds of thrust. The right engine, SN: 251-268 was a leased engine from AVIALL and, according to the engine logbook, had a total time of 2,336 hours when installed on April 7, 1984. Tne left engine, SX: 241-133, had a total time of 3,112.6 fiau?s. Aecordi-q tu the aircraft records, the last inspection was a 150-hour check cor pleted op. -4pril 14, 1984, at a totel airframe time of 8,393.4 hours. The estimated &reraft time on the d&tt of the accident was 8,483.3 hours. Re maximum certificated ramp weight for this airmaft is 12,749 fbs. with a maximum takeoff weight of 12,499 Ibs. The maximum landing weight is 11,880 lbs. with e . T . E X ~ ~ U E zero fuel weight of 9,000 I~s. OR J m e 7 , 1984, a review of the aircraft (logbooks 4 end 5) and the e??gine -8in:er.snce records indicate that the airplane was being maintained in accordance with zsiicsSe FAXk. 30 msjor discrepancies were noted during the review. Airworthiness 3irectives hed k e n complied with. AU flight control cables were replaced or. I ~pirl. _I& 22, I C8.l. -. 1

-22- Table I. Figure 1. Table II. Figure 2 Table m. Figure 3. Table IV. Figure 4. Table V. Figure 5. APPEHMX D RADAR DATA Printout of radar data from accident flight. Plotted data of accident flight. Printout of radar data from first profile, descent from FL 200 to 10,000 feet, spoilers retracted. Plotted data from first profile. Printout of radar data from second profile, descent from FL 200 to 10,000 feet, spoilers extended. Plotted data from second profile. Printout of radar data from the third profile, descent from downwind to final, spoilers retracted. Plotted data from third profile. Printout of radar data from fourth profile, descent from down wind to final, spoilers extended. Plotted data from fourth profile.

-23- APPENDTY D a 3 3 i

APPENDIX D -24-

-25- .- v: I L I / O i 3

APPENDIX D -26- . c 51- av c z -0 E C Z .....................................

. . . I G, (D ! -27- APPENDIX D Figure 2.--Plotted data from first probile, spoilers retracte6.

POINT YO M I N SEC 3 4 5 6 7 8 10 9 11 12 1 3 I 4 15 I6 17 19 68 20 2 1 2J 15 24 26 * 2'1 2 3 * 2 8 I 6 3 3 . 3 6 16 42.85 1 6 30.09 1 6 4 1 . 4 5 l b 52.16 Ib 56.8) 17 1.59 17 10.95 1 7 6.20 17 15.57 17 0.20 1 7 29.57 17 3 4 . 3 1 17 38.96 17 43.71 17 4 0 . I I 17 52.96 1 7 57.15 18 2.35 38 6.9b 1 8 11.SR 1 7 34.95 1Y 40.11 Table In.--Printout of radar data from second profile, 3escent from FL200 to 10,000 feet, spoilers extended. PRINJOUT Ut OUTPUT IIATA TMACU VFRT. IMGLt' V t l . . U t . G k v n 1 I I I 1 I 1 1 1 I I t 1 1 1 1 I 1 1 1 I 1 1 t 9 1 00. 402.1 9200. YU1.6 u500. 7900. ~ U O . m 401.3 7 7 U 0 . 403.6 7200. 4u4.2 bhO0. 4UH.5 6100. 39'1 .Y 5bUD. Jfi4.4 5100. 3117.6 4600. 3U9.b 41uu. 3YL.7 3600. 383.8 3200. 375.4 2900. 1h00. 3be.b 2i0U. 351.6 344.9 1 0 0 0 . IhUO. 345.7 1 JOU. 345.4 3 4 3 . 3 3 3 4 . 4 3 2 5 . 2 04UO. 3 2 5 . 3 0;cuo. 0000. 314.1 OOOfJ. 317.0 A%: 3u11.4 FLIGHT PATH OLG -10.55

• 7.14
• 11.56

-7.2b -b. 2h -9.6U -L.h<

• 9.04

-Y.J3

• 9.37

-9.20 -9.16

• 0.43

-b.69

• 5 . 8 1
• 0.23

-6.35 -1.16

• 7.21

-6.41 -b.5b

• 5.52

-b.b5

• 4.51
• 2.31

n.uo L I t T G.S 0.75 0.04 1.11 1.21 0.YO U.91 1.04 I .us 1 .00 1.04 1.03 1 .U7 1 .ou 0.98 1.01 0.98 1 .u1 1.01 1.167 1.03 1.10 1.15 1 .OY 1 .w u.Y:l 0.98 T-U GS

• 0.11
• u . 3 3
• 0.11
• 0.12
• ( I . 02

" U . 1 5 -0,211

• 0.42
• 0.13

-0.24

• 0.16
• 0.32
• 0.30
• 0.31
• 0.29

-0.14

• 0.21
• 0.10

-0.25

• 0 . 2 4

-0.12

• 0.22

-0.17

• 0.09
• 0 . 1 4

-0.16

• 24.61
• 13.12

1. 19

b.95 21.69 0.73

• 19.45

1. 36

-1Y.42 9.49 19.49

• 0.2
• 3.98

1. b4

Y.43 -7.61 -1.

• 0.

6 . @ 1

• 9.39

b. 19

• 9.46

-8.a;

• 2 . 4 8

-6.03

• 9.77

-9.4

• 4.51
• 4 . bo

-8.52 -8.11

• 7.37
• 7.49

-7.64

• 7.54
• 7.45
• 6.41
• 4.39
• 3.61
• 3.02

-3.86 -4.19

• 4.70

-3.Y5

• 3.84

-2.38 -3.69 -1.111 4.04 1.55 AIRSPECD l H U E IND. KqOfS KNOTS U 269.2 219.5 288.5 2Y6.6 290.3 284.9 93.0 297.Y 293.8 287.H 271.1 283.4 261 - 5 270.5 =?!A 2m1.u j u .u M:! 5%:: N I m I 261.5 261.3 255.5 241 .b

• SMOOTHED VALUES APE 4PYRUXIMATE NEAR END POINTS

. . . .

. . . . . .. . . . . . .. . . . . .

.. . ~ , . .

. . . . . . , .. . . ..: . ~ . . . . . . . .

.. . . . . .

. ... I i

1

! A i u i

! 1 i . .

. .

..

Tnble 1V.--Printout of rndnr dntn from the thrid profile, descent from downward to finrll, svnilcrs rctrnc?ted. 3 4 5 b 7 9 U IO 1 1 13 12 1 4 15 lb 1 7 18 20 19 21 22 23 24 25 27 2b 2M 29 30 31 12 33 3 4 3s 3b 3 1 30 3Y 40 41 4 2 4 3 4 4 4 5 46 41 4 Y 5 0 51 5 2 5 3 54 55 56 5 7 58 5Y b o 61 b2 4 n d n 1y.o) 3 8 3 I . Y S 38 37.34 3 n 51.04 3 E 5 5 . 1 0 39 0.34 39 9.11 39 14.33 39 19.07 39 23.71 3Y 2n.32 39 32.96 39 31.11 39 42.46 39 41.07 39 SI.#> 40 1.14 39 5b.46 4 0 5.YS 40 10.51 4 0 19.YS 40 29.4s 40 24.7C 4 0 33.95 4 0 3 8 . 1 0 4 0 43.32 40 52.70 4 0 5 1 . 3 3 4 1 1.Y6 41 b.71 41 11.45 41 1b.01 41 20.S2 41 25.4s 41 J0.16 41 34.95 41 39.58 4 1 44.44 0 1 49.01 42 3.19 42 7.VS 4 2 1?.57 12 1 7 . J 2 4 2 22.07 42 2b.Jl 4'2 11.45 4 2 30.11 42 40.n3 4 2 45.51 42 50.20 42 54.V5 42 59.57 43 4.32 4 3 23.11 41 Y . 1 0 43 3 51 4 ) 21.d2 1: 2 43 J : 2 0 120l10. I I H O O . I l 1 0 0 . 11500. 1 1 3 0 0 . ll7nn. 11000. 102u0. 1oTnn. 10000. 91100. '1000. 9400. 9200. 8900. muon. MbO0. R400. M 300. 8100. 1 Y O O . 1300. 1 7 0 0 . b900. 7100. 6 4 0 0 . 5 Y O O . 5400. 4h00. 4400. 4 3 0 0 . 4200. 4 0 0 0 . 3bOU. 3no I , 3300. 3200. 3200. 1100. 294)0, 3000. 2800. 2 1 0 0 . x n o , ?boo. 2bOO. 2 4 0 0 . 221J0. 2130. 2000, 1900. 1700. 1 bO0. 1300. 1100. 1000. 900. 15UCl. 2 5 iJ (1 , 7 5 0 0 . f L I b H T rltu DEL -0.52

• 1 . 3 1
• 2 . 5 1

-3.61

• 2 . 9 1

-3.21

• 6 . H Y

-5.70 -4.93 -4.95

• 5 . 0 4

-5 -b:!: -5. J u -3.y3 -4.m3 -3.b2 -3.95 -5.22 -5.20 -5. 3b -5.43 -9.65 -5.56

• 1 ) . 32
• I I .52

-10.69 -7.4b

• 3 . y 5

-2.60 -J.Y4 -5.42 -5.45 -b.Utl

• 5 . w
• I . 4 0

-1.51 -3.011

• 3 . 1 1

-2.17 -2.15 -3.44 -1.bl 0.00 -2.12 -2.19 -2.31 0.00 -D.bb -4.97

• 4 . b 3

-1.66 -7 .t(5 -7.Y9 -5.90 -m.72 -a.u7 -5.59 -5.21 -S.Ub 0 I I I I 0 0 1 I I 1 0 0 1 1 I I 6 0 0 0 I 1 1 1 I 1 1 1 1 1 1 I 1 1 0 1 0 1 I I 1 1 0 1 n i 0 I u 1 0 0 0 I I I I I 1 .VI

• 4 3

.os .01 . uu .')2 . U8 .03 .99 .o I . 0 2

• 0 0

.95 .9u . I I .01

• UV

.62 .Yb . 96 .99 .9B .I1 . OY .1Y 6 Ib .4h .2Y .4R .43 .I4 .2Y .1r . 2 1 .5b

• 3 6 .

I I .9b .97 .04 .Ob .03 .uo .07 .Yb .OQ . U I . bY .02

• 9 5

.9b .Y4 .Y9 .02 .01 . 0 3 .03 ,on .os .on 'P- L cs

• 0 ' U i

-n,%b "b.58 " 0 + 5 H -11.5h -n,o5 *U.J'l -0.21 '0,OY

• 0 . 0 5

-0.15 -0.10 -0.43 -0.23 0.21

• 0 . 0 7

-0.21 -0.06 -0.12 -0.21 -0.10 0.27 0.0J 0.11 -0.10 -0.33

• 0 . 1 4

-0.oy -0.19 -11.1 I -0.12 -0.15

• 0 . l b

-0.211 -0.20 -U.15 -0.15 -0.u2 -0.1b -0.3b -0.12 -0.1Y -0.25 -0.lb 1).07 -0.19 -b,15 -u.23 -0.lb

• 0 . 2 1

-u.04 -0.22 -0.01 -0. I I 0 . 0 4 0 . 1 2 -0.18 -n. 30 -n.ou

• 0 . 1 0
• 0 . 1 3

-2,03 0 . 6 )

• 1.40

;4 -3.05

• 3 . 1 2

-1.52

• 1.14
• I .u1
• 1 . 2

-2.211 -0.19

• 0.04
• I . 4 2

-1.11 -1.21 -1.10 -1.05

• 1 . 3 1
• h. jY

-9.4Y -#. 68

• 7 . 1 4

-0.1 3 -3.87 0.64 -0.14 -1.9) -1 . Y S -3.10

• 1 . 3 4

1. n3
2. 64
3. 03

1 * 5 2 2.76 3.11 2.10 5 . 0 1 7.5h 5.Yb 7.09 7.04 b.23 2 . 7 0 b . 7 0 4 . 5 u 5.h2 b.d6 I2.2Y u . 1 s 11.11 9 . 4 2 Y.4U

• 1 . 4 s

IJ.J/ 0.07 1u.zn 4 4 2 . 4 4.18.0 4 2 4 . 3 385.4 293.6 211.7 26Y.0 1 7 5 . 6 373.0 272.6 26U.0 249.9 249.3 2b1 . I 282.5 2 b O . l 259.3 2b2.1 258.0 251.5 246.3 203.0 295.6 3 l b . Q 2998.6 311.7 287.5 286.5 2dl. 1 276.6 2 7 4 . 1 271.0 268.8 25Y.B 245.4 234.1 228.0 22d. 2 22M.O 217.9 2 0 3 . 6 IRY.0 180.2 114.7 l8J.Y lb2.5 lbl3.4 161.6 150.5 147.2 143.0 13'1.3 1d4.7 12b.7 12Y.O 123.5 137.1 322.

s5*j

2 ~ 3 . 1 3 w u I

Table 1V.--Printout of radar dnta from the thrid profile, descept from downwind to final, spoilers retracted (cont'd). P H I N T U U T Or' UUTPUT DATA

• SMOOTHED VALUES ARE APYHOXlHATY NEAR END POIh'lS

. .

APPEBDlX D -32- ? i i t ' i

i t . .

. . . .

.&... ... . .

. . . , ~. . .

. . . . . . . . .

. .

. . .

. . . . . .

. . . . .

. . . . . ~. . . . . . . . . . .

. .

Figure 4.--motted data from third profile, spoilers retracted.

4 3 5 6 7 H ( 0 Y 1 1 12 l b 15 18 I 1 19 20 21 24 d 3 26 a s 2 1 29 30 1: ? 2 zm 35 34 35 30 17 '19 40 41 4 a 4 ) 0 4 4 5 0 b bl 4 8 49 so 51 52 53 5 4 55 5 0 J l 59 6 0 61 4 2 3m 5m 35 49.10 5 5 U . 9 1 36 8 . 0 8 i 6 3 . 4 5 36 12.70 36 11.20 36 2 1 . 9 s 36 26.415 36 31.11 3 b 40.45 36 15.70 36 45.01 36 5'3.0 31 1 . 7 0 3 1 l?.lj 31 B.bb 37 17.M2 3 7 2 2 . 5 1 31 21.2b 3 1 31.95 31 3 6 . 7 0 3 7 4 1 . 1 4 3 9 4 5 . 9 5 31 50.58 37 55.32 )a 4 . 7 0 5 1 59.95 38 Y . 4 30 Ir.o? 38 l n . a 2 3 9 23.45 39 28.14 38 3 * . Y 5 38 31.45 3 m 42.14 3 8 4h.84 38 51.5U 38 56.21 39 0 . 9 5 39 5 . 1 0 39 lS.0U I 9 1 0 . 1 3 39 19.70 39 14.45 .39 11.83 39 29.14 39 Jtl.bl 39 41.21 f 9 4 1 . 0 7 I 9 52.10 40 2.16 3 9 57.45 40 6.Yb 40 11.5Y 40 16.33 40 '20.95 40 25.71 40 10.46

L

1 I I 1 1 1 1 1 1 I I 1 I TITUOL: FT 2000, 2000. 1900. 1800. 1800. 1 bOO. 1500. 1300. 0900. IIGO. ObOO. 0300. 9900. Y I I O O . 9b00. 9500. 9300. 9100. 89(J0. 8700. u300. 8300. 7 9 0 0 . 1500, 1 7 0 0 . 7300. 6 9 3 0 . 7100. 6400. 5100. 5100. 4 3 0 0 . 4100. 4200. 4100. 3700. )goo. 1000. 3300. 2moo. 2800. ? M O O . 2 0 0 O . 2500. 20011. 2 2 (1 'J . 0100. 0500. ?!loo. 2 0 G U . I ~ O I I . 1600. 1400. I jao. 1300. 1 2 0 0 . 1100. 1100. 1100. 1100. PHlN1'UUT tJF "UTPUT D A T A TPACK ANtiLt. UCHT. DEti V t L . FPU 2 2 2 2 : 2 2 2 2' 2' 2 2 2 2 2 2 2 2 2 2 2 2 2 2 I I $ : ; !, if t FIa 1 G H T PATH DFC 0.00 -0.U4

• I .11

-0.91 -2.01 -3.18

• 3 . J Y
• 0 . 6 2

-4.711 -6.21 -7.41

• 6.09

-4.M6

• 3 . n

-4.05

• 3 . 9 7
• 5 . 3 4

-5.3b

• 5 . 4 3

-5.53 -5.42

• 2.78

-1.Y3 "5.36 -5.34 -5.42 -5.47 -5.bl -15.09 -9.34 -15.u -1b.61 -12,tJY

• I .11

*>.YU 0.05 -5.30 -8.34

• 10.20

-7.5n

• 3.04
• 3 . 1 4

1. 00

• 5 . 2 1

0 . 0 3 0.OC -1u.14

• 8 . 1 1

-Y.1)1

• 7 .

-2. I 1 -1 * 29 . 2 . 39 0.00 0.00 0 . 0 0

• 3 . 9 !

'"1; -b.?Y -4.64 LlFT C,S 0 . 9 6 1 . 0 2 1 .os 1 .U4 U , Y 1 U.'fb 0.95 0.94 0.91 0.Y) I .02 1.10 1.08 1 .OQ 0.Y9 1 .0u 0.96 0.97 1.01 1.05 I .u7 I.Ob 0.68 1.01 1.03 1 .0u 1.14 0.UJ 1 . 1 3 1 . 1 4 1-26 1 .on 1.58 1 .b2 1.13 I .07 I .24 1.11 1.41 1.41 I * 2 1 0 . U Y 1 .Ob 1 . 0 3 1.15 0.117 0.H5 1.00 I .Ob I .02 1 .oo 1.14 0 . Y U 1 .Ob 1.10 I.IU I ,Ob I .04 1.04 0.99 T-11 GS -0.02 -0.4C -0.28 -0.61 -0.51 -0.37 -0.2Y v 0 . 3 4 -0.30

• 0 . 1 0
• 0.16
• 0 . 2 3

1. 01

• 0.22
• 0 . 2 2

-0.09

• 0 . 0 1
• 0 . 2 0
• 0 . 0 7
• 0 . 1 7

-0.0b -0.15

• 0 . 0 6

1. 01

-0.09 -0.1Y -0.18 -0.04 -0.0b 0.00 -0.06 -0. -0.50

• 0 . 1 4

1. 00

-U.OH

• 0 . 2 2
• 0.26

-0.311 0.15 -.0.11

• 0 . 5 0
• 0 . 5 0

-0.15

• 0 . 0 6
• 0 . 1 0
• 0 . 0 4

-11.23 -0.12

• 0 . 1 4

1. 01

-0.lb -0.21 -0.0i 0.04 u.24

• 0.01

-0.12 -0. ;j -0.22 aII.31 -17.65 -12.30

• 1 1.41

4 . 5 9 12.64 -12.75 7.13 -3.47 16.35 9.6'1 1 . 8 5 0 . 0 1 0.02 -1 72 20.23 -10.36 14.IY 8.56 12.04 -28.75 1.79 -3u.94

• 2 9 . 6 U

-44.60

• 4 1 . 5 7

-14.40 *29.Y4 -40.99

• 4 4 . 7 2
• 3 9 . 6 2

-44.96

• 3 J . M l

-20. 79

• L Y . l J

-12.94 -0.17 16.93 9.15 -15.9U -4.10 5.45 -1m.15 -1.26 13.94 1.15 15.OH 12.lb -1J.12

• 1 I .42

1. 67
2. 75

:1:;a -4.85 -!:21 3: 5': ::a:!: 4: :!? 1.10

• 0 . 0 1

O . @ b -0.16 -0.55 -1.10 -1.52

• 2 . 7 4

-3.70

• 2.20

-1.17 0 . 0 6 0.16 0.4i

• I . 2 1

1. lU

-0.92

• I .O1

-0.95 -0.6H -1.54 I .Yb -3.11'1 -1.04 -1.36 -1.10 -1.51 -12.15

• 6 . 7 4

-13.40 -14.bt -U. 3.69 -0.81 3.62 -2.13 -5.04

• 5 . 9 6

-2.OY 2 . 4 b 4.31 0.uo 0 , Y O 9.bU 8.05 -1.14 -1.84 -0.511 5 . jn , . 4 u 8 . 6 0 11.01 6.tlY 11.24 10.72 9.10 M . 5 1 0.09 256.20 242.06 239.69 2 4 3 . 1 6 2 3 6 . 2 7 231.25 235.80 740.04 231.71 ? 3 .01 241.28 243.33 243.26 243.10 235.03 248.9 245.90 24b.Ul 252.26 2 5 5 . 6 5 1 5 6 . 7 6 760.86 2 3 1 . 9 9 328.79 22 .bL1 1 9 4 . 6 2 lUU.69 150,30 140.21 t 2 1 . 4 0 106.28 92.35 64,bU 5 3 . 3 3 45,lY 3 b . 5 7 3 6 . 4 1 3U.40 5'J.Y) 4 0 . 6 ) 4 5 . 7 7 40.81 50.15 32.40 5l.dl

1. )8
2. 6'4

3 9 . U 7 7 1 . 2 4 )I( e b U 59.42 b4.12 %:P4 219.1~3 28.34 2 3 8 . 0 7 2 5 3 . 5 1 ;:;:4: 4 5 2 . 4 395.4 364.R 3J7.9 316.2 308.4 29b. I 2L12.8 2 8 2 . 2 287.1 292.9 265.8 261.9 264.8

1. I

:E:$ $!I:$ ;:;:I 2 5 8 . 5 2 5 1 . 2 2 5 7 . 2 266.6 267.6 2 6 5 . 2 254.0 364.3 80.5 2bB.8 2 1 1 . 2b6.O 263.1 2 6 9 . 0 261.4 254.8 3::

• 4

3 4 5 . 2 49:i 240.0 2 1 2 1jb:ll 170.5 1 7 9 . 4 1 1 Y . O 1 1 6 . 2 i 6 9 . 3 1 5 4 . 9 111.0 15b.J 151.1 144.5 15Y.6 174.9 164.6 178.5 3 @ 0 , J 314.1 361.3 311.9 105.6 6 6 5 . 3 259.5 249.8 239.9 239.2 245.3 251.1 235.6 244.6 225.9 22b. I 229.7 225.5 225.7 225.2 220.4 221 * 3 336.6 216.7 3b.2 236.11 2 2 8 . 1 254.9 2 6 5 . 4 l93.5 229.i 1 3 8 . 241.4 139.1 2 4 1 , 231.0 235.5 230.5 204.4 170.5 lb4.2 1 7 3.0 174.1 173.1 1 7 1 . Y 165.5 151.8 ISM. I 153.4 14d.5 lY1.J lb1.0 229.8 151.'1 1 4 2 . 1 w I w I

POINT NO U I N SEC Table V.--Printout of radar dotn from fourth profile, descent from downwind tu final, spoilers cxtendetl. (cont ' d ) 1 I O U . 1100. 1100. 1100. 1100. fIOO. 1000. L O O O . 1060. 100.1, IQO(1. 1000. 1 0 0 0 . 1000. voo. 900. 9 6 6 . b 0 0 . p0u. 'ton. 101). b 0 v . bOO. 0 . 0 0 0.uo 0.00 u * I10 'b)l ' 5 6

1. uo
2. 1)U
3. 00

0 . 0 0 u. OG 0 . 0 0 -till. 3 1 0.00 -b22.1? 0.00 l b 4 Y . 2 0 -04'1.20

• 6 j 0 . 0 2

-b)O.V? -6Il.SU

• 6 1 1 . 5 b

1. 00

-b11.5a Y L I l i H T P l l l i DEG 0.uo J.0I) 0 . 0 0 0.00

• 1 . 2 0

0 , I l O 0.00 0.ou 0 . o v 0.00

• 2 . 4 5

1. 00

-2.59 0.00 -2.61

• 2 . 5 ~

-1.11 -1.21 -2.05

• I . 9 4

1. 00

4:s; L I F T G , S t -07 t::i 1 .OJ 1.07 1 .00 1.00 1.uo 0.96 1 *03 1.01 O.9H 1 .oo I .02 I .02 1.01 1 .OJ 1 .OI ;:;\ r-o CS d.21 0.05 -0.31

• 0.0

0 . 2 4 "0.0Y 0.00 0 . 0 4 0.02 -0.17 0.10 -U.14 -0.11 0 . 0 4 0.00 0.16 0 . 1 8 -0.02 0 . 0 7

• 0 . 0 5

-"a?

• o . \ a

O,l! w I P

• 15.00
• 12.26
• 9 . 5 t
• 6 . 7 7
• 4.03
• 1 . 2 9

1 L - 1 ! .46 EAST RANGE i N N . M . D F i e 5.-Pkttt& data from fourth pmfde, spoilers extended. -36- APPENDIX E ACCIDENT HISTORY In Lancaster, California, on October 17, 1978. an unmodified iearjet 24, crashed duping a trlinirtg flight. The training schedule for Learjet type rating required the introduction of single-engine approaches and si-nulated engine faiiure on takeoff at Or after 1'

• Board

concluded that the pilot did not maintain directionai con:rol of the a!?era% !?ZSB Accident Docket Xo. 3-3022) 1 - On December 4, 1978, a Learjet 25? with e Century Lii w i z ~ nodification, crashed in Anchorage, Alaska, during the landing phase of flight fo!wing a visilai approach. Light-to-mderate icing was forecast in clouds Selow 12.000 feet in the Anchorage area, and turbulence accompanied by gusting winds %as reported in the airport vicinity. The flightpath was normal almost to touchdown when the airplane suddenly pitched up and began to bank steeply from side to side. The airplane rolled to the right end continued cver until the right wing struck the ground. Of the sever: persons aboard the airplane. 90th pilots and three passe:lge,-s were killed, an:: two passmgers suffered serious injury: the airplane was destroyed. The Safety Board deternined that the probable czuse of the accidefit wgs en eccounter with strong, gusting crosswinds during the landing zttezpt, tvhich caused ?he ai-craft to roll abruptly and unexpectedly. The ensuing loss of control resulted from inappropriate pilot techniques during the atteinpt to regain con?-oi o f the aircraft. Suspected light ice accumulations on the aerodynamic surfaces may have contributed to a stall and loss of control. (Aircraft Accident Repor?--%!et Xarine, inc., Gates iearjet X Z R S , Century III, Model 23C, Anchorage International ..lirpoft, Anchorage, Alaska, DecexSer 4, 1978" (NTSB-AAR-79-18)) On December 20, 1978, a Learjet 25, tioward!Raisbeck ?.?ark Ii Conversion, airplane, with a crew of two and five passengers aboard, erashe6 during takeoff. in right bank, then to an 80°to 90O left bank, and finally to ar, 80" to 90° right bank. They Yinneapolis, Minnesota. Witnesses staled that after liftoff, the Learjzt rolled t o a 45" estixzted that the airplane reached a maximum aititude of 100 to 15C feet. The airplane struck ?he ground approximately 5,300 feet beyond the approach er,d of the runway in a nose-high attitude and then bounced and skidded about 803 feet before coming to a stop. All five mupsnts received serious injuries, and the airplane was destroyed. Causai factors relaied to this accident involved pilot preflight preparation, sncxjice on the airplane, improper flap setting, and improper pitch trim setting. {NTS!? Accident Docket KO. 3-1353) On January 19, 1979, e Leai'jet 2SD, equipped with a CeEtury wing modification to improve siow-speed performance and to permit operations on shorter runways crashed during a night, nonprecision approach. During descent, the airplane, which was pi!oted by two pilols who held L.eerjet type ratings, flew in iiyht to moderate,

APPENDIX E -37- } occasionally severe ice conditions. Shortly before the Learjet was to land, a ?rlcISonnell Douglas DC-9 took off. %+iinesses saw the Learjet cross the threshold in a normel la&ing attitude. and seconds later, be@n a series of left and right rolls. The aircraft was in a steep right bank when the right wingtip fuel tank struck the runway 2,640 feet t? .-and the threshold, and the airplane burst into Games. All six occupants of the air( 3ft were killed, and the airplane was destroyed. The Safety Board determined that the probable cause of the ecddent was the pilot's loss of control of the airplane. Tne loss of control may have been initiated by wake turbulence of a departing aircrC3ft. by a premature stall caused by an accumulation Of wing ice, by delayed application of engine thrust durin& an attempted go-around, or by a combination of all these factors. (.%ireraft Accident Report--"~Tas~ey-Ferguson, Gates Leerjet 25T3, N137GL1 Detroit, Michigan, Jsnuary 19, 1979" (NTS3-AAR-80-4)? On July 6, :97Y, an unmodified C'ltra Air Learjet 25B crashed on landing at Pueblo, Colorado. The purpose of the flight was an F.4A checkride for the two-well qualified crewmembers. ,After 40 Einutes of rourine airwork, the aircraft was configwed for a single-engine ILS approach and landing. When the aircraft was stabilized on the final approach, the FA.4 inspector said he left the cockpit and belted himself down and that the airplane then went through severe yawing and rolling oscillations. Witnesses recalled seehg the airplane nose-high with the wings rocking through several cycles. The aircraft, with high engine power applied, clirnbed steeply to 50 feet, roUed inverted, end crashed. Both 3ilots were kilied, the F A A inspector was seriously injured. and the air2lane xes destroyed. b The postaccident inspection revealed that the rudder trim was set ai zero. The pilot apparently was holding rudder ta compensate for the retarded engine during ?he approach rather thm trimming off the pressure. Causal factors included the improper rudder trim setting and the possibility that the heei of the pilot's cowboy b o t may have jasmed between the bottox of :he rudder pedal and the cockpit floor scuff plate. ( N E E Accidertt Dockst So. 3-3982) On 3:I~v 3 , 198G. an unmodified Gates Learjet Model 23 was being operated by Kennedy Flite Center, Xichinondl Virginia, on a flight from Richmond to Louisville, Kentucky, continuing to Gainesviie, Florida, and returning to Richmond. Upon arrival in the Richxond arez, the flightcrew requested an instrument ianding system (ILS) approach to runway 33 at Egrd International Air?ort. The flightcrew were cleared for the tipproach and landing. 3'i;nesses stated that the airptane crossed the runway threshold "a bit high," started to rock. and rolled inverted as engine thrust increased. The airplane crashed adjacent to the runway at 0312 and burst into flame. Both pilots were killed. The Safety Board deterniced that the probable cmse of the accident was the pilot3 fai1r;re to maintain prope? eirspeed and aircrzft attitude while transitioning from final approach through flare to touchdown. The !owspeed/high angle-of-attack flight condition precipitated xino rolloff, wingtip strikes, and ultimate loss of aircraft control. The pilot:s improper lechnrque during roundout may have been due to fatigue, his limited knowledget training. and experience regarding the flight characteristics of t h e Leerjet aircraf:, and distraction caused by concern over the intensity of the approach lighting. {Aircraft Accident Report--"Kennedy Flite Center Gates Learjet 23, 3866JS, Byrd Internations! Airport, Xichnond, Virginia, Na17 6, 1980." (NTSE-AAR-80-12)) ?

FD07118 ｜ 1985_美国_MAR8508.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1985 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

PB85-916408 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 MARINE ACCIDENT REPORT FIRE ABOARD THE BAHAMIAN PASSENGER SHIP M/V SCANDINAVIAN SUN PORT. OF MIAMI MIAMI, FLORIDA AUGUST 20, 1984 NTSB/MAR-85/08 UNITED STATES GOVERNMENT

,(---..'\ ~ TECHNICAL REPORT DOCUMENTATION PAGE

1. Report No.
2. Government Accession No.

NTSB/MAR-85/08 PB85-916408

1. Tit I e and Subtitle

LV arme Accment ttepon-- Fire Aboard the Bahamian Passenger Ship M/V SCANDINAVIAN SUN, Port of Miami, Miami, Florida, August 20, 1984

1. Author(s}
2. Performing Org~nization Name and Address

National Transportation Safety Board Bureau of Accident Investigation Washington, D.C. 20594 12.Sponsoring Agency Name and Address NATIONAL TRANSPORTATION SAFETY BOARD Washington, D. C. 20594 IS.Supplementary Notes 3.Recipient's Catalog ~o. 5.Report Date July 9, 1985 6.Performing Organization Code 8.Performing Organization Report No. JO.Work Unit No. 4184 II .Contract or Grant No. 13.Type of Report and ·Period Covered Marine Accident Report August 20, 1984 14.Sponsoring Agency Code 16.Abstract About 2300, on August 20, 1984, a fire erupted in the auxiliary machinery (generator) room and spread to adjoining spaces of the Bahamian registered passenger ship SCANDINAVIAN SUN shortly after it docked at the Port of Miami Terminal, Miami, Florida. It had just completed a daily 1.4-hour round trip cruise to Freeport, Bahamas, with 530 passengers and 201 crewmembers on board. One passenger and one. crewmember died as a result of smoke. inhalation, 4 persons received minor injuries, and 58 persons were treated for smoke inhalation. Damage and repair cost was estimated to be $2.3 million. The National Transportation Safety Board determines that the probable cause of the fire on board the SCANDINAVIAN SUN was the crew's failure to tighten a threaded pipe fitting on the No. 1 diesel generator's lubricating oil line adequately which allowed the fitting to vibrate free and oil to spray from the line which ignited when it contacted the hot exhaust manifold of the engine. Contributing to the spread of the fire outside the auxiliary machinery (generator) room was the failure of the crew of the SCAN DIN AVIAN SUN to keep closed the watertight door and the self-closing fire· .door between the engineering spaces and the accommodation spaces. Also contributing to the spread of the fire was a delay in closing the automatic fire doors and stopping the ventilation system because a watch was not maintained in the pilothouse where the alarms and fire detection cabinets were located.

1. Key Words

_tt·1re, passenger snips, :SULA::S, International Maritime Organization (IMO), fire doors, ventilation, safety orientation, drills, fire proof constru~tion, CO system, carbon monoxide, short inlernational voyages, in port watch, Control Verification Program 19.Security Classification (of this report) UNCLASSIFIED NTSB Form 1765.2 (Rev: 9/74) 20.Security Classification (of this page) UNCLASSIFIED 18.Distribution Statement This document is available to the public through the National Technical Information Service, Springfield, Virginia 22161 21 .No. of Pages 34 22.Price

CONT~TS INTRODUCTIQN SYNOPSIS INVESTIGATION .- -. The Accident - Emergency Response • Injuries to Persons • • • Vessel Damage Crew Information Vessel Information General. Method of Operation . . .- Fire Detection/Suppression Equipment • Overhaul of'the No. 1 Diesel Generator Port and Waterway Information ' , I Meteorological Information • Medical and Pathological Information. Propagation of Fire Survival Aspects . Test and Research ·• Analysis and Test of Pip~ Fitting Analysis of Lubricating Oil • -. Oil Consumed Other Information • SOLAS R~gulations • .. USCG Control Verification Examinations. ANALYSIS Fire Vessel Design and Construction Communications . USCG Control Verification Program Emergency Drills Contingency Planning. Smoke Production and Movement. CONCLUSIONS Findings . Probable Cause RECOMMENDATIONS. APPENDiXF..S Appendix A--Personnel Information .- • J • . ' Appendix B--Eff ects of Carboxyhemoglobin and Hydrogen Cyanide_. ii 1 1 2 2 6 9 9 10 10 10 11 14 14 17 17 17 18 19 19 19 19 20 20 20 20 21 21 22 24 24 24 25 25 26 26 27 27 29 29 31 ,0 0 ' ' " ~

I/·~ !U' \ .. ' • \, ~ ,:./i. NATIONAL TRANSPORTATION SAFETY BOARD . . •WASHINGTON, D.C. 20594 Adopted: . July 9, 1985 MARINI! ACCIDENT REPORT FffiE ABOARD THE BAHAMIAN PASSENGER smP M/V SCANDINAVIAN SUN PORT OF MIAMI, MIAMI, FLOJ;tl:OA . AUGUST 20, 1984 INTRODUCTION This accident was investigated jointly by the Nationai Transportation Safety Board and the· U.S. Coast Guard. The Safety Board conducted an on scene investigation between August 22 and August 25, 1984. No public hearing was convened. This report is based upon evidence developed in the investigation~ The Safety Board has considered all facts pertinent to its statutory responsibility to determine the. cause. or probable cause of the accident and to make recommendations. · · The Safety Board's analysis and recommendations are made independently of the U.S. Coast Guard. To insure public awareness of all Safety Board recommendations and responses, a notice of all recommendations and responses is published in the Federal Register. · · SYNOPSIS About 2300, on August 20, 1984, a fire erupted in the auxiliary )machinery (generator) room and spread to adjoining spaces -of the Bahamian registered passenger ship SCANDINAVIAN SUN shortly after it docked at the Port of Miami, Miami, Florida. It had just completed a daily 14-hour round trip cruise to .Freeport, Bahamas, with 530 passenge rs and 201 crewmembers on board. One :pa·ssetiger and one crewmember diea as a result of smoke inhalation, 4. persons received minor injuries, and· 58 persons: were treated for smoke inhalation. The cost to repair damage· was estimated to l;>e $2.3 million. ",· , ' . . ' ' ' . The National Transportation Safety Board determines that the probable cause of the fire on. board ttie SCANDINAVIAN SUN was 'the crew's failure to tighten a threaded pipe fitting on the No. 1 diesel generator's lubricating oil .line adequat~ly which allowed the fitting to vibrate free and oil to spray from the line which ignited when it contacted the hot exhaust ·manifold of the engine. Contributing to the spread of the fire outside the auxiliary machinery (generator) rc;>om was the failure of the crew of the SCANDINAVIAN SUN to keep. closed the watertight door and the self-closing fire door , between the . . engineering, spaces and the· accommodation spaces. Also contributing. to the spread of the fire was a delay in closing .the automatic fire doors and stopping the ventilation system because a watch was riot maintained in the pilothouse 'where the alarr:ns and fir~ detection cabinets were located.

-2- INVESTIGATION 'lbe Accident At 0830, y on ~August 20, 1984, the Bahamian. registered passenger ship SCANDINAVIAN SUN (see figure 1) departed the ·Port· .of Miami on Dodge Island, Miami, Florid1;1., on its daily ro_und trip cruise to :Freeport, Bahamas. The ship arrived in Freeport at 1350 and departed at 1652~ It returned to the Port of Miami Terminal at 2255 and moored starboaro side to berth 7. Aboard the ship· were· 530 passengers · and 201 crewmembers. .. Shortly .afterward, the second .engineer, who h~d the. watch in the engineering spaces, told the motorman, who was on watch in the engineroom, to move four cylinder liners from the tween deck (upper level) in the generator room to the vehicle area on the Bimini Deck. · The second engineer then went into the generator room and secured a waterline located near the after bulkhead of the tank top deck. (lower level) of the generator room. Shortly afterward, he saw oil spraying on the overhead above generator No. 1. The second engineer proceeded forward. toward the watertight door (WTD) at frame No. 52, leading to the tank top level in the main engineroom to reach the engineer's control room on the tween de~k (upper level) of the engineroom, and to shut down generator No. 1. However, bef9re reaching the WTD, he heard a small explosion and saw flames above generator No. 1. (See figure 2.) The second engineer then-proceeded to the control room where he secured the generator and activated the engineer's alarm which sounded in the de

D , ,, \ Void Space Watertight Door On Lower Level (Tank Top Levell Access Hatch Deck Plate on Bimini Deck Vehicle Area (on Overhead of Generator Room) t Frame 38 -3- Port Auxiliary Machinery (Generator) Room :;::=: {1111 ~-, , ,J ,..J ' Exhaust Ladder Down To Lower Level Tween Deck Starboard Open to Lo~er Level (Tank Top Levell of Generator Room) ~ Ladder Up To Trunk Space On Bimini Deck 1-1 Main Engine .Room Ladder Down · 4>T\;::er (jjjj1J7_ Ladder Up ~ To Trunk ~ sPace On Bimini Deck Engineering Control "E Room ca I dl I iii " -~ ., iii 8 t Watertight Door On Lower Level (Tank Top Levell C½:f] 1-1 Ladder Up To Trunk Space on Bimini Deck ) Ladder Down To Lower Level Tween Deck Frame 52 ''/ NOTTO SCALE Figure 2.--Plan view of generator room.

..-4- The master was in his room which is below the pilothouse and on the E:imma Deck Q· · when he heard the engineer's alarm. He immediately proceeded to the pilothouse where · ~ he saw that the fire detection panel indicator lights were flashing for the generator room; Bimini Deck-port side aft and yehicle area; Andros Deck-port· side aft and amidsh'ips; Nassau Deck-aft, port and starb9ard1arid lobby; Bahamas Deck-Lucaya West dining room and casino; .Exuma Deck-Hideaway Lounge, Castaway Lounge, smokestack, and starboard circular sti;tirway; and Bridge Deck-circular stairway ·and .Discotheque. (See figure 3.) The lights indicated that at leas_t one fire detector in each zone had been activated. As the ship entered port, passengers gathered in the passageways adjacent to the lobby on the Nassau Deck .in anticipation of disembarking. · The lobby was kept clear of passengers and crew while· U.S. Customs and: U.S. Immigration personnel examined the ship's documents to clear the .ship to allow it legal entry into the United States. The ship received clearance from the authorities about 2300, y and the passengers began to disembark using the starboard gangway which Jeads to the upper level of the terminal for their individual Customs clearance. Shortly afterward; passengers .and crewmembers saw smoke coming from overhead ventilation ducts in the lobby and the after port stair tower. At 2305, all four of the fire doors in the lobby were closed by crewmembers using the local release buttons next to th.e doors. About 2308, the chief purser closed the door to the gangway, and passengers .no longer were allowed to disembark beQause the purser feared· that they might become trapped on the gangway. At the time, between 100 and 150 passengers had disembarked. Between 380 and 430 passengers still remained aboard the vessel. About 2312, the master closed all automatic fire doors, stopped all ventilation fans, and sounded the crew fire alarm. About 1 minute later, he sounded the abandon ship a signal ~/ on the ship's general al.arm in both crew and passenger areas. Passengers were · .,-.~> advised of the fire over the public address system by the cruise director and were directed by crewmembers to move to the forward weather (outside) decks~ Some passengers and crewmembers located throughout the· 's~ip and Customs agents later reported that they did not hea~ the alarm or the public address announcement. At 2314, 2315, and 2319, the master attempted to contact the u. S. Coast Guard (USCG) .on VHF-;FM radio channels 13 and 16 but he did not receive any answer. His transmissions did not include an urgency identifier or other indications of urgency. The USCG radiom_an .on watch in the USCG Gro~p Miami Co_mmunications Center (Group Miami) 1./ stated that it was a busy watch·period and that although he heard transmissions from the SCANDINAVIAN SUN he did not hear to whom the transmissions were directed. At 2320, the USCG radioman called the SCANDINAVIAN SUN and asked. if they were calling the Coast Guard, but he did not receive an answer. · Meanwhile, about 2313, the staff captain 5/ was on the Bimini Deck vehicle area, preparing to receive supplies when "someone noticed fire" in the area of the partially 2/ The times used are the best avail.able as obtained from interviews, master's notes, chief engineer's notes, fire department logs, and the ship's log whi~h was written the morning after the fire. The exact timing of all events was not available as there is no ship's data recorder or similiar device to automatjcally record ·significant events. No ship d_ata recorder was required by existing regulations. ~/ 7 short and 1 long blast •. 1./ The USCG Group Miami Office is located on Causeway Island, approximately 2 miles east of Dodge Islandis Berth 7. · §.I The officer next in line of responsibility for the ship after the master. Q ' -· -=-,'

..-Aft Smoke Stack CO2 Control Cabinets Discotheque Lucaya West Dining Room

Void Space *Bridge Remote Control **Manual Frame 30 ***Vehicle Area in Center of Deck (See Figure 5) * Frame 40 Main Vertical Zone Boundary(---) Main Engine Room Frame 50 Frame 60 Auxiliary Machinery (Generator) Room Figure 3. --Inboard profile, portside. Sun and Sports Deck Bridge Deck Exuma Deck East Room Bahamas Bimini Deck Tween Deck Tank Top Frame 70 Legend Castaway Lounge Casino Lower Trailer Hold· Separator Room (Port) Stabilizer Room (Stbd)

Frame 80

Heaviest Smoke Not To Scale []]ill Fire· I c:11 I

-6- closed sliding fire door No. 8. (See figure 4.) . The staff captain,. who, according to the ship's emergency plan, was in-charge of .on-scene firefighting,immedia~ely f~rmed two firefighting teams and a backup team consisting of the crewmembers wllo were in, th~ vehicle area. A· firehos~ .was rigged from the ~tarbc:;,ard side of the vehicle area ~nd w9:ter was sprayeq onto fire door No. 8· a~d on th~ f'!el tank of :an empty _refrig~rated tr~uler located _next to the fire do.or. About 2315; longsliore_men. removed the tra1l~r from the vehicle area and the. ship's firefighters . entered the vestibule tprough fire door No. 8. While attacking .the fire in the vestibule and p'ort. pa~sageway, the firefighters heard.' a banging noi.se from the second· crew room aft of the vestibule. • The staff captain and the first officer proceeded, to crew room 236 where they· rescued a, crewmem.ber. 'J'he crewmember had earlier attempted to exit his room, but flames in the passageway outside of h\s door blocked his escape. About 2321, tlle fire appeared to be extinguished in the passageway and vestibule. · · The chief engineer who al$o' was on the Bimini Deck said. that about 2315 he saw smoke coming ·from the edges of the access hatch plate in the deck in the vehicle area above the g'enerator room. He immediateiy started for the engineroom through the vestibule and .trunk space on the starboard side of the ~imini Deck which gave access to the lower level of the. engineroom. The chief engineer entered the generator room through the WTD at frame No. 52 at the after end o_f the lower level of the engineroom. He observed flames in the overhead and -heavy black smoke. Meanwhile., the second engineer and first engineer had _donned self-contained breathing apparatus and had begun to fight the fire through the WTD _at frame No. 52 with two firehoses. · Shortly afterward, the chief engineer concluded that tlle fire ~ould not be extinguished with water and decided to energize the CO system ;tp the generator room. The WTD at frame No. 52 was closed by activating a l&cal control switch 'next to the door. The Nos. 2 and 4 diesel generators were shut down, and the engineroon;i spaces were evacuated. The firefighters on the Bimini Deck were then ordered by the first officer to vacate the vestibule as CO?. was going to be released into the generator room. When the chief engineer reached the Bimini Deck, he used the staff captain's hand-held radio to can· the pilothouse and requested that the after WTD at frame No. 38 in the generator room be closed. About 2324, the five ren:iairiing remotely controlled WTDs were closed from the bridge. using the ,master control switGh. Licensed engineers and the ship's ele

0 j/- - (C)· ~ .... aq C: .., CD "'" I I '"Cl ...... ll:> ::, < .... CD :E 0 .......... _ r+ r+ ::r ::r ct> CD C/l ~ r+ ll:> ..... 3 .., s· r+ 0 .... =E 0 ct> CD :" (';) "" -0 0 .., r+ C/l .... 0. CD s· r+ ::r ct> ll:> .., CD ll:> Crew Room 236 -AFT Crew Room 234 Crew Room 244 31.5 Feet AFT Bath Room Port Side Electric Shore Connection FD Linen FD Vestibule Sliding Fire Door No. 8 FD Electric Cabinet Clean Linen ro Gen. Room Tween Deck 'Frame 51 Vehicle Aroo Side Port Port Stair Tower To Engine Room Engine Room Erner- gency Exit Port Main Engine Exhaust C. 0 .,:; II) 21 C " C. to tJ FD b I -:J I

-8- upper level of the terminal to the lobby to assist the passeng~rs. Two of these itispectors o--/ also entered the smoke filled lobby and rescued an elderly male ·passenger who had b~en ~ overcome by -smoke and had collapsed. After assisting the passenger ashore, the inspectors r~entered the·ship's lo9by but did not find anyone else. At 2317, the MFD dispatched firefighters and equipment from three fire st~Uons and one medical.unit from a· Miami-rescue station. · The MFQ units began arriving on_ scene at 2321. The MFD units attached hoses to shoreside hydrants i;lnd an aerial ladder truck was pos_itioned near the forward part of the ship. . The ladder was raised -to the gangway on the Nassau Deck- to allow firemen with self-contair:ied breathing apparatus to _search the lobby and adjoining passageway for persons overcome by smoke; none were founq. The .ladder was then repositioned to remove passengers who had gathered at the bow of the ship. About :75 passengers disembarked using the ladder. Some firemen remained on the forward weather decks with other passengers to reassure them of their safety and to prevent ·panic. The District fire chief who had arrived on scene. witJ1 the MF D units assumed command of the firefighting operations. He set up a command post on the dock between the ship's mid-section and the terminal building. The master of the SCANDINAVIAN SUN assisted the fire chief by assigning ship's personnel .. to guide shore.side firemen on board the ship. MFD firemen wearing self-contained breathing apparatus first started fighting the fire through fire door No. 8 on the Bimini Deck. They extinguished the flames at the base of the stair tower but were driven back by heat and steam w~ich form~d when water contacted the hot steel. The firefighters then moved the firehoses from fire door No. 8 to the starboard side of the Bimini Deck in order to enter the engineroom. However, they were unable to enter the generator room because the WTD· at frame No. 52 was closed. The door could not be opened using the local control switch next to the door. About 0004, August 21, · a SCANDINAVIAN SUN crewmember released pressure · in the hydraulic cylinder cl()sing mechanis_m and opened the WTD at frame No. 52. · After the fire, the door was tested and functioned properly. The. cause of the .malfunction of the door !l}echanism could not be determined. When the firemen ent~red the ,generator room, they . did not find any fire <;>n the lower level and only small fires or:i the upper or tween deck level which they quickly extinguished with a minimum·· amount c:>f water. The firefighters __ _ returned to the Bimini Deck port stair tower and after reaching the Andros Deck had to retreat to replace their air tanks. Before leaving, they lashed the. firehose on the stairway railing with the nozzle in the open fog position directing water upward. An MFD backup firefighting team arrived shortly afterward and continued efforts to extinguish the fire in the port stair tower. The fire was compl~tely extinguished about 0035. In a telephone call at 004.6, the Coast .Guard Captain of the Port (COTP) established a 100-yard safety zorie QI around the ship, and Group Miami provided a patrol boat to enforce the zone. At 0052, as the. smoke began to clear, the remaining 305 to 355 passengers were directed aft and disemb°arked via the stern ramp on the Bimini Deck~ At 0100, crewmembers on the forward decks were directed aft to disembark. At the same time, the COTP arrived on scene and met with the master ·of the ship and the MFD fire chief. The fire chief wanted to ventilate the ship to clear out the smoke but the master strongly advised against doing so. The master wanted to maintain the concentration of the CO which he believed had been released to the generator room to prevent a reflash/ of the fire. The COTP also advised against ventilating the ship. The vice president for QI A safety zone is a water area, shore area, or water and shore area established for safety or environmental protectjon purposes; access is limited to authorized .persons, vehicles, or vessels. USCG District Commanders and COTPs have been delegated authority to establish safety zones from the Corn rnandant, USCG. '!/ Marine Accident Report--"Fire Aboard the Bahamian Passenger Vessel MIV SCANDINAVIAN SEA, Cape Canaveral, Florida, March 9, 1984" (NTSBIMAR-85103). 0\ .), -<'. A ~

/ LO -9- operations for Scandinavian World Cruises who had arrived on scene about 2345 on August 20 also advised the MFD against ventilating in order to prevent a possible reflash of the fire which had occurred on a similar ship 7 / belonging to the company. The fire chief accepted this advice and did not ventilate the ship. After overhauling the fire ~ and extinguishing some spot fires, the MFD declared the fire out at 0106. At 0333, the fire .chief turned over firefighting responsibilities to the ship's master, and the master set a reflash fire watch. A hose was charged from a shoreside hydrant and led onto the Bimini Deck near fire door No. 8. A USCG command post trailer on the dock received fire patrol reports every 30 minutes. At 0900, the USCG command post was secured. At 0130, the command post received a report from members of an excursion group that one of its members was missing. A check of the passenger list confirmed that the group had rented room. 440 on the Andros Deck to store personal belongings and for use in the event a group member became sick or required rest. Search parties were formed with the staff captain, other members of the crew, and the MFD. Self-contained breathing apparatus were worn because of the heavy concentrations of smoke. Searches of room 440 were conducted at 0200, 0220, and 0400 by ship's crew and fire department search teams, but the missing female passenger was not located. The room was dark and smoke filled with about 1-foot of visibility. A search also was made of the upper decks and the lifeboats. Between 0305 and 0325, a Coast Guard patrol boat conducted a water search for t9e missing passenger in case she had jumped ov~r board. The search had negative results and the safety zone was cancelled at the end of the search. About 1300, the passenger was found fully clothed in the shower of roqm 440 by members of the Miami Police Department who were investigating her disappearance. A muster was held for all crewmembers at 0130 in the terminal building. The names were called out from the crew list and checked off as each person responded to their name. Due to similar sounding names an incorrect response was made to a name called, and consequently one crewmember was not determined to be missing until he failed to report to the chief chef for work later that morning. About 1145 the chief chef and the first officer found him dead in his room. Injuries to Persons MFD+ Rescue u .s. Crew Passengers Units Customs Total Fatal 1 1 0 0 2 Non-Fatal Injuries 2 0 2 0 4 Smoke Inhalation 5 49 3 1 58 None 193 480 53 8 734 Total 201 530 58 9 798 Vessel Damage The fire damage in the generator room was minor. The vestibule, aft of the port trunk space, and the crew passageway aft of the vestibule sustained extensive damage. Fire damage in the stair tower on the Bimini and Andros Deck levels was extensive. On the Nassau Deck, the after portion of the stairtower was burned severely and the damage in the forward portion was limited mainly to smoke and heat damage. Burning carpeting ~ The process of moving and separating burned material to locate any hot or smoldering debris and to cool or wet it down to prevent any reflash of the fire.

-10- on the decks and insulation in the overhead in the areas of ·severe fire caused heavy smoke ~-- during the fire. The ship was repaired arid returned to service on October 22, 1984. -Total

cost of repairs was estimated at $2.3 _million.

-

_ - · -.

· Crew Information The SCANDINAVIAN SUN was manned in accordance with Bahamian Law.' The II1aster arid licensed .officers were Danish nationals and held Certificates of Competency from Denmark and the Bahamas. (See appendix A.) . Personnel in the deck department, the engineering department, hotel staff, entertainers, and the cruise staff were employed .by Scandinavian World Cruises. Personnel in the catering, concession, and casino - operations were employed by independent contractors. However, all persons employed on the SCANDINAVIAN SUN were considered ship's crew and, therefore, subject to the master's lawful orders. While the SCANDINAVIAN SUN is moored, the watch shifts to the gangway and the pilothouse is left unattended. The deck watch consists of the mate, a quartermaster at the gangway, and a roving fire patrolman. The mate on watch is responsible for the ship's business and can be contacted by telephone in his room or by hand-held portable radio during his assigned 24-hour watch. The quartermaster and the roving fire patrolman each stand a 6-hour watch, The roving fire patrolman must make hourly rounds to all accessible parts of the ship, except the machinery spaces where there is a watch, between 2300 and 0700. The rounds are recorded on a key-,-type recording clock. The engineering watch consists of an engineering officer and two unlicensed persons. r They carry out normal watch routine and maintenance of equipment throughout the ~ machinery spaces. No one stands watch in the engineering control room, which is left unattended, except for an occasion~! check of the space or. when a watchstander enters to use the intraship telephone. ·Vessel Information _ General.-~The SCANDINAVIAN SUN, originally named the FREEPORT, was built in September 1968 by the . Orenstein and Kappel Shipyard, Lubeck, Federal -Republic of Germany, as a combination passenger and roll-on/roll-off vehicle carrier. (See figure 5.) It is constructed of welded steel, and it was built according to the rules and regulations of the West German classification socfoty Germanischer Lloyd (GL). The vessel has retained GL classification for its hull and _machinery. The ve_ssel's principal characteristics are: ~ength Breadth Depth Draft Gross Tons Net Tons Displacement Tons Horsepower 441.1 feet

1. 5 feet
2. 3 feet'
3. 1 feet

9,902.9 4,660.1 8,286 16,000 The SCANDINAVIAN SUN is a twin-screw motor vessel with controllable pitch propellers, bow thruster, and stabilizer fins. It is powered with two 16-cylinder Ottensener Eisenwerk (Hamburg, Germany) diesel engines and has a cruising speed of 20 knots.

-11- . Four diesel generators, numbered 4, 1, 2, and 3 from port to starboard, are located in the auxiliary machinery room aft of. the engineroom. The Nos. 1, 2, and 3 generators were installed as original equipment when the ship was built, and the No. 4 generator was installed in 1976. At the time of .the· 1;1.ccident, the No. 3 generator had been removed temporarily for overhs,uling.. · The vessel is divided into five main vertical fire zones by fire-resistant bulkheads and insulated steel decks. International regulations require that· the distance between these boundaries generally should not exceed 40 meters (131 feet). Where bulkheads had paneling installed, the paneling was generally 3/4-inch thick consisting of a 9/16-inch asbestos-type cement mineral board laminated between a melamine veneer.!_/ and a fire-resistant backing board. In the passageways and stair towers, aluminum panels are suspended overhead about 8 inches below the deck above. Within this space are electrical cables, ventiiation and air conditioning ducts, and oth~r utilities. Combustible material in this space consisted of electrical insulation and pipe coyering. The steel decks in the passenger area generally are covered with fire resistant carpet consisting of 80 percent wool and 20 percent nylon, and other are~s were covered by c.eramic or vinyl tile. Fire doors are installed throughout the ship within the fire zones and in the .zone boundaries. There are 37 sliding ·self-closing, 165 hinged seif-closing, and 65 hinged automatic fire doors. The hinged automatic fire doors can be closed locally by depressing a . switch near the top of the door or remotely using a master control switch in the pilothouse. There is no provision to close the doors selectively from the pilothouse either zone by zone or within each zone. An emergency. diesel generator is located in the emergency ·generator room at the after end of the bridge deck •. Power to the automatic fire doors, the public address system, the general alarm bells, arid other emergency ~ystems was supplied by batteries in the battery room .located above the co2 room on the starboard side of the Bridge Deck. Method of Operation • .:.-From 1968 until 1981, the FREEPORT operated on 3-- and 4-day cruises out of Miami, Florida, to Nassau· and Freeport, Bahamas. In 1981, the vessel operated on 7-day cruises in the Caribbean during the winter months, and it operated between ports in the northeast United States and Nova Scotia, Canada, during the summer

•

. ✓ months. After completing its 1981 slimmer season, the ship was ~old to DFDS 10/ Seaways, :Bahamas · and was operated by Scandinavian World Cruises. It underwent overhaul and conversion in Hamburg, West Germany, from October 1981 to January 1982 to adapt it for daily cruise service. It was registered, in the Commonwealth of the Bahamas on January 25, 1982, and. renamed the SCANDINAVIAN SUN. On February 19, 1982, the SCANDINAVIAN SUN commenced daily cruise operations between Miami, Florida, and Freeport, Bahamas. Scandinavian World Cruises daily prepares a man if est of passengers and a current crew list. Copies of the lists are kept on the ship and in the main office on Dodge Island. Between August 1 and August 20, 1984, the SCANDINAVIAN SUN carried a total of 15,369 passengers, averaging 768 passengers per day. Passenger and crew rooms are located outboard of the vehicle area along the port and starboard sides on the Andros and Bimini Decks respectively. Passenger rooms also are located on the Nassau and Bahamas Decks. 9/ A pressure laminated plastic sheet formed from melamine resins. 10/ Det Forenede Dampskibs-Selskab or The United Stea.mship Company. l I: ! ' l , j l I! l : '' ! I l. !.: ;

1-'rj ~-.., Cl) CTI . I I 0 Cl) ::, Cl) .., i:ri - i:ri .., .., i:ri ::, ~ 3 Cl) ::, ..+ 0 ..... 00 (') > z 0 -z > < -> z 00 C: z . ~ Cl) Cl) ..+ .... - SEE FIGURE 3 IIUCVEfflCAlUIE BOUNDARY TOP Of HOUSE FUNNEL CO2 CONTROL CABINETS, 0 LUCA.WA WEST DINING ROOM ---- SUN AND SPORTS DECK GANGWAY 9l0E'PORT •- Oj I I . BRIDGE DECK NASSAU DECK ANDROS DECK BIMINI-DECK TWEEN DECK ....... VfATICAl ZOfllE BOUNOAIIY BRIDGE DECK j:XUMA DECK BAHAMAS DECK

-~ --~' IT.I NASSAU DECK .... OQ r .., CD :11 I I 0 CD ::s CD .., It)

ANDROS DECK

It) .., .., It) i SEE FIGURE 4 CD 3 CD ::s r+ I 0 BIMINI DECK ...... ..... c,.:, 00 I 0 > __ z_ C, SEE FIGURE 2 -z ~ -> z 1WEENDECK 00 C: z . - ~ CD CD r+ t..:i MAINENGINl

000M

TANK TOP

· -14- Fire Detection/Suppression Eguipment.--The SCANDINAVIAN SUN is equipped with a heat detection ·system· and two· smoke detection systems. There is a smoke sampling detection system in the lower ·trailer hold on. the Tank Top .deck terminating in its own smoke detection cabinet in the pilothouse. The presence of smoke will activate an aural and visual alarm in the ·cabinet~ · The· engineering spaces also ~re monitored by an ionization smoke detection system that terminates in the same cabinet in the pilothouse as the heat sensors. Throughout the vessel there are 685 heat sensing detectors grouped into 45 zones with at least one sensor in every compartment. The fusible-link sensors in the machinery spaces are activated when the temperature,exceeds 68° Celsius (154° F) and in accommodation spaces when the temperature· exceeds 48° Celsius (118°.F). If a sensor is activated, a light in a cabinet on the bridge will indicate the location and an aural alarm will sound. · · A two-position switch on the pilothouse console next to the general alarm buttons operates the fire control system. When the switch iS in the automatic positjon, it ~ill automatically release all of the fire doors so they will close, shut down all the ventilation, and sound the crew fire alarm whenever any heat or ionization smoke detector is activated. When the switch is in the manual position, a .person in the pilothouse must activate the individual controls for automatic fire door closure, ventilation shutdown, and general alarms. It was the ship's unwritten policy to routinely place the switch in the automatic position after all passengers had disembarked. On the night of the fire, the switch was .still in the manual position. There are separate locally controlled fixed CO.2 systems for the paint room, lamp room, and the em1;3rgency generator room. The maJor fixed CO extinguishing system services the main engineroom, the generator r"oom, the· stabilizeJ room (starboard side ~ · forward of the engineroom), the separator room (port side forward of the engine room), ( . and the lower trailer hold. The major fixed CO2 extinguishing system has 55 cylinders, each containing 45 kilograms (99 pounds) of co2 which .are located in a seps,rate compartment just forward of the port stair tower '.on the Exuma Deck. The co2 release control for the lower trailer hold· is located in a cabinet on the after bulkheaa in the pllothouse. The CO2 release con~rols-for the engineering.~paces are located in three 14-- · by 14-inch cabinets on the exterior of the port stair tower on the Exuma Deck, just aft of the CO2 cylinder compartment~ The co2 reiease control cabinets are designated as follows: upper left cabinet is for the separator room, lower left cabinet is for the stabilizer ro.om, and the upper right cabinet is for the engineroom and the generator room. (See figure 6.) The cabinets are kept locked at all times. One key for the cabinets is in the chief engineer's possession and a duplicate key is ke()t in the pilothouse. · Overhaul o'f the No. 1 Diesel Generator.--At 0001 on August 19, 1984, while the vessel was moored at the .Port of Miami, the engineers on watch started to overhaul the No. 4 cylinder. of the No. 1 diesel generator. 'l'he ·repair required removal of the cylinder head and an access plate located on the starboard side of the engine. A platform on the forward starboard side of the engine in the area of the five forward cylinders (the engine has 8 cylinders) provided a flat .surfa~e 2 1/2 feet wide by 4 1/2 feet long and 2 feet above the deck to gain' access to the top of the engine. The platform was positioned over a 3-inch lubricating oil line and the lu_bricating oil ·cooler. A threaded 1/2-inch pipe fitting in the lubricating oil line which was plugged protruded about 1 to 2 inches through a 2- by 6-inch rectangular opening near the center of this platform, by the No. 4 cylinder access plate. (See figure 7 .) During an interview with the second engineer, he stated that the pipe fitting was not removed •. The repair of the No. 4 cylinder was completed by 1230, August 19, 1984, and the diesel generator was placed in operation at 1630 and was run ( continuously until the accident. A postaccident examination of the No. 1 diesel generator ". - revealed that 'the pipe fitting was not in place in the generator's lubricating oil line; it was found on the engine acc~ss ·platform.

((.'Q .... _ .. (f'i ,~v In Case of Fire in Separator Room

1. When Opening the Door of Release Station

Fire Alarm Will Sound.

1. Make Sure That All Personnel Has Left the

Burning Room.

1. Shut Off Ventilation, Oil and Fuel Oil Supply.

Close All Openings.

1. Open CO2 Valve.
2. Break Glass of Control Box "CO2 Release"

and Pull Out Handle. • • ua:~ngu For This Cabinet t 14" I Hinge \ • -15- Dog I 4"---------.. ~I CO2 CONTROL CABINETS In Case of Fire i!l Engine Room

1. When Opening the Door of Release Station Fire

Alarm Will Sound.

1. Make Sure That All" Personnel Has Left the

Bur~ing Room.

1. Shut Ventilation, Oil and Fuel Oil Supply.

Close All Openings.

1. Open CO2 Valve.
2. Break Glass of Control Box "CO2 Release"

and Pull Out Handle. • Marking For This Cabinet l D Figure 6.--Carbon dioxide cabinets. J

,i -16- Figure 7.-- No. 1 diesel engine,generator (looking down and aft from the. tween deck level). (

-18- Figure 8.--Port of Miami (Dodge Island), Miami, Florida. Smoke inhalation as the cause of death may involve many factors. For example; in a fire there generally are multiple factors that contribute to -a lethal environment. These factors include: (1) toxic products in addition to carbon monoxide, such as hydrogen cyanide and ~ydrogen chloride, (2) oxygen depletion, (3) heat, and (4) particulate matter (soot). (See appendix B.) . · Propagation of Fire The fire at diesel generator No. 1 spread very rapidly upward and to port, toward an opening in the overhead above the escape ladder that leads from the generator" room to a trunk space on the Bimini Deck common to the generator and the main engine rooms. The trunk space provides access down to the machinery rooms, up to the smokestack, and aft to a manually operated WTD. Aft of the WTD is a self-closing fire door which opens into a vestibule. From the trunk space, the fire spread in two directions: upward into the smokestack.and aft througl) the open doors to the vestibule. The supply 11/ ventilation to the engineroom prevented the fire from spreading forwarq and down into the engineroom. From the vestibule, the flames spread aft past the partially closed sliding fire door No. 8 and through an open door ·into a fore and aft passageway lined with crew rooms on the port side. Flames in the vestibule also spread to tne port side passing through an open automatic fire door at the base of the pQrt stair tower· that led from the Bimini Deck to the Andros, Nassau, Bahamas and Exuma Deck levels. On the Andros Deck, the flames spread forward on the port side through· another open automatic fire . door into a passageway in the passenger accommodations about 4 passenger rooms forward of the fire door, but the flames did not penetrate any of the Glosed doors. The fire continued upward to the Nassau Deck mainly in the after portion of the stair tower. Some ~ame, heat, and smoke damage was evident in the forward section 11/ A system in which fresh air is forced mechanically into ship spaces and displaced air is drawn off by uptake vents or exhausted through doors or other openings.

I I ! ' :( I ' ~ I ' ! 1! !' ii ,, ·I ~ ', i

J

I ,, :1 ,, ~ I } { ' '1 •/ i I I , ,( I \ ;1 :, 'i . ~ I -19- of the Nassau Deck stair tower level, including the lobby area. Above the Nassau Deck, smoke and heat spread upward in the stair tower to the Bahamas and Exuma .Decks. Survival Aspects Passengers are provided with a boarding pass which is divided into three parts •. Two parts are perforated to serve as boarding permits in Miami and Freeport. On the reverse side of the third part is a description of the emergency signal, the card holder's emergency muster station, and a description of how to don a life preserver. Immediately after the SC AND IN A VIAN SUN departed Miami, a public address announcement welcomed passengers aboard and directed their attention to the emergency instructions on the boarding pass. The emergency alarm signal was explained, and muster locations and locations of areas where the crew would dispense life preservers·, if needed, were identified. Separate emergency instruction placards in three languages were posted in all passenger cabins, public locker rooms, and public toilets • . Because the SCANDINAVIAN SUN was on a short international voyage, 12/ it was not required by international regulations 13/ to conduct emergency drills when the ship left port. Neither is there any requirement to provide. passengers with a safety orientation at any time during the cruise. Fire and boat drills are conducted with the crew each Wednesday afternoon while- the ship is in Freeport and the passengers are ashore. The ship's mobile firefighting group musters in a different part of the ship for each drill and training sessions are conducted by the officers. After the fir.e drill is completed, an abandon ship drill is held. Crew members are mustered at their emergency stations and boat crews are trained in lifeboat handling using a different ,boat at each drill. Test and Research Analysis and Test of Pipe Fitting.--On August 27, 1984; the USCG MSO Miami sent the plugged pipe fitting and its two brass washers to the Metropolitan Dade County Police Department's Crime Laboratory for analysis to determine if the fitting had been purposely\ loosened by a tool. Their findings indicated that there were no recent tool marks on the fitting, the threads were not damaged, and there were no tool marks on the washers. On October 5, 1984, while. the SCANDINAVIAN SUN was in drydock, a marine inspector from the USCG MSO Jacksonville, Florida, conducted a vibration test using the pipe fitting in the lubricating oil line on the No. 1 diesel generator. The results of the test indicated that it took 4 1/2 turns clockwise to hand tighten the fitting in the lubricating oil line and 100-inch pounds of torque to loosen the fitting after tightening. The fitting was reinstalled and torqued to 100-inch pounds, and the generator was run for 3 minutes at its operating speed of 900 rpm. The fitting did not loosen. It was then loosened one-fourth turn from its hand tight position, and, with the engine running, it immediately and readily rotated loose. After the elbow loosened one turn, the engine was stopped before the fitting backed out completely. Analysis of Lubricating Oil.--Between August 29 and 31, lubricating oil was taken from the No. 1 diesel generator and analyzed by an independent laboratory. The analysis 12/ A voyage that is not more than 600 miles long from the port of departure to the termination of the voyage and in which a ship is never more than 200 miles from a port. of safety. (SOLAS 1974, Chapter III, Regulation 3) 13/ SOLAS 1974, Chapter III, Regulation 18.

revealed that the oil had been diluted.about 10 percent by diesel" fuel. Its autoignition 14/ temperature was 670° F, its flash poin_t 15/ was,, 390° F, and its·f~re point Ji( wa:s 435°F. The Mobil Material Safety Data Bulletin for uncontaminated Mob1lgard 3.24 hsts the flash point as 425° F. It does not list autoignition or fire point temperatures. Although the exhaust manifold on the djesel engine was insulated, there were some exposed' metal surfaces. .The chief engineer estimated that the exhaust manifold temperatures are typically bet~een 400° C and 450° C (752° F and 842° F). Oil Consumed~--The lubricating 9il's pressure was, approximately 70 psi when th~ generator .was operating~ Normally, the lubricating oil reservoir held 700 liters; after the fire, the chief engineer· determin·eq that the res·ervoir contained 560 liters, a loss of 140 liters (about 37 gallons). The Safety Board calc!lla~ed that at the lubricating oil's operating pressur·e, it would have taken approximately 1 minute for the engine to lose 37 gallons of oil based upon the viscosity of the oil, the diameter of the opening, ·and the . of discharge. · · · Other Information SOLAS Regulations.--When the SCANDINAVIAN SUN's kee~ was laid in October 1967, the rules in the Convention for the Safety of Life At Sea of 1960 (SOLAS 60), as developed by the International Maritime Consultative Organization· (IMCO), now the International Maritime Organization (IMO), were in effect. · Germanischer Lloyd stated that the SCANDINAVIAN SUN was built to SOLAS 60 including part H. Chapter II of SOLAS 6.0 originally included Parts A through F dealing with vessel construction, as it pertains to subdivision and stability, machinery and electrical installations, fire protection,· detection and extinguishment, and general fire precautions. · Parts G and H were contained in the. 1966 and 1967 Amendments to SOLAS 60 which were not ratified by sufficient countries to go into effect internationally. Nearly identical requirements were incorporated in SOLAS 74. The ship's 1981 conversion adhered to the regulations in SOLAS 7 4. Part of the regulations in SOLAS 60 and 74 address the combustibility of materials used in construction but .leave it to each government to determine the specifications regarding the combustibility of materials. Although there is an international fire test, there is nci international standard for the acceptance or rejection of a material. An international standard for m·easuring smoke when materials and furnishings burn is under development, but it is not yet available. · USCG Control Verification Examinations.-The USCG ex;amination of foreign passei:iger ships·is conducted under the al,lthority of Chapter I, Regulation 19, SOLAS 74, which allows signatories (countries) of the convention to verify that the conditions on thE;! ship or its equipment correspond substantially to the ship's SOLAS safety certificate. The record of the examination of a foreign vessel by the USCG is contained in CG-840F, Control Verification or Examination of ·Foreign Vessel, r.evised in June 1981. to include new iteqis not listed in the previous edition. However, the Coast Guard does not consider the CG-840 F to be a checkoff list to be completed during every examination but rather a memory aid to assist the inspector to record the items that were examined. One set 'of USCG inspection records (CG-840F) used for the examinations of the SCANDINAVIAN SUN indicated that the ship was constructed to Method I, while Method II and Iii standards 14/ Temperature at which oil self-ignites in air at one atmosphere. 15/ Temperature at which oil can be ignited by a spark or flame. · 16/ Temperature at which oil can be ignited by a spark or flam·e ·and will burn· f9r at least 5 seconds. ' ·

,.,.21- were noted on other inspection records.· The three methods of constructi.on are defined in Regulation 34 of SOLAS 60. In general, Method I construction !'.!~:msists of n~ncombustible fire resistant construction~ Sprinkle.rs or fire detectors are not required t,>ut may be installed. Method II construction· allows unlimited combustible construction materials and compensates· by requiring a sprinkler system throughout the ship to detect and sµppress fire. Method ·m construction is similar to Method I but allows limited combustible construction materials and compensat~s by requiring a .fire detection system throughout and limiting combustible furnishings. A ship is built· to meet qne particular set of construction requirements but may meet more. thari one method. In the 196~ .and 1967 Amendments to. SOLAS 60 and in SOLAS 74, standards based on the method of construction have been replaced by a single standard of structural f1re prote'Ction. I ANALYSIS Fire The pipe fitting protruding above the surface of the access platform on the s~arboard side of the No. l diesel generator llampered the engineering personnel working on th!;? starboard side of the engine. Even though the second engineer stated that the pipe fitting was not removed while repairs were being made to the cylinder, it seems quite likely that the fitting was removed to facilitate access to the cylinder while it was being overhauled and that the fitting probably was only hand tightened when it was ·replaced. The fitting probably vibrated loose while the generator was operating from 1630, August 19 until it rotated free of the threaded opening about 30 hours later at 2300 on August 20. After the accident, the fitting was replt:!,ced with a plug and wired to prevent it from rotating loose. When the fitting rotated loose, lubricating, oil which was under about 70 pounds pressure, sprayed vertically above the engine and probably. atomized as it discharged under pressure. Droplets of oil probably fell back .down on .to the hot engine manifold. Atomized oil also was carried by the strong supply air ventilation draft toward. the overhead escape trunk which led to the trunk ,space at the bottom of the port smokestack . casing on the Bimini Deck. The most prob&ble source of ignition of the lubricating oil was the hot exhaust manifold on the Nd. 1 diesel engine. While the manifold generally was well insulated, there were some exposed hot metal surfaces where minimum temperature exceeded the aµtoignition temperature of the lubrication oil. . ( ' The engine lost about 37 gallons of lubricating oil in the approximate 1 mipu~e it tqok the engineer on· watch to shut down the No. 1 · diesel generator to stop the spraying oil. After the oil was ignited by the manifold, the flame ·spread along the path of ttie atomized oil and ignite

-22- provide in a statisfactory explanation.· It is not likely that the WTD and the fire door would have been kept open as a ·c~mvenient passageway for engineering personnel because the supply ventilation from the machinery spaces would have aliowed stale fume laden air to exhaust into passenger and crew accommodation spaces. It was "more likely that the doors would have been temporarily blocked open for the transfer of the four cylinder liners to the Bimini Deck vehicle area. Flame and soot patterns on the doors and bulkheads between the port trunk and vestibule on the Bimini Deck, ho~ever, clearly indicated that the two doors were open during the fire. Had either the manual WTD or the self-closing fire· door been closed during the fire in the generator room, the fire would have traveled upward into the smokestack and not aft into the vestibule or into any accommodation spaces. Because the SCANDINAVIAN SUN was moored to the dock and in the process of disembarking passengers when the fire started, most of the passengers were out of their rooms and either disembarking or preparing to disembark when the fire started. This made crowd control easier and kept the passengers away from their rooms and being overcome by smoke. Upon the discovery of smoke and flames, the senior ship's officers on the vehicle deck reacted quickly. to form firefighting te·ams. This prompt action saved the life of Qhe crewmember who was trapped in his room (room 236 on the Bimini Deck) by flame and smoke. Vessel Design and Construction When the ventilation was stopped and the fire doors in the stair tower were closed, [. the fire in the stair tower was effectively contained and any further. propagation of fire \J!. outside the tower on the Andros Deck and above was prevented. There was no apparent damage behind the paneling in the stair tower although the veneer on the mineral board backing was burned on the Bimini and Andros Decks and on the after part of the Nassau Deck. Wherever doors were closed, whether fire doors or not, they prevented the passage of flames because the fire was of a relatively short duration. However, smoke was transported throughout the ship by the ventilation and air conditioning system as evidenced by · the· soot deposited in rooms, passageways, exhaust duct filters, and vent exhaust louvers .. Soot deposits were greatest near the port stair' tower and gradually decreased with distance away from the tower. The original owners of the SCANDINAVIAN SUN adhered to the 1966 and 1967 fire safety amendments to SOLAS 60 during construction although they were not required to do so. Apparently they were anticipating that the amendments would be adopted internationally and that the ship would be required to meet them if the ship was to carry U.S. citizens out of a U.S. port. The firefighting efforts were enhanced by the low flame spread materials that were used during construction of the ship when it was built in 1968. Some of the passengers, crewmembers, and Customs officials did not hear the general alarm. Duplicate electrical cables for emergency and essential control circuits lead down on each side of the ship and through the stair towers. The electrical cables in the port stair tower were burned on the Bimini, Andros, and Nassau Decks rendering them useless. The starboard stair tower was not affected by the fire, and the general alarm should have been heard across the ship. With the exception of the smoke detection system in the lower trailer hold, ~·· the fire detection system on the SCANDINAVIAN SUN consisted of ionization and heat " detectors with an aural alarm and indicating lights in the pilothouse. The detectors in the vicinity of· the fire functioned properly and registered fire in the pilothouse detector

.. (,o··., ,,, ' -, , . \ '. (() -23- panels. The pilothouse was unmanned and a qualified person was not in position to take immediate action to close the automatic fire,.doors and to stop ventilation immediately upon activation of alarms in the detection panels. By the. time. the r:naster arrived on the bridge, 14 of the 45 fir.e alarm zones on the fire detection panels already were indicatfog fire conditions. Although he secured the ventilation and closed the fire doors immediately upon assessing the situation, the flamei, a,lready had entered the stair tower at the Bimin.i Deck ~nd spread fire and smoke up to the top of the stair tower as well as. outside the stair tower on the Andros and. Nassau Decks where passengers were gathering to disembark •. Therefore, the effectiveness of the system was diminished because no one was -on hand to take immediate action to isolate the ·fire· and secure ventilation~ The local closure of the automatic fire doors in the lobby' by crew members prevented name spread and greatly reduced the damage in the lobby. The Safety Board believes that in order to protect the ship and the passengers, the pilothouse shoulq be manned continuously to monitor the alarm systems, at least so long as there are passengers still on board. Alternatively, the automatic/manual switch should be placed in the. automatic position when the watch is moved from the pilothouse to the gangway. The Board believes also that. the USCG ~hould urge IMO to require an a-µtomatic/manual fire control system for fire door closing and ventilation stops on all passenger ships, regardless of other built-in fire safety devices. · Automatic fire doors should be closed quickly in the event of a fire to prevent fire spread. A heat or smoke· detector should be made part of the release switch on fire doors which would close the door in the event that the detector is activated and could quickly seal off the fire. The individual door switch should be in addition to any other fire door closing system on the ship. Closing a fire door in this manner would be accomplished quickly without depending upon manual or automatic ren:iote operation of the _door from the bridge after fire has been detected. This would pose no additional hazard to persons caught behind a door as a person can exit through a fire door that has been closed by turning the latch -handle to open the door. The door will automatically close itself after the person has exited. The only control cabinets for CO2 release for the main engineroom/generator room, the stabilizer room, and the separator room are on the port side of .the Exuma Deck on the outside bulkhead on the stair tower. Unlock,ing and opening the CO cabinet door automatically caused the ventilation to shut down and.an alarm to be soun~q in the space served by the co2 system~ On the njght of the accident, only two of the three cabinets were labeled: the upper left cabinet was marked "separator .room" and the upper right cabinet was marked "engineroom .• " The lower left cabinet was unmarked~ SOLAS regulations require that CO controls be labeled ciearly. The cabinet marked "engineroom" contained a. singfe co2 control for both the engineroom and the generator room. · The lower left cabinet contained the CO2. control for the starboard stabilizer room. 'This control wa,s activated by the c}:lie1' engineer after discussion with -the engineers assemble9 at the cabinets as to which c~mtrol provided CO2 to the generator room. It was ·not learned until 5 days after the fire that four cylinaers of co2 were released into the stabilizer room i:11stead of the generator room. Therefore,· the fixea CO2 system contributed nothing to extinguishing the generator room fire. After the fire, the cabinets were properly labeled. Coast Guard regulations for U.S. passenger ships require that there be at least two release controls for the CO2 system: one immediately outside the space protected and one at the CO2 cylinder room. SOLAS regulations require that CO2 release controls be grouped togetlier in. as few locations as possible. Controls should 5e provided to allow activation of CO2 systems locally outside the space protected as well as remotely from the master contro1S. If there had been a local control of the CO2 system to the generator: room, time would have been saved in releasing the CO2 and the fire probably would have

-24- been extinguished before it was able to propagate out of the generator room. Training ship's officers in the fixed firefighting systems aboard the ship and local CO2 controls also would lessen the chance of releasing CO2 into the wrong space. _ . Communications When the USCG Group ·Miami radio watchstander failed to respond to the radio calls from the SCANDINAVIAN SUN, notification to the MFD was delayed. The MFD could have been at the scene 3 minutes earlier if the radioman had responded to the first call at

1. U.S. Customs inspectors reacted to the fire quickly and called the MFD.

USCG Control Verification Program Because millions of U.S. citizens are carried on foreign passenger ships out of U.S. ports each year, ships should be examined as thoroughly as possible within the context of -the SOLAS conventions. The 1966 and 1967 Amendments to SOLAS 60 establish a single method of construction (essentially fireproof) which most closely resembles SOLAS 60 Method I construction with the addition of fire detectors. Since there is_ only one method of construction authorized for passenger ships built to the 1966 and 1967 Amendments to SOLAS 60 and the SOLAS 7 4-convention, the method of construction is not specified on the SOLAS · certificate issued by the ship's government of registry. Because the SCANDINAVIAN SUN was built to the SOLAS 60 standards, including the 1966 and 1967 Amendments, the USCG examination records did not need to specify a method of construction for the SCANDINAVIAN SUN. However, the examination records variously indicated all three of the SOLAS 60 methods of construction for the ship although none of them, in fact, was applicable. This inconsistency is indicative of possible confusion on the part of the inspectors and suggests a need for additional guidance and training. The USCG should provide guidance to the inspection offices to upgrade the inspector's knowledge of passenger ship construction and in reviewing plans and conducting control verification examinations. Emergency Drills Because the SCANDINAVIAN SUN makes short international voyages, passengers are not required to participate in any emergency drills and there is no requirement to brief the passengers in emergency procedures. The only safety information provided to passengers on the SCANDINAVIAN SUN is tl)at displayed on posters throughout the ship, that set out on the boarding card, and that incorporated in the welcoming announcement on the public address system. On its daily trips, the SCANDINAVIAN SUN can carry up to 1,100 passengers, or up to 34,100 passengers per month. On a longer international voyage, passengers are required to participate in a drill soon after sailing. Because the hazards which may arise on a short international voyage are no different, passengers should receive some type of safety orientation similar to,. if not the same as, that given to passengers on longer international voyages. Because a drill or safety orientation was not required or held, the deceased passenger may not have been aware of the action~ to take in case of a fire on board a ship. Attendance at a drill or safety orientation might have provided her with information that could have saved her life. An orientation similar to that given on commercial aircraft would not seem to be too burdensome in cruise operatioos. It would not need to be extensive or time consuming but should include a demonstration of the donning of life preservers, a description of evacuation or disembarkation routes, the function of the automatic fire doors, and actions to take in the event of a fire. The Safety Board believes that passengers on short international voyages should receive more thorough safety orientation than that which is printed on the boarding pass, announced over the public address system, or posted throughout the vessel. As the ' 0 ·. -· fA. w

--25- U.S. representative to IMO, the USCG should propose adoption of ·a -requirement for additional safety orientation for passengers -on ships · engaged on short international voyages. Contingency PJanning ' , --- Proper pre-planning ·by the USCG, the Port· of Miami (Dodge Island),' and the .MFD resulted in an effective firefighting operation on Augus.t.20, 1984. The USCG MSO Miami Shipboard Fire- Contingency plan and the MFff Firefighting Plan for Dodge Island indicated clearly who was to be 1n-:charge of firefighting and ·the responsibilities of those involved in fighting the fire. The MSO -Miami plan also states clearly that -USCG equipment and manpower is limited and that the COTP only will be available for advice and consultation in matters of ship construction, sta_bility, and other technical areas concerning vess~ls as to which: the. fire chief may need assistance. · The MFD plan for fighting fires on Dodge Island states clearly that the ranking MFD offi~er on-scene is in overall charge o_f the firefighting operation. The fact that everyone knew that the MFD fire chief was in-charge upon arrival eliminated any confusion and all manpower was applied to useful functions. The actions taken by the· ship's crew· before the MFD arrived, firefighting by the MFD, and tl)e crew's guidance to _ the firefighters led to the fire being _ quickly extinguished. The Safety Board noted with interest that the COTP Miami has an indoctrination program whereby three to four MFD personnel are invited to board foreign passenger ships with the USCG inspectors during control 'verification examinations. The program -creates an awareness of the unique problems involved in moving about a large compartmentalized ship. Because of the differences in ship arrangements, the professional firemen should continue to use ship's personnel as guides and as a source of-information during shipboard fires. · Nevertheless, -this -program in Miami is effective and should be considered for a~option at other ports where cruise ships dock. · Smoke Production and Movement _ Sh~pboard fires typically produce a lot of smoke. Dense smoke reduces visibility and, in unfamiliar surroundings, passengers, firefigliters, and even the ship's crew can become disoriented. This may have been the situation with the deceased passenger. Once the ventilation is stopped· and the amount of fresh oxygen is reduced, the fire becomes oxygen limited .and t~nds to produce more smoke.· The aniount, density, and spread of smoke are primary factors which make shipboard fires so difficult to fight. Inhalation of smoke ~ontaining carbon -monoxide and other toxic agents can be fatal. More fatalities result from smoke inhalation than from thermal burns. Lubricating oil was the initial combustible and smoke producer in this fire. The lubricating oil, the melamine bulkhead veneer, and the wool carpeting contributed to the smoke and flame spread on the SCANDiNAVIAN -SUN. Melamine is a product of formaldehyde and Urea and is mixed with· -cellulose or wood flour or stone powder, depending upon its _application. Two possible toxicants produced are hydr·ogen cyanide and carboq monoxide. Wool carpeting also can produce these by-products. Control of smoke is imperative and reducing the .combustibility and smoke production of materials used on ships would improve the safety margin that passengers and crew need in a ship fire to avoid injury and to be able to)eave a ship safely. There is no limiting international smoke standard for shipboard materials. The United States has standards for testing for smoke development for interior materials but not for furniture, draperies, or electrical insulation.

-26- As a result of its investigation of the fire on the SCANDINAVIAN SEA, the Safety Board_made the fo\lowing recommendation to the ·u.s. ~Coast Guard: · Propose to the International Maritime Organization (IMO), modification of the fire standards of SOLAS 7 4 to include criteria' (1) to· limit smoke generation as well as flame spread of bulkhead paneling· for passenger vessels, (2) to reduce the fuel loading in passenger · and crew accommodations, and (3) to standardize the testing of combustible materials used iri construction. (Class II, Priority-A

passengers waiting to disembark.

Prompt action by the U.S. Customs inspectors in cal~ing the Miami Fire Department resulted in an early response ~o the fire.

. The fire could have been isolated earlier if a pilothouse watch had been maintained to monitor the fire detection. system on ·. the bridge . or if the automatic/manual fire control system had been switched to the automatic position. .

·The fire-would have been confined to the generator ro~m and the smoke stack had either the manual WTD or the self-closing fire door on the· Bimini Deck between th~ port trunk and the vestibule been closed.

The fire. could have been prevented from entering the stair tower on the Bimini Deck had the automatic fire door control switch on the door been equipped to be activated by a heat or smoke detector in addition to the pilothouse master control. ·

The· delay in closing the automatic fire doors and the delay in stopping the ventilation allowed the· fire to enter the stair tower at the Bimini Deck and toxic fumes to· enter living spaces where a passenger lost her life. A:_- ~/ t\ I

· Bec~u~e one C?2 ca~inet was unmarked and because the crew was not ft,/ suff1c1ently fam1bar with the CO2 system, the CO2 erroneously Was released into the starboard stabilizer room instead of the generator room where the fire started.

-27- The Coast Guard Group Miami Communications Center watchstander did not respond promptly to the SCANDINAVIAN SUN's calls on the radio. There was good coordinatio·n between the Miami' Fire Department and the SCANDINAVIAN SUN personnel. in fighting the fire and coordinating rescue operations. _ The fire resistant· construction of the SC AN DIN A VIAN SUN proved effective in containing the fire· within the stair tower after the automatic fire doors were closed and ventilation was shut down. · The safety of passengers on short international voyages, wotild be enhanced if passengers were given a safety orientation or were required to participate in an emergency drill. Probable Cause The National Transportation Safety Board determines that the probable cause of the fire on boarq the SCANDINAVIAN SU 1N was the crew's failure to tighten B; threaded pipe · fitting on the No. 1 diesel generator's lubricating oil line adequately which allowed the fitting to vibrate free and oil to spray from the line which ignited when it contacted the hot exhaust manifold of the engine. Contributing to the spread of the fire outside auxiliary machinery (generator) room was the failure of the crew of the SCANDINAVIAN _SUN to keep closed the watertight door and the self-closing fire door between the engineering spaces and the accommodation spaces. Also contributing to the spread of the fire was a delay in closing _the automatic fire doors and stopping the ventilation system because a watch was not maintained in the pilothouse where the alarms and fire detection cabinets were located. RECOMMENDATIONS As a result of this accident investigation, the National Transportation Safety Board made the following recommendations: --to the U.S. Coast Guard: Direct inspectors conducting control VE;?rification examinations to stress to ships' officers the need to close fire doors and to stop ventilation immediately upon detection of a fire. (Class II, Priority Action) (M-85-57) Provide inspectors additional training and guidance in passenger ship control verification examinations, including the correct determination of the fire safety method of construction of a vessel as the basis for an appropriate and thorough inspection. (Class II, Priority Action) (M-85-58) Propose to the International Maritime Organization an amendment to SOLAS 7 4 to require that passenger ships on short international voyages conduct drills or safety orientations for passengers at emergency muster stations immediately upon departure from port. Safety orientation briefings should include a demonstration on the donning of life preservers, evacuation or disembarkation routes, information concerning the function of automatic fire doors, and actions to take in the event of a fire or other emergency. (Class II, Priority Action) (M-85-59)

-28- Propose to the International Maritime Organization an amendment to SOLAS 74 to require that heat or smoke detectors be inade a part of eac~ automatic fire door release switch on passengers ships so that the door will close when the detector is activated. (Class II, Priority Action) (M-85~60)· ' ' ' Propose to the International Maritime Organ.izatioh an amendment to SQLAS 74 to require that all passenger ships carrying more than 36 persons on international routes have an automatic/manual fire control system in the pilothouse that integrates . the fire detectors, the automatic fire door controls, the ventilation system controls, and the general alarm into a unified system. ( Class II, Priority Action) (M-85--61) --to Sca,ndinavian World Cruises: Require that officers instruct crewmembers at each weekly fire drill aboard the SCANDINAVIAN SUN and other vessels in the company fleet on the importance of keeping self-closing fire doors unobstructed and of keeping watertight doors closed. (Class II, Priority Action) (M-85-62) Initiate a training program on the fixed CO2 systems,' including selection of the compartments to be flooded, for all aeck an9 engineering officers and selected crewmembers on the SCANDINAVIAN SUN and other vessels in the company fleet. (Class· II, Priority Action) (M-85-63) · · Require that the SCANDINAVIAN SUN and other vessels in the company fleet maintain a watch in the pilothouse manned by qualified personnel whenever passengers are aboard to monitor the alarm systems and to take immediate action in the event of an emergency. (Class II, Priority Action) (M-85-64) Require that the SCANDINAVIAN SUN and other vessels in the company fleet equipped with tne automatic/manual fire control system set the switch controlling the automatic fire door release, ventilation stops, and general alarm in the automatic position whenever the pilothouse watch is secured. (Class II, Priority Action) (M-~5-65). BY THE NATIONAL TRANSPORTATION SAFETY BOARD . July 9, 1985 /s/ JIM BURNETT Chairman /s/ PATRICIA A. GOLDMAN Vice Chairman /s/ G.H. PATRICK BURSLEY Member 0 ' I f) . ' '. tf(\ V

· ( (() Master -29- APPENDIXES APPENDIX A PERSONNEL INFORMATION Captain Finn E. Hansen, 42, was the relief master of the SCANDINAVIAN SUN. He began his seagoing career in 1958 on DFDS cargo vessels as a deck apprentice and advanced progressively to chief officer. In 1966, he obtained a Danish Certificate of Competency as Mate first class and in 1982 as Master first class. He had served 5 years on DFDS passenger ships employed in positions as second officer to relief master. In 1981, he obtained his license as first officer and, in 1983, as Master first class from the Commonwealth of the Bahamas. Staff Captain Mr. Richard Berg-Larsen, 30, started sailing on DFDS cargo vessels as a deck apprentice and advanced progressively to first officer. In 1975, he obtained a Danish Certificate of Competency as Mate second class and Mate first class in 1975 and Master first class in 1983. He had served 4 years on DFDS passenger ships employed in positions as second officer to staff captain. In 1982, he obtained his license as first officer, and in . 1984, as Master first class from the Commonwealth of the Bahamas. First Officer Mr. Tom W. Olsen, 29, began working for DFDS as a first officer on cargo vessels in

1. He obtained a Danish Certificate of Competency as mate second class in 1978 and

a Bahamian license as second mate in 1984. First Officer Mr. Tom my Isaksen, 35, started sailing in 1967 as an apprentice officer. He worked as first officer on DFDS cargo vessels in 1979, and on passenger vessels in 1983. He obtained a Danish Certificate of Competency as Mate second Class in 1979, and a Bahamian license as second Mate in 1983. Chief Engineer Chief Mogens R. Enevoldsen, 55, had served on the SCANDINAVIAN SUN for 1 month before the accident. He began sailing in 1948 as an assistant engineer. He began working for DF OS in 1957 on cargo vessels as third engineer and progressed to chief engineer. He has served 17 years on DFDS passenger ships as chief engineer. The chief obtained his Danish Certificate of Competency as engineer in 1948, and chief engineer in

1. He also holds an equivalent Bahamian license issued in 1982.

First Engineer Mr. Claus Jensen, 29, started sailing as an assistant engineer in 1976. Since 1980, he had served on DFDS cargo vessels as third and second engineer. He has served 2 years on passenger ships as second and first engineer. In 1980, he obtained his Danish Certificate of Competency and Bahamian license as third engineer

APPENDIX A -30- First Engineer Mr. Ole Jorgensen, 28, began working on DFDS cargo vessels in 1978 and had served 3 years as third and second engineer on DFDS passenger vessels. In 1982, he obtained a Danish Certificate of Cor,npetency as tl'\ird engineer and in 1984 a license as second class engineer of motor ship at London, England. Second Engineer iVIr. Gert Jensen, 31, began working on DFDS cargo and passenger ships as second engineer in 1979. He obtained a Danish Certificate of Competency in 1981 as· third engineer and in 1982 a license as second class engineer of motor ships at London, England. Third Engineer Mr. Anders Jensen, 24, began working for DFDS on the SCANDINAVIAN SUN in May 1984 as third engineer. In 1984, he obtained a Danish Certificate of Competency as third engineer and third class engineer of motor ships at London, England. 0- . \ f\, ~ ()) \ -

( (() ' ' i ('\ \ \j -31- APPENDIX B EFFECTS OF CARBOXYHEMOGLOBIN AND HYDROGEN CYANIDE The toxicological effects of various carboxyhemoglobin (COHb) concentrations h~ve been listed by Kim mer le (l 97 4) 17 / in the table below. While the table does not def me incapacitation or disorientation,7l can be concluded that incapacitation will occur at approximately 50 percent COHb saturation. On the average, death is likely to occur at 60 percent COHb or greater. Human Responses at Various Concentrations of Carboxyhemoglobin Percent ____ , _____ COHb Concentration _________ S~mptoms in Humans ______________________ _ 0-10 10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100 None Tension in forehead, dilation of skin vessels. Headache, pulsation in sides of head. Severe headache, ennui, dizziness, weakening of eyesight, nausea, vomiting, prostration. Same as above, increase in breathing rate and pulse, asphyxiation and prostration. Same as above, coma, convulsion, Cheyne- Stokes respiration. Coma, convulsions, weak respiration and pulse, death possible. Slowing and stopping of respiration, death within hours. Death in less than an hour. Death within a few minutes. To determine how long it takes to reach the incapacitating concentration of COHb, one must choose a concentration of CO in the air. In typical fires, the rate of growth of the fire is usually exponential, which is also the most likely rate of generation of CO. In this accident, a flash fire occurred as the result of atomized lubrication oil ignition so that exponential growth may not be as appropriate as selecting an average concentration which was assumed to be 5,000 ppm. Using the Coburn equation, 18/ it was calculated that it took approximately 10 minutes during this fire for the victimsto reach 50 percent 177 G. Kimmerle i974, Aspects and methodology for the evaluation of toxicological parameters during fire exposure, Journal of Fire and Flammability Combustion Toxicology Supplement 1. 18/ R. Coburn, R. Foster and P. Kane 1965, Consideration of the physiology and variables that determine the blood carboxyhemoglobin concentration in man. Journal Clin Invest. 41: 1899-1910.

APPENDIX B -32-- COHb saturation, the point of incapacitation. Incapacitation is defined as the in.ability to ({J perform a simple learned response. Animal studies 19/ suggest that physical collaps~ , occurs almost simultaneously with incapacitation. It could not be determined if loss of clarity of thought· occurs) before physical collapse fro~ these studies. How these results relate to humans in terms of ability to think and make decisions is unknown~ ' J The toxicology of hydrogen cyanide (HCN) is also ·well documented (Doull, Klassen and Amdur 1980). Basic~lly, it inhibits respiration at the cellular level. Even though the pharmacology of HCN is known, the correlation of environmental concentrations with blood lev.els and resulting toxicity has not been documented. One of the reasons this relationship · has not been established is the · difficulty .in determini1'g the HCN concentration in accidental poisoning and in exp~rimental animal exp(>sur'e. The two victims in this fire had toxic levels of HCN that contributed to their deaths. The two toxic products, HCN and CO, are additive in their effect on the human body. 19/ H. Kaplan et al. 1984, a research study of the assessment of escape impairment by irritant combustion gases in posters.sh aircraft fires. DOT Final Report No. DIF A- 3-81-006. *U.S. GOVERNMENT PRINTING OFFICE: 1985- 491-098: 20044

FD07130 ｜ 1986_美国_AAR8602.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1986 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

PB86-910402 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT AIR CANADA FLIGHT 797 McDONNELL DOUGLAS DC-9-32, C~FTLU GREATER CINCINNATI INTERNATIONAL AIRPORT COVINGTON, KENTUCKY JUNE 2, 1983 NTSB/AAR-86/02 (SUPERSEDES - - NTSB/AAR-84/09) UNITED STATES GOVERNMENT REPRODUCED BY, NJ:lI u.s. Department of Commerce National Technical Information Service Springfield, Virginia 22161

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TECHNICAL REPORT DOCUMENTATION PAGE I. Report No. I 2.Government Accession No. NTSB!AAR-86!02 PB86-910402 4. Ti tie and Subt i tie Aircraft Accident Report-Air Canada Flight 797, McDonnell Douglas DC-9-32, C-FTLU, Greater Cincinnati International Airport, Covington, Kentuckv. June 2 1983 (Suoersedes NTSBIAAR-84/09)

1. Author(s)
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National Transportation Safety Board Bureau of Accident Investigation Washington, D.C. 20594 12.Sponsoring Agency Name and Address NATIONAL TRANSPORTATION SAFETY BOARD Washington, D. C. 20594 IS. Supplementary Notes 3.Recipient 1s Catalog No. 6.Performing Organization Code 8.Performing Organization Report No. lO.Work Unit No. 3751-G 11.Contract or Grant No. 13.Type of Report and Period Covered Aircraft Accident Report June 2, 1983 14.Sponsoring Agency Code 1&.Abstract On June 2, 1983, Air Canada Flight 797, a McDonnell Douglas DC-9-32, of Canadian Registry C-FTLU, was a regularly scheduled international passenger flight from Dallas, Texas, to Montreal, Quebec, Canada, with an en route<·'Stop at Toronto, Ontario, Canada. The flight left Dallas with 5 crewmembers and 41 passengers on board. About 1903, eastern daylight time, while en route at flight level 330 (about 33,000 feet m.s.l.), the cabin crew discovered a fire in the aft lavatory. After contacting air traffic control (ATC) and declaring an emergency, the crew made an emergency descent, and ATC vectored Flight 797 to the Greater Cincinnati International Airport, Covington, Kentucky. At 1920:09, eastern daylight time, Flight 797 landed on runway 27L at the Greater Cincinnati International Airport. As the pilot stopped the airplane, the airport fire department, which had been alerted by the tower of the fire on board the incoming plane, was in place and began firefighting operations. Also, as soon as the airplane stopped, the flight attendants and passengers opened the left and right forward doors, the left forward overwing exit, and the forward and aft right overwing exits. About 60 to 90 seconds after the exits were opened, a flash fire enveloped the airplane interior. While 18 passengers and 3 flight attendants exited through the forward doors and slides and the three overwing exits to to evacuate the airplane, the captain and first officer exited through their respective cockpit sliding windows. However, 23 passengers were not able to get out of the plane and died in the htn~i..re..oXb'T'h.·.e....i°~·r.pJ··lan~'u~"'...""'O~~¥-'QtJ..-------------,..,'I""'"";::-:-"7""""'7";""-:-;----;:,-;-~:::_::-_i 17.Key Words' ~ 18.Distribution Statement ~ Air carrier DC-9 lavatory fire electrical This document is available arcing source of ignitiO~ comb~stible materi~ls to the public through emerg~ncy descent flash'fire evacuation proced~res. the National Technical , , Information Service Springfield, Virginia 22161 19.5ecurity Classification (of this report) UNCLASSI FI ED NTSB Form 1765.2 (Rev. 9/74) 20.Security Classification (of this page) UNCLASSIFIED , ..~ 21.No. of Pages 22.Price 116

Abstract Cont'd On August 8, 1984, the National Transportation Safety Board adopted the report and probable cause of the accident. On December 20, 1984, the Air Line Pilots Association submitted a petition for reconsideration of the contributing factors statement of the probable cause that was adopted in the original report. As a result of the Air Line Pilots Association's petition, the accident report and the probable cause have been revised. The National Transportation Safety Board determines that the probable causes of the accident were a fire of undetermined origin, an underestimate of fire severity, and misleading fire progress information provided to the captain. The time taken to evaluate the nature of the fire and to decide to initiate an emergency descent contributed to the severity of the accident. i i

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CONTENTS SYNOPSIS . . . . . . . FACTUAL INFORMAnON . History of the Flight . • • . Injuries to Persons . . . .. • • . . . . • • • . Damage to Airplane. . • . Other Damage • . • • Personnel Information. Airplane Information . Flight and Cabin Maintenance Logbook Writeups . . • • Passenger Cabin Modification. Meteorological Information. Aids to Navigation . . . Communications • . . Aerodrome Information Flight Recorders • . • . . • • . Wreckage and Impact Information. . . . . • . External Fuselage. . . • . . . . . . Interior Fuselage Forward of the Aft Lavatory Aft Lavatory Area . . . . • . . . • . . . . . . Cargo and Aft Accessory Compartments .. Cockpit Controls and Instruments. • . . • . . . . . . Medica.l and Pathological Information . . • . . Fire Response . . . . . . . . . . . • • • Survival Aspects . . . • . . . . . . . . . . . . . . Tests and Research . . • . . . . . . • Federal Bureau of Investigation (FBI) Laboratory Tests. . Electrical System Components • . . . . Flush Motor and Lavatory Components .. Flush Motor Seizure Test. . . . . • . . . Fire and Heat Tests. . . . . . . Airplane Cabin Fire Research. . . Other Information. . . . . . . Air Canada Operational Procedures . . Use of Aft Lavatory. . . . . . . Smoke Detectors . . . . . • . . Examination of Other DC-9 Airplanes • . . . . . . Air Traffic Control Procedures . . Air Traffic Control Radar Data. • DC-9-32 Descent Performance . . ANALYSIS . . General . . . Fire. • . . Operational and Survival Factors Firefighting • • . . . • . . . In-flight Fire Prevention/Detection CONCLUSIONS. . Findings. . . . . Probable Cause. iii 1 2 2 8 9 9 9 9 10 11 12 12 12 12 13 14 14 16 16 25 27 27 a8 30 35 35 35 36 38 38 42 43 43 46 47 47 47 50 51 53 53 53 59 68 68 69 69 71

RECOMMENDATIONS. . APPENDIXES . • . .• ..•• Appendix A-Investigation and Hearing. • • • • • • • • • Appendix B-Personnel Information . • Appendix C-Airplane Information. .. • ••• Appendix D-Cockpit Voice Recorder Transcript , Appendix E-14 CFR 25 Flame Resistance Criteria . • Appendix F-Air Canada DC-9 Emergency Equipment • Appendix G--Petition for Reconsideration of Probable 71 79 79 80 82 83 97 98 Cause. . . . . . • . . . . • . • . • . . • . • 99 Appendix H-NTSB Response to Petition for Reconsideration of Probable Cause. • • • • • . • • • • • . . • • • • • '. • 109 iv

NATIONAL TRANSPORTATION SAFETY BOARD WASIDNGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT Adopted: January 31, 1986 AIR CANADA FLIGHT 797 McDONNELL DOUGLAS DC-9-32, C-FTLU GREATER CINCINNATI INTERNATIONAL AIRPORT CO~GTON,KENTUCKY JUNE 2,1983 SYNOPSIS On June 2, 1983, Air Canada Flight 797, a McDonnell Douglas DC-9-32, of Canadian Registry C-FTLU, was a regUlarly scheduled international passenger flight from Dallas, Texas, to Montreal, Quebec, Canada, with an en route stop at Toronto, Ontario, Canada. The flight left Dallas with 5 crewmembers and 41 passengers on board. About 1903, eastern daylight time, while en route at flight level 330 (about 33,000 feet m.s.l.), the cabin crew discovered smoke in the left aft lavatory. After attempting to extinguish the hidden fire and then contacting air traffic control (ATC) and declaring an emergency, the crew made an emergency descent and ATC vectored Flight 797 to the Greater Cincinnati International Airport, Covington, Kentucky. At 1920:09, eastern daylight time, Flight 797 landed on r~nway 27L at the Greater Cincinnati International Airport. As the pilot stopped the airplane, the airport fire department, which had been alerted by the tower to the fire on board the incoming plane, was in place and began firefighting operations. Also, as 'soon as the airplane stopped, the flight attendants and passengers opened the left and right forward doors, the left forward overwing exit, and the right forward and aft overwing exits. About 60 to 90 seconds after the exits were opened, a flash fire engulfed the airplane interior. While 18 passengers and 3 flight attendants exited through the forward doors and slides and the . three open overwing exits to evacuate the airplane, the captain and first officer exited through their respective cockpit sliding windows. However, 23 passengers were not able to get out of the plane and died in the fire. The airplane was destroyed. The National Transportation Safety Board determines that the probable causes of the accident were a fire of undetermined origin, an underestimate of fire severity, and misleading fire progress information provided to the captain. The time taken to evaluate the nature of the fire and to decide to initiate an emergency descent contributed to the severity of the accident. -I ...

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1. FACTUAL INFORMATION
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History of the Flight The in-flight fire On June 2, 1983, Air Canada Flight 797, a McDonnell Douglas DC-9-32, of Canadian Registry C-FTLU, was a regularly scheduled international passenger flight from Dallas, Texas, to Montreal, Quebec, Canada, with an en route stop at Toronto, Ontario, Canada. At 1625 central daylight time, Flight 797 left Dallas with 5 crewmembers and 41 passengers on board and climbed to its assigned en route altitude, flight level (FL) 330 (approximately 33,000 feet m.s.l.). II According to the captain, about 30 minutes after departure, a 30-inch-Iong by 9-inch-wide louvered panel at the bottom of the cockpit door was kicked accidentally from its mounts and fell to the floor. The panel was placed to one side and the flight continued. Except for a deviation to the south of their filed flight plan route to avoid weather, the flight progressed without incident until it entered the Indianapolis Air Route Traffic Control Center's (ARTcC.lair.space. At 1851:14 eastern daylight time 2/, the three circuit breakers associated with .the aft lavatory's flush motor and located on a panel on the cockpit wall behind the captain's seat, tripped in rapid succession. (The motor is a three-phase alternating current (a.c.) motor; each phase incorporates a circuit breaker for protective purposes.) After identifying the circuit breakers, the captain immediately made one attempt to reset them; the circuit breakers would not reset. The captain assumed that the flush motor had probably seized and took no further action at this time. About 1859:58, the captain again tried unsuccessfully to reset the three circuit breakers. According to the cockpit voice recorder (CVR), he told the first officer that the circuit breaker(s), "Pops as I push it." About 1900, a passenger seated in the last row asked the No.3 flight attendant 31 to identify a strange odor. The flight attendant thought the odor was coming from the aft lavatory. She took a CO2 fire extinguisher from the cabin wall and opened the lavatory door a few inches. She saw that a light gray smoke had filled the lavatory from the floor to the ceiling, but she saw no flames. While she was inspecting the lavatory, she inhaled some smoke and closed the door. The No.3 flight attendant then saw the No.2 flight attendant nearby and asked her to tell the flight attendant in charge of the situation. The No.2 flight attendant testified that she did not remember if she had been told there was smoke or fire in the lavatory; however, when she reached the flight attendant in charge she told him that there was a fire in the lavatory. Upon being advised there was a fire, the flight attendant in charge instructed the No.2 flight attendant to inform the captain and then to assist the No. 3 flight attendant in moving the passengers forward and in opening the eyebrow air vents over the passenger seats to direct air to the rear of the cabin. The flight attendant in charge then took the CO2 extinguisher and opened the lavatory door about three-quarters open. He also saw no names, but he observed thick curls of black smoke coming out of the seams of the aft lavatory walls at the top of the wash basin behind the vanity and at the ceiling. II All altitudes herein are altitude above mean sea level, unless otherwise indicated. ~I All times hereafter are eastern daylight time based on the 24-hour clock. ~I There were three flight attendants on this flight-the flight attendant in charge, a flight attendant designated No.2, and a flight attendant designated No. 3 (see section 1.15 for an explanation of these designations).

-3- He then proceeded "to saturate the washroom with CO2,'' by spraying the paneling and the seam from which smoke was seeping and spraying Hie door of the trash bin. He then closed the lavatory door. At 1902:40, the No. 2 flight attendant reached the cockpit and told the captain, "Excuse me, there's a fire in the washroom in the back, they're just...went back to go to put it out." Upon being notified of the fire, the captain ordered the first officer to inspect the lavatory. The captain then donned his oxygen mask and selected the 100-percent oxygen position on his regulator. The first officer left the cockpit but did not take either smoke goggles or a portable oxygen bottle with him. (The airplane was not equipped with nor was it required to be equipped with self-contained breathing equipment or a full face smoke mask.) The first officer said that he could not get to the aft lavatory because the smoke, which had migrated over the last three to four rows of seats, was too thick. The flight attendant in charge told the first officer what he had seen when he opened the lavatory door, that he had discharged the CO2 extinguisher into the lavatory, and that he had not been able to see the source of the smoke before closing the door. He told the first officer, however, that he did not believe the fire was in the lavatory's trash container. The first officer told the flight attendant in charge that he was going forward to get smoke goggles. At 1904:07, the first officer returned to the cockpit and told the captain that the smoke had prevented him from entering the aft lavatory and that he thought "we'd better go down." He did not tell the captain that the flight attendant in charge had told him that the fire was not in the trash bin. However, at 1904:16, before the captain could respond, the flight attendant in charge came to the cockpit and told the captain that the passengers had been moved forward and that the captain didn't "have to worry, I think its gonna be easing up." The first officer looked back into the cabin'and said that it was almost clear in the back. At 1904:23, he told the captain, "it's starting to clear now," and that he would go aft again if the captain wanted him to do so. According to the captain, the first officer~s smoke goggles were stored in a bin on the right side of the cockpit and were not easily accessible to the first officer while he was not in his seat. Since the first officer needed the goggles and since there was a hurry, the captain gave him his goggles and,. at 1904:46, directed him to go aft. The first officer also testified that the captain and he "did not-discuss the type of fire at all" during the time he was in the cockpit before he went to the lavatory the second time. At 1906:52, while the first officer was out of the cockpit, the flight attendant in charge told the captain again that the smoke was clearing. The captain testified that he believed the fire was in the lavatory trash bin and that he did not decide to descend at this time because, "I expected it (the fire) to be put out." In the meanwhile, the first officer proceeded to the aft lavatory and put on the smoke goggles. He testified that he had intended to open the door to see what the situation was inside, but when'he discovered that the lavatory door felt hot to the touch, he decided not to open it and instructed the cabin crew to leave it closed. At that time, he noticed a flight attendant signaling him to hurry back to the cockpit. The first officer returned to the cockpit and got into his seat, and at 1907:11, he told the captain, "I don't like what's happening, I think we better go down, okay?" The captain testified that, from the first officer's voice inflection, he knew that the first officer believed the fire was out of control and that he had to descend immediately. About 1905:35, while the first officer was aft to inspect the aft lavatory, the airplane had experienced a series of electrical malfunctions. According to the captain, the master caution light illuminated, indicating that the airplane's left a.c. and d.c.

-4- electrical systems had lost power. At 1906:12, the captain called Indianapolis Center and requested the Center to standby because the flight had an "electrical problem." About 30 to 45 seconds later, the Louisville high radar sector controller working Flight 797 lost the flight's radar beacon target. The controller then directed the computer to track all primary targets. Flight 797's position was then depicted on the scope by a plus sign and associated data block. About 1907:41, after the first officer had returned to the cockpit, the master warning light illuminated and the annunciator lights indicated that the emergency a.c. and d.c. electrical buses had lost power. The captain's and first officer's attitude direc- tional indicators tumbled. The captain ordered the first officer to activate the emergency power switch, thereby directing battery power to the emergency a.c. and d.c. buses. The attitude directional indicators' gyros began erecting, however, because of the loss of a.c. power, the stabilizer trim was inoperative and remained so during the rest of the flight. The descent At the Air Traffic Control Facilities.-At 1908:12, Flight 797 called the radar high sector controller at Indianapolis Center and said, "Mayday, Mayday, Mayday." 4/ The Louisville radar high sector controller acknowledged the call, and at 1908:47, the flight told the controller that it had a fire and was going down. The controller told the flight that it was 25 nautical miles (nmi) from Cincinnati and asked "can you possibly make Cincinnati." The flight answered that it could make Cincinnati and then requested clearance; it was then cleared to descend to 5,000 feet. At 1909:05, Flight 797 reported that 'it was leaving FL 330. The flight then told the controller that it needed to be vectored toward Cin, that it was declaring an emergency, and that it had changed its transponder code to 7700 -- the emergency code. However, the transponder was inoperative due to the power loss, and the emergency code was never portrayed on the Center's radarscopes. At 1909:29, the Louisville radar high sector controller directed the flight to turn to 060 0 and told it that the Greater Cincinnati Airport (Cincinnati Airport) was at "twelve o'clock at twenty miles." The controller said that it was obvious to him that Flight 797 had to descend "immediately;" therefore, he issued the clearance and stated that he was going to coordinate the descent with the other sectors at the center later. He further stated that the 060 0 heading was intended to place the flight on course toward Cincinnati Airport. He heard Flight 797 report leaving FL 330; however, because of the inoperative transponder, mode C altitude information was no longer being received and there was no indication on his radarscope that the flight was descending. At 1909:17, Indianapolis Center's Lexington low altitude D (LEX-D) controller called the approach controller at the Cincinnati Airport's Terminal Radar Control (TRACON) facility to alert him of an impending handoff in his southwest sector. Six seconds later, the LEX-D controller told the approach controller at Cincinnati he had a "code for you," and at 1909:25, the LEX-D controller then told the Cincinnati approach controller that he had "an emergency for you, Air Canada seven nine seven." The approach controller replied, "Zero six six two, thirty-five thousand." Zero six six two was the code assigned to Continental 383, a westbound flight at FL 350. At 1909:33, the LEX-D controller answered, "Yeah, thirty-three right now, he's twenty-five southwest." The approach controller replied, "Radar contact, okay." However, at 1909:38 when the approach controller accepted the handoff of Flight 797, he had mistaken the radar beacon !! The international radiotelephonic distress signal. When repeated three times, it indicates imminent and grave danger and that immediate assistance is requested.

-5- target of Continental Flight 383 as that of Flight 797. Shortly after he had accepted the handoff, the approach controller had notified the Cincinnati Airport tower local controller that he intended to land an Air Canada jet with an on board fire on runway 36. The tower's local controller alerted the airport fire station, and crash-fire-rescue (CFR) vehicles were dispatched and positioned for an emergency landing. The firefighters had also been advised that the airplane had electrical problems, that smoke was corning from the aft lavatory, and that there was smoke or fire in the rear of the airplane. At 1910:01, almost coincident with the end of his message to the local controller, the LEX-D controller informed the approach controller of Flight 797's assigned 060° heading. Although the approach controller repeated the heading, he stated that he could not recall hearing this message. At 1910:25, Flight 797 contacted the Cincinnati approach controller, declared an emergency, and said that it was descending. The approach controller acknowledged and told the flight to plan for a runway 36 instrument landing system (ILS) approach and requested the flight to turn right to 090°. He then realized the target he was observing was not responding and attempted unsuccessfully to assign a discrete transponder code to it in order to track it better. Thereafter, at 1910:48, Flight 797 reported that it had a fire in its aft lavatory and that the cabin was filling with smoke. The controller asked the flight to "say the type airplane, number of people on board, and amount of fuel (on board)." The first officer answered that he would supply this data later because "I don't have time now." At 1912:40, the approach controller called the Evansville/Nabb D controller on the landline to request assistance. Almost simultaneous with the call, he also observed an eastbound primary target and began to monitor it. At 1912:44, th~ flight requested the cloud ceiling at the airport and the controller responded that ~the ceiling was "two thousand five hundred scattered, measure(d) eight thousand feet overcast, visibility one two (12) miles with light rain." The controller then decided that the eastbound target was Flight 797, and at 1912:54, he requested the flight to "say altitude." The approach controller said that, by 1912:54, he knew that he was observing Flight 797's primary target, but that it was not "fully identified." He also knew, based on the target's position -- about 3 nmi east of runway 36's extended centerline and about 8 nmi south of its threshold -- and its reported altitude of 8,000 feet, that it was too high and too fast to land on runway 36. He decided to use runway 27L for landing, and used the primary target to monitor the flight and vector it toward the airport. At 1913:38, after Flight 797 was unable to tell him its heading because its heading instruments were inoperative, the approach controller asked the flight to turn left. The controller said that this was an identification turn and that it was also designed to place the airplane closer to the airport. At 1914:03, after observing the target In a left turn, the approach controller said that Flight 797's primary target was now "fully identified." He then told the flight that this was a "no gyro" 5/ radar approach for runway two seven left..." and cleared it to descend to 3,500 feet. He then told the flight that it was 12 nmi southeast of the Cincinnati Airport, cleared it to land on runway 27L, and informed it that the surface wind was 220° at 4 knots. He informed the tower of the change of landing runways and the tower directed the fire department to position its vehicles along runway 27L. (See figure 1.) §./ No gyro

approach/vector

A radar approach/vector provided in case of a malfunctioning gyro compass or directional gyro. Instead of providing the pilot with headings to be flown, the controller observes the radar track and issues control instructions "turn right/left" or "stop turn" as appropriate.

-6- CRASH/FIRE/RESCUE STATION UNIT#' 907 UNIT#' 913 'L' UNIT#' 967 UNIT#'980 TOWER DRIVE aREATER ClNClNNATlINTERNATIONALAJRIIORT Figure l.-Standby Positions of Crash/Fire/Rescue Units.

-7- At 1915:11, Flight 797 reported that it was level at 2,500 feet, and at 1915:27, that it was "VFR [visual flight rules] now...." The approach controller vectored the flight to runway 27L, and at 1915:58, told it that it was 12 nmi from the airport. The flight descended to 2,000 feet, and the controller continued to supply range calls. At 1917:11, the controller told the flight that the crash-fire-rescue vehicles were standing by and again asked the flight to provide the number of persons and the amount of fuel on board. Flight 797 answered, "We don't have time, its getting worse here." At 1917:24, the runway and approach lights were turned up to full intensity. At 1917:35, Flight 797 reported the airport in sight; the approach controller cleared it to land, and told it that the surface wind was 230 0 at 4 knots. At 1918:48, the approach controller told the flight that it was 3 nmi from the airport and then asked the tower local controller if she had the airplane in sight. The local controller said that she did. After telling Flight 797 that it was 2 nmi from the airport, the approach controller asked the local controller to tell him when Flight 797 had landed. At 1920:09, the local controller told the approach controller, "He's landed." On the airplane.-As the airplane descended, the smoke front continuously moved forward filling the passenger cabin and entering the cockpit. The first officer had left the captain's smoke goggles in the aft end of the airplane~ Therefore, after he returned to the cockpit, he gave one of the two pairs of smoke goggles stowed on the right cockpit wall to the captain. (See appendix F.) Although there was another pair available, the first officer chose not to use them. The captain donned the smoke goggles and wore them during the descent and landing. The captain said that during, the descent, he wore his oxygen mask and the oxygen regulator was set to the 100-percent position; therefore, he had no trouble breathing. However, during the latter stages of the approach and landing, he had difficulty seeing the instruments because of the smoke in the cockpit and had to lean forward to do so. He testified that his perspiration was causing his smoke goggles to steam up and he had to pull them away from his face from time to time to clear them. The first officer also wore his oxygen mask during the descent and set his oxygen system regulator to the 100-percent position and encountered no trouble in breathing. The captain began the emergency descent almost simultaneously with the flMaydayfl call. The throttles were retarded to idle and the speed brakes were extended. However, when the speed brakes were deployed, the spoiler/speed brake handle was moved inadvertently to the full aft position and the spoiler panels were deployed to the full-up or ground position. The captain testified that this had no effect on the airspeed during the descent but it increased the descent rate. The descent was flown at 310 knots indicated airspeed (KIAS), and since the needle on the instantaneous vertical speed indicator (IVSI) was pegged, the rate of descent exceeded 6,000 feet per minute (fpm). According to the flightcrew, Flight 797 was operating in visual meteorological conditions before the emergency descent. The captain said that the airplane was almost totally in clouds from about FL 250 to about 3,000 feet; however, it did not encounter either turbulence or icing. At leveloff at 3,000 feet, the airplane was in and out of the cloud bases so he descended to 2,000 feet to obtain VFR flight conditions. According to the flightcrew, except for the cloud conditions at 3,000 feet, the emergency descent and landing were not affected by weather.

-8- The cockpit door was left open throughout the descent. The captain testified that he did not remember the door's being open and that he did not order it opened. During the initial stages of the descent, the cabin crew completed moving the passengers forward of row 13. They briefed them on the emergency evacuation procedures and passed out wet napkins until instructed by the first officer to sit down. They also designated passengers to open the overwing exits and briefed them on opening them; they then prepared them for the landing. After the initial level off at 3,000 feet, the captain ordered the first officer to depressurize the airplane in preparation for landing. The first officer complied, and although it is not required by the emergency procedure checklist, he turned the air conditioning and pressurization packs off. He testified that although he knew this was not required by procedure, he did so "because the smoke was getting bad at that point and my reasoning was I have to do something.•••" He said that he thought the packs were feeding the fire. A few moments afterward, he opened his sliding window in an effort to clear the smoke from the cockpit, but closed it almost immediately because of the high noise level. The first officer opened and closed the window several times during the final stage of the flight. The landing When the captain sighted the runway, he extended the landing gear. Since the horizontal stabilizer was inoperative, the captain extended the flaps and slats incrementally through the 0°, 5°, 15°, 25°, and 40° positions. He allowed his indicated airspeed to stabilize at each flap position as he slowed to approach speed. He flew the final approach at 140 KIAS and completed the landing. After touchdown, he made a maximum effort stop (using extended spoilers and full brakes). Because of the loss of the left and right a.c. buses, the antiskid system was inoperative and the four main wheel tires blew out. The airplane was stopped just short of the intersection of taxiway J. (See figure 1.) After the captain completed the emergency engine shutdown checklist, both he and the first officer attempted to go back into the cabin and assist in the passenger evacuation, but were driven back by the smoke and heat. Thereafter, they exited the airplane through their respective cockpit sliding windows. After the airplane stopped, the left (L-l) and right (R-l) forward cabin doors, the left forward (L-2) overwing exit, and the right forward (R-2) and aft (R-3) overwing exits were opened, and the slides at the L-l and R-l doors were deployed and inflated. The 3 cabin attendants and 18 passengers used these 5 exits to evacuate the airplane. After the 18 passengers and 5 crewmembers left the airplane, the cabin interior burst into flames. Twenty-three passengers perished in the fire. Neither the passengers, crew, nor witnesses outside of the airplane saw flames inside the cabin before the survivors left the plane. The fuselage and passenger cabin were gutted before airport fire personnel could extinguish the fire. (See figure 2.) 1.2 Injuries to Persons Injuries Crew Passengers Others Total Fatal 0 23 0 23 Serious 0 3 0 3 Minor 0 13 0 13 None 5 2 0 7 Total "5 41 0 46

-9- , ~ ~ \";,~ ." «~ < ..~"':<.:<~ ..~<" .."- •. '--- .:;.&#< .:..•. " "'.. ~" '"~ 'o/*"" .,....~~~...~ ""''''''' • '" ~~ ",," ~'"""'~ .. "",- . ~, Figure 2.-Airplane after fire burned through top of fuselage. 1.3 Damage to Airplane The airplane was destroyed by fire. 1.4 Other Damage None. 1.5 Personnel Information The flightcrew were certificated and the flight attendants were qualified in accordance with current Canadian regulations. (See appendix B.) Air traffic control (ATC) controllers were qualified in accordance with current United States regulations. 1.6 Airplane Information The airplane, a McDonnell Douglas DC-9-32, Canadian registry C-FTLU, was owned and operated by Air Canada, a Canadian Crown corporation. The airplane was manufactured on April 7, 1968, and had been operated by Air Canada since delivery to the company at that time. (See appendix C.)

-10- On September 17, 1979, the airplane experienced an in-flight failure of its aft pressure bulkhead shortly after takeoff from Logan International Airport, Boston, Massachusetts. §.I The separation and ensuing depressurization occurred shortly after the airplane had leveled off at FL 250. At the time of the Logan accident, the airplane had flown about 28,425 hours and had completed 26,816 landings. The damage to the aft part of the airplane was extensive. There was disruption of some engine and flight control components. Except for severed flight data recorder connections, no damage was found on any electrical components, wires, and cables examined during the investigation. However, in effecting repairs, numerous wire bundles were cut in order to examine the airplane and to facilitate the removal of damaged structure and reinstallation of replacement structure. Repairs to the airplane were made by McDonnell Douglas and inspected by Air Canada under its authority as a Canadian Ministry of Transport (MOT) approved company. The aft pressure bulkhead and aft accessory compartment were rebuilt at Logan Airport between September 18, 1979, and November 20, 1979. The installation of the aft lavatories and interior furnishings was made by Air Canada at their Dorval Base in Montreal. Air Canada and McDonnell Douglas each wrote engineering reports on repairs to the airplane. An FAA Form 337, which was part of the Air Canada report 71, listed 29 individual repair items. Item 3 of this list stated, "Spliced electrical wires through aft pressure bulkhead per service sketch 2958." The sketch designated where the splices were to be made and the manner in which they were to be made. In addition, the Air Canada report stated that the contractual agreement required "that the repairs be carried out to restore the aircraft to condition substantially conforming to specification for the airplane as originally delivered." The airplane was returned to service December 1, 1979. During the investigation of the Cincinnati accident;, all of the wire splices made during the repairs at Logan which were found and not destroyed were examined. No evidence of arcing or short circuiting was found. 1.6.1 Flight and cabin Maintenance Logbook Writeups Between June 1, 1982, and June 2, 1983, 76 writeups were entered in the airplane flight log concerning the two engine-driven generators and the auxiliary power unit (APU) generator. One writeup concerned the right engine-driven generator; 6 writeups concerned the left engine-driven generator; 34 concerned the APU generator; and 35 concerned crosstie relay lockout malfunctions. Of the 35 writeups relating to the crosstie relay lockout, only 1 - on December 30, 1982 - described an accompanying generator malfunction. The last crosstie relay lockout malfunction occurred on March 18, 1983. The seven writeups on the engine-driven generators concerned the generators' tripping off line. On August 1, 1982, the right generator tripped and was reset by the flightcrew; on August 2, the right generator's voltage regulator was replaced. The six left generator malfunctions occurred between December 28, 1982, and January 4, 1983. On January 4, 1983, the left generator control panel was removed and replaced and thereafter the generator operated without further problems. A shop check of the removed control panel disclosed a bad solder connection between circuits on the under frequency protection printed circuit board. 61 National Transportation Safety Board Accident Report AAR-80-13. 7../ Air Canada Engineering Report No. 920-754-3, December 10, 1979.

-11- Between May 7, 1983, and June 2, 1983, the flightcrews logged 38 APU generator malfunctions; during this period there were no engine-driven generator malfunctions logged. Thirty-four writeups indicated that the APU generator would not come on line; four indicated that the generator had tripped from the line. The examination of the flight log showed that corrective action had been taken for these entries. Except in an electrical emergency, the APU generator is not used in flight. Flight 797's flightcrew did not try to start the APU generator during the flight from Dallas to Cincinnati. Between September 1, 1980, and June 2, 1983, the cabin logbook entries indicated only minor deficiencies in the toilet pump flushing system and routine flush pump and flush motor changes; all were signed off properly with no out-of-the-ordinary repairs having been made. The last flush system component change was made on May 4, 1983; the pump assembly was replaced and the repair signed off by a mechanic and an inspector. On May 2, 1983, during a scheduled major maintenance check, an unscheduled work card -- No. 150 -- contained the following writeup, "Insulation at bottom of pressure bulkhead in rear cargo (compartment) soaked with toilet detergent liquid, investigate leak." The item was signed off, as follows, "Connectors checked and tightened. Also, insulation replaced where needed." 1.6.2 Passenger cabin Modification During June 1982, Air Canada refurbished the airplane's passenger cabin. The right aft lavatory was removed and replaced with a clothing stow~ge area. Overhead luggage bins were installed and the cabin walls and ceilings were replaced. . The modification was performed using an assembly kit manufactured by the Heath Tecna Corporation, Kent, Washington, in accordance with the provision of Supplemental Type Certificate (STC) No. 1429 NM, issued by the FAA Northwest Regional Headquarters, Seattle, Washington, on February 2, 1982. Since the Heath Tecna assembly kit was designed to be used on all DC-9-32 airplanes, Heath Tecna had to apply for and received an STC. The materials, drawings, and plans contained in the assembly kit constituted a major overhaul of the airplane's interior. Since the DC-9-32 airplanes had been certificated before May 1, 1972, the manufacturer had to demonstrate that materials met the flammability standards of 14 CFR 25.853 (a) (b) as amended on May 1, 1972, in order to receive an STC; these standards still apply. (See appendix E.) The flammability tests were conducted in accordance with prescribed FAA standards, and all materials in the kit met the flammability standards. In addition, all wiring used in the kit met MIL W-81044 specifications previously approved by the FAA. At the time of the accident, the airplane's seat cushion material was polyurethane foam, the window panes were transparent acrylic sheet, the interior cabin side walls were made of acrylonite butadiene styrene (ABS) plastic sheet, the ceiling panels were made of composite nomex honeycomb core with fiberglass facing materials, and the cabin sidewalls and ceiling panel facings were decorative vinyl laminate with Tedlar facings.

-12- 1.1 Meteorological Information The 1700 National Weather Service (NWS) surface analysis for June 2, 1983, showed a west to east warm front in central Kentucky. At 2000, the analysis showed a warm front extending from southern Ohio through western Kentucky with associated rain and rainshowers. Weather radar data from the Cincinnati Airport for 1830 and for 19'30 indicated weather echoes containing rainshowers. These echoes were located south through west of Cincinnati Airport and extended out .to about 100 nmi•. The maximum echo tops were reported at 14,000 feet at 1830; at 1930, the tops were reported at 13,000 feet. According to the NWS, light rain began at the airport at 1734 and ended at 2024. Between 1900 and 2000, a trace (less than 0.01 inch) of rain was measured. Surface weather observations for the Cincinnati Airport were as follows, for the times indicated: 1850 - 2,500 feet scattered, measured ceiling 8,000 feet overcast; visibility -- 12 miles, light rain; temperature - 63° F; dewpoint -- 55° F; wind -- 190° at 7 knots; altimeter setting -- 30.04 inHg. 1930 - 2,500 feet scattered, estimated ceiling 8,000 feet overcast; visibility -- 12 miles, light rain; temperature -- 62° F; dewpoint -- 55° F; wind 180° at 5 knots; altimeter setting -- 30.03 inHg. 1.8 Aids to Navigation Not applicable. 1.9 Communications There were no known radio communications difficulties. 1.10 Aerodrome Information The Greater Cincinnati International Airport, elevation 891 feet, is located 9 miles southwest of Cincinnati, Ohio, in Covington, Kentucky. The airport is certificated for commercial operations in accordance with 14 CFR 139, Subpart D. The landing area consists of three runways: 18/36, 9R/27L, and 9L/27R. Runway 27L is 7,800 feet long and 150 feet wide, and has a grooved concrete and asphalt surface. Runway 27L has high intensity runway edge lights (HIRL), centerline lights, a medium intensity approach light system with runway alignment indicator lights (MALSR), and visual approach slope indicator (VASI-L). The touchdown zone elevation is 875 feet. Runway 27L is served by an ILS approach. Standiford Field, elevation 497 feet, is 5 miles south of Louisville, Kentucky. The airport is certificated for commercial operations in accordance with 14 CFR 139, SUbpart D. The landing area consists of two runways: 1-19 and 11-29. Runway 1-19 is 7,800 feet long and 150 feet wide, and has a concrete surface, HIRL, and an approach light system. Runway 11-29 is 7,429 feet long and 150 feet wide, and has an asphalt

-13- surface, HIRL, and runway end indicator lights (REIL). Runway 29 has an approach light system; runway 11 has a VASI, but no approach lights. Runways 11 and 19 are served by an ILS approach; runway 11 is served by a localizer (back course) approach. 1.11 Flight Recorders The airplane was equipped with a Leigh VDR-2 digital flight data recorder (DFDR), serial No. 127, and a Fairchild A-100 cockpit voice recorder (CVR), serial No. 1613. Both recorders were removed from the airplane after the accident. The CVR was brought to the Safety Board's Audio Laboratory for processing and readout. Since the Safety Board's Washington laboratory is not equipped to readout the Leigh DFDR, the readout was performed at the Flight Research Laboratory, National Research Council (NRC), Ottawa, Ontario, Canada, and was observed by Safety Board personnel. Cockpit Voice Recorder.-The CVR casing was damaged by fire and smoke; however, the crash-proof enclosure protected the tape and the quality of the recording was excellent. A tape was transcribed beginning at 1848:12 and ending at 1907:41 when the CVR ceased operating. Using the time signal recorded on the FAA's Indianapolis ARTCC's tape as a basis for comparison, the CVR tape timing was accurate to the second. (See appendix D.) The entire CVR tape was examined for sounds of electrical arcing or other events which might be associated with the accident. About 10 minutes into the tape, at 1848:12, a sound resembling that of electrical arcing was recorded. The sound was repeated at 1848:15, 1851:03, 1851:05, 1851:14, 1851:42, 1859:59, and 1900. The crewmembers testified that they did not hear arcing sounds at these,_times. The sprectral content of the first two electrical arcing sounds differed from those which followed. The early sounds were impulse-type and contained a broad band of frequencies resembling radio static. All of the later arcing sounds contained a 400 Hz component with harmonics extending through the frequency range of the recorder. At 1905:35, an electrical pUlse was recorded simultaneously on both the captain's and first officer's radio channels. The pulse, which lasted about 7 milliseconds, occurred about the time the captain said that the left a.c. bus was lost. Signals from the radio channels are taken from the captain's and first officer's audio selector panels. Flight Data Recorder.-The recording medium of the Leigh DFDR is a 1/2-inch, continuous loop, 7-track magnetic tape. A total of 33.5 hours of data encompassing 76 airplane performance parameters are recorded. The recorder, which was not damaged, was opened at the NRC flight recorder laboratory; the tape was removed and then wound on a standard computer-tape reel. The accident flight was identified both by the recorded flight number~and by tracing the altitude and heading time histories from the takeoff at Dallas. The data showed that the recorder stopped operating 1 hour 42 minutes into the flight while the airplane was at FL 330. The DFDR recording contained several anomalies that took the form of signal spikes or data losses in a number of recorded parameters. These anomalies were used to establish a correlation between the CVR and DFDR times. Since the DFDR did not contain microphone keying information, it was necessary to identify events that were common to both recorders. The DFDR anomalies were examined and charted together with the electrical signals which had been recorded on the CVR channels. The time

-14- increments between the specific events, as recorded on the CVR and DFDR, were compared and a correlation established. From this information, it was determined that the DFDR also stopped recording at 1907:4l. 1.12 Wreckage and Impact Information Both engines and their associated cowlings were intact, undamaged, and showed no evidence of exposure to abnormal heat or fire. There was no evidence of oil or fuel leakage, and the main engine fuel supply system did not leak when pressure tested. The engine fire extinguisher bottles had been discharged. The APU was intact and was not damaged. The exterior of the APU and surrounding compartment were free of soot and other fire damage. The APU enclosure within the aft accessory compartment was not damaged by fire; however, the enclosure was coated slightly with soot. Visual inspection and tests of the hydraulic and fuel systems revealed that neither system contributed to either the initiation or propagation of the fire. The empennage and wings were not damaged by either fire or heat. The leading edge slats and trailing edge flaps were fully extended. The nose gear was extended and locked. Except for the right axle where the splash guard had been cut away in order to tow the airplane from the runway, the nose gear was not damaged. The nose wheel tires were inflated. Both main landing gears were extended and locked. Except for the support bracket on the left main gear, which was bent and twisted slightly aft, the main landing gear was not damaged. However, all four main wheel tires had blown on landing. 1.12.1 External Fuselage The cabin area of the upper fuselage down to below the level of the cabin windows was damaged heavily by fire; below that level the fuselage was relatively intact. The majority of the cabin windows were either missing or had partially melted out. (See figures 3 and 4.) Forward of the aft pressure bulkhead, the upper areas of the cabin windows were discolored and burned away in several locations. The fuselage skin above the left aft lavatory was intact, but a rectangular area corresponding closely to the shape of the lavatory had been discolored to dark brown and a large area of paint had been burned away. The rectangular area began above the engine pylon and extended to the top of the fuselage. (See figures 3 and 4.) Forward of the aft lavatory, between fuselage station (FS) 929 and FS 758, the top of the fuselage was damaged heavily by heat and had been burned away down to the top of the cabin windows. Between FS 758 and FS 484, the fuselage upper skin was intact but was buckled and discolored by heat at the very top between the 11 o'clock and 2 o'clock positions (aft looking forward). Between FS 484 forward to the cabin entry door (FS 200), the upper skin of the fuselage had burned away partially. Except for some sooting around the edges of the left and right forward cabin· entrance doors, the fuselage forward of FS 200 was intact with no apparent heat or fire damage. There were thick soot deposits along the lower side of the fuselage beginning at the cabin air outflow valve at FS 945 and from around the access door in the lavatory service panel at FS 965. The soot pattern trailed rearward along the airplane's side,

-15- Figure 3.-Left side of the airplane. Figure 4.-Left side of the airplane, rear view, depicting rectangular burn pattern and soot trail.

-16- including the tailcone. The cabin air dump valve, at FS 920, was open, and light soot deposits trailed aft from around the edges of the valve. (See figure 5.) The lavatory service panel is just aft of the cabin outflow valve. The entire area inside the service panel access door was covered with soot and a black tarlike substance. The thickest deposits were on the inside surface of the panel access door adjacent to the vent tube and flush/fill pipe outlets. (See figure 6.) An area of heat-damaged fuselage skin was found about 2 feet above the lavatory service panel and adjacent to the toilet area 'of the aft lavatory. The damage, which appeared to have been caused by heat from inside the fuselage, consisted of blistered paint, which was discolored and blackened, and warped skin. The discolored area extended from about 10 inches forward of to about 28 inches aft of FS 1,000 and extended downward from the left engine panel for about 9 inches. 1.12.2 Interior Fuselage Forward of the Aft Lavatory All cockpit windows and windshield panels were intact; the pilot's and first officer's side windows were open. The entire cockpit area including the windows and windshield panels was sooted heavily. Except for some heat damage in the overhead switch and circuit breaker panel and to wire bundles just forward of the cockpit door, the cockpit was not damaged. Except for the cabin floor and the aisle carpet, the entire passenger cabin back to the aft lavatory was either consumed or damaged by fire. The aisle carpet was covered by debris but had not been discolored or damaged by heat. Of the 100 passenger seats, only the seat frames and cushions of Nos. 12A and 12B remained intact. Seat Nos. 12A and 12B are adjacent to the left forward overwing emergency exit which had been opened during the passenger evacuation and had been used as access by firemen to apply water to the fire. The remaining seats were either completely or partially destroyed by the fire. (See figures 7 and 8.) The aft lavatory steel potable water tank at FS 990 remained intact and attached to its ceiling mounts forward of the aft pressure bulkhead. The overhead ducting behind and above the tank was intact; however, forward of the tank the ducting had been burned away. Above the water tank, the fuselage insulation was partially in place; however, it was wet and soggy. The electrical wire bundles which were routed around the water tank were burned forward of the tank. 1.12.3 Aft Lavatory Area The aft lavatory was on the left side of the cabin, and began at FS 965 and extended aft to FS 1019, or just forward of the aft pressure bulkhead. The lavatory's outboard wall conformed essentially to the shape of the airplane's fuselage. There was a vanity section containing a stainless steel sink and amenities located along and extending forward from the aft wall. The commode containing a flushing motor was located along the lavatory's outboard wall. A trash chute and container were located below and behind the sink, and a fresh air supply outlet was positioned below the sink in the door of the vanity. Also, below the trash container, an aluminum shelf was installed. In addition, there was an oxygen outlet located in the oxygen mask compartment in the amenities section. (See figures 9 and 10.)

-17- Figure 5.-Soot trail deposits on left side of fuselage at lavatory service panel and outflow valve. Figure 6.-Lavatory service panel with access door open.

-18- Figure 7.-Cabin interior viewed aft from the forward galley area. Figure 8.-Cabin interior viewed aft from the midwing area.

-19- SICK BAG DISPOSAL SICK BAG CONTAINER OXYGEN MASK COMPARTMENT WASTE DISPOSAL DOOR OUTBOARD WALL AFT WALL / IIdj /;,l~ I' I /; /---------~ ASHTRAY ENTRANCE DOOR COLD AIR OUTLET SANITARY NAPKINS Figure 9.-Diagram of aft lavatory, viewed aft.

-20- Figure lO.-Aft lavatory viewed toward aft and outboard wall. Lavatory sink door is open exposing trash receptacle. Toilet shroud has been removed showing the top of the flush motor between the commode and forward wall of the amenities section.

-21- The aft lavatory was damaged extensively by fire and heat. Most of the lavatory's interior walls had been burned away. The entry door, which had been kept closed, was destroyed except within 16 inches of the floor. The aft pressure bulkhead and fuselage skin which comprised the outermost portion of the lavatory enclosure were intact, but were buckled and discolored to dark brown. The stainless steel sink and the section of the vanity frame supporting the sink were intact against the aft lavatory wall. The plastic door on the front of the sink portion of the vanity was burned away. The cold air outlet nozzle mounted in the door was recovered in the debris and was in the closed position. Except for the top of the trash chute, which had burned away at the point where it attached to the top of the sink at the waste disposal door, the trash chute and trash container behind and below the sink were intact. The aft side of the container was scorched, but not burned, and the paint on the inside surface of the container was blistered. Paper trash in the container was scorched but was not burned. The aluminum shelf below the container was intact; it was covered with debris, but exhibited little evidence of heat damage. The lavatory floor in this area was intact, but was covered with damp debris. Included in the debris were a plastic vial and a paper maintenance tag, neither of which was burned. These items were located on the floor under the sink area. A Halon 1301 automatic fire extinguisher was mounted below the sink basin, and it had discharged automatically into the trash chute. The extinguisher is designed to discharge Halon gas through one, or both, of two heat activated nozzles. One nozzle discharges directly into the open area below the sink and the other into the trash chute. At temperatures in excess of 173° F. the nozzle tips will melt causing the Halon to be discharged under pressure. t The amenities section of the vanity extends from the sink to the lavatory outboard wall and from the commode to the lavatory aft wall. The section contains the oxygen mask compartment and containers or dispensers for paper towels, toilet paper, sanitary napkins, and sick bags. (See figure 9.) The amenities section had been damaged extensively by fire and was almost completely disintegrated along the outboard corner. The oxygen mask compartment was damaged severely and parts of the compartment and its cover door were burned away. The lowest level of the amenities section between the amenities compartments and the aluminum bottom shelf was a void space through which was routed the wiring for the commode's flush pump motor; the aluminum oxygen line to the oxygen mask compartment; the aluminum cold air supply line to the adjustable nozzle outlet below the sink; and a stainless steel pipe from the sink. The outboard top of this area had burned away. The outboard corner of the aluminum bottom shelf had partially melted away; the remainder of the shelf was intact. The lavatory aft wall below the bottom shelf was intact and was not burned. Within this portion of the amenities section, the stainless steel drain pipe was intact. The oxygen line had been partially consumed where it entered the oxygen mask compartment and where it exited the amenities section; the remainder of the line within the amenities section was intact. The cold air supply line was intact from the divider wall between the sink and the amenities section to the area near the intersection of the pressure bulkhead and the outboard wall of the lavatory. In this area, a 1.5-inch-Iong elliptical-shaped hole was melted through the top of the line. The aluminum alloy used in

-22- the cold air supply line melts between 1,000° and 1,200° F. ~/ The remaining outboard end of the cold air supply line was scorched and partially melted away about 2.5 inches beyond the elliptical hole. There was extensive heat damage to the vanity wall and floor in the area adjacent to the elliptical hole. The plastic top and shroud of the commode were burned away. Except for some burning around its upper edges, the commode's fiberglass waste tank was relatively intact, was partially filled with debris, and contained about 6 to 7 inches of water. The flush pump and flush pump motor assemblies were recovered in several pieces among the debris in the waste tank. The waste tank in the commode is serviced by a stainless steel flush and fill line which runs from the tank to its terminus in the lavatory service panel. The stainless steel pipe was intact, however, the flex hose and joints which connect the pipe to the waste tank had burned away. The plastic ball in the flush and fill pipe check valve had burned away and the brazed joint between the two portions of the check valve housing was partially melted. Soot and tar deposits were found on the lavatory service door directly opposite the flush and fill line outlet, and rivets on the pipe connector to the service panel had been melted. The flush motor was found attached to its mounting flange which was attached to the pump well. The flush motor assembly was found in approximately its normal position in the waste tank next to, but detached from, the flush pump and filter assembly. The motor housing was completely melted. Large concentrations of molten metal were found on the forward side of the mounting flange facing the toilet bowl, and on the aft side where the 3-phaseelectricalleads enter the motor housing. A portion of the wiring harness which supplies' a.c. power to the flush timer, flush motor, and flush button was encased in the molten metal on the aft side of the motor. The rotor section of the flush motor was encased in molten metal above the field windings; however, the rotor did not appear to have been damaged extensively by heat. (See figure 11.) The flush pump and filter assembly found in the waste tank was partially intact. The filter and pump mechanisms, which apparently had been located below the water line in the waste tank, were in good condition. Above the water line, the plastic housing for the pump and filter was melted away. This housing also encloses the filter gear train and is part of the assembly used to mount the pump and filter to the pump well. The exposed shaft and gears showed heat damage. The gears, which make up the filter gear train that connects the motor to the pump and filter, were found lying in the waste tank. The plastic mounting ring, which mates the pump and filter housing to the pump well, was found intact among the debris in the waste tank. There was some slight melting of the top surface of the mounting ring. All of the components of the flush motor and pump assembly were removed for further examination. When the flush motor and its associated mounting were removed from the toilet tank, two wires in the motor harness and all of the wires in the power harness broke just aft of the motor housing due to brittleness. To facilitate removal of the flush motor assembly, the remaining wires of the motor harness were cut a few inches aft of the motor housing and tagged for identification. ~/ ASM Metals Handbook, Vol. 2, Edition 9.

-23- ~-JI/o--Mounti ng A Flange

TANK TOP FILTER

' FILTER ..l""'ilit+to-kJ,...++~>--' GEAR TRA IN This area of pump housing destroyed PUMP WELL ~--Pump Well PUMP ANIJ FIL1 ER BOWL ASSEMBLY_____. I ---.----- --\' ----~~ :rA.-,K. (~.- ~~~l-,,~ ~ Waste Tank-----4 ~ FLUSHLINE~ If' Figure ll.-Lavatory pump and filter system.

-24- The flush timer was found intact, mounted in its normal position, on the inboard interior cabinet wall below and to the left of the sink. The timer's two electrical connectors and their respective wiring harnesses were connected to the timer. The timer and connectors showed evidence of external heat and smoke damage only. The connectors were removed and all mating connections were examined. No damage was observed at any of the connections. The timer was removed for further examination. The wiring harness that supplies 3-phase power from the timer to the toilet flush motor was examined. The harness was undamaged between the timer and a point midway into the lower amenities portion of the vanity., The insulation had melted away from the wires on the wiring harness section between the midway point and the lightening hole 10/ where the harness leaves the vanity and connects to the motor. The exposed wires in this section were brittle. The wiring harness that supplies a.c. power from the ground service bus to the timer and flush button was found partially intact. The harness was undamaged in the area from the timer outboard to the lower amenities portion of the vanity. From this point, continuing outboard and forward through the lightening hole in the vanity, the wire insulation and the wires were brittle. The harness was encased in molten metal from the aft end of the motor ,housing, across the width of the housing, to the forward end of the housing. The harness was not identifiable from a point just forward of the motor housing to slightly aft of where the harness leaves the lavatory forward bulkhead through an overhead lightening hole. From the overhead lightening hole, the harness was routed outboard and down to the cabin floor. Varying degrees of heat damage were observed on the harness in this area. The remainder of the harness, from a point just below the cabin floor forward along the left side of the airplane to the circuit breakers on the electrical power control panel, was undamaged. No wiring from this harness to the flush button could be identified. The lightening hole between the amenities section and toilet section through which the flush motor's power harness passes was examined. The nylon alligator grommet covering the hole's surface was not found; however, this entire area was damaged severely by heat and fire. The bracket supporting the harness' nylon cable clamp was partially melted away with only the portion of the bracket that was riveted to the structure remaining. An electrical continuity check was made of the harness using a volt-ohm meter. Because the insulation had burned off the wires in certain areas causing short circuits, the entire harness could not be tested. The harness was cut at a point 5 feet above the cabin floor, just forward of the aft lavatory forward bulkhead. Continuity was observed from this point to the circuit breakers. There was no evidence of line-to-line or line-to-ground short circuits. Electrical splices were found on the power harness just aft of the flush motor housing. The splices appeared to be intact and electrical continuity was established on four of them. The remaining splices could not be tested because there was not sufficient wire protruding from the splices. 10/ A hole resulting from the removal of non-load carrying metal in airplane members for the purpose of weight reduction.

-25- The power harness routing in this airplane differed from the McDonnell Douglas DC-9 installation drawings. These drawings indicate that the harness is routed from the lightening hole in the vanity, across the inboard side of the flush motor housing, and around the forward side of the housing. The harness is shown secured with support clips and cable clamps around the pump well. The harness in this airplane was routed across the outboard side of the motor housing. No support clips or cable clamps were found around the pump well. It could not be determined whether or not vibration induced insulation damage occurred at this point. The wiring harness associated with the aft attendant communications panel was examined. A number of electrical wire splices were found just above the standpipe feed-through located near the inboard end of the vanity. This harness and the attendant panel were removed for further examination. Electrical components normally located in the lavatory overhead area were found among the debris recovered from the lavatory floor around the waste tank. All components were heavily damaged by fire. The recovered components included portions of the upper and lower mirror light assembly, the circuit breakers and transformer to the aft reading lights, the razor convertor, and the control transformer for the aft miscel- laneous lights. All the overhead wiring from the aft pressure bulkhead forward to the cockpit was severely damaged by fire and heat. The wiring that penetrated the aft pressure bulkhead was spliced just forward of the bulkhead. All of the splices observed in the area of the aft pressure bulkhead and in the area of the aft lavatory were accomplished during repairs made to the airplane after the September 17, 1979, ~ft pressure bulkhead separation at Logan International Airport, and the splices were made in accordance with service sketch 2958. None of the wire splices in these areas showed evidence of arcing or shorting. Several samples of electrical wiring, all of which were spliced, were removed from the forward side of the pressure bulkhead for further examination. All of the wire splices removed and examined appeared to exhibit the same degree of extreme heat damage. The insulation covering was missing from all of the splices; however, no evidence of either electrical arcing or shorting was observed. 1.12.4 Aft Accessory Compartments and Cargo Compartments The internal fuselage of the aft accessory compartment behind the aft pressure bulkhead was intact with little evidence of heat damage. The insulation on the aft side of the bulkhead was intact but discolored. Except for the buckling and discoloration that was noted in the area above the aft lavatory's vanity, the aft pressure bulkhead was intact. The systems, lines, and wiring were intact except for some slight heat damage to the wiring nearest the lavatory. The forward cargo compartment was fully intact, and there was no evidence of either fire or heat damage. The rear cargo compartment also was intact. The fire and heat damage in this compartment was concentrated in the area below the aft lavatory. The under floor blanket insulation along the aft tunnel area of the rear cargo compartment was scorched from the aft pressure bulkhead forward to about FS 945 and from the airplane's centerline outboard to the fuselage skin. The heaviest scorching was under the aft lavatory at the point where the lavatory's aluminum vent tube was routed. This tube, which vents air overboard from the lavatory, begins near the commode and beneath the toilet shroud and ends at a venturi in the lavatory service door. It enters the tunnel just aft of FS 980 and is routed forward to FS 965 and then to the venturi.

-26- Between FS 980 and FS 965 the tube is routed below the three generator feeder cable bundles. The vent tube had melted away to within 6 inches of its terminus in the lavatory service panel. The hydraulic, fuel, and pneumatic lines routed through this area were intact with no evidence of leakage. The nylon conduits encasing the APU and the left and right generator feeder cables from the aft pressure bulkhead (FS 1019) to about FS 965 were melted away and the insulation on the exposed cables was scorched. The most intense scorching occurred between about 2 inches forward to 8 inches aft of FS 980. The generator feeder cables are routed through two lightening holes in a floor beam located at FS 980. The APU and right generator feeder cables pass through the inboard lightening holes; the left generator's three feeder cables pass through the outboard holes. A small notch, typical of the type of damage resulting from electrical arcing, was found in the outboard lower edge of the inboard lightening hole adjacent to one of the right generator feeder cables. The frame of the outboard lightening hole was burned away from around the bottom of the hole. The nylon support clamps for the feeder cable bundles were missing at both lightening holes. The clamp screws for the nylon support clamps were attached at the inboard hole, but were discolored by heat. At the outboard hole, the clamp screws were missing and the area where they attached was damaged by heat and partially burned away. At FS 965, the nylon support clamps for the APU feeder cables were intact while those for the right generator feeder cables were only partially intact. The support clamp for the left generator feeder cables was missing; however, the clamp screw was attached at the lightening hole. There was some heat damage, but no evidence of arcing on either lightening hole at FS 965. The support clamps were intact and the generator feeder cables were supported properly at the remaining lightening holes observed. , The examination of the feeder cables of the two engine-driven and the APU generators showed -that each had been damaged by intense heat in the area between FS 965 and FS 996. The feeder cables of the right generator showed evidence of arcing near FS 980. The nylon conduits containing the generator feeder cables are semi-rigid, pipelike structures. During the investigation, the support clamps in the lightening holes at FS 980 were removed from a sister DC-9-32. The conduits remained in place and did not contact the surfaces of either lightening hole. The feeder cables of the engine-driven and the APU generators were disconnected at the generator relays and at the engine and APU firewall connectors. When tested, each line showed continuity and no line-to-line or line-to-ground short circuits were observed. Eight-foot-long sections of the three generator feeder cable assemblies were cut out and removed for closer examination. Each feeder cable assembly exhibited an area about 2.5 feet· long wherein its nylon conduit had melted away and the insulation within this melted area was brittle and charred heavily. Examination of the left generator cable showed that the B- and C-phase lines had areas wherein the insulation had chafed. A metal globule was found on the exposed wire strands in this area. Another chafed area was in the C-phase line about 1/2 inch aft of the metal globule. There was some melting of the wire strands in this area; however, no evidence of arcing was found.

-27- A small area of chafed insulation was found on the phase B line of the right generator feeder cable bundle. A metal globule, similar to that noted on the left generator lines, was found on the exposed wires. The areas where the metal globules were found on the left and right generator. lines correspond to where the lines appeared to have contacted the floor beam structure under the aft lavatory at FS 980. The APU feeder lines showed no evidence of chafed insulation or electrical arcing. The examination of the airplane's electrical wiring included the components in the electrical and electronics compartment located below the cockpit. This compartment includes the components used for a.c. and d.c. bus power distribution and fault protection, and the electronic components used for communications, navigation, and flight control. There was light to moderate heat, water, and firefighting foam damage observed in the compartment; however, the wiring harnesses showed little heat damage. All components were intact and were mounted properly in their respective racks. The batteries, which had been disconnected by the firemen, were intact. The following were removed for further testing: the static inverter; the voltage regulators of the three generators; the left and right generator control panels; and the a.c. bus control panel. 1.12.5 Cockpit Controls and Instruments The readings of the cockpit instruments, the positioning of the cockpit controls, and the positioning of the switches in the cockpit were also documented during the investigation. With regard to the air conditioning and pressurization packs, the ram air switch was off, the right air conditioning supply switch was, off, and the left air conditioning supply switch was in the HP (high pressure) bleed position. The left air conditioning supply switch was reported originally to have been in the off position, and investigators could not determine if the switch had been movep. 1.13 Medical and Pathological Information BI~od samples were taken from the 18 surviving and 23 deceased passengers and were analyzed by the FAA's Civil Aeromedical Institute, Oklahoma City, Oklahoma, for carbon monoxide, cyanide, fluorides, and ethyl alcohol. The results of the analyses indicated that the deceased had elevated carbon monoxide levels ranging from 20 to 63 percent saturation; the threshold for carbon monoxide in the blood at which incapacitation occurs is between 40 and 50 percent saturation. The cyanide levels found in the blood samples of the deceased ranged from a low of 0.8 to a high of 5.12 micrograms/ml; the toxic level for cyanide in the blood at which incapacitation occurs is between 0.5 and 0.7 micrograms/mI. The fluoride levels ranged from 410 micrograms/100 ml to 63 micrograms/100 ml; however, the significance of these fluoride levels is unknown. Alcohol levels on three of the- deceased were in excess of 0.10 percent concentration. Blood samples were taken from the survivors about 2 to 3 hours after the accident. The concentrations of carbon monoxide and cyanide found in the survivors' blood samples were below 0.10 percent concentration and .06 micrograms/ml, respectively. Fourteen of the 18 survivors' blood samples tested negative for alcohol; the other 4 samples tested below 0.10 percent concentration. With regard to the blood alcohol levels, since the blood samples were taken 2 to 3 hours after the accident, these values may be low. Blood alcohol levels decrease at about 0.015 percent per hour after

alcohol intake has ceased.

-28- . Autopsies were performed on five bodies under the direction of the Boone County Coroner, and an additional five under contract for Air Canada. No evidence of antemortem impact injuries was discovered during these examinations. 1.14 Fire Response Although the fire on board Flight 797 began in flight, no one saw flames in the cabin until after the flight had landed and the survivors had left the airplane. The last passengers to depart the airplane through the left and right overwing emergency exits stated that they saw flames immediately after stepping onto-the wing. The firefighter on scene commander stated that some of his men went to assist the passengers down from the wing and that, at that time, he saw flames in the cabin. The crash-fire-rescue vehicles entered runway 27L at its approach after Flight 797 landed and followed behind the flight until the airplane was stopped. According to the fuel gauge readings noted during the cockpit documentation, the center wing tank was empty and there were 6,200 pounds and 6,050 pounds of jet-A fuel in the left and right wing main tanks, respectively. The airplane's fuel tanks did not rupture and the jet-A fuel was not involved in the fire. Flight 797 came to a stop about 1920, and 7 airport crash-fire-rescue vehicles containing 13 airport firefighters were positioned at the airplane. (See table 1.) Upon arriving at the airplane, the firemen saw heavy smoke rolling out of the overwing exits and front doors. About 1921, as surviving passengers and crewmembers were departing the airplane, the firefighters initiated an exterior attack on the fire. Foam was discharged from the turrets on the firetrucks onto the top of the airplane's fuselage and on the ground beneattf it in order to cool the interior of the airplane and to provide a foam blanket in case of a fuel spill. Other firefighters assisted passengers at the escape slides and helped passengers off the wing to the ground. When the on scene commander ordered an interior attack on the fire to be made for rescue purposes and to extinguish the fire, passengers were still leaving the airplane through the left forward cabin door and overwing window exits. The first interior attack was made through the left aft window for several reasons. According to the on scene commander who executed the order, he believed that most people would try to exit the airplane through the left forward door; therefore, he did not want to block that exit with a ladder and hose. Also, with the escape chute deployed, it would have been difficult for the firefighters to enter at that door with their protective equipment and hoses. The on scene commander testified that it would have been possible, ''but it would have slowed us down." The on scene commander also testified that he wanted to enter the airplane through the overwing window exits, ''because we wanted to get in between the passengers and the fire to make their chances (to escape) better." Within minutes of arriving at the airplane and after the passengers were off of the left wing, two firefighters mounted the left wing carrying a loS-inch handline, opened the left aft overwing emergency exit, and applied foam into the cabin. The firefighters were wearing proximity suits with self-contained breathing apparatus; however, they were not wearing the proximity suits' protective hoods because the hoods did not fit over their breathing apparatus. After applying the foam into the cabin, they attempted to enter it through the overwing exit but were driven back by the intense smoke and heat. According to one of the firefighters, he did not see any flames during this attempt to enter the

-29- Table 1.--Responding Airport Crash Fire Rescue Equipment Agent Discharge Quantities Vehiclesj Capacity Rate Used Unit No. (gallons) ~ (gallons) Crash truck Unit 907 3,000* 750* 3,000 + 500 AFFF** Unit 913 3,000 * 750 3,000 + 500 protein Quick Reaction Vehicles Unit 967 100 AFFF 0 450 pounds Purple K. * ** 0 Engine Companies Unit 951 1,000* 1,000 1,000 Ladder Companies Unit 960 300* 1,500 300 Ambulances Unit 964 nja nja nja Rescue Squads Unit 980 nja nja nja *Water

• *Aqueous film forming foam

***Dry chemical extinguishing agent

• Indicates more than the cited amount was used.

-30- cabin. About 2 to 3 minutes after the attempt to enter the cabin from the wing failed, the tailcone was jettisoned, and these two firefighters, using a ladder, entered the aft fuselage with a lo5-inch handline. The rear pressure bulkhead door was opened; however, the firefighters were driven back by the intense heat. The firefighters attempted to reenter the left overwing exit and then the forward left cabin door; both attempts were unsuccessful. At 1925, the on scene commander called for firefighting and ambulance mutual aid assistance. Although the call went out as "ambulance only," two firetrucks arrived on the scene about the same time as the ambulances. Before the fire was extinguished, 12 pieces of firefighting equipment and 53 firefighters had responded in mutual aid from neighboring towns. According to the on scene commander, the firemen "had the fire pretty well under control..." when water and extinguishing agent additive were almost exhausted. According to the commander, supplies began to run out about 10 minutes after firefighting efforts were begun, and at 1952, the on scene crash-fire-rescue units depleted their water supplies. The units were replenished through supply lines laid by airport and mutual aid personnel to a hydrant located about 800 feet from the airplane. At 2017, 56 minutes after the firefighting began, the fire was extinguished. The amount and type of firefighting equipment required at an airport is described in 14 CFR 139.49 and is based on of the longest airplane having five or more daily scheduled departures from the airport. At the time of the accident, the Greater Cincinnati International Airport was classified as an Index C airport. (Index C: airplanes more than 126 feet and not more than 160 feet long.) Therefore, the airport fire department was required to have one lightweight vehicle providing at least 500 pounds of dry chemical extinguishing agents, or 450 pounds of dry chemicals and 50 gallons of water for aqueous film forming foam, and two additional self-propelled fire extinguishing vehicles. The total quantity of water for foam production required for Index C is 3,000 gallons. At the time of the accident, the firefighting equipment at the airport exceeded Index C requirements and met those of Index E (airplanes more than 200 feet long). Standiford Field, Louisville, Kentucky, is also classified as an Index C airport. 1.15 SUrvival Aspects The procedures to be followed by Air Canada flight attendants during emergency situations are set forth in Air Canada Publication 356. Flight attendants are directed to "secure the nearest appropriate type hand fire extinguisher and immediately attack the fire," and simultaneously to call or signal another flight attendant to notify the captain immediately. A flight attendant must maintain continuous communication with the captain. The procedures also relate the need to "use the axe to obtain access if necessary. Rapid access to the fire may require local destruction of various panels." The flight attendant in charge testified that he had been taught how to use the fire axe during initial training; however, he was not taught which lavatory panels could be removed or destroyed without endangering critical airplane components. The flight attendant in charge also testified that it was obvious that the fire was contained behind the lavatory paneling, but that he did not consider using the crash axe because he would have had to destroy the whole area of paneling in the lavatory to "get to it." Although the procedures do not indicate that the use of the fire axe must be authorized by the captain, the flight attendant in charge testified that since the axe is stowed in the cockpit behind the captain's seat, there would be no way to get the axe without the captain's knowledge.

-31- Air Canada Publication 356 contains both pictures and descriptions of the fire extinguishers used on their airplanes; it also depicts where each fire extinguisher is located on each airplane operated by the company. Publication 356 explains and depicts how each fire extinguisher operates and what type extinguisher should be used to fight different types of fires. With regard to a lavatory fire, Publication 356 states, in part, "Execute flame knockdown by repetitive discharges of a carbon dioxide (C02) or dry chemical extinguisher." The pUblication also contains directions for the most effective use of each type of extinguisher. According to the manual, the user of a CO2 extinguisher should, "AIM the gas at the outside edge (of the fire) and then in a circling fashion towards the center." All Air Canada flight attendants receive "hands on" training in the use of all fire extinguishers during initial and recurrent training. In addition, during initial training they are required to extinguish an actual fire. Publication 356 also states, in part, that if excessive smoke and fumes are present in the cabin, the flight attendants should "relocate passengers away from the area of severe smoke and fumes if possible." The passengers had been moved forward in the cabin, and no passenger was seated farther aft than row 12. The two passengers in seats Nos. 12D and 12E refused to move forward because their seats were next to the right forward overwing exit window. (See figure 12.) Once the passengers had been repositioned and the cabin air vents opened and directed aft, the smoke appeared to lessen, but shortly thereafter the smoke began to increase rapidly. Several passengers stated that the cessation of airflow from the vents coincided with the increase in the smoke. Other passengers stated that it occurred at the beginning of the descent or sometime shortly after the airplane began descending. Air Canada emergency procedures state that the oxygen masks should not be deployed below 10,000 feet as a means of avoiding smoke inhalation. Below 10,000 feet less than 1 liter per minute is being supplied through the mask, and therefore, due to the design of the mask and the low altitude, the user is merely breathing ambient cabin air. The company procedures also state, "When fire conditions exist, dropping the masks and pressurizing the oxygen manifold may contribute to combustion." The procedures further note, "If loss of cabin pressure has caused the masks to drop... ," the passengers should remove them as soon as practical once the cabin pressure altitude drops below 13,000 feet. The flight attendants designated several male passengers to open the overwing exit windows after the airplane landed and stopped. None of those designated could recall whether the attendant had given them specific directions as to how the exits were to be opened. However, nearby passengers recalled hearing a flight attendant describing the operation of the overwing emergency exit windows. Three of the four emergency overwing exit windows were opened by passengers, and none encountered difficulties in operating and removing the window exits. During descent, the cabin filled with black, acrid smoke from the ceiling down to about knee level. Passenger and flight attendant testimony and statements indicated that all of the surviving passengers had covered their faces with either wet towels distributed by the flight attendants or articles of clothing. They all attempted to breath as shallowly as possible, and all reported that the smoke hurt their noses, throats, and chests and caused their eyes to water. By the time the airplane landed, they could not see

(Denotes Location of Survivors Before Leaving Airplane and Location of Fatalities After the Accident) o Fatality o Survivor EB Flight Attendant ....o~

....

BIT.- Figure 12.-Diagram of passenger seat locations. c) I c..,) to.:> I

-33- their hands in front of their faces while seated or standing. Some of the passengers said that they leaned forward in their seats and put their heads down and that this seemed to relieve some of the distress they were experiencing. One passenger was experiencing severe distress trying to breathe. He was brought forward and seated on the forward flight attendant jump seat, and the flight attendant in charge administered oxygen to him from the portable bottle. The Air Canada Land Emergency Procedures require the flight attendant in charge to make numerous announcements advising the passengers of what they are required to do during a forthcoming emergency landing and airplane evacuation. The announcements include, in part, a description of the brace positions, the location of the doors and exits, instruction to passengers to remain in their seats until the flight attendants direct them to move toward the doors and exits, instruction on which exits to use during the evacuation, information on how to get off the airplane wing after using an exit window, and what to do after leaving the airplane. According to company procedures, the public address (PA) system should be used for all announcements before the airplane has been stopped and before the doors and exits have been opened. A megaphone, which was stowed in the right overhead luggage rack above row 2, was not put to use. Air Canada emergency procedures state that the "megaphone is to be used inside the airplane if the PA system is not working, and outside the airplane to give instructions after the evacuation," and the flight attendant in charge is responsible for removing the megaphone. According Publication 356 and the Air Canada director of flight attendant training, the megaphone is not to be used to issue evacuation commands once the airplane doors and exit windows have been opened. At the Safety Board's public hearing into the accident,the flight attendant in charge testified that he tried to use the aft PA microphone "after the smoke subsided and it didn't work." He also testified that he had thought of using the megaphone; however, by that time the airplane was in a steep descent, the smoke was advancing rapidly, and he thought it would have been "unwise to waste valuable time.•." to try and go back and get the megaphone. The Air Canada DC-9 emergency evacuation procedures call for three flight attendants on the airplane. A flight attendant in charge is positioned on the forward jump seat, and he or she is to open both forward doors and inflate the escape slides. The No.2 attendant's position is in seat No. 13C, and he or she is responsible for supervising the removal of the overwing exit windows and the evacuation through the overwing exits. The No.3 attendant's position is the aft jumpseat, and he or she is responsible for either directing the passengers to move forward or to open the alternate tailcone exit should the other exits be blocked. However, the procedures also state that if the No.3 flight attendant is unable to occupy the aft jumpseat, seat 13B will be used if it is available. Seat 13B is the aisle seat of t,he two seats adjacent to the left aft overwing exit window. Sometime before landing, the first officer told the flight attendants to sit down. When the command was given, the flight attendant in charge was seated in the forward jumpseat aiding a sick passenger, and he stayed in that seat. The No.2 and No.3 flight attendants were distributing wet towels. The No.2 flight attendant moved aft and sat in an aisle seat at approximately row 8; the No.3 attendant sat in seat 3C. While seated in 3C, she briefed a passenger in row 2 to restrain the passengers from moving toward the airplane forward doors until they had been opened and until he had received instructions to move toward and out of these doors. Shortly thereafter, she got up and moved aft checking passenger seatbelts. When she reached the vicinity of row 9, she was

-34- joined by the No. 2 attendant, and they both moved forward rechecking seatbelts and comforting passengers. When they reached the forward cabin area, the No. 2 flight attendant sat down in row 3C and remained there until the airplane landed. The No.3 flight attendant moved aft again. She sat down in an aisle seat in rows 7, 8, or 9 and remained in that seat until the airplane landed. While seated, she shouted ''brace'' instructions to the passengers before the airplane landed. Several passengers said that they heard these instructions. After the airplane landed and stopped, the flight attendant in charge opened the left forward cabin door, inflated the slide, and sent a passenger seated on the jump seat down the slide. He then positioned himself in the doorway and shouted for the passengers to, "come this way." One of the passengers recalled hearing that order. Another passenger testified that by this time, given the conditions in the cabin, it was doubtful if anyone could draw sufficient breath to shout loud enough to be heard at any distance. With regard to the flight attendant's duties during a "Land Evacuation With Warning," Publication 356 states, "Flight attendants should do all possible to evacuate everyone, but are not obliged to risk their own lives." The flight attendant in charge testified that he stayed in the left cabin entrance doorway until no more passengers were coming. At that tim"e, the heat was becoming too intense to remain, and he exited the airplane. The No. 2 flight attendant went forward after the airplane stopped. She saw the attendant in charge open the forward door and deploy the slide. She saw a male passenger exit through the door, and she followed him out of the airplane. Thereafter, she helped and supervised other passengers as they left the airplane. The No. 3 flight attendant got to her feet after the airplane stopped. The smoke was so thick that she could not see. She testified that she "did not think to go back to the overwing exits, so she felt her way forward." She went to the right forward cabin entrance door, opened'the door, and inflated the slide. She stood in the doorway, yelled, "Come this way," waited 3 to 4 seconds, and then exited the airplane down the slide. She waited a couple of seconds at the bottom of the slide and when no one came, she ran around to the left side of the airplane and began to assist the other crewmembers in rendering aid to the survivors. Seven passengers and two flight attendants exited the airplane through the left forward cabin entrance door and slide; one flight attendant exited through the right forward door and slide; four passengers exited through the right forward overwing emergency exit window; one passenger exited through the right aft overwing emergency exit window; and six passengers exited through the left forward overwing emergency exit window. The three overwing exit windows were opened by designated passengers. The smoke in the cabin was reportedly so thick that most of the passengers had to get to the exits by using the seatbacks to feel their way along the aisle. None of the passengers noticed if the emergency lights were illuminated. Several passengers said that, when they either bent forward or got on their hands and knees, they were able to breath and see a little better, but it was not much of an improvement. One of the passengers who used an overwing emergency window exit said that she was able to locate it when she saw a very dim glow of light coming through the aperture. Another stated that she was able to locate the overwing emergency exit window when she felt a slight draft on the back of her knees. During the evacuation, passengers in the seats 2-B, 2-E, 3-A, 3-C, 3-E, 5-C, and 8-C exited through the left forward cabin door; passengers in seats 9-E, 10-A, 10-B, 11-A, 11-B, and 11-E exited through the left forward overwing window exit; passengers in

-35- seats 10-E, ll-C, 12-D, and 12-E exited through the right forward overwing window exit; and the passenger in seat 9-C exited through the right aft overwing window exit. Except for two fatalities found in the aisle at rows 14 and 16, the majority of the fatalities were found either in the aisle or seated in rows 2 through 9. (See figure 12.) The fatalities at rows 14 and 16 had been seated in seats 8-B and 9-B, respectively. 1.16 1.16.1 Tests and Research Federal Bureau of Investigation (FBI) Laboratory Tests The following items from the aft lavatory of Flight 797 were delivered to the FBI laboratory for analysis: samples of waste tank water; fiberglass insulation from the aft lavatory; a plastic vial and tag recovered from the lavatory floor; an aluminum shelf; fiberglass flooring; and soot deposits from the inside of the lavatory service panel access door. The results of the examination were as follows: No flammable accelerants were identified on the items listed above. The source of the spots on the fiberglass flooring could not be determined. The soot deposits contained residues which were characteristic of a phenolic residue, resulting from the burning of phenolic resins such as those contained in the cabin and lavatory walls and other materials. 1.16.2 Electrical System Components The electrical system components removed from tQe forward electronic compartment beneath the cockpit were tested under Safety Board supervision at the Westinghouse Electric Corporation, Lima, Ohio. Functional testing of the a.c. bus control panel, and the voltage regulators and generator control panels of the APU and the left and right engine-driven generators showed that these units were operational. Inspection of the APU generator control panel revealed that connectors on the printed circuit board had corroded and that the electronic components on one of the printed circuit boards had been damaged by water and foam. The Safety Board concluded that this was damage incurred after landing as a result of the firefighting activities. Tests of the two engine-driven generator control panels showed that the differential control circuitries in each of the panels had detected faults on their respective a.c. buses, displayed the faults on the control panels, and then tripped each generator off its respective bus. The differential current circuitry of a generator control panel is designed so as to trip the associated generator from the line within 0.1 second after detecting a 20- to 40-ampere fault current. During the test of the generator control panels, the protective trip occurred within the prescribed limits. The static inverter used to provide emergency a.c. power was tested functionally by the Safety Board at Air Canada's Maintenance Base, Dorval, Quebec, Canada. The 28-volt d.c. power terminals were found to be short circuited, and the unit was torn down for detailed examination and testing. Two of the eight power transistors were found to be short circuited. When the shorted transistors were replaced, the inverter functioned normally. The Safety Board could not determine the cause of the short circuits.

1. 16.3

-36- . Flush Motor and Lavatory Components The flush motor, flush motor components, and various other electrical components removed from the airplane were taken to Transport Canada's Safety Engineering Laboratory in Ottawa, or to Air Canada's Maintenance Base, Dorval International Airport, Quebec, and examined and tested. The tests and examinations were performed under the supervision of Safety Board personnel. X-rays of the aft lavatory flush motor were taken before it was disassembled. The X-rays revealed no evidence of internal melting or shorting of motor components. Solidified melted metal was observed which appeared to be melted motor housing. Solidified melted metal deposits were removed from inside the motor, below the rotor. The motor shaft appeared to be encased in solidified melted metal; however, it could be rotated very slightly. A wire was still attached to a ground stud inside the motor. When the stud was removed, the wire broke due to brittleness. There was no evidence of electrical arcing observed on the ground wire or the stud. A portion of the solidified melted metal which partially encased the stator was removed, and the stator was rotated about 180°. The fiberglass insulating m.aterial around the stator windings and the silicone glass was intact but scorched. The stator assembly was intact and showed no visible signs of electrical arcing. When the remainder of the solidified melted metal deposit which partially encased the stator was removed, two wire segments were found which had been encased partially within it. One additional wire segment was loose under the metal deposit. The source of the metal deposit apparently was a portion of the motor housing which had melted, flowed downward, and entrapped the wires between the motor mounting flange. When the metal deposit was removed from the mounting flange, 180° of the wire's circumference was visible. The fiberglass insulation on the visible portion of the wire segments was intact, but showed evidence of scorching. Wire splices were found in the two wire segments encased in the molten metal as well as in the loose wire segment. The splices were located just outside the solidified melted metal deposit. No evidence of electrical arcing was observed on the exposed wire segments or on the splices. X-rays were taken of the solidified melted metal deposit and wire segments; the x-rays revealed no evidence of electrical arcing. The motor was removed from its mounting flange. The gasket between the motor mount and the mounting flange was brittle and scorched. The remaining solidified melted metal from the motor housing appeared to have flowed down around the rotor shaft and formed a deposit around the motor mount. The mating face of the motor mount was intact and showed no evidence of melting. The motor's stator assembly was removed and inspected. The cable clamp that routes the power leads from the timer harness to the motor stator was still intact around four wires. The mounting hardware was still attached to the clamp; however, the attachment point at the motor housing could not be found; it apparently had melted away. The four power leads still were routed to the stator windings. X-rays of the stator assembly revealed no evidence of electrical arcing or internal melting. The stator windings, where the power leads were connected, was partially disassembled. The enamel insulation around the wire used in the stator windings had been melted away, and bare copper wires were exposed. No evidence of arcing was observed at the power lead stator connections or in the stator windings.

-37- Six segments of wire from the flush motor timer harness were found in the pump well next to the motor mount. Four of the segments had splices in them; the other two wires had no splices. The two wire segments that had not been spliced were considerably shorter than the four segments with splices. The insulation sleeving around the splices appeared to have been melted away; however, the mechanical connections of the splices were intact. The splices showed no evidence of electrical arcing or shorting. However, three of the wire segments showed signs of electrical arcing-the wire ends were melted into the shape of a globule. The metallic globules, which were located on the wire segments at the point where the wires traversed the lightening hole in the partition between the toilet and amenities section, were examined using a scanning electron microscope (SEM). The X-ray energy dispersive analysis indicated that they were copper. The flush motor wiring harness was examined closely for any evidence of electrical arcing or shorting. The connector at the flush timer end of the harness showed evidence of damage from intense heat. Except for a small tear 25 inches from the connector, the sleeving which surrounded the wires was found intact from the connector to a point 35 inches away. The teflon insulation on the individual wires within the harness was found intact from the connector to a point 38 inches away. From that point to the end of the harness, the sleeving and teflon insulation had melted away progressively, and toward the end of the harness, bare wires were exposed. No indication of electrical arcing or shorting was observed on any of the wires. The 5-ampere phase-A, phase-B, and phase-C flush motor circuit breakers were removed from the cockpit and were X-rayed, revealing no internal damage. During a functional test, all three circuit breakers tripped when the electrical load exceeded the 5-ampere rating. The circuit breakers were connected to a power source and load and subjected to a lOO-percent lO-ampere current overload. Only the phase-A circuit breaker exceeded the time limit designated in the specifications before it'tripped. The Safety Board could not determine the reason for the failure of the phase-A circuit breaker to meet its specifications; however, all three circuit breakers showed evidence of damage due to an external heat source. The flush motor timer was examined. A continuity check of the timer's three-phase power relay contacts showed that they were open -- the normal position of the relay when the flush button is not engaged. A 3-foot, 5-inch portion of the flush timer's WIring harness, from the connector at the timer to just outside and forward of the lightening hole in the vanity structure, was removed and examined for any evidence of electrical arcing and shorting. The first 2 feet of the sample was relatively intact. From a point 2 feet 6 inches to a point 3 feet 5 inches from the connector, the outer insulation layer of the individual wires had been gradually melted away; however, the fiberglass inner insulation remained intact. The wires were bare of insulation over the last 5 inches of the harness, and when the harness was removed, the wires broke due to brittleness. No evidence of arcing or short circuiting was observed on any of the wires. The following electrical components were removed from the lavatory and examined for electrical arcing and short circuiting: the lower mirror light assembly, the upper mirror light and dimming switch assembly, the aft reading light transformer and circuit breakers, the razor outlet converter, the aft attendant panel, and the aft miscellaneous lights control transformer. All of these components and their associated wiring were damaged by heat, and portions of some of them were missing; however, no evidence of electrical arcing was observed on any of the wires.

-38- . In addition, several samples of spliced electrical wlrmg were removed for examination from the forward side of the aft pressure bulkhead. All of these samples exhibited evidence of exposure to extremely high temperatures. The insulation covering was missing from all of the splices; however, no evidence of electrical arcing or shorting was observed. 1.16.4 Flush Motor Seizure Test At Air Canada's Dorval Maintenance Base, the Safety Board simulated the conditions produced by a seized or frozen flush motor assembly drive shaft. A Western Gear Motor, Model 353JC2, identical to that on Flight 797, was connected to a test fixture which provided U5-volt a.c. three-phase power through 5-ampere circuit breakers connected to the motor power leads. The rotor shaft was locked, the motor was operated, and the internal motor temperature and motor case temperature were measured. The internal motor temperature began to rise as soon as power was applied. At 1 minute 30 seconds after power was applied, smoke was visibly emanating from around the motor cover plate. At this time, the motor temperature was 331 0 F. At 6 minutes 15 seconds after power was applied, maximum rotor temperature of 617 0 F was reached. A few seconds later, two phases of the motor stator windings opened. At 7 minutes after power application, maximum motor case temperature, 405 0 F, was reached, at which time both rotor and case temperatures began to decrease. Both temperatures continued to decrease until the test was terminated. At 27 minutes 16 seconds after power application, the remaining motor stator winding opened. Since no further current flow was observed in any of the three-phase motor leads, the test was terminated. The rotor temperature observed at this point was 546 0 F and the case temperature was 374 0 F. The 5-ampere circuit breakers did not trip during the test. The maximum current flow recorded during the test was 1.85 amperes per phase. After the motor assembly cooled, it was examined. Examination revealed that the rotor was heavily darkened around the circumference of the rotor area which aligns with the stator. The rotor was intact and appeared undamaged. The stator exhibited a heavily darkened area around its circumference where it aligned with the rotor. X-rays of the stator did not reveal any internal electrical arcing or melting. 1.16.5 Fire and Heat Tests During the investigation, the Safety Board conducted flammability tests on the materials contained in the Heath Tecna cabin interior assembly kit. In addition, tests were conducted to determine the effects of fire and/or heat flux on DC-9-32 lavatory components, flush motor pump components, wiring bundles, wire insulation, and waste materials. These tests were conducted at the FAA Technical Center, Pomona, New Jersey. Cabin Materials Burn Tests.--The materials contained in the Heath Tecna Kit were subjected to the current standard Bunsen Burner tests as set forth in 14 CFR 25.853. (See appendix F.) All of the materials tested met prescribed standards. A piece of polyurethane seat cushion, similar both in time of service and in composition to the seat cushions on Flight 797, was subjected to vertical and horizontal Bunsen Burner tests. The material failed the vertical test but passed the horizontal test.

-39- The FAA project manager in charge of full-scale fire testing at the Technical Center was asked why the material had failed the test after only 18 months in service. He speculated that the particular piece of foam tested had lost some of its fire-retardant capabilities because of the effects of wear and body moisture on the outer surface. He testified at the Board's public hearing that Center technicians had encountered similar failures when testing older seat cushion materials and that he did not believe that the degraded capability of the seat cushion would have contributed to the propagation of the fire on Flight 797. Cold Air Supply Line Tests.--The susceptibility to heat of a cold air supply line similar to the one that had melted through on Flight 797 was evaluated. A sample cold air supply line was placed near an electric'2lly powered heat element capable of producing a radiant heat flux of about 7 BTU/ft -sec. The amount of heat flux was controlled by placing the subject line at predetermined distances from the heat source. The cold air supply line was capped at one end, and as the line heated, a constant internal pressure of 1 psi was maintained by manually opening a relief valve. During each test, the aluminum cold air supply line was held stationary for about 15 minutes until there was no noticeable increase of pressure within the line. Three tests w~re conducted. The heat fluxes in the cold air supply line were about 2, 5, and 7 BTU/ft -sec. There was no evidence of heat damage to the line and hardness test results showed that the line remained within its specified tolerances. The BTU's generated from burning paper towels were also evaluated. Three paper towels were crumpled by hand and ignited by a match, and thE2 heat flux was measured. The maximum measured heat flux was about 4 BTU/ft -sec, and the temperature was about 1,200° F. The heat generated by burning toWels r'ith and without airflow was also evaluated; the maximum heat flux remained at 4 BTU/ft -sec. DC-9-32 Lavatory Mockup Tests.--A partial DC-9-32 lavatory was constructed with actual airplane hardware. Tests were conducted to explore the effects of radiant heat from a toilet flush motor on adjacent lavatory components, and the effects of fire impinging on the flush system power harness. Thermocouples were placed at various locations within the mockup to monitor temperatures. No air flow was used for these tests. A Western Gear Flush Motor, Model 353JC1, Serial No. 2984, was used in the first test. In order to simulate an overheated motor condition, the rotor shaft was mechanically restricted. The motor was then mounted on a pump assembly utilizing a cast aluminum mounting flange and installed in the waste tank. Except for the restriction of the rotor shaft rotation, these conditions simulated exactly the assembly of the accident airplane. Three-phase U5-volt a.c., 400 Hz power was supplied to the motor through a wiring harness of the same length and type as that installed in the accident airplane. The power supply end of the harness was protected by the use of three 5-ampere circuit breakers. The wiring harness in the lavatory mockup was routed similarly to the installation in the accident airplane. A flush timer was not used for this test; however, the power harness was routed to the location, in the vanity, where the timer was installed. The power harness was mated to the flush motor through the use of a junction box and normally used connectors.

-40- . Three-phase power was applied to the motor until all three stator windings of the motor had failed open. Light smoke was observed coming from the toilet bowl about 5 minutes 45 seconds into the test. Subsequently, the phase-A, -B, and -C stator windings failed open at 6 minutes 40 seconds, 17 minutes 45 seconds, and 11 minutes 25 seconds, respectively. The maximum motor case temperature -- 431 0 F -- was reached at 9 minutes 45 seconds after power was applied. The maximum temperature on an adjacent lavatory component (toilet shroud) of 157 0 F was reached 13 minutes 55 seconds after power was applied. Twenty-five minutes of data was recorded at which time the test was terminated. No evidence of any deformation, discoloration, or overheating of any of the vanity or waste tank components was observed. ' The flush motor was removed from the lavatory mockup and examined. Oily residue was found below the motor case on the mounting flange. When the top cover plate of the motor was removed, evidence of overheating of the cover gasket, rotor, and stator assemblies was apparent. The rotor appeared locked when hand rotation was attempted; but when additional torque was applied to the shaft, the rotor turned freely. The rotor assembly was removed and evidence of arcing at numerous points along its top outboard face was observed. The stator assembly was removed from the motor case and examined. The lower gasket under the stator assembly was intact; however, oily residue was observed. An electrical continuity check was made of the stator windings; no continuity was observed phase-to-phase or each phase-to-neutral. However, there was high resistance continuity between the phase-B winding to the stator assembly case, and the phase-C winding to the case. These resistance readings were greater than 2 megohms and 1.3 megohms, respectively. The wire harness which provides power to the stator assembly show~d no sign of damage. ~ In the second test, a flush motor housing containing a controllable electric heating element was placed in the waste tank in the lavatory mockup. The voltage to the heating element was then increased until the temperature on the outside the motor case reached a maximum of slightly above 800 0 F. This temperature exceeds by nearly 100 percent the highest temperature that has been reported on this type of motor. The maximum temperature of 8030 F was reached 42 minutes into the test. Forty-four minutes into the test, the maximum temperature on an adjacent lavatory component -- the toilet shroud -- had reached 255 0 F. Power was removed from the heating element. The only observable change to any lavatory component was in a 5-inch-square area in the aft outboard corner of the toilet shroud directly above the flush motor. This area was deformed upward to a height 2 1/4 inches above the shroud support bracket on the forward face of the vanity. There was no discoloration, melting, or any other deformation of the shroud; however, some adhesive material, used to bond a doubler to the underside of the shroud around the toilet bowl cutout, flowed from the bond line and dripped onto the flush motor case. The adhesive also dripped onto the elastomeric hose running from the flush pump mounting flange to the toilet bowl. The motor case remained intact; however, obvious signs of overheating were present. The name plate on the top cover was completely blackened, and the inside of the cover was brown around the outer edge, becoming lighter toward the center. Flush Motor Power Harness Fire Test.--A test fixture was constructed using a piece of 0.030-inch sheet aluminum 21 1/2 inches by 6 inches. A 1 1/2-inch diameter lightening hole was cut in the fixture, an alligator grommet was installed around the

-41- lightening hole, and a nylon cable clamp was installed above the hole. A flush system power harness and a flush motor harness supported by the cable clamp were routed through the lightening hole perpendicular to the test fixture. This configuration simulated the lavatory vanity structure, lightening hole, and flush system wire routing in the lower outboard forward vanity area of the accident airplane. The flush system primary power harness used for this test consisted of eight conductors of MIL-W-5086 type wire bundled in heat shrink tubing. One end of the harness was connected to a U5-volt a.c., 3-phase, 400-Hz electrical power source and to ground. The harness was protected through the use of three 5-ampere circuit breakers connected at the power supply end of the circuit. The other end of the harness was not connected so as to simulate power being supplied to a flush timer that was not activated (flush button not pushed). The test fixture was electrically grounded to the same point as the harness. A portable propane torch was used as the heat source. The torch was positioned under the fixture and the nozzle was removed from the torch in order to produce a broader flame pattern. The torch was adjusted so that the flame's vertical height covered the entire height of the test fixture and the width of the flame was sufficient to cover the diameter of the lightening hole and adjacent structure. Three-phase a.c. power was applied to the test fixture, and the test began when the propane torch was placed under the test fixture. After 28 seconds, the nylon cable clamp began to melt and drip. After 40 seconds, the wire bundles fell and rested on the bottom of the lightening hole. At 4 minutes 7 seconds into the test, audible arcing was heard and electrical arcing was visible where the wire bundles contacted the bottom of the lightening hole. Less than a second later, all three circuit breakers tripped in rapid succession. The flame impinging on the power harness and flush motor harnesS self-extinguished. The heat generated by the torch was measured using a calorimeter and therm020uple. The heat flux from the flame area that impinged on the wires was 4.4 BTU/ft -sec at a temperature of 1,650 0 to 1,700 0 F. A continuity check was made of the power harness before it was removed from the test fixture. Phase B-to-ground measured 175 ohms, and phase C-to-ground measured 90 ohms. Both wiring harnesses were removed from the test fixture and examined. The power harness was discolored for about 2 1/4 inches. The length of harness that was actually burned was 1 3/8 inches. The area of the harness that had burned through was examined under high magnification. At least one conductor clearly showed evidence of electrical arcing -- a copper ball could be seen on the wire. The flush motor harness was discolored for 2 inches and was actually burned for about 3/4 inch. Chafe Tests of the Flush Motor Power Harness.--The Safety Board conducted chafe tests of the flush motor wiring harness at the FAA Technical Center using an exemplar power harness from an Air Canada DC-9. In order to simulate a flush timer in its normal state with a deactivated flush button, the harness was powered; however, no load was connected. The harness was routed through the lightening hole between the amenities and toilet sections and then pUlled back and forth vigorously through the hole by two persons. During the pulling, which encompassed a distance of 2 inches, a heavy downward force was exerted against the structure of the lightening hole.

-42- The first chafe test was conducted with the nylon alligator grommet around the surface of the lightening hole. After 10 minutes of rubbing, the outer heat shrink cover of the harness was penetrated. The outer nylon insulation of two of the eight wires in the harness had been chafed slightly; however, the insulation had not been penetrated. The same test was conducted with the alligator grommet removed. After 2 minutes of rubbing, the heat shrink outer covering had been penetrated and the nylon outer insulation of one wire was chafed. After 3 minutes, the insulation of one wire was penetrated exposing bare conductors; however, no electrical activity was observed. After 4 minutes, the exposed wire broke. After about 8 minutes, electrical arcing occurred between another wire in the harness and the structure of the lightening hole, but none of the circuit breakers tripped. The test was resumed, and 2 seconds later, the exposed wire severed at the point of contact with the lightening hole. The phase-B circuit breaker tripped simultaneously with the severing of the wire. The method used to expose the wires in the harness during the two tests was not intended to duplicate what would occur during actual operating conditions had either the harness support failed, or had the alligator grommet been missing, or both. Given the light weight of the harness, even had the support and the grommet been missing, the harness would not have been subjected to the abuse during actual operating conditions that it was subjected to during the tests. The tests were conducted to determine what would occur if the wires in the harness were exposed and to determine the effort required to abrade the insulation and chafe the wires. 1.16.6 Airplane cabin Fire Research ,> Small scale individual fire tests of cabin materials do not replicate the dynamic range of conditions present in actual cabin fires. Consequently, about 1978, the FAA instituted a research program at its Technical Center involving full scale cabin fire tests. The tests are conducted in a full scale, wide-body test platform, constructed from a surplus McDonnell Douglas C-133 airplane. The purpose of the tests has been to understand and demonstrate the behavior of cabin materials in a postcrash fire. The results of these tests were described at the Safety Board's public hearing by the FAA project manager in charge of full-scale fire testing and are also contained in the Advisory Group for Aerospace Research and Development (AGARD) Report L8-123, "Aircraft Fire Safety." Of particular relevance to this accident are those data relating to flashover, flashfire, seat-blocking, and cabin hazards created by burning interior materials. The FAA project manager testified that two main phenomena occur when large fires are expanding; one is the flashover, the other is flashfire, and most often, they occur in combination. Flashover in an airplane cabin environment occurs when enough heat has built up along the ceiling so that the radiant flux down to the materials below the heat layer reaches a level that is high enough to cause an almost instantaneous ignition of the material. FAA research has indicated that flashover produces nonsurvivable conditions throughout the cabin within a matter of seconds. Flashfire is the burning of combustible gases. According to the FAA project manager, it "is really a mild explosion." Flashfire occurs when materials in a localized area burn and emit combustible gases. The combustible gases, a result of incomplete combustion, accumulate until they reach a flammable limit and will, if there is a source of ignition, ignite. The resultant fire will propogate rapidly, usually at the ceiling where the combustible gases have collected. With regard to the ignition source, the FAA project

-43- manager testified that the fire itself usually provided the source of ignition. Again, conditions inside the cabin will become nonsurvivable within a matter of seconds. Since flashfire is dependent on the concentration of heat and combustible gases in the upper levels of a cabin, airflow through the cabin would reduce the buildup levels by dispersing and venting some of the products overboard. The FAA project manager testified that airflow through a cabin would have a "vast influence on delaying" a flashfire. The AGARD Report presents a survival model relating the effect of height above floor level on survivability. The model takes into consideration the effects of heat, carbon dioxide, carbon monoxide, hydrogen cyanide, and irritant acid gases such as hydrogen fluoride and hydrogen chloride. The report states that the survival model is hypothetical and its main purpose is to provide a means of predicting the time-of- incapacitation within a fire enclosure based on measures of elevated temperature and toxic gas concentration which change, in some cases substantially, with time. Thus, it is a tool for reducing a fairly large number of somewhat abstract measurements into a single, cogent parameter: time-to-incapacitation, or the hypothetical time at which an average individual can no longer escape unassisted. How well the model relates to escape potential under actual fire conditions is unknown and, realistically, cannot be determined. It has been long recognized that a zone of safety exists near the floor inside an enclosure in which there is a fire. The validity of this belief was examined by measuring the major hazards at three elevations and calculating the survival time at each elevation. The calculated data showed that the survival times at 1 feet 6 inches, at 3 feet 6 inches, and at 5 feet 6 inches were 202 seconds, 193 seconds, and 159 seconds, respectively. 11/ 1.17 1.17.1 Other Information Air canada Operational Procedures Air Canada flightcrew's normal, abnormal, and emergency operational procedures are contained in its DC-9 Airplane Operating Manual (AOM). In addition to the flightcrew's normal, abnormal, and emergency procedures, the AOM contains descriptions of, and procedures for, operating the airplane's systems and components. Unless otherwise noted, all procedures cited or excerpted herein are from the AOM. Electrical System.--Two a.c. generators, one on each engine, provide electrical power for the airplane. A third a.c. generator, driven by the APU, serves as a standby a.c. electrical power source when the airplane is in flight. Four transformer rectifier (TR) units transform and rectify the a.c. power output of the generators to provide a supply for all d.c. operated services and units. Automatic protective circuits will isolate the affected part of the a.c. system if certain faults occur and advisory annunciator panel lights located on the annunciator panel will indicate these conditions to the flightcrew. Two nickel cadmium (Nicad) batteries are installed to supply a limited portion of the d.c. distribution systems under certain abnormal conditions and the batteries are maintained in a charged condition by a battery charger unit. In the event all a.c. generating capability is lost, the flightcrew can place the emergency power switch to "on" and route battery power to the emergency d.c. bus and emergency inverter. The emergency inverter, in turn, powers the emergency a.c. bus and provides a.c. power to essential airplane components among which are the airplane's attitude and heading indicating instruments. !!/ AGARD Report LS-123, page 6-18, Figures 9(a) and 9(b).

-44- Individual units are protected by individual trip-free circuit breakers. These, when tripped, cannot be electrically reset until cooled. Those units requiring three-phase supply will have individual breakers in each phase. Electrical S stem Abnormalities.-The procedures to be followed in the event of circuit breaker trip s are contained in the abnormal operation section of the AOM. Unless directed otherwise in a specific abnormal operation, the pilots may attempt to reset any tripped circuit breaker. The procedure notes that it may be necessary to allow about 3 minutes cooling time before a circuit breaker will reset. It also states, "If the breaker will not latch or trips immediately after reset, leave,the breaker open (out)." The procedure also contains the following note, "All circuit breakers protecting a single phase are trip free. Manually holding in a breaker which will not latch, will not complete a circuit." The Air Canada Manager of Flying Operations testified that if a circuit breaker cannot be reset, flightcrews are instructed to wait for "an appropriate cooling period" and then try to reset it. If the reset fails, the circuit breaker is left out. He testified that "no more investigation is required because the electrical power to the malfunctioning circuit has been cut off and you don't want to do anything that might restore it." The emergency procedures section of the manual contains a checklist for detecting the source of electrical smoke or fire. The 4-page checklist essentially requires the pilots to shut down each of the airplane's electrical systems, assess the quantity of smoke, and then turn on each component of the system one at a time in order to ascertain which component is the source of the smoke. } Smoke Removal Procedures.--The following abnormal procedures concern the removal of smoke from either the cockpit or the passenger cabin of the airplane: The procedure used by Air Canada for removing smoke from the passenger cabin by opening the right forward galley door and aft pressure bulkhead door was developed by McDonnell Douglas. Its DC-9 cabin smoke removal test flights showed that when the right forward galley service door and the aft pressure bulkhead door were unseated, smoke introduced into the cabin by smoke generators was forced forward and out of the galley service door. This flow pattern was the result of the differential in airflow outside the two doors. The higher local airflow outside the galley service door produced a lower outside ambient pressure at the galley service door relative to the ambient pressure inside the tailcone at the aft pressure bulkhead door, thus forcing the smoke forward and out the galley service door. The procedure was presented to the FAA for approval as an emergency procedure and was rejected. According to the FAA DC-9 project manager test pilot, FAA disapproval was not based on the efficacy of the smoke removal capability, but on the fact that it required a flight crewmember to leave the cockpit to operate the doors during a period wherein it believed his presence was required in the cockpit. According to the test pilot, the FAA flight test personnel were not authorized to judge whether or not the door operation could be performed by flight attendants; therefore, based on the foregoing, the procedure was disapproved. However, the regUlations did not preclude the manufacturer from providing the procedure to DC-9 operators as a manufacturer's recommended procedure. McDonnell Douglas provided the procedure to its DC-9 operators, and Air Canada, with the approval of Transport Canada, incorporated the procedure in its AOM.

-45- During the public hearing, a fire protection engineer who had participated in the on-scene investigation as a member of the Safety Board's structures group testified that in his opinion, if these doors had been opened as envisioned in the abnormal procedure, "there's a very strong potential that (the forward airflow) would have pulled the fire out of the lavatory into the cabin and certainly would have moved the smoke forward and faster over the passengers heads." He stated that it would have endangered the passengers and also the safety of the airplane. According to the captain, and the Air Canada manager of flight operations, the company did not advocate using the cabin smoke removal procedure unless the fire was out. The captain also testified that the procedure required the first officer to leave the cockpit in order to either supervise the opening of the doors or to open them. In the circumstances of the accident flight, given the airplane's electrical and mechanical problems, he believed the first officer was needed in the cockpit. Therefore, the captain did not consider ordering the crew to use the cabin smoke removal procedure. Emergency Descent Procedures EMERGENCY DESCENT "atructurallntagrity ia in doubt. limit 1PMd" much.. poasible Ind Ivoid high mlneuverlng Ioada. • IGN Selector OVERRIDE • CABIN SIGNS ON • AUTO PILOT OFF • THROTILES ..........................•.......•... CLOSE • SPEED BRAKES .......................•......•... EXTEND • Inlttlteo-acent O.7SM/320-350KIAS • Do not exceed 10' pitch down. • Do not retrlm horizontal atablllzer. A"ER DESCENT When at minimum altitude. advl.. Flight At1endlnta to reaume ,.atricted operiliona and oxygen therapy al required. Cabin altitude below 10,000 ft CREW OXYGEN MASKS STOW PI. Announcement AS REQUIRED Air Conditioning and Pressurization System.--Airplane pressurization and air conditioning is provided by the left and right air conditioning and pressurization packs (packs) which are supplied bleed air from their respective engines. Normally, the right system supplies the air requirements of the cabin and the left system supplies the air requirements of cockpit. The AOM states, "The distribution of conditioned air to the flight compartment is designed as a continuous smoke removal system." With the packs operating, conditioned air enters' the cabin through ceiling outlets. The air is exhausted through perforated panels at the cabin floor line and through the left and right tunnels in the cargo bays to the outflow valve. The outflow valve controls the exhaust rate to the atmosphere. The airflow in the cockpit is similar to that of the cabin. Opening the outflow valve, either manually or electrically, causes the airplane to depressurize. Engine bleed air is furnished to the packs from the engine's 8th stage (low pressure) or 13th stage (high pressure) bleed air manifolds, depending upon engine power settings and the demands on the pneumatic supply. If the pack supply switch is in the

-46- "auto" position and the low pressure bleed air decreases to about 18.5 psi or less, the system's augmentation valve opens and high pressure bleed air is introduced into the system to maintain 18.5 psi. When bleed air pressure returns to 18.5 psi, the augmentation valve will close. (The augmentation valves are powered by the left and right d.c. buses and will fail closed if electric power is lost. The other two valves in the system -- the flow control and pressure regulation valves -- are powered by the d.c. emergency bus and will fail open if electric power is lost.) During a descent, if the engines are at flight idle thrust, high pressure bleed air is required to maintain the minimum system pressure. At level flight thrust settings, at any altitude, the low pressure bleed air will maintain the pneumatic pressure at or above 18.5 psi. At 33,000 feet, in level flight and with the pack switches in "auto," the entire cockpit and cabin air volume (4,391 cubic feet) is exchanged every 2.2 minutes. During descent to 3,000 feet with the engines at flight idle thrust, the time required to exchange completely the cabin and cockpit air varies from 2.3 to 2.7 minutes. In level flight at 3,000 feet, the exchange would be completed within 2.2 minutes. The positions of the flow control and pressure regulation valves during flight could not be determined from their positions after landing. Regardless of the position of their respective pack supply switches, with no pneumatic pressure in the systems and with all electric power off the airplane, these valves would have returned to the open position. (There was no evidence that smoke entered the cabin through the air conditioning system.) With regard to·the aft lavatory, the air supply enters the aft lavatory through the louvered door and from the overhead duct. It is vented out of the lavatory through the floor and the aluminum vent tube within the toilet shroud. In addition, the flow of air in the amenities section of the vanity flows forward into the toilet area below the shroud and is also vented out of the airplane through the vent tube. Given this flow pattern, the FAA project manager was asked what effect opening the lavatory door and then chopping away the lavatory wall panels would have had on the fire. He testified that since he did not know the exact location of the fire or its intensity, it would be difficult to determine what effect opening the door would have had on the fire. "However, because there is a vast amount of air supplied through the vents in the lavatory," he did not believe that opening the door would have provided. a large amount of additional air to the fire. Consequently, opening the door might have allowed some smoke and some flames, if there were flames in the area, to escape for a short period of time while the door was open. With regard to removing the lavatory paneling, he testified that the lavatory area is not a closed container; there is already airflow in the area behind the sidewalls. He suspected that opening the area by removing the paneling "would not sufficiently intensify (the fire). It may initially get it burning a little bit, but anything that you could do to get at the fire to fight it, if you had the means of doing so, and you could do it, should be done." 1.17.2 Use of Aft Lavatory Passenger interviews indicated that the left aft lavatory was used several times during the flight. The last known passenger to use the lavatory stated that she had operated the toilet while she was in the lavatory and that it had operated normally, and she heard no unusual noises while the toilet was operating. She observed nothing unusual while she was in the lavatory and when she exited there was a male passenger waiting to enter. The male passenger could not be identified. According to the passenger, about 25 minutes after she left the lavatory, she "heard a commotion in the back of the airplane." The passenger also stated that she does not smoke.

1. 17.3

Smoke Detectors -47- The lavatories on board Flight 797 were not equipped with smoke detectors nor were they required to be so equipped by either Canadian or United States regulations. With regard to the capability of a smoke detector to detect the fire on board Flight 797 during its early stages, the FAA project manager testified that it would have depended upon the location of the detector. Had a smoke detector been placed under the lavatory seat, it might have detected a fire in that area very early after ignition. However, if a fire was in the lavatory itself, a detector under the seat might not have detected it early. He testified that, if the fire had been behind the walls of the lavatory, a detector installed below the lavatory seat might not have detected the fire because the airflow in the area might have been very small and flowing down the sidewall out of the lavatory and away from the detector rather than toward it. The evidence developed by the Safety Board during the investigation showed that while technology has reached a point where smoke detectors that could be used in airplane lavatories are available, unresolved problems curtail their acceptability. Among the problems noted by air carrier operators were locating the detectors, the sensitivity of the detectors, and the reduction of the false alarm rate to one that would be acceptable to an operator. However, since the public hearing, two U.S. air carriers have voluntarily installed smoke detectors in the lavatories of their airplanes. To date, these carriers have indicated that they have not experienced false alarm problems with the installations. One of these carriers, Pan American World Airways, installed residential type, battery operated ionization detectors on the ceilings of the lavatories of all the airplanes in their fleet. Since January 1, 1984, they have had 35 to 40 smoke deteCtor alarms. Tw_o of these alarms were caused by actual lavatory trash bin fires. The fires were caused by cigarette ignition of waste paper in the bin. In these two incidents the smoke detector activated before the automatic Halon suppression system in the trash container activated. The majority of the other incidents were the result of passengers smoking in the lavatories and air contamination of the cabin environment from some external source such as the airplane engines. 1.1'1.4 Examination of Other DC-9 Airplanes During the investigation, the Safety Board examined the circumstances surrounding a report of heavy smoke which originated in the aft lavatory on board a chartered DC-9. The examination disclosed that the aft lavatory flush motor had overheated and had emitted smoke; however, there was no fire. During the examination of the vanity area, which was identical to that in the Air Canada DC-9, paper debris and a bottle top were found beneath the trash container and to one side of the trash container. Toilet paper was found on the Jower shelf of the amenities section and the lightening hole containing the flush motor power harness was stuffed with wadded toilet paper. 1.17.5 Air Traffic Control Procedures The Indianapolis ARTCC and Cincinnati TRACON controllers provided ATC assistance to Flight 797 at the onset of the emergency, during the emergency descent, and during the subsequent landing. Indianapolis Center was equipped with a National Airspace System Stage A (NAS Stage-A) computer; the Cincinnati TRACON was equipped with an Automated Radar Terminal System ill (ARTS ill) computer. The NAS Stage-A computer can track, display, and attach a data block to a nonbeacon or primary target; the data

-48- block displays the airplane's call sign, ground speed, and last assigned altitude. The ARTS III computer in service at the Cincinnati TRACON could not track, display, or attach a data block to a primary target; however, the airport surveillance radar was capable of displaying an airplane's primary target. Since Flight 797's transponder was inoperative, an automated handoff of the flight from Indianapolis Center to the Cincinnati TRACON was not possible. Therefore, the controllers used the interfacility landline to hand off the flight manually. FAA Order 7110.65C, "Air Traffic Control," January 21, 1983, contains the recommended procedures for transferring radar identification of an airplane from one controller to another or from one facility to another. Controllers are required to be "familiar with the provisions that pertain to their operational responsibilities and to exercise their best judgment if they encounter situations that are not covered by it (the Order)." The procedures require the controller initiating a manual handoff to convey to the receiving controller that he has a ''handoff.'' Thereafter, he shall provide the receiving controller with the position of the target relative to a fix, a map symbol, or a known radar target which is displayed on the screens of both the receiving ~ontroUer and the transferring controller. The controller initiating the handoff should provide the airplane identification, its assigned altitude, any restrictions, and if applicable, whether the airplane is climbing or descending. He should also advise the receiving controller of pertinent information not contained in the data block or flight progress strip. Pertinent information includes assigned heading, airspeed and altitude restrictions, observed track, and beacon code if different from that normally used or previously coordinated. The receiving controller shall, in turn, insure that the target's position corresponds with that given by the transferring controller or that there is an appropriate association between an automated data block and the target being transferred before accepting a handoff. Paragraph 661b of the Order states, "If identification is questionable for any reason, take immediate action to reidentify the aircraft or terminate radar service." With regard to identifying a primary target, paragraph 654 states, in part, that a primary target can be identified by "observing a target make £ingl an identifying turn or turns of 30 degrees or more, provided•.•only one aircraft is observed making these turns." Three methods of identifying beacon targets are provided in paragraph 655. The controller can either request the airplane to activate the identification (ident) function of the transponder and then observe the identification display; request the airplane to change to a specific discrete or nondiscrete transponder code and then observe the display change; or request the airplane to change its transponder to "standby" and observe the loss of the beacon target, then request the airplane to return the transponder to normal, and observe the reappearance of the beacon target. The Louisville high controller said that the handoff of Flight 797 to the Cincinnati TRACON was a "team effort," between him and the LEX-D controller. The LEX-D controller's position, which was located across the aisle from the Louisville high controller's position, is a nonradar position and is responsible for coordination between sectors, flight plan updating, and computer inputs. The LEX-D controller, who was radar-rated, had not been in direct communication with the Louisville high controller; however, he had overheard him discuss the emergency with Flight 797. The LEX-D controller did not cross the aisle either to observe the Louisville high controller's

-49- radarscope or to talk with him. He said that he tried to configure the radarscope next to his position to obtain a transponder code and data block on Flight 797, but his initial attempts failed. He knew the flight was being vectored to land at Cincinnati; therefore, at 1909:17, he called the Cincinnati TRACON on the landline to alert the Cincinnati approach controller of an impending handoff in his southwest sector. He also asked his radar controller seated at the radarscope next to his position to program the computer to display Flight 797's data block so that he could get its transponder code for the handoff. The LEX-D controller stated that he also had overheard Flight 797 receive clearance to descend to 5,000 feet and to turn to 060°. He knew the airplane had an onboard fire, but he was not aware of its electrical problems. According to the Center's standard operating procedures, Flight 797 should have been handed from. Louisville High Radar Sector to the Evansville/Nabb Low Radar Sector and then to Cincinnati approach control. The LEX-D controller said that he independently made the decision to effect a direct handoff of Flight 797 from the Louisville high controller to the Cincinnati approach controller. The LEX-D controller said that, when the approach controller accepted the handoff, he did not hear the approach controller say the 0662 transponder code; he only heard him say the altitude. He said that, at that moment, he was talking directly to his radar controller seated beside him and he believed that the "yeah" in his response was directed to his radar controller. He was not aware that he had also transmitted the word "yeah" to the Cincinnati approach controller when he called later to correct the altitude. According to the LEX-D controller, by 1909:25, Flight 797's primary target symbol and data block were being displayed on the adjacent radarscope. However, he did not tell the approach controller that Flight 797's transponder was "inoperative because he was not sure that it was, in fact, inoperative. He stated that a beacon can be missed for several sweeps of the radar antenna, and in the interim, until it is reacquired, the computer will display a primary target symbol on the radarscope. The LEX-D controller stated that there were no beacon targets near Flight 797 during the handoff. He believed that he had pointed out the correct target and that the Cincinnati approach controller had accepted the target he had pointed out. Thereafter, at 1910:01, the LEX-D controller called the approach controller on the landline and told him that Flight 797 had been assigned a 060° heading and that the approach controller repeated the heading and signed off with his operating initials. At 1910:08, the LEX-D controller told the approach controller that the flight was descending to 5,000 feet. When the Cincinnati approach controller was alerted to the impending handoff, he saw a westbound beacon target in the southwest sector of his radarscope. The target was above the 12,000-foot upper altitude filter limit of his scope and was displayed as an asterisk with no data block. As a result of the 1909:23 and 1909:25 transmissions from the LEX-D controller, he knew he was accepting an emergency but he also expected to receive a transponder coded handoff. He used his computer trackball 12/ slewed to the target he had observed earlier, entered the position into his computer; and received a partial data block containing a 0662 transponder code and the airplane's altitude -- FL 350. (Under these conditions, the partial data block would only be displayed for about three sweeps of the radar antenna.) He advised the LEX-D controller of the code, the altitude he had observed, and when LEX-D answered "Yeah, thirty-three now, he's twenty- five southwest," it confirmed his belief that he had identified and accepted Flight 797.

-50- _The approach controller said that there were no other beacon targets or primary targets near the 0662 code. He said he was aware of the altitude difference, but he also was aware that Flight 797 had declared an emergency and was probably descending. Therefore, the mode C altitude data might be la~ging. At the time of the handoff, he had not been told the flight's assigned heading. Beheving he had identified the correct airplane, he assigned a radio frequency and waited for Flight 797 to contact him. The approach controller stated that after he had requested the 090 0 turn and saw no response from the target he had been observing, he observed a partial data block containing an Air Canada 797 identification tag in the vicinity of the secondary target he had initially identified as Flight 797; the TRACON supervisor also stated that he had seen this data block. About 1911, the Evansville/Nabb D controller had "forced" an amended flight plan for Flight 797 into the Cincinnati ARTS TIl equipment. The flight plan, as amended, contained Flight 797's assigned transponder code, changed its destination to Cincinnati, and stated that the flight was descending to 10,000 feet. Had Flight 797's transponder been operating, the "[orce" would have configured the Cincinnati ARTS TIl computer to accept an automated handoff at the geographic point where the computer was programmed to accept handoffs from the Evansville/Nabb sector. However, since Flight 797's transponder was inoperative, the ARTS TIl computer could not locate a beacon target to associate with the "forced" data block and the "force" merely placed the data block on the approach controller's radarscope. The data block, because it did not match a properly coded beacon target, was displayed only for about three radar sweeps. The approach controller was asked based on his emergency procedures training, how far from the threshold of runway 3g he would have had to have placed Flight 797 in order for it land on that runway. He testified that it would depend on the weather. If the descent was conducted in visual flight conditions, he thought that "the pilot might be able to descend from five or six thousand feet from a point ten miles south of the airport at a slower- speed and complete a landing. If it were an IFR (instrument flight rules) approach, he'd want to be level at twenty-five hundred feet or three thousand feet maybe seven or eight or ten miles from the airport. In this situation, it was difficult for me to judge how quickly the aircraft could descend (and) how tightly he could turn." The controller testified that he wanted to avoid vectoring Flight 797 to runway 36, have it arrive too high and too close to the runway threshold to complete the landing, and then have to circle the airport in order to land on another runway. The controller was not familiar with nor was he required to be familiar with either the indicated airspeeds or the descent rate capabilities of a DC-9-30 airplane during an emergency descent. He also said that even if he had identified Flight 797's primary target earlier he would not have turned the flight away from the airport and toward the south in order to space it to land on runway 36. He would have ''kept him going for the airport at all times." 1.17.6 ATe Radar Data Data Analysis Reduction Tool (DART) radar data information was obtained from the Indianapolis ARTCC. The data included airplane position information and available mode C altitude information for Flight 797 and for Continental Airlines Flight 383, which was transmitting on code 0662. The Safety Board's laboratory reconstructed the ground radar tracks of both Flights 797 and 383. Runways 9R-27L and !,Y A movable position identification device available to the controller to identify radar targets on his radarscope.

-51- 18-36 of the Greater Cincinnati Airport were digitized and plotted with the ground tracks. Times of key transmissions and selected key events were included along Flight 797's radar ground track. The last radar fix retrieved from the DART's data occurred at 1914:15, and the last transponder information from Flight 797 was received at 1906:12. (See figure 13.) 1.17.7 DC-9-32 Descent Performance According to the manufacturer, assuming a descent at flight idle thrust, landing gear retracted, flaps/slats retracted, speed brakes extended, at a temperature 3° C warmer than international standard atmosphere temperature (ISA +3° C), a final descent weight at 3,000 feet of 81,600 pounds, and at airspeeds of .78 Mach and 310 KIAS, Flight 797 was capable of achieving the following descent rates: at 30,000 feet at 20,000 feet at 5,000 feet 7,800 fpm 5,700 fpm 5,100 fpm The time required to descend from 33,000 feet to 3,000 feet was 5 minutes 11 seconds and the still air distance was 34 nmi. Since the touchdown zone elevation of runway 27L at the Greater Cincinnati International Airport was 875 feet, additional time would be required to complete the descent from 3,000 feet, decelerate from descent speed, configure the airplane for landing, and fly the final approach. The Safety Board constructed a descent model containing the time required to complete these phases of the descent and landing. The model is based on the following assumptions: Phase of Flight Time 1. 2. 3. Descend from 3,000 feet to 2,000 feet at 500 fpm and decelerate from 310 KIAS to 200 KIAS. Extend the landing gear, and extend the flaps incrementally; stabilize the airspeed at each flap increment. Final approach-descend from 2,000 feet to 875 feet at 750 fpm. 2 minutes 1 minute 1 minute 30 seconds Based on the times contained in this model and the manufacturer's performance data, the total time required to descend from 33,000 feet and land on runway 27L was 9 minutes 41 seconds. The field elevation at Standiford Field, Louisville, Kentucky, is 497 feet. The Safety Board estimated that 10 minutes 11 seconds would have been required to descend from 33,000 feet and land at Standiford Field.

1. 21
2. 18
3. •
4. •
5. 13
6. 12
7. •

:D." :EZ .....37 ~ W ...... CJ Zc( 1•.14 a: %... 112.03 a: 0z 117.12 KEY EXCERPTS FROM AIR TRAffIC CON11IOL TRANScRIPTS AIR CANADA SEVEN NINETY-6EVEN WOULD YOU SQUAWK ZERO FOUR ZERO FIVE AND IDENT ANY SAY ALTITUDE. ZERO FOUR ZERO FIVE. THE ALTITUDE IS EIGHT THOUSAND. ARE YOU HEADING ZERO NINE ZERO AIR CANADA SEVEN NINETY-6EVEN. SEVEN NINETY SEVEN, STOP TURN. RADAR CONTACT, YOUR POSITION IS ONE TWO MILES SOUTHEAST OF (THE! CINCINNATI AIRPORT. ITHAT lSI A NO GYRO SURVEILLANCE APPROACH ON TWO SEVEN LEFT, YOU'RE CLEARED TO LAND ON THAT RUNWAY. THE WIND ClSI TWO TWO ZERO AT FOUR. AIR CANADA SEVEN NINETY SEVEN TURNING LEFT. AIR CANADA SEVEN NINETY·SEVEN IF ABLE. TURN LEFT. OKAY WE. CHECK, WE DON'T HAVE ANY HEADING ANY MORE, ALL WE HAVE IS A SMALL HORIZON. I C1I ~ I LOU AC 117 CYG .BREYIAnDNS 'l91UI CVG '1'13:13 AC 717 '191"'41 AC 797 I '1913,10 CVG , '191:z,1iI AC 797 I '191:z,S4 CVG ,.... '1914,16 CVG INDIANAPOLIS CENTER lOUISVILLE HIOH RADAR AIR CANADA FUGHT WI GREATER CINCtNNAn APPROACH CONTROL ARRIVAUDEPARTURf WEST SECTOR SYMBOLS -AOENCY TRANSMISSIONS DEPICTED ON RADAR PLOT ··KEY EVENTS. NOT ATC TRANSMt&8IONS. DEPICTED ON RADAR PLOT. AGENCIES MAKING TRANSMISSIONS GREATER CINCINNATI AIRPORT + 1910,&3 :2Z "~-;;ONTINENTAL .383 .. "1101:41 AC 717 TRANSPONDER SIGNAL POST. '1_12 AC 717 WE'VE GOT AN ELECTRICAL PROBLEM HERE, WE MAY BE OFF COMMUNICATIONS SHORTLY, STAND BY. AIR CANADA 797 LOUISVILLE, KENTUCKY STANDIFORD FIELD + '1912,22 CVG AIR CANADA SEVEN NINETY-6EVEN, .... CAN YOU MAKE A RIGHT TURN TO ZERO NINE ZERO. '191U4 CVG AIR CANADA SEVEN NINETY·SEVEN, IF ABLE SQUAWK ZERO FOUR ZERO FIVE. '191UJII AC 797 AIR CANADA SEVEN NINETY-6EVEN, RIGHT TURN HEADING ZERO NINE ZERO. -----------" '1911~ CVG WHEN ABLE TURN RIGHT ZERO NINE .... ZERO VECTOR FOR THE ILS THREE SIX APPROACH AND MAINTAIN FIVE THOUSAND AIR CANADA SEVEN NINETY·SEVEN. '1910,30 CVG AIR CANADA SEVEN NINETY·SEVEN, • CINCINNATI APPROACH ALTIMETER THREE ZERO ZERO THREE. IDENT, PLAN RUNWAY THREE SIX ILS. WIND AT CINCINNATI TWO TWO ZERO AT FOUR, WE ARE VFR, CAN YOU MAKE IT TO THE AIRPORT. '19111-.26 AC 717 APPROACH AIR CANADA SEVEN NINETY-6EVEN, MAYDAY, WE'RE GOING DOWN. '191_ LOU AIR CANADA 717, CINCINNATI APPROACH. ONE ONE NINER POINT SEVEN. "1109,_ CINCINNATI APPROACH CONTROL ACCEPTS HANDOFF OF AIR CANADA 717 FROM INDIANAPOUS CENTER. '134 AC 797 HEADING ZERO SIX ZERO FOR SEVEN NINE SEVEN. WE NEED RADAR VECTORS TO AN AIRPORT. '1.211 LOU AIR CANADA SEVEN NINE SEVEN• INDIANAPOUS. ROGER, RIGHT HEADING ZERO SIX ZERO. '1_ AC 717 FIVE THOUSAND, LEAVING THREE THREE ZERO. AlR CANADA SEVEN NINE SEVEN. '1_41 AC 717 WE'RE GOING DOWN, WE HAVE A RRE. '1 AC 797 MAYDAY, MAYDAY, MAYDAY. 176.57 111.• 113." 161.34 171.41 STANDIFORD FIELD COORDINATES NORTH 181.5 EAST 214.0 163.23 151,1' 1&&.00 200.00 204.11 208.23 212.34 211.'" 220.57 224.. 221.80 232.12 231.03 241.14 246.21 •.37 253.411 267.10 211.72 •.83 •.• 274.01 211.18 212.21 EAST RANGE IN N.M. Figure 13.-Ground radar tracks for Flights 797 and 383.

-53- As stated earlier, the captain had inadvertently extended the speed brakes to the ground position. According to the manufacturer, during the emergency descent at .78 Mach and then at 310 KIAS, the airflow over the wings would blow the speed brake panels down to the position they would have assumed had he extended them to the position prescribed in the flight manual. Thus, despite the mispositioning of the speed brake control lever, the airplane's descent rates during the emergency descent would have been essentially the same as those cited above. At 1909:05, Flight 797 reported that it was leaving FL 330. Thereafter, it reported it was at 8,000 feet at 1912:59; at 2,500 feet at 1915:11; and, at 2,000 feet at 1916:07. Based on these altitude callouts, the average rates of descent obtained during the emergency descent were as follows: between 1909:05 and 1912:59, 6,410 feet per minute (fpm); between 1912:59 and 1915:11, 2,500 fpm; and between 1915:11 and 1916:07, 536 fpm.

1. ANALYSIS
2. 1

General The airplane was certificated, equipped, and maintained in accordance with Transport Canada and U.S. FAA regulations and company policies and procedures. The flightcrew was qualified and certificated properly and the flight attendants were qualified for the flight. Each flight and cabin crewmember had received the training and off-duty time prescribed by Canadian regulations. There was no evidence of any preexisting medical or psychological conditions that might have affected thfi! performance of the flight and cabin crews. Involved air traffic controllers were certificated properly, and each controller had received the training and off-duty time prescribed by FAA regulations. Accordingly, the Safety Board directed its investigation to the ignition and propagation of the fire; to ATC procedures; to the performance of the pilots and flight attendants after the fire was discovered; and to factors which affected the survivability of the passengers and crewmembers. 2.2 Fire Ignition.-The evidence substantiates a conclusion that when the smoke was detected by the flight attendants, there was a fire located within the vanity and/or the toilet shroud in the aft lavatory. Therefore, the Safety Board tried to identify all possible ignition sources in this area. Given the location of the fire at the time the smoke was discovered, the Safety Board identified five possible ignition sources: an incendiary or explosive device; deliberate ignition; a burning cigarette; the toilet flush motor; or the flush motor electrical harness. In addition to these five, the arcing damage found on the feeder cables of the left and right a.c. generators and the maintenance history of the airplane a.c. generating system led the Safety Board to investigate a sixth possible source of ignition-the generator feeder cables which were routed beneath the floor of the aft lavatory. Based on the examination of the physical evidence and the results of the FBI laboratory analysis, the Safety Board concluded that neither an explosive nor incendiary device was involved. Also, there was no evidence that the fire was deliberately set.

-54- . Since the tests of the materials used in the aft lavatory showed that they met the fire resistance criteria contained in 14 CFR 25, it would have been virtually impossible for either a lighted cigarette or sparks produced by electrical arcing to ignite the materials used in the construction of the lavatory. In order to ignite the lavatory partitions and walls, some combustible material capable of sustaining high temperature combustion for the amount time necessary to ignite the lavatory walls had to have burned. Therefore, in investigating the possibility that the fire was ignited by a burning cigarette, the Safety Board focused on two areas below the vanity which could have contained combustible materials and into which a cigarette might have fallen-the sink area containing the trash chute and receptacle and the adjoining- amenities section. Since the lavatory trash receptacle was the most logical place for combustible material to collect and since a burning cigarette could fall down the trash chute into the receptacle, the damage in this area was evaluated. Had a cigarette started a fire in the receptacle, the only propagation path out of the receptacle would have been the trash chute. In order for the fire to reach and short circuit the wires in the flush motor harness, it would have had to have burned from the top of the trash chute to the lightening hole containing the harness. The lightening hole where the flush motor harness wires had short circuited was several feet outboard and well below the top of the chute and the fire damage was not continuous from the top of the trash chute to the area of the lightening hole. Moreover, it was unlikely that a fire could have spread from the top of the chute, which had burned away where it attached to the sink shroud, down to the flush motor harness, shorted the wires, and then remained undetected for 11 minutes. Although there was some evidence of flame damage both in the area of the trash chute and the receptacle, the automatic Halon fire extinguisher had discharged only into the chute. The evidence showed that as the trash receptacle was being heated by the fire, warm air within the receptacle rose into the trash chute, and was trapped in the area where the heat-activated discharge nozzle was located. Based on the damage in this area, the Safety Board concludes that the air reached the melting point of the nozzle before the temperature below the sink could attain that level and the entire Halon supply was discharged into the trash chute. In addition, since there was no evidence of a continuous flame path from the top of the trash chute down to the area of intense fire damage under the vanity, the Safety Board further concludes that the fire did not originate within the trash chute. Also the presence of unburned trash within the trash receptacle further corroborates this conclusion. The amenities section of the vanity was almost completely destroyed by fire. The flame patterns showed that the area of most intense burning was in the lower aft outboard corner of the void space located in the lowest level of the amenities section and almost directly below the failed cold air supply line. The fire was so intense that it melted a part of the aluminum bottom shelf in this area, while the remainder of the shelf remained intact. Since the cold air supply line outlet was closed, there was no airflow through this pipe initially. However, once the line melted through, airflow began which supplied air to the fire and caused it to intensify. The cold air supply line break coincided almost exactly with the most intensely burned area on the aft bulkhead. Given this evidence of fire damage and given the fact that the amenities section adjoins the sink area containing the trash chute and receptacle, the Safety Board attempted to determine whether a lighted cigarette could have penetrated the void space of the amenities section. An aluminum partition separated the sink section containing the trash chute and receptacle from the open space below the amenities section. However, about 4 inches above the floor there is a 4-inch-square hole in the partition through which loose material

-55- can pass into the open space beneath the amenities section from the area beneath the sink. Thus, if the fit between the trash chute and waste disposal door or between the chute and trash receptacle had not been secure, it is possible that a lighted cigarette placed in the chute partition could have fallen from the chute and thereafter rolled or made its way through the hole into the open area below the amenities section. The fact that debris can enter this area was illustrated by the discovery of the vial and maintenance tag below Flight 797's vanity, and the waste materials found in this area on another air carrier's DC-9. The Safety Board concludes that the possibility that this occurred cannot be ruled out. To investigate the possibility that the fire was ignited as a result of an overheated flush motor, the Safety Board conducted two tests. The highest temperature achieved during the tests was 803 0 F, which was not high enough to ignite lavatory components in the vicinity of the flush motor. In addition, the motors used in the tests were damaged internally by heat. The flush motor involved in the accident did not show any evidence of internal heat damage or internal failure. In order for the flush motor to overheat in service, three malfunctions must take place: the motor must seize; the flush button must be held in or fail in the depressed, or power on, position; and finally, the timer must either be defective or fail. (A properly functioning timer will limit the flush motor to a 10-second cycle even if the flush button is held in the depressed position. Once the timer cycles the motor off, the flush button must be released and then depressed again to restart the motor.) The recovered components of the timer circuitry were tested functionally after the accident and were found to be operational. The last known person to use the lavatory did so about·35 to 40 minutes before the fire was detected. She stated that the flush motor worked properly at that time. She also stated that another passenger was waiting to enter the lavatory when she left; therefore, the Safety Board concludes that the flush motor was operating normally within 35 to 40 minutes before the fire was discovered. Given the facts that (1) the test demonstrated that an overheated flush motor would not produce temperatures high enough to ignite adjacent lavatory materials; (2) evidence showed that the flush motor had not failed internally and was not damaged internally by heat; (3) there was no evidence to indicate that the flush motor timer had failed; and (4) the flush motor was most probably operating normally before the fire was discovered, the Safety Board concludes it unlikely that the flush motor was the source of ignition of the fire. Another possible source of ignition near the area where the fire was discovered was the flush motor wiring harness. The tripping of the three circuit breakers accompanied by the arcing sounds recorded by the CVR occurred at 1851:14. The three circuit breakers tripped almost simultaneously indicating that the circuitry of all three phases shorted at the same time. The only evidence of wiring damage was found where the flush motor wiring harness passed through the lightening hole in the partition between the amenities section and the toilet section of the lavatory. The damage noted in the wiring harness at this location could only have been the result of fire and heat, and the Safety Board concludes that the damage to the wiring which caused the three flush motor circuit breakers to trip was caused by heat and fire. Beginning 3 minutes 2 seconds before the three circuit breakers tripped, numerous arcing sounds were recorded on the CVR. These sounds were accompanied by voltage fluctuations and the electrical components which showed these fluctuations, as well as the flush motor, were all powered by the right a.c. bus. Because of the extensive

-56- fire damage in the area, it could not be determined whether the flush motor electrical harness had been properly suspended in the lightening hole, or whether the protective grommet had been installed around the rim of the lightening hole. Based on the available evidence, a hypothesis that the grommet was missing and that the wires were not suspended properly before the fire cannot be supported readily by tangible evidence. However, assuming that this may have occurred, tests were conducted after the accident which showed that, although considerable force and effort were required to expose the conductors, the harness could chafe against the exposed edge of the lightening hole. The tests showed that the chafed wire could arc against the edge of the hole without causing the circuit breaker to trip. Such an occurrence could account for the unexplained arcing signals noted on the CVR. A trash fire ignited by this initial arcing could explain how an external heat source was generated which melted through the insulation of the remaining wires and caused the circuit breakers to trip simultaneously. Also, tests demonstrated the simultaneous tripping o~ the three circuit breakers after a 4-minute exposure of the harness to a 4.4-BTU/ft -sec external flame. Since the flammable source which fueled the fire initially could not be identified, the flame used in the test might not have been representative of the heat level of the initial fire aboard Flight 797. Although the Safety Board cannot eliminate the flush motor electrical harness as a possible ignition source, given the facts that (1) the tests demonstrated that a great amount of effort and force was required to chafe away the flush motor harness and the insulation of the wires in the harness; and (2) the fact that the harness would not have been subjected to the abuse during actual operating conditions that it was subjected to during the tests, the Safety Board concludes it unlikely that the chafing of the harness wires against the lightening holes was the source of ignition for a fire in the amenities section of the aft lavatory. The sixth P9Ssibility of an ignition source -- a high resistance short circuit on a generator feeder cable where it passed through the lightening hole in the floor beam below the lavatory floor at FS 980 - was considered primarily because of clear indications of arcing between the left and right engine generator feeder cables and the floor beam. These indications consisted of a notch burned into the floor beam at FS 980, chafed areas on both engine generator feeder cables which exposed the bare conductors at FS 980, and the physical indications of short circuiting on the exposed conductors of both feeder cables. Further, this potential ignition source was in proximity to the floor of the aft lavatory. In addition, this ignition source was given consideration due to repeated electrical problems with this aircraft prior to the fire and the "electrical arcing" sounds recorded on the CVR. This arcing was recorded 3 minutes prior to the tripping of the three circuit breakers on the lavatory flush motor. A decrease in the right a.c. bus voltage occurred simultaneously as recorded on the DFDR. For ignition from this source to occur, the cable must have contacted the aluminum frame at FS 980. This would assume that the conduit was either missing and/or broken, that the cables were not supported properly at FS 980, and that the differential current fault would have been of a low order which would elude the protective circuits designed to trip the generators. Given these conditions, it appears possible that sufficient electrical energy could be transferred from the cable to heat and eventually ignite the nylon conduit and propagate a fire to other combustible materials, probably the epoxy behind the aft and side walls of the lavatory. The damage and destruction which occurred beneath the lavatory floor in the vicinity of FS 980 precluded a determination of whether the generator feeder cables were properly suspended within the lightening holes at that location; however, the evidence of chafing in the fiberglass insulation of the generator feeder cables where they passed through the lightening hole at FS 980 indicates that the cables may not have been properly

-57- supported, and that they could have sagged and chafed against the floor beam. Further, although the fault protection circuitry had actuated and had tripped the generators off the line, this occurred about 14 and 16 minutes after fire damage had caused the three circuit breakers of the flush motor harness to trip. Since the protective circuitry only operates when the current differential between the generator and the bus exceeds about 20 to 40 amperes, it appears that a transfer of up to 40 amperes through the abraded cable insulation could have provided sufficient heat to have ignited the nylon conduit. In an effort to examine the possibility of the generator feeder cables as an ignition source, the electrical system discrepancy reports were reviewed to determine whether any might have indicated an intermittent electrical short circuit in the generator feeder cables. The analysis failed to disclose a problem that could be related to such a condition in the feeder cables, even though the electrical problems continued up to the time of the accident flight. Because of the extensive damage at FS 980, it was not possible to determine if the electrical wiring was properly secured and protected, nor was it possible to positively establish a fire pattern which would permit a conclusive determination that the fire started as a result of a generator feeder cable fault. However, this possibility could not be dismissed. Propagation.-Regardless of the ignition source, the physical evidence showed that there was an area of intense burning in the lower aft outboard corner of the lowest section of the amenities section, and it also showed that the fire propagated forward from that point. As the fire moved forward from the amenities section, it also burned through the lavatory walls allowing the smoke, hot gases, and fumes to rise in the air space between the lavatory shell and the airplane's outer skin and between the aft pressure bulkhead and the lavatory's liner walls. The seams connecting the lavatory side walls and ceiling walls are not sealed; thus as the smoke rose, it began to enter the lavatory through the sidewall and ceiling seams, while the fire remained concealed behind the amenities section and below the toilet shroud. As the fire moved forward into the area between the toilet shroud and the top of the waste tank, the hot gases, smoke, and melted plastic were still being vented overboard through the lavatory vent line. The vent line exits the lavatory and enters the tunnel in the aft cargo compartment aft of FS 980. It is then routed forward below the generator feeder cable bundles to a point just forward of FS 965 where it exits the airplane through a venturi in the lavatory access panel. The hot gases caused the aluminum vent tube to melt away, thus permitting the entry of superhot gases into the floor beam area below the lavatory floor and their impingement on the generator feeder cable bundles where they passed through the lightening holes in the floor beam located at FS 980. As a result of the heat, faults developed on the left and right generator feeder cables, and between 1905:35 and 1907:41, the protective circuits tripped them off the line. ~ . The flexible connection for the waste tank flush and fill pipe and its check valve assembly was located close to the inlet of the lavatory vent line. When the flexible connection and the plastic ball in the check valve failed, this stainless steel flush and fill pipe also became an overboard vent. The deposits of soot and tar on the access door to the lavatory service panel and the melted rivets in the pipe connector at the service panel confirm that the pipe did become an overboard vent.

-58- The path of almost all fires is upward and in the direction of the airflow. Except for the damaged area below the lavatory floor, the fire damage noted on the airplane was above the airplane's floor line. The lowest and aftmost point of fire damage was within the amenities section at the outboard part of the lavatory and the forward wall of the aft pressure bulkhead, respectively. From this location, based on the damage pattern, the path of the fire was upward and forward. The direction of airflow within the amenities section and the toilet shroud was also forward. The damage below the lavatory was in the tunnel below its floor. While there was some evidence of fire damage, the damage in this area was for the most part heat damage, and the lavatory floor had not burned through. The most severe damage in this area was located above the failed lavatory vent tube between FS 965 and FS 980. In this area, the suspension and insulation of the generator feeder cables had melted away and arcing had occurred. Given the proximity of the failed lavatory vent tube to these cables and the type damage noted on the cables and structure in this area, the weight of the evidence indicates that the damage in this area was caused by the hot gases from an existing fire in the lavatory being vented through the tube. This evidence tends to further corroborate the hypothesis that the arcing of the generator cables was the result of the fire and not the source of its ignition. The momentary smoke abatement noted by the first officer and flight attendant in charge between 1904:16 and 1904:23 was probably attributable to the dilution effect of opening the lavatory door and discharging the C02 into the area, reclosing the lavatory door, and the almost simultaneous failure of the lavatory vent line and the flush and fill pipe connections and check valve, all of which increased the ventilation rate beneath the toilet shroud and accelerated the flow of smoke and gases to the area below the lavatory floor and overboard. The rectangular scorched area on the airplane's outer skin above the left engine and coinciding with the aft lavatory's frame channels showed that as the fire consumed the lavatory structure it used the airspace between the lavatory outboard wall and the airplane's outer skin as a flue. The superheated gases progressed up these channels and forward along the space between ceiling liner and the airplane's outerskin, and began to preheat the ceiling panels. Smoke and fumes generated by the fire began to collect in the ceiling space. The smoke, fumes, and hot gases then entered the cabin through the ceiling and sidewall liners and began to collect in the upper portions of the cabin. After the captain stopped Flight 797 on the runway, both forward exit doors and three overwing emergency exit windows were opened and an unlimited supply of fresh oxygen became available to the fire. With this availability of oxygen, the preheating of the ceiling panels, and the large quantities of unburned gases in the upper cabin, a back draft and flashfire occurred, and the fire progressed rapidly through the entire cabin. The evidence showed that the carpets, the lower portions of the sidewall panels, and combustible portions of the lower seat structure, including armrests, did not ignite and burn, whereas almost all combustible materials above the windowline were destroyed or heavily damaged by fire including large portions of the airplane structure and skin. The physical evidence indicated that the fire in the cabin ignited initially near the ceiling and thereafter the seat surfaces were ignited by the heat radiated from the fire at the ceiling and luggage rack level. Therefore, the Safety Board concludes that flashfire, rather than flashover occurred.

-59- Based on estimates by firemen and passengers, the flashfire probably occurred within 60 to 90 seconds after the doors and overwing exits were opened. The upper fuselage skin, after the cabin ceiling's insulation blanket was consumed by fire and the cooling effects of the airflow of flight ended, failed rapidly. The absence of significant smoke stains on the outside of the open exits supports this view, since following the failure of the upper fuselage skin, the airflow would reverse and go in the windows and doors and out the ruptured fuselage skin at the top of the airplane. In summary, although no positive conclusion can be drawn as to the precise point of origination of the fire, the evidence indicates that the fire propagated through the lower part of the amenities section of the lavatory vanity. Because of the direction of the airflow from the areas below the vanity and above the toilet waste tank, the smoke, fumes, and hot gases were vented overboard and pUlled away from the passenger cabin and the open area of the lavatory, allowing the fire to burn undetected for almost 15 minutes. The first noticeable evidence of smoke within the open area of the lavatory was observed after the fire penetrated the lavatory liner and began to rise behind and outboard of the liner. Smoke then began to penetrate the sidewall and ceiling seams of the lavatory lining as described by the two flight attendants. 2.3 Operational and SurviVal Factors The captain and first officer testified that they did not hear the arcing sounds recorded by the CVR. The DFDR showed that the arcing sounds were accompanied by voltage excursions on the right a.c. bus. The airplane's wiring diagrams showed that the DFDR and CVR wiring was routed near the generator cable feeder bundles. Spectrum analysis of the arcing sounds showed that they contained harmonics that were above the frequency range that would normally be detected by the microphone and preampliJier in the cockpit area microphone (CAM) channel. Given the proximity of the CVR wiring to the generator cable bundles, the Safety Board concludes that the arcing signal was electromagnetically induced into the CAM's circuitry and, therefore, not audible to the flightcrew. Since the arcing sounds which were recorded by the CVR were not heard by the flightcrew, the tripping of the flush motor's three circuit breakers at 1851:14 was the first abnormal occurrence they noted. At 1851:27, the captain tried unsuccessfully to reset the circuit breakers. At 1859:58, he again tried unsuccessfully to reset the three circuit breakers. Air Canada flightcrews are taught to make one attempt to reset a tripped circuit breaker. They are taught that it may be necessary to allow a 3-minute cooling time before a circuit breaker will accept a reset and that circuit breakers protecting a single phase are trip free; therefore, a circuit cannot be completed by holding in an unltitched single-phase circuit breaker. Most important, they are taught that a tripped circuit breaker denotes that the circuit protected by the circuit breaker is no longer powered. The flightcrew and other Air Canada flight personne! stated that circuit breaker trips during flight are not an uncommon occurrence, and the procedure contained in Air Canada's DC-9/AOM allows personnel to cope adequately with such occurrences. In this case, the captain attempted to reset each of the tripped circuit breakers twice; the first attempt occurred almost immediately after they had tripped and was unsuccessful. He testified that he "thought at the time that the unit (flush motor) might be overheated so I just continued the routine of the flight... and after a certain time had passed... I attempted to reset the circuit breakers again to make sure. • .• The circuit breakers would not move." Although the captain was unable to detect any movement of the circuit breakers, the CVR showed that arcing sounds, which were not

-60- audible to either the captain or first officer, accompanied each attempt to reset each circuit breaker indicating that the circuit breaker had moved and momentary electrical contact had been made. However, once the contact was made, the protective circuitry caused the breaker to trip again. Since the fire was already well established, the attempts to reset the circuit breakers had no effect on the sequence of events. About 1902:40, 11 minutes 26 seconds after the initial trip of the three flush motor circuit breakers, the No.2 flight attendant informed the flightcrew that there was a "fire." When the circuit breakers tripped, there was no reason, based on their training, for either pilot to surmise that an emergency capable of compromising the safety of the airplane existed. Although in this instance the failed component could be checked visually, the abnormal procedures checklist made no distinction between failed components which are visually accessible to crewmembers and those which are not. The pilots are required only to allow the circuit time to cool, and thereafter, limit themselves to one reset attempt. If the circuit breaker cannot be reset, they can assume that the component is shut down and, if required, perform the action set forth in an applicable checklist. While it can be argued that the captain, from the standpoint of passenger comfort, should have requested a flight attendent to inspect the lavatory and ascertain the reason, if possible, for the failure of the flush motor circuit, it wa.s a matter of judgment on his part as to whether he should require this to be done. In retrospect, his decision not to do so may have forestalled an early opportunity to discover the fire. Initial actions taken by the cabin crew when the smoke was discovered were inadequate to assess quickly the origin and scope of the fire. When the flight attendant in charge opened the lavatory door, he was able to see into the lavatory and observe that the smoke was emerging through the seams of the aft wall of the lavatory. Even though he stated that he knew the fire was not in the trash container, he never did open the door of the sink compartment to inspect visually the trash chute and container. The dispersal of the CO2 into the lavatory had little or no effect on the fire. In order for the extinguishing agent to be effective, it must be applied to the base of the flames. According to Air Canada procedures, the fire axe should be used, "if necessary," to remove paneling to obtain access to the fire. After assessing the situation in the lavatory, the flight attendant in charge did not request that the axe be brought to him from the cockpit because he did not believe he could use it. He testified that he did not consider using the axe to remove the paneling because, "I would have to destroy half the aircraft to get to it." The flight attendant in charge's testimony also showed that, while he knew the company procedure, since he had not been shown which paneling could be removed with the fire axe without endangering critical airplane components, he was reluctant to use the axe. Moreover, he was afraid that this action might provide a draft to the fire and accelerate combustion. Based on the conditions in the lavatory, the Safety Board cannot determine whether removing the lavatory paneling would have enabled the flight attendant in charge to expose and attack the fire successfully or whether the removal of the paneling would have accelerated the propagation of the fire. Further, given the situation inside the lavatory, even had the fire axe been brought to the lavatory, the Safety Board is not convinced that the flight attendant in charge could have carried out the firefighting activities contained in the Air Canada manual effectively without a full face smoke mask with self-contained breathing apparatus.

-61- After he had dispersed the CO into the lavatory and closed the lavatory door, the flight attendant in charge briefed the first officer on what he had done. Also, he told the first officer that he did not believe the fire was in the trash container but was located elsewhere. Neither he nor the first officer told the captain that they had not seen the fire and that they did not know exactly where it was or how intensely it was burning. On the other hand, the captain did not question either man about the location or severity of the fire. The only crewmembers to observe the conditions in the lavatory were two flight attendants. The first officer made two trips aft, but did not enter the lavatory. He retreated the first time because he did not have smoke goggles with him; the second time, based on the heat he felt on the lavatory door, he decided that it was not advisable to open the door. Since the flight attendant in charge and the first officer were not able to determine the location of the fire, they were not able to assess the severity of the fire. Consequently, based merely on their assessment of the course of the smoke drifting into the lavatory though the seams of the lavatory walls, they provided the captain with an inadequate assessment of the fire's severity. The fire was reported to the captain at 1902:40 and he directed the first officer to go aft and assess the situation. About 1904:07, the first officer returned to the cockpit and he told the captain, "I think we had better go down;" however, he later testified that at that time he was not thinking of an emergency descent. Almost simultaneously, the captain received a series of optimistic reports from both the flight attendant in charge and the first officer concerning the smoke conditions in the aft cabin area, and at 1904:46, the captain directed the first officer to go aff a second time to reassess the conditions in the aft cabin area. As a result, about 5 minutes 30 seconds elapsed between the time that the No.2 flight attendant told the captain there was a fire in the aft lavatory and his decision to begin the emergency descent. While an actual in- flight fire is an extremely rare occurrence, all reports of smoke in the cabin must be regarded as potentially serious. However, such reports often turn out to be smoke from an overheated flushing motor or waste ignited by a discarded cigarette in a trash receptacle designed to contain a fire, conditions which are normally identified and corrected by flight attendants without further consequences. Therefore, the Safety Board realizes that there is a need to evaluate the situation before deciding on the emergency action required. However, in this case, the time to make the decision appears excessive given the circumstances. Most significantly, neither the flight attendant in charge nor the first officer was able to fix precisely the source of the fire or to assure the captain that it had been extinguished. The safety Board believes that a precautionary emergency descent should have been initiated as soon as it became evident that the fire had not been visually located and could be attacked directly with extinguishant. This became known at 1904:07 when the first officer came forward from his first inspection of the aft cabin area, about 3 minutes before the decision to begin an emergency descent. At 1904:07, after the first officer returned from his first trip aft, Flight 797 was about 14 nmi northeast of Standiford Field, Louisville, Kentucky, at FL 330. Had the emergency been declared at this time and the descent started, performance data indicate that Flight 797 could have landed at Standiford about 1914:18, or about 5 minutes 51 seconds earlier than it landed at Cincinnati. However, given the actual conditions in the airplane during the descent, it is not realistic to expect the captain to have duplicated the times and optimum rates contained in the descent performance profile. For example, the evidence showed that during the actual descent, the total time required to descend from 33,000 feet to 3,000 feet was about 1 minute longer than that required in the descent profile. The Safety Board believes that the evidence indicates that ;t would be reasonable

-62- to assume that, given the conditions in the cockpit, the descent and landing would require 1 to 2 minutes longer than the elapsed time shown in the descent profile. Therefore, the Safety Board believes that, had Flight 797 landed at Standiford Field, the flight most probably would have landed about 3 to 5 minutes earlier than it did at Cincinnati. While the research data does not permit the Safety Board to conclude whether the shortened flight time would have delayed or prevented the flashfire, there can be no doubt that the decreased exposure time of the passengers to the toxic environment in the cabin would have enhanced their physical and psychological,capability to escape after the cabin doors and overwing exit windows were opened. Consequently, the Safety Board concludes that the delayed decision to descend contributed to the severity of the accident. At 1908:12, when the captain did declare an emergency, Flight 797 was closer to Cincinnati than Louisville; therefore, the Louisville high controller vectored it toward the Greater Cincinnati Airport and cleared it to descend. At 1909:05, the flight departed FL 330 and it landed at Cincinnati at 1920:09. In the process, however, there was a faulty ATC handoff which occurred at 1909:38. The Safety Board concludes that the faulty interfacility handoff leading to the misidentification of Flight 797 resulted from the attempt on the part of the controllers at the Indianapolis Center to expedite the handling of an aircraft experiencing a dangerous in-flight emergency. The Safety Board believes that the LEX-D controller's decision to hand off Flight 797 directly to Cincinnati approach control was a valid exercise of the controller's discretionary authority and if handled properly would have eliminated additional radio frequency changes and decreased flightcrew and controller workloads. The Safety Board also concludes that by beginning the handoff without direct communica- tion with the LouJsville high sector controller who was handling Flight 797 and by not including him directly in the handoff procedure, the timely transfer of vital information between the two facilities was either compromised or never accomplished. The most important omission was the LEX-D controller's failure to tell the Cincinnati approach controller that he was being handed off an airplane with an inoperative transponder. The Cincinnati approach controller also contributed, though to a lesser degree, to the faulty handoff. Instead of waiting for the initiating controller to apprise him of the identification, transponder code, heading, and altitude of the target to be transferred, he trackballed out to the target he assumed was the subject of the alerting call he had received from Indianapolis Center at 1909:17. Thus at 1909:23, when the LEX-D controller told him, "I got a code for you," instead of waiting for the remainder of the information, he supplied the transponder code to the initiating controller and thereby contributed to the ensuing communications breakdown. The primary question presented by the faulty handoff was whether it delayed the landing of Flight 797. At 1909:05, when Flight 797 began the emergency descent, the DARTS data showed that it was about 27 nmi southwest of, and turning toward, the Greater Cincinnati Airport. According to the optimum performance data, it would require 34 nmi to descend from 33,000 feet to 3,000 feet. In addition, the winds aloft data showed that the winds during the flight's descent were from the west at speeds ranging from about 85 knots at FL 330 to about 8 knots at 3,000 feet; thus it would require more than 34 nmi to descend to 3,000 feet. The evidence was conclusive that regardless of which runway the controller elected to use for landing, he would have to vector Flight 797 through some type of traffic pattern in order to land it at Greater Cincinnati Airport. In this case, he elected to vector it to land on runway 27L.

-63- According to optimum descent performance data, it would require 9 minutes 41 seconds to descend and land at the Greater Cincinnati Airport. Since the descent began at 1909:05, the earliest possible landing time was 1918:46, or 1 minute 23 seconds earlier than the flight had actually landed. However, since it is unrealistic to expect the captain to have duplicated the optimum descent data during the approach, and given the small difference between the calculated landing time and the actual landing time, the Safety Board concludes that the faulty handoff did not delay the landing of Flight 797 appreciably. Since the descent and landing at Greater Cincinnati Airport was accom- plished expeditiously and since ATC procedures did not delay the landing, the Safety Board concludes that the only factor which significantly delayed Flight 797's landing was the flightcrew's delayed decision to descend. During the descent, the smoke in the passenger cabin continued to accumulate; it was heaviest at the ceiling and became increasingly thick from the ceiling down to the floor. As the airplane descended, the smoke moved forward in the cabin. In addition, with the loss of electrical power, the augmentation valve in the pressurization system closed, and high pressure bleed air was not available. Therefore, when the engines were retarded to flight idle for the descent, little or no fresh air was being introduced into the cabin. Some of the passengers noted that air stopped flowing out of the eyebrow vents during the descent, confirming that the augmentation valves had closed. However, when the airplane was leveled off after the descent and engine thrust applied, the exchange of air would have been restored, provided that the air conditioning and pressurization packs had not been turned off. The captain's difficulties during the descent were compounded by the condition of his flight instruments. About 8,000 feet during the descent, the emergency inverter was lost. The Safety Board could not determine the cause of the failure; however, with the loss of the inverter, the emergency a.c. bus was lost. The airplane's ADI's, horizontal situation indicators, and radio magnetic indicators became inoperative, and the only attitude indicating instrument available was the small emergency standby AD!. The captain flew the latter part of the descent, the traffic pattern, and the landing using the standby AD! and his airspeed indicator. In addition, with smoke entering the cockpit, he had difficulty seeing the instruments. The damaged cockpit door was not closed after the first officer reentered the cockpit. The captain had not ordered the door to be left open and was, in fact, not aware that it was open. The first officer had decided to leave the door open because it facilitated communication with the cabin crew. As a result, the smoke entered unimpeded into the cockpit. Since the louver panel was missing from the cockpit door, closing the door would not have blocked totally the entry of the smoke. However, even with the panel missing, a closed door would have delayed the accumulation of smoke within the cockpit. The smoke in the cabin increased rapidly during the emergency descent; however, the flightcrew did not try to use the cabin smoke elimination procedure -- depressurize the airplane after it descended below 10,000 feet, open the aft pressure bulkhead door, and open slightly the right forward cabin door. The captain testified that he did not order the procedure to be used because the fire was not out and because he needed the first officer's assistance in the cockpit in order to fly the airplane safely. Had this procedure been tried, the airflow through the cabin would have been directed forward and out the right forward cabin door. Though ideally the procedure would be used when a fire has been extinguished, according to the airplane manufacturer, the procedure can be used when a fire is still burning. According to the manufacturer, the flightcrew must

-64- judge whether survival depends on the elimination of the entrapped smoke regardless of the effect that a draft of air might have on the fire. However, the fire protection engineer who investigated the airplane fire damage believed that opening the doors would have created "a very strong potential" that the fire would have been drawn from the lavatory into the cabin; that the smoke would have been moved forward faster; and that the use of the procedure would have endangered the passengers and the safety of the airplane. The evidence concerning what would have happened had the procedure been used was highly conflicting, and therefore, the Safety Board will not speculate as to what might have occurred had the procedure been used. After descending through 3,000 feet, the captain ordered the first officer to depressurize the airplane in order to prepare it for landing and to insure that the flight attendants and passengers would be able to open the doors and overwing exits. The first officer depressurized the airplane and then, although the procedures do not require this to be done, turned the air conditioning pack switches off which still would have been operating because they are powered by the emergency d.c. bus. The evidence showed that the captain did not order the first officer to shut off the air conditioning packs, nor did he know that they were shut off. The first officer testified that after the airplane had been depressurized he decided to turn the packs off because the smoke was getting bad; he thought he had to do something, and he thought that "those packs, they are just feeding the fire." The statement and testimony concerning when the air conditioning packs were shut off is slightly conflicting. However, the consensus of all the testimony and statements indicated that they were almost certainly turned off by the time the airplane reached 2,000 feet. ;.> The ATC transcripts showed that Flight 797 reported "at two thousand five hundrEfd (feet)" and "we're VFR now," at 1915:11 and 1915:27, respectively. The flight landed at 1920:09. Based on the flightcrew's testimony and statements and the times in the ATC transcript, the Safety Board concludes that the air conditioning packs were turned off at least 4 minutes before the airplane landed in which almost two complete changes of cabin and cockpit air otherwise would have occurred. During the descent, the augmentation valves in the air conditioning and pressurization packs had failed to the closed position; therefore, the smoke in the cabin and cockpit was not being purged overboard as rapidly as it would have been had these valves remained operational. Consequently, the rate at which the smoke was filling the cabin and cockpit increased which may have led to the first officer's belief that the air conditioning and pressurization packs were supplying air flow to the fire. Given the conditions that existed in the cabin during the descent, the first officer's action was understandable; however, when the packs were shut off, the best available means of eliminating smoke from both the cockpit and the cabin was inoperative. Since the ram air valve never was opened and the pressurization system had been shut off, there was virtually no fresh air supply to the cockpit and cabin. With no exchange of air in the aircraft, smoke and heat continued to accumulate at the ceiling and to build down toward the floor and the toxicity of the air in the cabin began increasing at an accelerated rate. Moreover, with no airflow available to reduce the buildup of heat and combustible gases at the upper levels of the cabin, the onset of factors conducive to flashover or flashfire was accelerated. In conclusion, once the decision to descend was made the flightcrew executed an emergency descent and then, in coordination with the approach controller, flew a descending traffic pattern to the landing runway using only rUdimentary airplane

-65- instrumentation. The captain, though confronted with a hostile cockpit environment, loss of engine and flight instruments, and an inoperative horizontal stabilizer trim system was able to maintain his concentration, and with the assistance of his first officer, configure the airplane for landing, slow it to the desired indicated airspeeds, and despite the unfamilar longitudinal control forces resulting from the inoperative horizontal stabilizer, land the airplane safely. Considering the conditions which confronted the captain during the descent and landing, the Safety Board concludes that the captain exhibited outstanding airmanship without which the airplane and everyone on board would certainly have perished. Evacuation of the Airplane Although fatalities occurred, this accident must be considered survivable because none of the survivability factors were violated. By definition, a survivable accident is one in which the forces transmitted to the occupants do not exceed the limits of human tolerance to abrupt acceleration, either positive or negative, and in which the structure in the occupant's immediate environment remains structurally intact to the extent that an occupiable volume is provided for the occupants throughout the crash sequence. 13/ In this accident, the fuselage integrity was not breached during the landing and none ofthe occupants were exposed to decelerative forces beyond the limits of human tolerances. According to the passengers and flight attendants, when the airplane landed the visibility in the cabin was virtually nonexistent at heights higher than 1 foot above the cabin floor. In addition, during the descent and landing, the passengers and crew were exposed to constantly increasing quantities of smoke and toxic gases, and these factors combined to make the evacuation procedures more difficult to execute and complete. The flight attendants' efforts to move the passenge~ forward of row 12 and away from the source of the smoke and heat (except for two passengers in seats 12D and 12E who had refused to move because their seats were next to the right forward emergency exit window) and their selection and briefing of able-bodied male passengers to open the four overwing exit windows, apparently were successful since three of these four exits had been opened and were used by surviving passengers. Additionally, the flight attendants attempted to brief passengers on how to assume the brace position and other items relevant to the emergency situation. However, because of the smoke and toxic gases in the cabin, they had great difficulty communicating, and in some cases, passengers did not hear all these instructions. Virtually all the survivors stated that they had covered their mouths and noses with towels, articles of clothing, or other like items, as instructed by flight attendants. Wet towels will filter out smoke particles, acid gases such as hydrogen chloride and hydrogen fluoride, and hydrogen cyanide. While breathing through items of clothing will also filter out smoke particles, the clothing would probably be less effective in filtering out the acid gases and hydrogen cyanide. Neither filter system will reduce the carbon monoxide'concentration. Therefore, although this procedure was not contained in the company manual, the initiative on the part of the flight attendants to distribute wet towels and instruct the passengers to breathe through the towels or other items of clothing may have aided the survival of the passengers. 13/ Aircraft Survival Design Guide, Volume 1: "Design Criteria and Checklists," U.S. Army Research Technical Laboratory, Technical Report 79-22A, December 1980.

-66- .In spite of these efforts, several factors limited the success of the evacuation of the passengers. The flight attendants at the forward doors were not able to make themselves heard inside the cabin. The location of the fatalities in the cabin tends to confirm that those who succumbed either made no attempt to move toward an exit or started too late and were overcome as they attempted to move toward an exit. Studies indicate that in the absence of commands, some passengers will remain seated and await orders, a phenomenom known as ''behaviorial inaction." 14/ It is also possible that some of the passengers were incapacitated because of exposureto toxic gases and smoke during the descent and landing. The statements and testimony of the survivors who exited the airplane through the overwing exit windows indicated that the visibility in this area of the cabin was probably worse than that in the forward cabin. The survivors who had moved aft to reach the overwing exits found them because they had memorized the number of rows between their seats and the exits and thereafter counted the rows by feeling the seatbacks as they moved aft; because they were able to see a dim glow of light when they reached the exit area; or as in one case, the survivor felt a slight breeze across the back of her legs when she reached the area of an open exit. The evidence showed that the cabin environment deteriorated rapidly after the doors and overwing exit windows were opened. Although all of the passengers had been seated forward of row 13 when the airplane stopped, two of the fatalities were found in the cabin aisle at rows 14 and 16. It is likely that these passengers had made their way aft trying to locate the overwing exits; however, the visibility had deteriorated so badly that they were not able ·to locate them. Based on this evidence and the difficulties experienced by the survivors who were able to locate the overwing exit windows, the Safety Board believes that had floor level, or near floor level, emergency lighting denoted the location of the overwing emergency exit windows, not only might these two passengers have been able to find them, the task of the other survivors would have been made easier. Many of the survivors stated that they were able to see better either by bending forward or by crawling. The survivors' experiences appeared to follow closely the results of research contained in the AGARD report concerning the stratification of toxic gas concentrations within a cabin and its effect on survival times. Based on the results of the FAA's cabin environment research studies, the Safety Board concludes that the cabin environment became nonsurvivable within 20 to 30 seconds after the flashfire. The evidence also indicated that there were instances in which the flight attendants had not complied completely with the Air Canada evacuation procedures. In the event of failure of the PA system, Air Canada procedures direct the use of a mega- phone to make required announcements before the airplane door and exit windows are opened. Even though the flight attendant in charge knew that the airplane PA system was inoperative, he did not remove the megaphone to make the announcements prescribed in the company briefing format. Although he was busy attending to a sick passenger, he could have required one of the other attendants either to take care of the passenger or to take the megaphone and make the announcements to augment the individual briefings given to the passengers by the Nos. 2 and 3 flight attendants. The Safety Board concludes that had this been done, the emergency briefings probably would have been heard, by more, if not all, of the passengers, and in any event in greater detail. However, even had all the passengers heard the briefings, the Safety Board cannot conclude that this would have altered appreciably the sequence of events which occurred after the doors and exit windows were opened. One of the required announcements contained in the briefing 14/ Daniel Johnson, "Behavioral Inaction Under Stress Conditions Similar to the Survivable Aircraft Accident," Safety Journal, 1972, First Quarter.

-67- format would have directed the passengers to remain seated while the flight attendants completed opening the doors and exit windows and until the attendants directed them to get up and move toward the doors and exits. The evidence showed that a passenger seated in row 2 had, in fact, been briefed to restrain the other passengers from moving toward the forward doors until he received the evacuation command from the flight attendant in charge. This procedure is designed to prevent congestion at the doors and exits so that the attendants can operate them without interference. In a smoke-free environment this is an excellent procedure; however, on Flight 797 the procedure would have operated to the detriment of the passengers. The poor visibility made it impossible for the passengers to see either the opened doors, the opened exit windows, or the flight attendants. Given these conditions and given the contents of the briefing announcement, the safety Board believes it highly unlikely that the use of the megaphone during the descent would have provided a better briefing to the passengers who did not move after the airplane stopped and the doors and exits were opened. Since neither the No. 2 or No. 3 flight attendant was able to reach and occupy her designated emergency landing position, no direct supervision of the emergency evacuation through the overwing exit windows was provided by a flight attendant. Both of these attendants were in the cabin aisle either briefing or attending passengers when they were directed to sit down by the first officer. Despite that, they continued to move along the aisle checking seatbelts and briefing and comforting passengers. Since the conditions in the cabin made it impossible for them to look outside and estimate how soon the airplane would land, it was incumbent upon the flight attendants to seat themselves as soon as possible after receiving the first officer's command. The No.2 and No.3 flight attendants were seated in seat 3C and in an aisle seat in rows 7, 8, or 9, respectively, when the airplane stopped. Neither flight attendant tried to reach her designated supervisory position at the overwing exit windows. In order to do so, the No.2 attendant would have had to have moved aft against the flow of passengers moving toward the forward doors. The No. 3 flight attendant was closer to the overwing area. However, had she tried to go aft, it is doubtful if her presence would have altered the evacuation sequence at these exits. She probably could not have reached the exits before the passengers seated at rows 10 through 12 reached them, opened them, and left the airplane. The survivors who exited the airplane through the overwing exit windows stated that they barely had the strength and presence of mind to negotiate the exits and that they were 3 to 5 rows closer to the exit than the flight attendant. Even assuming that the No. 3 flight attendant had reached the area of the exits, her ability to exercise supervisory functions at the four exit windows would have been diminished severely, if not totally. In summary, the evidence showed that two flight attendants had opened the two forward doors, deployed and inflated the slides, and attempted to call out required commands and directions to the passengers. They remained at their posts at those doors until they were either driven out by the heat or until they believed that no more passengers were moving toward the doors. They had briefed passengers on the location and operation of the overwing emergency exit windows. Though not required by company procedures, they had, until directed by the first officer to "sit down," passed out wet towels and directed the recipients to breathe through them and otherwise attended to the passengers. The Air Canada procedures require their flight attendants to "do all possible to evacuate everyone, but they are not obliged to risk their own lives." Given the location of the flight attendants when the airplane stopped on the runway and given the conditions within the cabin at that time, the Safety Board can only conclude that any attempt by the

-68- flight attendants to move farther aft into the cabin and to remain within the cabin for any appreciable length of time could not have been made without placing their survival in dire jeopardy and that it is doubtful that additional lives would have been saved thereby. 2.4 Firefighting The response of the crash-fire-rescue units and the methods used by the firefighters to extinguish the fire on board Flight 797 were consistent with those used to fight typical airplane fires, primarily fuel spills and interior fires. The tactics used by crash-fire-rescue units in response to these types of fires are designed to protect the passengers leaving the airplane and to assist them in moving from the endangered area. Thereafter, the attempt can be directed to save the airplane. The efforts of the firefighters in this case were complicated by the fact that they did not know how many passengers and crewmembers were on board and they did not know how much fuel was on board. However, they did know that smoke had been reported coming from the airplane's aft lavatory and that there was smoke or fire in the rear of the airplane. In evaluating the attempts to attack or contain the fire, the question arises as to whether an entry at the left forward door with a handline would have been possible and more logical. From this location, the fire might have been pushed back and several passengers possibly rescued from the interior. When the firefighters arrived at the llirplane and began applying foam on the top of the fuselage and on the runway directly underneath the airplane, flames were not visible. The fire did not become visible until after the last survivor had left the airplane. The on scene commander testified that when his personnel began the attack, passengers were still exiting through the left forward door, and he believed that an attempt to enter the airplane at that door at that moment would have impeded' passenger egress. He also believed that the deployed escape chute would have impeded and slowed the entry of his personnel into the airplane. In addition, the firefighters did not know the seat location of the passengers. Therefore, the first interior attack was mounted at the left overwing exit and was designed not only to assist the passengers in this area, but also to insert firefighters between the fire and the remainder of the passengers still on board. The decision to mount the initial interior attack through the left overwing exit was an operational decision made by the on scene commander, and was based upon his assessment of the situation. Based upon the evidence, the Safety Board concludes that his decision was reasonable and that the ensuing flashfire could not have been averted by other tactics. The evidence also showed that the firefighters involved in the three interior attacks were not able to don their protective hoods over their self-contained breathing apparatus. The lack of protective hoods impeded the interior attacks. Testimony of the FAA's airport safety specialist indicated that the requirements for protective equipment for airport firefighters are ambiguous or nonexistent, and that the provisions of 14 CFR 139 do not specify the need for training in interior firefighting tactics. The deficiencies of 14 CFR 139 in addressing crash-fire-rescue training and protective equipment have been addressed in some detail in the National Transportation Safety Board's recent Airport Safety Study. 15/ 2.5 In-flight Fire Prevention/Detection During this investigation, the Safety Board identified the continued presence of causal factors similar to those identified in previous Safety Board investigations of 15/ Safety Study: "Airport Certifications and Operations." (NTSB/S8-84/2).

-69- airplane lavatory and cabin fires. As a result of these earlier investigations, the Safety Board had made recommendations to the FAA designed either to preclude the recurrence of similar occurrences or to minimize their severity should they recur. Had comprehen- sive action been taken in response to some of these recommendations, the Safety Board believes that the severity of this accident would have been lessened. On September 5, 1973, the Safety Board issued the following Safety Recommendations to the FAA: Require a means for early detection of lavatory fires on all turbine- powered, transport-category aircraft operated under Part 121 of the Federal Aviation Regulations, such as smoke detectors or operating procedures for the frequent inspections of lavatories by cabin attendants. (Safety Recommendation A-73-67) Require emergency oxygen bottles with full face masks for each cabin attendant on turbine-powered transport aircraft in order to permit the attendants to combat lavatory and cabin fires. (Safety Recommendation A-73-68) While the FAA has required more frequent inspections by flight attendants, neither smoke detectors nor full-face smoke masks are required by regulation to be placed on board transport category aircraft. Given the conditions inside the lavatory on Flight 797 when the flight attendants first opened the door, the Safety Board believes that an operable smoke detector would have alerted the crew to the existence of the smoke before it was actually discovered. The flight attendant in charge was able to see the aft wall and that smoke was emerging from the seams in the lavatory walls when he entered the lavatory. The Safety Board believes that had an oxygen bottle with a full-face smoke mask been available and used, it might have encouraged and enabled the first attendant to take immediate and aggressive actions to locate the source of the smoke and to fight the fire, as set forth in the company manual. The Safety Board believes that had either the smoke detector or the full-face smoke mask, or both, been available and used on Flight 797, the consequences would have been less severe. There can be little doubt that, at the very least, earlier detection of the smoke would have produced a more prompt assessment of the severity of the conditions in the lavatory, and consequently an earlier decision to descend and land.

1. CONCLUSIONS
2. 1

Findings 1. The airplane was registered, equipped, and maintained in accordance with Canadial1 regulations, and it was operated within the United States in accordance with applicable Federal Aviation Regulations. 2. The flightcrew and the cabin crew were qualified and trained in accordance with Canadian regulations and Air Canada requirements. Each crewmember had received the off-duty times prescribed by Canadian regulations. 3. A fire propagated through the amenities section of the aft lavatory and had burned undetected for almost 15 minutes before the smoke was first noticed.

-70- 4. The fire was not set deliberately nor was it the result of an explosive or incendiary device. 5. The Safety Board could not identify the origin of the fire. 6. The first malfunction to evidence itself to the flightcrew was the simultaneous tripping of the three flush motor circuit breakers, about 11 minutes before the smoke was discovered. The flightcrew did not consider this to be a serious problem. 7. The smoke in the aft lavatory was discovered bya flight attendant. The smoke was reported to the captain as a fire. 8. The source of the smoke was never identified either by the flight attendants or the first officer. The captain was never told nor did he inquire as to the precise location and extent of the "fire," which had been reported to him. Crewmember reports that the fire was abating misled the captain about the fire severity and he delayed his decision to declare an emergency and descend. 9. Because of the delayed decision to descend, the airplane lost the opportunity to be landed at Louisville. Had the airplane been landed at Louisville, it could have been landed 3 to 5 minutes earlier than it actually did land at Cincinnati. The delayed decision to descend and land contributed to the severity of the accident. 10. A faulty ATC handoff did not delay significantly Flight 797's landing at Greater Cincinnati Airport. 11. The fire consumed the lavatory walls, propagated into the ceiling, and then began to move forward. Smoke, toxic fumes, and heated gases began to enter the cabin, spread forward, and collect along the ceiling of the cabin. 12. The flight attendants' passing out wet towels to the passengers and instructing them to breathe through the towels or through articles of clothing aided in the survival of some of the passengers. 13. The first officer turned off the air conditioning and pressurization packs in the belief that the airflow was feeding the fire. The resulting loss of circulation accelerated the accumulation of smoke, heat, and toxic gases in the cabin and likely decreased the time available for evacuation. 14. Three of the four overwing exit windows were opened by designated passengers who had been selected and briefed to open them by the flight attendants. 15. When the airplane stopped, smoke had filled the cabin and visibility within the cabin was almost nonexistent 2 to 3 feet above the cabin floor.

-71- 16. A flashfire occurred within the cabin within 60 to 90 seconds after the doors and overwing window exits were opened. Flames from this fire were not evident until after the survivors had left the airplane. Flames from the original fire never were evident within the airplane or to persons on the ground. 17. This was a survivable accident. 3.2 Probable cause The National Transportation Safety Board determines that the probable causes of the accident were a fire of undetermined origin, an underestimate of fire severity, and misleading fire progress information provided to the captain. The time taken to evaluate the nature of the fire and to decide to initiate an emergency descent contributed to the severity of the accident.

1. RECOMMENDATIONS

On July 11, 1973, the Safety Board participated in the investigation of the Varig Airlines Boeing 707 accident near Paris, France, in which 124 persons died after a fire erupted in the rear lavatory. As a result of that accident, the Safety Board, on September 5, 1973, issued the following Safety Recommendations to the Federal Aviation Administration (FAA): Require a means for early detection of lavatory fires on all turbine-powered, transport-category aircraft oper.ated under Part 121 of the Federal Aviation Regulations, such as· smoke detectors' or operating procedures for the frequent inspections of lavatories by cabin attendants. (Safety Recommendation A-73-67) Require emergency oxygen bottles with full-face smoke masks for each cabin attendant on turbine-powered transport aircraft in order to permit the attendants to combat lavatory and cabin fires. (Safety Recommendation A-73-68) Organize a government/industry task force on aircraft fire preven- tion to review design criteria and formulate specific modifications for improvements with respect to the fire potential of such enclosed areas as lavatories in turbine-powered aircraft operating under the provisions of Part 121 of the .Federal Aviation Regulations. (Safety Recommendation A-73-70) Following the investigation of the Pan American World Airways, Inc., Boeing 707 accident that occurred on November 3, 1973, while the flightcrew was attempting to land at Boston, Massachusetts, after the detection of a fire in the cargo compartment, the Safety Board issued these additional Safety Recommendations to the FAA: Provide operators of the subject aircraft with data to enable flightcrews to identify smoke sources, and require operators to establish procedures in their operating manuals to control and evacuate smoke effectively during the specific flight regimes. (Safety Recommendation A-73-121 issued January 10, 1974)

-72- Require that transport category airplanes certificated under Part 4B of the Civil Air Regulations prior to the effective date of amendment 4B-8 comply with Part 25.1439 of the Federal Aviation Regulations. (Safety Recommendation A-74-5, issued February 6, 1974) Require that a one-time inspection be made of all smoke goggles provided for the flightcrew of all transport category airplanes to assure that these goggles conform to the provisions of Part 25.1439 of the Federal Aviation Regulations. (Safety Recommendation A-74-6, issued February 6, 1974) As a result of two other lavatory fires, one aboard a Boeing 747 airplane on July 17, 1974, and the other aboard a Boeing 727 airplane on August 9, 1974, the Safety Board recommended that the FAA: Require that automatic-discharge fire extinguishers be installed in lavatory waste paper containers on all transport aircraft. (Safety Recommendation A-74-98, issued December 5, 1974) In response to Safety Recommendation A-73-67, the FAA issued an Air earrier Operations Bulletin (No. 1-76-17, "In Flight Lavatory Fires") instructing Principal Operations Inspectors to encourage air carriers to prohibit smoking in the lavatories and to institute routine flight attendant inspections of lavatories before takeoff and periodic- ally during flight. This action was followed by an Airworthiness Directive which required the installation of "No Smoking" and "No Cigarette Disposal" signs in the lavatories of transport category airplanes. Although these actions fell short of the Safety Board's intention to promote the installation of smoke detectors such as those using ionization and photo-electric technology to trigger an alarm signal, the Safety Board, in May 1979, closed Safety Recommendation A-73-67 and assessed the FAA's action as acceptable. While the Safety Board at that time was sympathetic to the industry's position that the lack of demonstrated reliability and the potential for false alarm problems associated with such smoke detectors would degrade their effectiveness, it now is convinced that the technology exists to provide an effective and reliable early warning fire detection system in the lavatories of transport category airplanes. Further, the Safety Board notes that the FAA report "Feasibility and Tradeoffs of a Transport Fuselage Fire Management System," (FAA RD 76-54, dated June 1976) concludes that such systems are feasible with current technology. Safety Recommendations A-73-68 and A-74-5 both addressed the need for standards and requirements for protective breathing equipment to provide flightcrew members with a supply of oxygen and a mask of eye protection so that they could continue to perform necessary airplane control functions and cabin duties, as well as firefighting functions in the event of an in-flight fire. In response to Safety Recommendation A-73-68, the FAA issued a revision to the Federal Aviation RegUlations effective February 1, 1977, which reqUired the installa- tion of protective breathing equipment in each isolated separate compartment of the airplane in which crewmember occupancy is permitted during flight. This revision was not responsive to the recommendation since it did not provide for portable protective breathing equipment for use in passenger compartments. Also, the FAA issued an NPRM

-73- in 1975 proposing to amend 14 CFR 25.1439 to include new standards for oxygen masks and eye coverings. However, the proposal was later withdrawn with the reasoning that further testing was needed to establish the standards. The FAA's response regarding Safety Recommendation A-73-68 and A-74-5, in August 1981, advised the Safety Board that an updated Technical Standard Order (TSO) would be prepared to prescribe minimum standards for emergency equipment to provide flightdeck and cabin crewmembers with eye and respiratory protection from toxic atmospheres during in-flight emergencies. The FAA has stated that it intends to issue an Advisory Circular after it adopts the TSO to recommend that operators upgrade the protective breathing equipment aboard their airplanes to meet the new TSO standards. The FAA has stated that the Advisory Circular would also recommend that operators provide equipment beyond regulatory requirements for cabin attendants. The Safety Board assumes that the issuance of TSO-C99, "Protective Breathing Equipment," on June 27, 1983, completed the first phase of FAA's intended action. An FAA witness from the Civil Aeromedical Institute testified at the Safety Board's public hearing in the Air Canada case that much of the equipment in current use fails to comply with the newly established minimum standards. He described serious shortcomings particularly in the effectiveness and fit of smoke goggles. Another FAA witness from Aviation Standards Office of Airworthiness stated that he was not aware of any FAA plans for regUlatory action to require that the protective breathing equipment currently installed on transport category airplanes in accordance with the provisions of 14 CFR 25.1439 and 14 CFR 121.337 meet the minimum standards prescribed in TSO-C99. Furthermore, the FAA has not indicated that it intends to require by regulation the installation of portable breathing equipment which would be available immediately in passenger compartments for use by cabin attendants in combating cabin fires. The Safety Board believes that regUlatory action is required and that the contemplated Advisory Circular recommending voluntary action by operators is not adequate to assure passenger safety. ...1-. In evaluating the FAA's actions regarding Safety Recommendation A-73-70, the Safety Board acknowledged that the establishment of the Special Aviation Fire and Explosion Reduction (SAFER) Advisory Committee in May 1978 would be responsive to the recommendation. The mandate of this committee, which was composed of government and industry representatives, went beyond the specific scope of the Safety Recommenda- tion and considered the broader aspect of the airplane fire problem by addressing the postcrash scenario. The SAFER committee's short-term recommendations were directed primarily toward actions to inhibit the ignition and rapid propagation of a postcrash fuel-fed fire. The committee determined that there was a need for continued research in interior cabin materials before new testing procedures and standards could be established regarding the flammability, smoke, and toxic emission characteristic of cabin materials. Although the FAA's action to convene the SAFER committee was viewed as responsive to Safety Recommendation A-73-70, the Safety Board maintained the recom- mendation in an open statu~ pending further progress toward the mandating of safety enhancing improvements to airplane cabin interiors. The Safety Board has received no further response from the FAA regarding this recommendation since March 14, 1979. However, the Safety Board has followed and has encouraged the continuing research being conducted at the FAA's Technical Center at Atlantic City, New Jersey. The Safety Board believes that this research has identified several potential cabin improvements which could be implemented now. The· Administrator announced on October 11, 1983, FAA's intention to issue two Notices of Proposed Rulemaking (NPRM) proposing new performance standards for the use of fire-blocking materials on passenger seats to inhibit the propagation of cabin fires and new standards for emergency lighting that would be more effective for passengers evacuating smoke-filled cabins. One of the parties to the Air Canada accident investigation has recommended that, in addition to relocating the

-74- cabin emergency lights, tactile aisle markers like those on the overhead stowage bins on many airplanes be installed near to the floor to guide persons to emergency exits in the smoke-filled environment. The Safety Board agrees with this recommendation. Further, in addition to the proposed improvements already announced by the Administrator, the FAA tests conducted at the Technical Center have identified other needed upgrading of equipment. These tests have demonstrated vividly that the performance of hand fire extinguishers with the Halon extinguishing agent is significantly superior to the performance of the carbon dioxide, dry chemical, or water-type hand extinguishers and that safety will be enhanced by replacing the latter types of extinguishers with the Halon type. The Safety Board strongly encourages the FAA to expedite the rUlemaking actions to make fire-blocking seat materials, improved emergency lighting, tactile emergency exit indicators, and hand fire extinguishers using advanced technology extinguishing agents mandatory in the transport airplane fleet as early as practicable. The FAA acted promptly in response to Safety Recommendation A-73-121 to assess the adequacy of the smoke removal procedures on the Boeing 707 airplane. As a result of the FAA's assessment and tests, the relevant section of the airplane's Flight Manual was revised to include improved and clearer smoke removal procedures. Both the recommendation and the FAA's actions were specifically directed to the Boeing 707 airplane. On that basis, Safety Recommendation A-73-121 was closed and FAA's response was deemed acceptable. However, the circumstances of the Air Canada accident indicate that the flightcrew encountered difficulty in controlling smoke in the cockpit of the McDonnell Douglas DC-9 airplane. The Safety Board questions the applicability of the prescribed procedures when a cabin fire continues to generate smoke and toxic gases. Further, testimony at the public hearing disclosed uncertainties among both flightcrew and expert witnesses r~garding optimal smoke control procedures, such as the best use of cabin air conditioning- systems. The Safety Board, consequently, believes that smoke removal procedures in all types of air carrier airplanes should be reassessed. ' The FAA did not concur in the Safety Board's recommendation to require that automatic~ischargefire extinguishers be installed in lavatory waste receptacles on all transport airplanes (Safety Recommendation A-74-98). The FAA reasoned that the combined actions of installing fUlly sealed waste receptacles to assure fire containment and extinguishment, as required by Airworthiness Directives for transport category airplanes, and the prohibition of smoking in airplane lavatories eliminated the need for mandatory installation of automatic-discharge fire extinguishers. Although automatic- discharge fire extinguishers have been installed in the lavatory waste receptacles of some airplanes, including the Air' Canada DC-9, they have not been required and are not generally installed. The Safety Board closed Safety Recommendation 74-98 after assessing FAA's action as unacceptable. Moreover, the Safety Board is concerned that the FAA's actions to assure a sealed design of the lavatory waste receptacle have not been adequate. On June 25, 1983, a flight attendant aboard an Eastern Air Lines McDonnell Douglas DC-9 airplane noticed smoke coming from the right rear lavatory as the airplane was being taxied to the gate after landing. It was determined that the fire had started within the lavatory waste receptacle and propagated behind the vanity to the lavatory aft wall before it was extinguished by the airport fire department. The inspection of the undamaged left rear lavatory in the airplane revealed that the upper area of the waste chute behind the disposal door was not sealed to contain a fire, and there was no fire extinguisher in the receptacle. Further, it was evident that waste could accumulate in the enclosed area of the vanity adjacent to the waste receptacle. Following this incident, the Safety Board's

-75- personnel have observed similar discrepancies aboard other airplanes. As a result, the Safety Board on JUly 1, 1983, issued the following Safety Recommendation: Issue a Telert maintenance bulletin to all principal airworthiness inspectors to inspect immediately all lavatory paper and linen waste receptacle enclosure access doors and disposal doors on the applicable aircraft for proper operation, fit, sealing, and latching for the containment of possible trash fires, in accordance with the requirements of AD 74-08-09. (Safety Recommendation A-83-46) On the same day that the recommendation was issued, the FAA issued a telegraphic General Notice (GENOT), No. 8320.283, describing discrepancies in airplane lavatories observed by FAA inspectors and emphasizing the need for an aircraft lavatory maintenance and inspection program designed to correct these discrepancies. The Safety Board believes that this immediate action was appropriate; however, it appears that the continued fire containment integrity of lavatory waste receptacles cannot be assured even with periodic inspection. Thus, the Safety Board will continue to advocate that more positive protection against fires in and adjacent to waste receptacles be provided by an automatic~Hscharge fire extinguisher. Until recently, Safety Board recommendations and related FAA actions to minimize the lavatory fire hazard have focused on the waste receptacle as the most common fire origin. However, since the Air Canada accident, the Safety Board has examined the potential hazard of overheated electrical components associated with the lavatory flush pump motor circuits. Concern regarding this safety hazard was expressed in Safety Recommendations A-83-47 through A-83-49 which were issued on July 19, 1983, T after the Safety Board's investigation of an incident which occU1"red on July 12, 1983, involving an American International Airways DC-9 on the ground at Charlotte, North Carolina, in which smoke was observed coming from the airplane's right rear lavatory while it was being serviced. Shortly thereafter, maintenance personnel observed that several circuit breakers had tripped, including the 5-ampere breakers for the 3-phase electric flushing motor. Examination of the components disclosed that the flushing motor had overheated, that a phase-to-phase short had taken place in the motor, and that the flushing circuit timer had been damaged by overvoltage. As a result, the Safety Board recommended on July 19, 1983, that the FAA: Issue an Airworthiness Directive (1) to require an immediate inspection of the lavatory flushing pump motor and the associated wiring harnesses between the timing components and the motor in the lavatories of transport category airplanes for evidence of moisture-induced corrosion or deteriorated insulation and to require that flushing pump motors or wiring harnesses which exhibit such ,conditions be replaced, and (2) to establish appropriate periodic intervals for repetition of these inspections. (Safety Recommendation A-83-47) Establish, in conjunction with the flush pump motor, timer, and airframe manufacturers, a procedure which airline maintenance personnel could employ to verify that the electrical circuitry of lavatory flushing pump motors has not been damaged by corrosion or other causes so as to produce excessive heat during motor operation. (Safety Recommendation A-83-48)

-76- Issue a Maintenance Alert Bulletin to require Principal Mainten- ance Inspectors to assure that airlines have an acceptable program (1) for the frequent removal of waste from all areas of the lavatory with particular attention to those enclosed areas in and around the waste receptacles, and (2) which gives sufficient emphasis to areas susceptible to the accumulation of fluids in the vicinity of wire harnesses and other electrical components which can cause corro- sion. (Safety Recommendation A-83-49) The Safety Board notes that the FAA has, in response to several of the Board's Safety Recommendations, issued Notices of Proposed RUle Making (NPRM): NPRM 83-14, NPRM 83-15, and NPRM 84-5. NPRM's 83-14 and 83-15 were issued on October 11, 1983. The proposed rules contained in NPRM 83-14 establish more stringent flammability requirements for type certification of transport category airplanes and would require that previously certified airplanes conform to the more stringent criteria within 3 years from the date the proposed rules are made effective. NPRM 83-15 would establish the requirement to provide floor proximity emergency escape path markings in transport category airplanes. The proposed rule requires that the floor proximity emergency escape path provide visual guidance to passengers when all sources of illumination more than 4 feet above the cabin aisle floor are obscured by dense smoke. Previously certified airplanes would have to comply with the new standard within 2 years from the date the proposed rule becomes effective. On May 17, 1984, NPRM 84-5, which contains three proposed rules, was issued. The proposed rules wguld require the installation of automatic fire extinguishers for each lavatory disposal receptacle for towels, paper, and waste. The rules would also require the installation of smoke detector systems in the galleys and lavatories of air transport category airplanes and increase the number of hand fire extinguishers to be located in passenger compartments. Because the chemical agent Halon 1211 has demonstrated superior performance and effectiveness in combating fires, the proposed rule would require that at least two Halon 1211 hand fire extinguishers be installed in the airplane cabins. All air carriers would have to comply with these provisions within 1 year after the rules become effective. Upon its consideration of this accident report, the Safety Board issued the following additional recommendations to the Federal Aviation Administration: Require that Air Carrier Principal Operations Inspectors review the training programs of their respective carriers and if necessary specify that they be amended to emphasize requirements: for flightcrews to take immediate and aggressive action to deter- mine the source and severity of any reported cabin fire and to begin an emergency descent for landing or ditching if the source and severity of the fire are not positively and quickly determined or if immediate extinction is not assured. for flight attendants to recognize the urgency of informing flight- crews of the location, source, and severity of any fire or smoke within the cabin.

-77- for both· flightcrews and flight attendants to be knowledgable of the proper methods of aggressively attacking a cabin fire by including hands-on-training in the donning of protective breathing equipment, the use of the fire ax to gain access to the source of the fire through interior panels which can be penetrated without risk to essential aircraft components, and the discharge of an appropriate hand fire extinguisher on an actual fire. (Class II, Priority Action) (A-84-76) Require that Airplane Flight Manuals, Air Carrier Flight Operations Manuals, and Flight Attef.ldant Manuals be amended to include compre- hensive discussions and illustrations showing the proper use of a fire ax and the locations in each model of aircraft operated where a fire ax can be used safely to gain access to a fire or smoke emission source. (Class II, Priority Action) (A-84-77) Require that those interior cabin panels of transport category airplanes, including panels of the lavatories and galleys, which can be safely penetrated with a fire ax be identified by an acceptable and standardized means. (Class II, Priority Action) (A-84-78) The Safety Board believes that its recommendations when implemented will reduce or eliminate possible sources of ignition, provide earlier detection of cabin fires, and provide improved procedures and equipment for flightcrew and cabin crew personnel to combat and control cabin fires. Since these recommendations address every possible fire source and every possible area where cabin fires most logically could originate, the Safety Board also believes that its actions will either prevent or reduce- the possibility of a recurrence of a fire similar to that encountered on board Flight 797. REVISED REPORT ADOPTED BY THE NATIONAL TRANSPORTATION SAFETY BOARD" /s/ JIM BURNETT Chairman /s/ PATRICIA A. GOLDMAN Vice Chairman /s/ JOHN K. LAUBER Member January 31, 1986 *This report was revised based on the Safety Board's reply to a Petition for Reconsideration of probable cause and findings (See appendix F.) The original report was adopted on August 8, 1984, by the following members of the National Transportation Safety Board: Jim Burnett, Chairman; Patricia A. Goldman, Vice Chairman; and G.H. Patrick Bursley and Vernon L. Grose, Members.

Page Intentionally Left Blank

-79-

1. APPENDIXES

APPENDIX A INVESTIGATION AND PUBLIC HEARING 1. Investigation The National Transportation Safety Board was notified of the accident about 1930, on June 2, 1983, and immediately dispatched an investigative team to the scene from its Washington, D.C. headquarters. Investigative groups were formed for operations and witnesses, air traffic control, meteorology, human factors, structures, powerplants, systems, flight data recorder, maintenance records, and cockpit voice recorder. Parties to the investigation were the Federal Aviation Administration, Air Canada, McDonnell Douglas Corporation, United Technologies Corporation, and the Greater Cincinnati International Airport. Transport Canada appointed an accreoiteo representative to assist the Safety Board during the investigation. The accredited repre- sentative was assisted by advisors from Air Canada, Canadian Air Line Pilots Association, and Canadian Air Lines Flight Attendants Association. Transport Canada also made available its laboratories and laboratory personnel. 2. Public Hearing A 4-day pUblic hearing was held in Fort Mitchell, Kentucky, beginning August 16, 1983. Parties represented at the hearing were the Federal Aviation Administration, Air Canada, McDonnell Douglas Corporation, Heath Tecna Corporation, Canadian Air Line Pilots Association, and the Greater Cincinnati International Airport. Transport Canada appointed an accredited representative to assist the Safety Board during the public hearing.

-80- APPENDIX B PERSONNEL INFORMATION O'lptain Cameron Captain Donald S. Cameron, 51, was employed by Air Canada on March 28, 1966. He 1101ds Canadian Airline Transport Certificate No. YZA 000964 with airplane single and multiengine land ratings. The captain is type rated in Grumman G-73, Vickers VC-9, Lockheed L-49, and McDonnell Douglas DC-3, -4, ,-8, and -9 airplanes. The captain's last class-1, group-1 Canadian Medical Certificate was issued February 17, 1983, and contained the following limitation, "Valid only when required glasses are available." Captain Cameron qualified as captain in the DC-9 during November 1974. He passed his last proficiency check on February 14, 1983; his last line check on July 16, 1982; and completed his last recurrent training on January 24, 1983. The captain had flown about 13,000 hours, 4,939 of which were in the DC-9. During the last 90 days, 30 days, and 24 hours before the accident, he had flown 111 hours, 39 hours, and 9 hours, respectively. The captain had been off duty about 11 hours 55 minutes before t'eporting fot' this flight. At the time of the accident, he had been on duty about 7 hours 35 minutes, 5 hours 10 minutes of which was flight time. First Officer Ouimet First Officer Claude Ouimet, 34, was employed by Air Canada on November 25, 1973. He holds Canadian Senior Commercial Pilot Certificate No. ULS 102366 with a Class 1, Group 1 Instrument Rating valid to February 1, 1984; ratings for all types of Class 7 airplanes of 12,500 pounds or less, and for the DC-9. The license is not valid for pilot-in-command in "airplanes of more than 12,500 pounds engaged in com mercial air set'vice and passengers carried." His last class-1, group-1 Canadian Medical Certificate was issued April 21, 1983, with no limitations. First Officer Ouimet qualified as first officer in the DC-9 during February 1979. He passed his last proficiency check on July 14, 1982; his last line chec1< on May 26, 1983; and completed his last recurrent training on January 12, 1983. The first officer had flown about 5,650 hours, 2,499 of which were in the DC-9. During the last 90 days, 30 days, and 24 hours before the accident, he had flown 144 hours, 75 hours, and 9 hours, respectively. The first officer had been off duty about 11 hours 55 minutes before reporting for this flight. At the time of the accident, he had been on duty about 7 hours 35 minutes, 5 hours 10 minutes of which was flight time. 14 CFR 129.15 states: No person may act as a flight crew-member unless he holds a current certificate or license issued or validated by the country in which that aircraft is registered showing his ability to perform his duties connected with that aircraft. Since both the captain and first officer possessed Canadian certifica.tes with DC-9 type ratings, they were qua.lified to operate DC-9 type airplanes within the United States.

Flight Attendant Benetti -81- APPENDIX B Flight Attendant Sergio Benetti, 37, was employed by Air Canada .Januarv 2, 1972. The flight attendant completed his initial training January 3, 1972, and 'lis last recurrent training on August 11, 1982. The flig-ht attendant had heen off duty for 11 hours 55 minutes before reporting for this flight. At the time of the accident, he had been on duty about 7 hours 35 minutes, 5 hours 10 minutes of which was flight time. Flight Attendant Kayama Flight Attendant Laura Kayama, 28, was employed by Air Canada in May 1976. The flight attendant completed her initial tl'aining in June 1976; and her latest recurrent training on February 16, 1983. Her duty and off duty times were identical with those of Flight Attendant Benetti. Flight Attendant Davidson Flight Attendant Judith L. Davidson, 33, was employed by Air Canada on July 9, 1973. She had completed her initial training on September 7, 1973, and her latest recurrent training on June 17, 1982. Her duty and off duty times were identical with those of Flight Attendant Benetti. Gregory L. Karam Gregory L. 'Karam, 36, was the approach controller at the Cincinnati TRACOM. The approach controller was employed by the FAA on January 9, 1974, and is a full performance level controller. His last second-class medical' certificate was issued November 5, 1982, and the controller was required to "possess glasses for near and distant vision." On June 2, 1983, the controller l'eported for duty at 1500 and assumed his approach control station at 1557. James L. Ferguson James L. Ferguson, 49, was the Louisville high altitude radar controller. He was employed by the FAA on December 12, 1956. He is a full performance level controller and is also an area supervisor at the Indianapolis ARTCC. The controller's last second class medical certificate was issued Fehruary 16, 1983 and contained no waivers or limitations. On June 2, 1983, the controller reported for duty at 1245 and assumed the Louisville high altitude !"adar controller duties at 1744. Jack B. Martin Jack Martin, 50, was the LEX-D controller. Be was employed by the 'FAA on December 2, 1957, and is a full performance level controller. l-lis last second-class medical certificate was issued February 24, 1983, and contained no waivers or limitations. On June 2, 1983, the controller reported for duty at 1200 and assumed the LEX-D position at 1745.

-82- APPENDIX C AIRPLANE INFORMAnON McDonnell Douglas DC-9-32, C-FTLU The airplane manufacturer's serial No. 47196 was delivered to Air Canada on April 7, 1968, and had been operated by the airline continuously since that time. A review of the airplane's flight logs and maintenance records showed that all applicable Airworthiness Directives had been complied with, and that all checks and inspections were completed within their specified time limits. The records review showed that the airplane had been maintained in accordance with company procedures and Canadian rules and regulations and disclosed no discrepancies that could have affected adversely the performance of the airplane and any of its components. The airplane was powered by Pratt and Whitney JT8DI-7B engines rated at 14,000 pounds of static thrust for takeoff at sea level at 84° F. The following is pertinent statistic1l1 data: Airplane Total Airplane Time Total Airplane Landings PowerplaJits 36,825 hours 34,987 Engine Serial Number Total Time Total Cycles No. 1 P657758D 20,942 hours 21,459 No.2 P657360D 28,990 hours 29,598

-83- APPENDIX D TRANSCRIPT OF AN AIR CANADA COCKPIT VOICE RECORDER, SIN 1613 REMOVED FROM A DOUGLAS DC-9 WHICH WAS INVOLVED IN ~~ ACCIDENT AT CINCINNATI, OHIO# ON JUNE 2# 1983 LEGEND CAM Cockpit area microphone voice or sound source ROO Radio transmission from accident aircraft -1 Voice identified as Captain -2 Voice identified as First Officer -3 Voice identified as male Flight Attendant -4 Voice identified as female Flight Attendant -s Voice identified as a male passenger CTR xxx * # ( ) (( )) Note: Indianapolis Center Varous aircraft Unintelligible word Nonpertinent word Questionable text Editorial insertion Pause All times are expressed in central standard time.

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS TIME Ii SOURCE CONTENT TIME & SOURCE CONTENT 1848:12 CAM ((Sound similar to arcing» 1848:15 CAM ((Sound similar to arcing» 1851:03 CAM ((Two sounds similar to· arcing» 1851:04 CAM-1 How is your sea food, nice? CAM CAM-2 ((Sounds similar to arcing and snapping» It's good m ~ CAM-l

• steak nice?

1851:09 CAM-2 Different, a little bit dry but okay 1851:14 CAM ((Sounds similar to arcing and snapping» CAM-2 (What was that?) CAM-1 , 1851:19 CAM-2 It's right there, I see it CAM-l Yeah CAM-l DC bus CAM-2 Which one is that?

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS TIME Ii SOURCE CONTENT TIME & SOURCE CONTENT CAM-1 DC bus the. ah. left toilet, left toilet flushing 1851:27 CAM-1 (I) better try it again, eh, push 'em in " . CAM-2 Push it in one more time, I guess 1851:41 CAM «Sound of arcing» CAM-2 What! (Xl U1 1851:42 CAM «Sound of arcing and snap» CAM-1 That's it 1851 :43 CAM «Sound of arcing and snap» CAM-1 Won't take it CAM-2 No CAM-1 See anything else? CAM-1 (There's nothing) on the panel CAM-l Ha 1852:08 CAM-l Like a machine gun CAM-2 Yeah, zap, zap, zap

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS TIME & SOURCE CAM-1 CAM-2 1852:26 CAM-1 1853:16 CAM-1 1853:21 CAM-1 1853:25 CAM-2 CAM-1 CAM-2 CONTENT

• put it in the book. there

Log it Now I want to log it. eh Somebody must have pushed a rag down the old toilet or something. eh? Jammed it. and it overheated Is it flushing you pushed? It's flushing. yeah (Motor) * TIME & SOURCE CONTENT I (Xl 0'1 1853:30 CAM-1 Toilet flushing. three breakers banged 1853:35 CTR Air Canada seven ninety seven, contact Indianapolis on one three three point zero five 1853:40 RDO-2 Air Canada seven nine seven, so long 1853:41 CTR So long

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS TIME • SOURCB CONTENT TIME & SOURCE CONTENT lB54: 18 CAM-l Don't see the ground too often, today eh? 1853:53 RDO-l Indianapolis Center, this is Air Canada seven nine seven maintaining three three zero direct louisville on course 1853:59 eTR Air Canada seven ninety seven Indianapolis Center roger CAM-l No, a lot of, a lotta cloud eh, the whole * the whole area 1856:56 CAM-2 Yeah, that feels good 1857:09 C~-l What the' does this mean 1857:12. CAM-l (Reg a bail) CAM-2 I don't know CAM-2 Regional examiner, regional * regional 1857:36 CAM-l We may be, I don't know, A.J. would be a three letter code if it was an airport, eh CAM-2 I don't know, it might be in the, ah, charts CAM-l Regional --- here's another regional A.J. ROO-?

I co -...J

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS TIME & SOURCE CONTENT TIME & SOURCE CONTENT CAM-l (Well it's) 1858:16 CAM-2 That (one) is lettered D.G. * CAM-l Oh I see. oh yeah, yeah * 1858:27 CAM-l Alternate. ah. must be our alternate here CAM-l Ah who gives a * 1858:43 CAM-l Nothing to do with us CAM «Sound similar to cockpit door» 00 00 CAM-3 Yeah thank you sir 1859:02 CAM-? UWX 1859:30 CAM-l Twenty nine U, W. and Xtwenty nine. those are the grid references 1859:37 CAM-2 Twenty nine. yeah 1859:42 CAM-l Twenty nine UWX three --- the left toilet flushing CAJ.1-2 Left

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS TIME & SOURCE CONTENT TIME & SOURCE CONTENT 1859:47 CAM-l Yeah aft left toilet flush, and-they wouldn't accept a reset 1859:58 CAM «Sound of first attempt to reset and sound similar to arcing» 1859:59 CAM «Sound of second attempt to reset'and sound similar to arcing» 1900:00 C~~ «Sound of third attempt to reset and sound similar to arcing» NOTE: «When questioned later, the captain and copilot said they did not hear the sound of arcing noted on the CVR CAM channel. They said they attempted to reset breakers just one time each» CA~-l Pops as I push it CAM-2 Yeah, right CAH-l Yeah 1900:51 CAM «Sound of cough» 1901:12 CAM-2 Zero two seven set for ya Don 1901 :33 CAM-1 Better --- have dinner here 1901 :42 CA~ «Sound of chime» co ~

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS TIME .. SOURCE CONTENT TIME & SOURCE CONTENT CAM-3 Yes 1901 :49 CAM-l Sergio could I try for mine now please CAM-3 Sure CAM-l Thank you very much 1901:59 CAM-l Do you want any of that fruit or should we give it to the girls --- far as I'm concerned CAM-2 No CAM-l I don't want it .0 o 1902:13 CAM-l There you go CAM-2 Thanks 1902:15 CAM-l You're in a left turn here to pick up oh t~ seven CAM-2 So okay twenty seven CAM-l Louisville to Rosewood 1902:28 CAM-l The next chart yeah that's it CAJ.l-2 Yeah 1902:34 CAfoI-l We're just over Louisville here

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS TIME , SOURCE CAM-2 CAM-2 1902:40 CAM-4 CAM-l CAM-4 CAM-2 CONTENT ((Sound of whistling)) Louisville --- Rosewood, okay Excuse me, there's a fire in the washroom at the back, they're just oh # went back to go, to put it out Oh yeah They're still, well they're just gonna go back now Want me togo there TIME & SOURCE CONTENT 1.0 I-' 1902:50 CAM-I Yeah go CAM-2

• the brakers # up

CAM-l Leave my, leave my, leave my dinner in the thing there for a minute CAM-4 Okay CAM-S (Can I buy you a drink cause there's something going on, drink or a shot) CAM-? Ah, I wouldn't say that 1903:06 CAM-S Yeah okay CAM-? Still there huh? CAM-S Yeah 1903:1l'i CAM-2 Got the, ah, breakers pulled

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS TIME 6 SOURCE CAM-l 1903:15 CAM-4 CAM-2 CAM-l 19J3:21 CAM-4 1903:31 CAM-4 CONTENT It's the motor Pardon me You got all the breakers pulled out? The breakers are all pulled, yeah ( make 'em all seat?) Captain is it okay to move everybody up as far forward as possible TIME & SOURCE CTR CONTENT Repuhlic two eighty eight Indianapolis, Memphis one three three point eight five three three eight five, goodbye 1904:07 CAM-2 1904:16 CAM-3 1904 :23 CAM-2 Okay I eh, you don't have to do it now, 1 can't go back now, it's too heavy, I think we'd better go down I got all the passengers seated up front, you don't have to worry I think its gonna be easing up Okay, it's starting to clear now 77L CTR 1903:54 CTR 1904 :00 CTR RDO-?

• * seven seven lima (Knoxsville)
• * two none zero --

Seven seven lima (Knoxsville) roger Delta sixteen twenty six continue descent to flight level two four zero, Indianapolis Center one two eight five five on two four zero at twenty eight fifty five, so long (Cleared) ah okay I \D IV

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS TIME • SOURCE CONTENT TIME & SOURCE CONTENT CAM-l Okay 1904:25 CAM-l Well I want --- hold on then CAM-3 (Mike) I just can't go back it too CAM-2 I will, go back ,if thatrs appears better, okay CAM-l Yeah that's okay CAM-? That's okay, yeah ((simultaneous with above» CAM-2 So --- .0 W CAM-l Take the, take the smoke mask CAM-2 You have control CAM-I Take the goggles 1904:36 CAM-I I'll leave the mask on CAM-2 Okay Note ((Orignated in back» Okay I want 1904:46 CAM-I Okay go back whenever you can but don't get yourself incapacitated ((This appears on radio channel as well» CAM-2 CAM-l No problem, no problem Okay

CONTENT TIME .& SOURCe INTRA-COClPlT CONTENT 1905:15 286G AIR-GROUND CotMJNICATIONS TIME & SOURCE Indianapolis good evening Citation tWo eight six golf, three one oh 1905:35 CAM «Electrical pulse app~a~s on tape radio channels) 1905: 18 CTR Citation two eight six gold Indianapolis 1905:36 CAM-4 Captain, your first officer wanted me to tell you that Sergio has put a big discharge of C02 in the washroom, it seems to be subsiding, all right 286G CTR Okay we're proceeding direct Pocket City Affirmative sir, direct Pocket, direct Evensville ~ ol::> 286G Six gold 1905:48 8747 Center Poca seven four seven level four three zero CTR Poca seven four seven Indianapolis roger 1906:07 RDO-l Memphis Center this is Air Canada seven nine seven

INTRA-COCKPIT AIR-GROUND Cc:»MJNICATIONS TIME , SOURCE CONTENT TIME & SOURCE CONTENT CAM-l CAM-3 1906:42 CAM-3 1906:50 CAM-l 1906:52 CAM-3 1906:54 CAM-l 1906:55 CAM-3 CAM CAM-2 (Coming along okay) Getting much better, okay I was able to discharge half of the C02 inside the washroom even though I could not see the source but its definitely inside the lavatory. Yeah, it's from the toilet, it's from the toilet C02 it was almost half a bottle and it now almost cleared Okay, thank you Okay, good luck ((Sound similar to cockpit door» Okay, you got it * 1906:09 CTR Canada seven ninety seven Indianapolis Center, go ahead 1906:12 RDO-l Yeah, we've got an electrical problem here, we may be off communication shortly ah stand by 1.0 In

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS TIME , SOURCE CAM-l CAM-l 1907:11 CAM-2 CAM-l 1907:14 CAM-2 1907:41 CONTENT Yeah Okay I don't like what's happening, I think we better go down, okay? Okay Okay, I'll be back there in a minute ((Recorder goes off» TIME & SOURCE 1907:28 P362 1907:32 CTR 1907:35 P362 CONTENT Hello Center, Piedmont three sixty two, we're level at flight level three three zero Three sixty two Indianapolis Center roger We'll take direct Holston Mountain if you can do that I.D (J'

-97- APPENDIX E 14 CFR 25 FLAME RESISTANCE CRITERIA Flame l'esistance criteria for airplane compartment materials are contained in 14 CFR 25.853. Section 14 CFR. 25.853(a) states in part: Interior ceiling panels, interior wall panels, partitions, galley structure, large cabinet walls, structul'al flooring and materials used in the construction of stowage compartments (other than underseat stowage compartments for stowing small items such as magazines and maps) must be self-extinguishing when tested veJ:'tically in accordance with the applicable portions of appendix F of this part, 01" other approved equivalent methods. The average burn length may not exceed 6 inches and the average flame time after removal of the flame SOUl'ce may not exceed 15 seconds. Drippings from the test specimen may not continue to flame for more tl1an an average of 3 seconds after falling. Section 14 CFR 25.853(b) states, in part: Floor covering textiles (including draperies and upholstery) seat cushions, padding, decorative and nondecorative coated fabrics, leather trays and galley furnishings, electrical conduit, thermal and acoustical insulation and insulation covering air ducting, joint and edge covering, cargo compartment liners, insulation blankets, ... must be self-extinguishing when tested vertically in accordance with the applicable portions of appendix F of this part, or other appr'oved equivalent methods. The . average burn length may not exceed 8 inches and the average flame time after the removal of the flame source may not exceed 15 seconds. Drippings from the test specimen may not continue to flame for more than an average of 5 seconds after falling. The acceptable test procedures, flame heat, and apparatus required to demonstrate compliance with 14 CFR 25.853 are contained in appendix F of 14 CFR. 25. With regard to vertical and horizontlil flame testing, and the appendix states, in part: (d) Vertical test. . .. For materials covered by section 25.853(a), the flame must be applied for 60 seconds and then removed. Flame time, burn length, and flaming time of drippings, if any, must be recorded. The bUl"n length determined in accordance with paragraph (h) of this appendix must be measured to the nearest one-tenth inch. (e) Horizontal test. . .• The flame must be applied for 15 seconds and then removed. Minimum of 10 inches of the specimen must be used for timing purposes, approximately 1 1/2 inches must burn before the bUJ:'ning front reaches the timing zone, and the average burn rate must be recorded. (h) Burn length. Burn length is the distance from the original edge to the farthest evidence of damlige to the t~st specimen due to flame impingement, including areas of partial or complete consumption, chllrring, or embrittlement, but not including areas sooted, stainerl, warped, ot' discolored, nor areas where matel"ial has shrunk or melted away from the heat source.

Appendix F. Air Canada DC-9 Emergency Equipment Crew Oxygen Masks Smoke Goggles (3) Megaphone First Aid Kit (Overhead Bin) Doctors Kit Extinguisher H20 Portable Oxygen Bottle Flashlights (2) Ico co I Portable Oxygen Bottle E"xtinguisher C02 Portable Oxygen Bottle (2) First Aid Oxygen Mask Extinguisher H20 & Dry Chemical Portable Oxygen Bottle Flashlights (3) Flight Attendant Oxygen Mask (2) First Aid Kit First Aid Oxygen Mask (Overhead Bin)

-99- APPENDIX G PETITION FOR RECONSIDERATION OF PROBABLE CAUSE _.- !~ ..i7 AIR LINE PILOTS ASSOCIATION 1625 MASSACHUSETTS AVENUE, N.W. CJ WASHINGTON, D.C. 20036 =(20217 97-4000 December 20, 1984 The Honorable James Burnett Chairman National Transportation Safety Board 800 Independence Avenue, S. W. Washington, D. C. 20594 Dear Hr. Burnett: The Air Line Pilots Association has reviewed the Aircraft Accident Report for the Air Canada DC-9 accident at Cincinnati, Ohio, on June 2, 1983. We were quite pleased with the technical effort which was expended by the Safety Board in their search for the source of the fire which occurred on board the aircraft. No stone was left unturned, and while the source could not be identified at this time, we believe that eventually the cause will be found. However, even though the source could not be located, the results of the research which was conducted will help to reduce the severity and loss of life in future accidents of the same type. Although we concur with the technical sections of the well written report, we disagree with certain sections of the report which deal with the judgment and decisions of the flight deck crewmembers. In this regard, we are therefore sUbmitting this Petition for Reconsideration. While the Air Line Pilots Association has no new evidence to'present at this time, we believe that the Board did not properly assess the evidence which was in hand with respect to the time factor in the captain's decision to descend. On page 61 of the Board report, the Board states, "Therefore, the Safety Board realizes that there is a need to evaluate the situation before deciding upon the emergency action required. However, in this case, the time to make the decision appears excessive under the circumstances. The Safety Board believes that a precautionary emergency descent should have been initiated as soon as it became evident that the fire had not been visually located and could be attacked directly with extinguishant. This became known at 1904:07 when the first officer came forward from his first inspection of the aft cabin area, about 3 minutes before the decision to begin an emergency descent."

APPENDIX G Mr. James Burnett -100- 2 December 20, 1984 We agree wholeheartedly that the emergency descent should have been initiated as soon as it became evident to the captain that the fire had not been visually located ~nd could not be combated directly. However, the evidence presented in the report indicates that this did not occur at 1904:01 as stated in the Board Report. On page 61 of the report, the Board states, "such reports, (of smoke in the cabin), often turn out to be smoke from an overheated flushing motor or waste ignited by a discarded cigarette in a trash receptacle designed to contain a fire, conditions which are normally identified and corrected by flight attendants without further consequences." At 1906:52, the captain, by his own testimony, and as indicated on page 3 of the Board report, still believed the fire to be in the lavatory trash bin, and he did not decide to descend at this time because, "I expected it (the fire) to be put out." He had been led to this decision by a series of positive reports with respect to the firefighting efforts of the crew. At 1904:16, only 9 seconds after the first officer had suggested that they go down, the flight attendant advised the captain, "you don't have to worry I think it's gonna be easing up." Seven seconds later, at 1904:23, the first officer advised, "Okay, it's starting to clear now." At 1905:35, another flight attendant advised, "Captain, your first officer wanted me to tell you that Sergio has put a big discharge of CO in the washroom, it seems ~o be SUbsiding all right." Some time after 1909:01, the flight attendant who gave the first report advised the captain, "Getting much better, okay." At 1906:52, the flight attendant advised the captain, "C02, it was almost Jfalf a bottle and it now almost cleared." At 1906:54, the captain responded, "Okay, thank you." Between, 1904:01 and 1906:54, the captain received 5 separate communications from three different crewmembers indicating that the fire was being brought under control and that the smoke was subsiding. It should also be noted that at 1904:46, 39 seconds after the Board indicates that it was evident to the captain that the fire could not be attacked directly with extinguishant, the captain sent the first officer aft to combat the fire. He would not have done so had he believed that the fire was not accessible at that time. Therefore, the above evidence indicates that the first time it became evident to the captain that the fire was not controllable was at 1901:11, when the first officer returned from the cabin and advised, "I don't like what's happening, I think we better go down, Okay?" Upon being informed for the first time that the fire was not under control, the captain made the decision to begin the descent immediately. Descent was begun as soon as the first officer resumed his seat and the aircraft prepared for an emergency descent. On page 10 of the Board report, under Finding number 8, the Board states, "Thereafter, he misconstrued reports that the fire was abating and he delayed ~i~ decision to declare an emergency and descend." Webster's dictionary efines the word "misconstrue" to mean "to misinterpret; misunderstand". The captain did not misinterpret, nor did he misunderstand any of the communication from his crew. He simply relied upon his crew and believed what he was told. There is a vast difference between believing an erroneous communication, and misinterpreting a communication. The word "misconstrue" carries a connotation of error on the part of the captain. It indicates that he misinterpreted what he was told, and thereby committed an error. There is simply no evidence to support such a conclusion. To believe is not to misconstrue.

Mr. James Burnett -101- 3 APPENDIX G December 20, 1984 The Safety Board's report contains many more erroneous conclusions based upon misconstrued evidence. However, these errors are succinctly described in First Officer C. Ouimet's notes on the N.T.S.B.'s report. The notes have been provided.to the Safety Board, and we will not reiterate them here. We will state, however, that we fully support Mr. Ouimet's conclusions. In light of the evidence contained in the Safety Board's report, we respectfully request that in Finding number 8, on page 70 of the report, the last sentence be changed to read, "Due to persistent reports from various crew members that the fire was abating, he delayed his decision to declare an emergency and descend." The last paragraph of the probable cause states, "Contributing to the severity of the accident was the flightcrew's delayed decision to institute an emergency descent." While that statement is technically true, it suggests that the captain's delayed decision was different from the decision that a more prudent captain would have made under similar circumstances. We do not believe that to be true. The Safety Board has had over a year to subject the captain's decisions and the results of those decisions to minute examination by not only the Board, but by a staff of many persons. Considering the not inconsiderable benefit of hindsight, the time which the Board has had to analyze ~e circumstances and the number of persons which were employed' in this task, it is grossly unfair and unrealistic for the Safety Board to expect a flight crew to evaluate an incident in a dynamic situation, and reach the same conclusions in a few seconds that it took the Safety Board and all of its staff over a year to reach. And we might point out that even after having the benefit of all the evidence and hindsight, during the "Sunshine" meeting of July 20, 1984, not even the Board Members could agree upon the time when the crew's decision to descend should have been made. We believe that given the constant stream of positive information which was conveyed to this captain regarding the severity of the fire, that ~ prudent captain would have made his decision to descend exactly when this captain did. Even when a crew performs heroically, as this crew did, the Safety Board cannot seem to resist the temptation to find fault with the crew, even though such a finding requires a distortion of the evidence to support such conclusions. It is very unfortunate that the news media did not quote the Board's comments that the captain exhibited outstanding airmanship without which the airplane and everyone on board would certainly have perished, but blared in headlines from coast to coast and in at least two countries, "Crew's delayed deciision causes accident." The crew's reputation was therefore destroyed by conclusions reached by the Safety Board which were not in accordance with the evidence in the Board's possession. We therefore respectfully request that the Safety Board change the last paragraph of the probable cause to indicate that the delayed decision was based upon evidence which was presented to the captain upon 5 different occasions by 3 different crewmembers, which evidence indicated that the fire was abating and that the smoke was subsiding, and that an emergency descent would not be required.

APPENDIX G Mr. James Burnett -102- 4 December 20. 1984 If we can be of any further assistance in processing this petition, please let us know. Sincerely. ).~o..~ Henry A. DUffy. President HAD/em

-103- NOTES ON N.T.S.B. REPORT AIR CANADA DC-9 C-FTLU CINCINNATI, JUNE 2, 1983 Submitted by: FlO C. Ouimet APPENDIX G ··The N.T.S.B. determines that the probable causes of the accident were a fire of undetermined origin, an underestimate of fire severity, and con- flicting fire progress information provided to the captain. Contributing to severity of the accident was the flight crew's delayed decision to ins- titute emergency descent.- So the criticism of the crew is contained in a time frame between 19:02:40 and 19:08:12 E.D.T., or the first 5 minutes and 32 seconds. Most of the explanation of that criticism is found on page 57 of the report. Paragraph 2, half way says: ··Neither he (flight attendant in charge) nor the first officer told the captain that they had not seen the fire and that they did not know exactly where it was or how lntensely lt was burning.··. J The board must have missed what is said by Mr. Benetti. on page 13 of Exhi- bit 12A, which is the transcript of the cockpit voice recorder. ··1 was able to discharge half of the COZ inside the washroom even though I could not see the source but it's definitely lnside the lavatory"· Those are the exact words of Mr. Benetti to captain Cameron. The report continues with paragraph 3: ··He (first officer) retreated the first time because he did not have smoke goggles with him...... In Exhibit 2A, first officer statement ··1 try to get tq the washroom but could not because of smoke··.· In the same N.T.S.B. report on page 3, paragraph 2 it says "The first officer said that he could not get to the aft lavatory be- cause the smoke, which had migrated over the last three to four rows of seats, was too thick··. Also in Exhibit 12A, transcript of the voice recorder page 10, I say to the captain during my first visit to the cockpit ...•• 1 can't go back now, it's too heavy··. So I did not retreat and never said I did because I did not have my·smoke goggles, but because I could not physically walk to the washroom in that smoke. 1 thought •• •/2

APPENDIX G -104-

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that, maybe, maybe using the smoke goggles would help me to get there with ~y tie around my nose and mouth. But, that is not the first reason why I went back tq the cockpit; the first thing I say after ....• I can't go back itls too heavy, I think \'ie'd better go down" Exhibit 12A, page 10. But we will come back to that part later. The report says in the same paragraph: "Since the flight attendant in charge and the first officer were not able to determine the location of the fire they were not able to assess the se- verity of the fire. Consequently••• , they provided the captain with an in- adequate assessment of the fire's severity.··. That is easier said than done, and I quote from the following reports. Passenger Arnold Friedman (Exhibit 6A): "The male FIA had sprayed it with an extinguisher. Heavy brown smoke billowed forward. The first officer went aft several times." Passenger Harry Mosely: ..••. the noise of the CO2 fire extinguisher when triggered. This sound came from the back of the aircraft. He looked back and sa\'I the smoke." Flight attt=!ndant J. Davidson: "She ingested some smoke which made her feel dizzy... Mr. Benetti was standing back while I was trying to walk through the smoke and said in his report: "The smoke had an electrical acrid smell and burned his throath.·' and Mr. Benetti managed only to discharge part of the C02. So the flight attendant and I were not able to determine the location of the fire because we COULD NOT, NOT PHYSICALLY POSSIBLE, TOO MUCH SMOKE. This is where the assessment of our story stops short of reality. The report continues in paragraph 4: "The Safety Board bel ieves that a precautionary emergency descent should have been initiated as soon as it became evident that the fire had not been visual- ly located and could be attacked directly with extinguishant. This became known at 19:04:04 when the first officer came forward from his first inspection of the aft cabin area, about 3 minutes before the decision to begin an emergency descent•..• Again, Exhibit 12A, page 10, I say "1 canlt go back now, itls too heavy (smoke). I think we'd better go down:'. So that is exactly what the report says we should have done and for the same reasons except for the "precautionary emergency descent~. I had in mind a descent, not a fuel saving descent of course because of the nature itself of the reason why •• ./3

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APPENDIX G we were going down, but not an emergency descent also as I testified because I did not know enough. In an emergency descent, I am required in my seat and f thought that I could do more, maybe, with my goggles and the fact that I vias caught by surprise by the acridity of the smoke the first time and I would not be this tiole. I wanted to give it another shot so that I could see or even better fight the fire. Again from the cockpit voice recorder, Exhibit l2A, at 19:04:46 the captain says: ··Okay go back \'/henever you can but don I t get yourse1 f incapacitated.'· and my answer is: "no problem, no problem··. Not knowing what we know now, was it that unrealistic to think that way? During all that time, I do have the motor pump in my head as a possible cause ••• Exhibit 12A, transcript of the cockpit voice recorder, at 19:02:50 just after the flight attendant's report of a fire and before I left the cockpit, I say: "Got all the breakers pulled:·. Again, just before I left, I say: "You got all the breakers pulled out?" and the captain answers: ··The breakers are all pulled, yeah:·. In the cabin, the smell seemed to be coming very possibly from something elec- trical according to passengers and flight attendants' reports in Exhibit 6A. So I associated the fire with the lavatory pump as I testified in Cincinnati, but I could not convince myself since the breakers were all out and therefore the pump was supposed to be dead. So this is what happened between 19:02:40 and 19:04:07 and I am convinced that Captain Cameron would have gone down as I suggested because we worked all month (May) together and we had a very good professional relationship. " BUT, and the next 3 minutes raised even more harsh critici~m from the N.T.S.B. report, we did not commence descent and that is because at 19:04:16 Mr. Benetti says (report page 3, paragraph 3): •••••didn·t have to worry, I think it's gonna be easing up:' and at 19:04:23, I say to the captain: ··It is starting to clear now.··. • •• /4

APPENDIX G -106-

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I never said not to descend, but I realize it implied just that, and the captain looked back and saw the cabin clear. Female flight attendant at 19:05:36: ··..• it seems to be subsiding now". Flight attendant in charge at 19:06:52: ..... it is almost cleared". That change of situation is confirmed by many passengers' statements in Exhibit 6A. Arnold Friedman: "There was a short interval in which the smoke subsided". Glen W. Davis: ··•••and the smoke cleared for a minute or two". In Exhibit 6A, page 39, the Human Factors Group Chairman's factual report: "Severa1 passengers reported a short interval, estimated by one passenger to be 5 minutes, during which the smoke subsided. ". I believe that is enough evidence to confirm that at the time "Ie \'/ere deci- ding for a descent, there was a significant change in our situation: a decrease and complete disappearance of smoke in the cabin. The report fails to recognize that fact in spite of all the reports in the exhibits. What is called "conflicting fire progress", "underestimate of fire severity", "miscontrued reports" ~/ere just a simple observation, a noting of the facts by the crew. Of course, we did not have the benefit of knowing the future and we believed what we saw, and so it was for everyone on board. I remember when I went back for the second time that some people had resumed their drinking and talking. There are a lot of questions that go through your mind in a moment like this: Was the C02 effective? Maybe, the motor pump blew, produced smoke and died? Remember the pump was very present in my mind. Those were reasonable assumptions at the time, much more than the extraordinary set of circumstances that the report says happened (page 54, paragraph 5): "The momentary smoke abatement noted by the first officer' and fl ight attendant in charge between 19:04:16 and 19:04:23 (right at the time of our decision to descend) was probably attributable to the dilution effect of opening the lava- tory door and discharging the C02 into the area, reclosing the lavatory door, and the almost simultaneous failure of the lavatory vent line and the flush and fill pipe connections and check valve, all of which increased the venti- lation rate beneath the toilet shroud and accelerated the flow of smoke and gases to the area below the lavatory floor and overboard..·• It is the timing and this amazing sequence of events that led us to believe that the situation had improved, and so it was for everybody on board, and no one that was not there can pretend otherwise. Again, all of this is very compatible with the lines of the report page 57, paragraph 4: .../5

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APPENDIX G ··While an actual infl ight fire is an extremely rare occurence, all reports of smoke in the cabin must be regarded as potentially serious. However, such reports often turn out to be smoke from an overheated flushing motor or waste ignited by a discarded cigarette in a trash receptacle designed to contain a fire, conditions which are normally identified and corrected by flight attendants without further consequences. Therefore, the Safety Board realized that there is a need to evaluate the situation before de- ciding on the emergency action required.··. So I did not just stand there but went back with my smoke goggles to evaluate the last events, touched the door and knew immediately that we had a major problem and there was nothing we could do except to get on the ground and fast. I told the flight attendants to prepare for emergency landing and at 19:07:11 told the captain (Exhibit 12A): • "1 don't like ,...hat is happening, 1 think ,...eld better go down, O.K:·. The captain concurred and so it was between 19:04:07 (first report to the captain) and 19:07:11 (second report) as the development of the situation caused the decision to descend to be delayed, again, not knowing what would happen 'after. So the N.T.S.B. report (page 57, paragraph 4) goes on to say: "As a result, about 5 minutes 30 seconds elapsed between the time that no. 2 flight attendant told the captain there was a fire in the aft lavatory and his decision to begin emergency descent ..• however in t~i~ case the time to make the decision appears excessive given the circumstances.... The decision to initiate emergency descent was in fact made at 19:07:11 (Exhibit 12A), which is not 5 minutes 30 seconds but 4 minutes 31 seconds. At 19:08:12, the first Mayday was heard by ATC, the one minute difference was the time that I took to take my seat, declare Mayday twice, select 7700 on transponder, select emergency powel~ "on·' and finally the third f4ayday was heard (Exhibit 2A Ouimet statement). The first two Maydays were not heard because of electrical failures. The left electrical side failed before I arrived, and as 1 was calling the first Mayday, the right side failed at 19:07:41 (Exhibit lOA, page 3/ Exhibit 12A, page 14 OFDR and CVR fai1ed/ N.T.S.B. report page 4 paragraph 2). Therefore there was no power to the "Emet"gency Bus" where no. 1 radio is supplied and consequently I was unable to transmit. This is ,...hen I selected ··Emergency Power" switch on and the third call went out. Here again the N.T.S.B. report is misleading on page 4: "The captain ordered the first officer to activate the emergency power switch...... _~ In Exhibit 2A, page 1, Captain Cameron states: "1 reached up to put the emergency power switch on to find that the first officer had a1ready done so.··. So it was between 19:07:11 and 19:08:12, that minute was not used to decide on the necessity of emergency descent but to deal with more problems of the situ- ation. Also, at that time, we had actually left flight level 330 according to _.../6

APPENDIX G -108-

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Exhibit 2A, page 1, where I state: ..•.• the third call consisted of a Mayday and that we had an emergency, we had fire on board, and that we were going down. and Exhibit 3, page 10, at 19:08:46: ··Yes sir, we're going do\'m, we have a fire ..·. On this route, we cross a lot of east-west-east traffic and you are con- cerned about changing altitude without clearance, but we had to go down at this point. I hope these notes from a principal witness clarify those 5 minutes and 32 seconds, but this information was all in the different reports and exhibits submitted. As for the speculation that Louisville would have been faster, I still do not understand why it would have been faster going into Louisville instead of Cincinnati since our problem was one of losing height not distance and we did not even make runway 36 in Cincin- nati with a close to maximum descent. CONCLUSION: Why is it that after 14 months of hearings, reports, investigations and researches, the members of the N.T.S.B. Board are not more knowledgeable about the flight crew's actions, and consequently are unable to render a valid judgment. Even with that information well infused, playing the tape backward, starting with this forceful fire on the ground in Cincinnati and looking at all of this does not give you the same perspective as we had when things started slowly just as we have often on flights. You could look back at the tape of the great victory of John McKenroe in the 1984 U.S. Tennis Open and still find things that he could have done better, but the fact is that his overall performance was good. The same goes for us and it is the eternal confrontation of the analyst versus the heat of the action. It is not easy, I admit, to have this sense of reality when one was not in the action but necessary to give any kind of credibility to an assessment of human performances. It is unfortunate that this report does us a lot of damage and does not do any good for the safety of the public. October 22, 1984.

-109- APPENDIX H NTSB RESPONSE TO PETITION OF RECONSIDERATION OF PROBABLE CAUSE National Transportation Safety Board Washington, D.C. 20594 February 11, 1986 Captain Henry A. Duffy President Air Line Pilots Association Petition for Reconsideration of Probable Cause Aircraft Accident - Air Canada Flight 797, ~cDonnell-Douglas DC-9-32, C-FTLU, Greater Cincinnati International Airport, Covington, Kentucky, June 2, 1983 Report No. NTSB/AAR-84/09 RESPONSE TO PETITION FOR RECONSIDERATION Based on its review of the Petition for Reconsideration (filed December 20, 1984), the National Transportation Safety Board hereby grants, in part, the Petition for Reconsideration. 'l In accordance with the Safety Board's rules (49 CFR Part 845), !fIe Safety Board !1a~ entertained a Petition for Reconsideration of its analysis, findings, and probable cause in the Aircraft Accident Report: Air Canada Flight 767, McDonnell-Douglas, DC-9-32, C-FTLU, Greater Cincinnati International Airport, Covington, Kentucky, June 2, 1983. On August 8, 198-1, the Safety Board issued the report on its investigation of the accident involving Air Canada Flight 797, a McDonnell-Douglas DC-9-32, of Canadian Registry, C-FTLU, a regularly scheduled international passenger flight from Dallas, Texas, to Montreah Quebec, Canada, with an en route stop at Toronto, Ontario, CanadA. The Dig.,t left Dallas with 5 crew members and 41 passengers on board. \"hile ell route at flight level 330 (about 33,000 feet m.s.l.), the cabin crew discovered smoke in the left aft lavatory. After attempting to extinguish the hidden fire and then contacting air traffic control (ATC) and declaring an emergency, the crew made an emergency descent, and ATC vectored Flight 797 to runway 27L at the Greater Cincinnati International Airport, Covington, Kentucky. AE. the pilot stopped the airplane, the airport fire department began firefighting operations. Flight attendants and passengers opened the left and rig:ht forward doors, the left forward overwing exit, and the right forward and aft overwing exits. About 60 to 90 seconds after the exits were opened, a flash fire engulfed the airplane interior. While 18 passengers and 3 flight attendants exited through the forward doors and slides and the three open overwing exits to evacuate the airplane, the captain and first officer exited through their respective cockpit sliding windows. However, 23 passengers were not able to get out of the plane and died in the fire. The airplane was destroyed. As a result of its investigation, the Safety Board determined that •.. the probable causes of the accident were a fire of undetermined origin, an underestimate of fire severity, and conflicting fire progress information provided to the captain. Contributing to the severity of the accident was the flightcrew's delayed decision to institute an emergency descent.

APPENDIX H -110- -2- In its investigation, the Safety Board found sufficient evidence to substantiate the conclusion that 8. fire propagated through the amenities section of the aft lavatory and had burned undetected for almost 15 minutes before the smoke was first noticed. Although, the Board was not able to identify the origin of the fire, it was able to eliminate several possibilities and identify its general location. The evidence disclosed that the fire propagated through the lower part of the amenities section of the lavatory vanity. Since the direction of airflow below the vanity and above the toilet waste tank permitted venting of smoke, fumes, and hot gases away from the cabin and open area of the lavatory, the fire went undetected for almost 15 minutes until it began to penetrate the lavatory liner and rise behind and outboard the liner, subsequently penetrating the sidewall and ceiling seams of the lavatory liner. The Petitioner acknowledged that it has no new evidence to present with regard to the probable cause of the accident. However, the Petitioner presents three principal assertions for the Safety Board's review: first, the Safety Board did not properly assess the available evidence regarding the time factor in the captain's decision to descend and land the airplane; second, the use of the word "misconstrue" in finding No. 8 carries a connotation of error on the part of the captain; and third, the contributing statement of the probable cause suggests that the captain's decision to institute an emergency descent was delayed longer than a prudent captain would have waited under similar circumstances. With regard to the first issue, the Petitioner referenced page 61 of the Board's report, which stated, in part, that "The Safety Board believes that a precautionary emergency descent shpuld have been initiated as soon as it became evident that the fire had not been visually located and could not be attacked directly with extinguishant. This became known at 1904:07 when the first officer came forward from his first inspection of the aft cabin area, about 3 minutes before the decision to begin an emergency descent." The Petitioner does not disagree with the Board's belief, but contends that the time at which this conclusion became apparent to the captain did not occur at 1904:07, and the Petitioner offers the following points from the Board's report to support its position: The Board acknowledged the occurrence of previous in-flight incidents involving lavatory fires which normally have been identified and corrected by flight attendants without further consequences; Trash receptacles in lavatories are designed to contain a fire; At 1906:52, the captain indicated that he believed the fire to be in the lavatory trash bin and that he did not decide to descend at this time because he expected the fire to be extinguished; The captain was misled by a series of reports from his crew indicating that the fire was under control and being extinguished. (These were five reports between 1904:07 and 1906:54 from three different crewmembers.) The captain sent the first officer aft to combat the fire 39 seconds after the time the Board believes it was evident to the captain that the fire could not be attacked directly with extinguishant; The captain would not have taken this action had he believed the fire was not accessible at that time.

-111- -3- APPENDIX H The Petitioner therefore concludes that the captain did not become aware of the uncontrollable nature of the fire until 1907:11, when the first officer returned from the cabin and advised, III don't like what's happening, I think we better go down. Okay?" The descent was begun immediately after the first officer resumed his seat. All parties to the investigation were in agreement that the time factor involved contributed to the severity of the accident. The Board's rationale with regard to the delayed decision was that had the captain decided to descend immediately after being told by the first officer, at 1904:07, that, "... I can't go back now, it's too heavy, I think we'd better go down,1l the flightcrew could have conceivably landed the airplane 3 to 4 minutes earlier. While the extent to which this time interval contributed to the severity of the accident could be debated, the Safety Board believes that the criticality of an early decision under such circumstances is not in issue. The facts known to the captain at 1904:07 should have been sufficient indicators of a potentially serious hazard that a precautionary descent should have been made immediately. The first officer for his part should have realized that the acrid smelling smoke probably was the result of an electrical fire, associated it with the tripping of the aft lavatory flush motor circuit breakers 11 minutes earlier, and informed the captain accordingly. Despite the fact the flight attendant in charge told the captain at 1906:42 that, "••• even though I could not see the source but it's definitely inside the lavatory," he, in fact, observed thick curls of black smoke emerging through the seams of the aft wall of the lavatory and believed that the fire was not in the trash container -and had also informed the first officer of his belief. His observations and assessment of the fire danger were inconsistent with his report to the captain. It is the Board;s belief that the: flight attendant in charge should have realized that his fire fighting effort was ineffective and that the temporary subsiding of the smoke was misleading. Therefore, the Board concludes that these crewmember reports influenced the captain's decision to delay the initiation of a descent. The delay increased the time for the fire to propagate and the time that passengers were exposed to the toxic environment before the airplane could be evacuated. With regard to the second issue, the Petitioner disagrees with finding No.8 on page 70 that the captain misconstrued the fire progress reports from his crew. The Petitioner believes that the captain relied on his crew's reports, and states that IlThere is a vast difference between believing an erroneous communication, and misinterpreting a communication." Further, the Petitioner contends that the evidence does not support finding No.8. Therefore, the Petitioner requests that the last sentence of finding No.8 be changed to read, "Due to persistent reports from various crewmembers that the fire was abating, he delayed his decision to declare an emergency and descend." After reviewing finding No.8, the Safety Board agrees that the word "misconstrued" may have conveyed the wrong intent. The Board agrees that the captain was misled by the reports from crewmembers that the smoke was SUbsiding. However, the Board continues to believe that, in the interest of safety, the captain should have been more assertive in seeking the nature of the fire instead of accepting the nonspecific comments of the crewmembers as assurance that the situation was under control. Had the crewmembers positively stated that the fire source had not been identified, the captain might have taken action sooner to descend in preparation for an emergency landing. With regard to the third issue, the Petitioner does not agree that contributing to the severity of the accident was the flightcrew's delayed decision to institute an emergency descent. While the Petitioner agrees that the time delay involved in commencing a descent contributed to the severity of the accident, the Petitioner believes that the cbntributing factor statement incorrectly implies that the captain's decision was different

APPENDIX H -112- -4- from the decision that a more prudent captain would have made under similar circumstances. The Petitioner maintains that the captain did not have the benefit of the amount of time the Safety Board had to analyze the situation and make a decision. The Petitioner states, "... it is grossly unfair and unrealistic for the Safety Board to expect a flight crew to evaluate an incident in a dynamic situation, and reach the same conclusions in a few seconds that it took the Safety Board and all of its staff over a year to reach." Additionally, the Petitioner states that the Board could not even agree on the time when the crew's decision to descend should have been made during its "Sunshine" meeting on July 20, 1984. Therefore, the Petitioner requests that the contributing factor statement be changed to indicate that the delayed decision to descend was based on evidence provided by three different crewmembers on five different occasions which indicated that the smoke was abating and that an emergency descent would not be required. While it may appear to the Petitioner that the Safety Board's report unjustly focused on the flightcrew's delayed decision to land the airplane, the Board's conclusion was not made without a careful and lengthy review of the facts. The Board did come to an agreement regarding the time the flightcrew should have made a decision to descend- 1904:07-which is evident in the report, and there were no dissenting opinions filed by the Board's members after the "Sunshine" meeting. The Safety Board is of the opinion that the Petitioner's suggested change would not agree with the basic rationale of the Board's analysis of the flightcrew's handling of the fire situation. The Board believes that all pilots should be well a~are of the potential catastrophic nature of a cabin fire during flight. Therefore, the Board believes that any indication of a fire should prompt a flightcrew to begin immediate preparation for an expedient landing. In this case, the captain first was told that there was a fire in the washroom, and he then was advised by his first officer that "it's too heavy, I think we'd better go down." Until that time, the captain did not have cause to believe that the fire would subside and he should have begun a descent immediately. Afterwards, he was misled by the crewmember reports. While the crewmembers should have realized that their comments could mislead and influence the captain's actions, the captain himself was ultimately responsible and he should have sought more positive verification that the fire had been extinguished. Further, the crewmember reports were only one element of information available to the captain. For example, the captain's comment "it's the motor" indicates that he did consider that the source of the fire might be electrical rather than paper burning in the wastebin. The captain should have known that an electrical fire which has progressed to the production of heavy smoke could be uncontained and out of control particularly when combined with his knowledge that circuit breakers had popped over 10 minutes earlier. This knowledge should have been sufficient to prompt the captain's immediate action. The Safety Board realizes that pilots must often make difficult, immediate decisions when confronted with abnormal or emergency situations. They often do not have the benefit of, or the time to weigh, all the facts. It is for this reason that flig'htcrews must be well trained to take the actions quickly that will be most effective in coping with the most severe and unexpected emergencies. The Safety Board had addressed its concerns in past safety recommendations regarding the need for effective cockpit resource management training to better prepare flight crewmembers to deal with complex, time-critical, decisionmaking situations, such as faced by this captain. Any indication of an in-flight fire justifies very rapid actions to land the airplane as quickly as possible. Therefore, the Board believes that the intent of the contributing factor statement must remain. However, the contributing factor statement has been revised since the final decision is the captain's alone. The Board considers the probable cause appropriate to emphasize the importance of an accurate and timely evaluation of the fire hazard by the flightcrew.

ACCORDINGLY, -113- -5- APPENDIX H (a) The Petitioner's Petition for Reconsideration and modification of probable cause and findings of the airplane accident report on Air Canada Flight 797, McDonnell-Douglas DC-9-32, C-FTLU, Greater Cincinnati International Airport, Covington, Kentucky, June 2, 1983, is hereby granted in part. (b) The Board's original report is revised and a corrected report will be issued to the public which contains modifications to finding No.8 and the probable cause. (c) The probable cause is revised as follows: The National Transportation Safety Board determines that the probable causes of the accident were a fire of undetermined origin, an underestimate of fire severity, and misleading fire progress information provided to the captain. The time taken to evaluate the nature of the fire and to decide to initiate an emergency descent contributed to the severity of the accident. (d) Finding No.8 is revised to read as follows: The source of the smoke was never identified either by the flight attendants or the first officer. The captain was never told nor did he inquire as to the precise location and extent of the "fire," which had been reported to him. Crewmember reports that the smoke was abating misled the captain about the fire severity and he delayed his decision to deQlare an emergency and descend. The Safety Board commends the Petitioner for the preparation of the petition and for its interest in aviation safety. BURNETT, Chairman, GOLDMAN, Vice Chairman, and LAUBER, Member, concurred in the disposition of this Petition for Reconsideration. ~u.s. GOVERNMENT PRINTING OFFICE. 1986-491-098.20080

Page Intentionally Left Blank

ACCORDINGLY, -113- -5- APPENDIX H (a) The Petitioner's Petition for Reconsideration and modification of probable cause and findings of the airplane accident report on Air Canada Flight 797, McDonnell-Douglas DC-9-32, C-FTLU, Greater Cincinnati International Airport, Covington, Kentucky, June 2, 1983, is hereby granted in part. (b) The Board's original report is revised and a corrected report will be issued to the public which contains modifications to finding No.8 and the probable cause. (c) The probable cause is revised as follows: The National Transportation Safety Board determines that the probable causes of the accident were a fire of undetermined origin, an underestimate of fire severity, and misleading fire progress information provided to the captain. The time taken to evaluate the nature of the fire and to decide to initiate an emergency descent contributed to the severity of the accident. (d) Finding No.8 is revised to read as follows: The source of the smoke was never identified either by the flight attendants or the first officer. The captain was never told nor did he inquire as to the precise location and extent of the "fire," which had been reported to him. Crewmember reports that the smoke was abating misled the captain about the fire severity and he delayed his decision to deQlare an emergency and descend. The Safety Board commends the Petitioner for the preparation of the petition and for its interest in aviation safety. BURNETT, Chairman, GOLDMAN, Vice Chairman, and LAUBER, Member, concurred in the disposition of this Petition for Reconsideration. ~u.s. GOVERNMENT PRINTING OFFICE. 1986-491-098.20080

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FD07151 ｜ 1990_美国_AAR9003.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1990 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

NATIONAL TRANSPORTATION SAFETY BOARD AIRCRAFT ACCIDENT REPORT USAIR, INC., BOEING 737-400 LAGUARDIA AIRPORT FLUSHING, NEW YORK SEPTEMBER 20, 1989

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable cause of accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Copies of these documents may be purchased from the National Technical Information Service, 5285 Port Royal Road, Springfield, Virginia 22161. Details on available publications may be obtained by contacting: National Transportation Safety Board Public Inquiries Section, RE-52 800 Independence Avenue, S.W. Washington, D.C. 20594 (202)382-6735

CONTENTS ............................................. EXECUTIVE SUMMARY v FACTUAL INFORMATION ........................................ History o f the F l i g h t 1 I n j u r i e s t o Persons ........................................... 4 ........................................ Damage t o the Airplane 4 Other Damage .................................................. 4 Personnel Information ......................................... 4 General ....................................................... 4 The Captain ................................................... 4 The F i r s t O f f i c e r ............................................. 5 .......................................... Airplane Information 6 Meteorological Information .................................... 6 .......................................... Surf ace Observations 6 Rainfall ...................................................... 7 Aids t o Navigation ............................................ 7 Communications ................................................ 7 Aerodrome Information ......................................... 7 .............................................. F1 i g h t Recorders 10 The Cockpit Voice Recorder .................................... 10 The F l i g h t Data Recorder ...................................... 10 Wreckage and Impact Information ............................... 13 ................................................. Main Wreckage 13 ........................................... Marks on the Runway 13 Medical and Pathological Information .......................... 16 F i r e .......................................................... 16 .............................................. Survival Aspects 17 Seat Damage ................................................... 17 Emergency E x i t Damage ......................................... 17 .................................................... Evacuation 17 Emergency Response ............................................ 19 Tests and Research ............................................ 20 ........................................ Powerpl ant Examination 20 ....................................... Rudder Trim Examination 20 Brake and Anti -skid Examination ............................... 21 Simulation Studies ............................................ 22 Other Information ............................................. 23 1.17.1 A i r c r a f t Systems Descriptions ................................. 23 1.17.1.1 The Nosewheel Steering System ................................. 23 1.17.1.2 The Rudder Trim System ........................................ 23 ....................................... 1.17.1.3 The Autothrottle System 25 .......................................... 1.17.1.4 The Autobrake System 25 1.17.2 USAir 6-737-300/400 P i l o t s Handbook Excerpts .................. 25 ........................................ 1.17.3 FAA Oversight o f USAir 26 .......................................... 1.17.4 Airplane Performance 27 1.17.5 Inadvertent Rudder Trim Anomalies ............................. 28 1.17.6 Corrective Actions ............................................. 29 1.17.7 FAA Drug and Alcohol Post-accident Testing Requirements ........ 30 .......... 1.17.8 Public Hearing Testimony on Accident-Related Subjects 31

P i l o t Experience and Pairing ................................... 31 Rejected Takeoff Special Investigation ........................ 32 Runway Safety Areas ............................................ 33 .................................. Overwater Emergency Equipment 35 ANALYSIS General ....................................................... 38 Activation o f the Rudder Trim ................................. 38 .................. Crew Failure t o Detect the Mistrimmed Rudder 39 Rudder Trim Control Design ................................... 41 ................................ Directional Control D i f f i c u l t y 41 The RTO Decision .............................................. 43 ........................................... Braking Performance 44 ............................................ Engine Performance 46 .............................. The "Bang" and Rumble on the CVR 47 ....................... Crew Coordination During the Takeoff Run 47 .......................... Cockpit Resource Management Training 47 .................... Pre-takeoff Emergency Procedures Briefings 49 ...................... Crew Coordination During the Takeoff Run 49 P i l o t Experience and Pairing .................................. 50 .................................. Making Runway Overruns Safer 51 Survival Factors .............................................. 52 ........................... Postaccident Toxicological Testing 54 ........................... Postaccident Aircrew Avai 1 abi 1 i t y 54 CONCLUSIONS ...................................................... Findings 55 ................................................ Probable Cause 57 ............................................... RECOMMENDATIONS 58 APPENDIXES ......................... Appendix AÃ Investigation and Hearing 61 ............................. Appendix BÃ Personnel Information 62 .............................. Appendix C. Airplane Information 63 ................. Appendix D- -Cockpi t Voice Recorder Transcript 64 Appendix E ~ S y n o p s i s o f F i r e and Rescue Critiques and Post- ............................. Accident Improvements 94

EXECUTIVE SUMMARY * On September 20, 1989, USAir,' Snc. flight 5050 was departing New York City' s LaGuardia Airport, Flushing," New York, for Charlotte Douglas International Airport, Charlotte, North Carolina. As the first officer began the takeoff on runway 31, he felt the airplane drift left. The captain noticed the left drift also and used the nosewheel tiller to help steer. As the takeoff run progressed, the aircrew heard a "bang" and a continual rumbling noise. The captain then took over and rejected the takeoff but did not stop the airplane before running off the end of the runway into Bowery Bay. Instrument flight conditions prevailed at the time and the runway was wet. The National Transportation Safety Board determines that the probable cause of this accident was the captain's failure to exercise his command authority in a timely manner to reject the takeoff or take sufficient control to continue the takeoff, which was initiated with a mistrimmed rudder. Also causal was the captain's failure to detect the mistrimmed rudder before the takeoff was attempted. The safety issues discussed in this report were the design and location of the rudder trim control on the Boeing 737-400, air crew coordination and communication during takeoffs, crew pairing, and crash survivability.

NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT USAIR, INC. BOEING 737-400 LAGUARDIA AIRPORT FLUSHING, NEW YORK SEPTEMBER 20, 1989 1. FACTUAL INFORMATION 1.1 History of the Flight On September 20, 1989, USAir flight 5050 was an "extra section" passenger flight to rep1 ace the regularly scheduled but cancel led fl ight 1846 from New York City's LaGuardia Airport (LGA), Flushing, New York, to Charlotte Douglas International Airport (CLT), Charlotte, North Carolina. As the first officer began the takeoff on runway 31 the airplane drifted to the left, and the captain used the nosewheel steering tiller to correct the drift. Later in the takeoff run, the flightcrew heard a "bang" and a rumbling noise. The captain then took over control from the first officer and rejected the takeoff. The airplane did not stop before running off the end of the runway into Bowery Bay. Instrument conditions prevailed, and the runway was wet. The flight was operating under Title 14, Code of Federal Regul ations Part 121. About 1400 hours eastern daylight time on September 20, the captain and first officer reported to USAir operations at Bal timore-Washington International Airport (BWI) to fly the Boeing 737-400 (B-737) N416US to LGA as USAir flight 1846. Scheduled departure from BWI was 1510, but air traffic inbound to LGA delayed the takeoff until 1935. Holding on the taxiway at BWI for 1.5 hours required the flight to return to the terminal area for fuel. Flight 1846 left BWI uneventfully and arrived at LGA's Gate 15 at 2040. Weather and air traffic in the LGA terminal area had caused cancellations and delayed most flights for several hours. According to all air1 ine personnel interviewed, delays that long are unusual and occur only a few times a year at LaGuardia. While on the ground at LGA, the captain went to USAir operations and then returned to the aircraft expecting to fly to Norfolk, Virginia. However, the USAir dispatcher decided to cancel the Norfolk leg, unload the passengers, and send the flight to CLT without passengers. Several minutes later, the dispatcher told the- captain that his airplane would not be flown empty but would carry passengers to Charlotte as USAir flight 5050. This seemed to upset the captain, according to the passenger service representative, who said that the captain expressed concern for the passengers because more delays would cause him and the first officer to exceed crew duty time limitations before the end of the trip. While passengers were boarding, the captain visited USAir's ground movement control tower to ask about how decisions were made about flights and passengers.

During the captain's absence, the first officer stayed in the cockpit. He said later that, while he was in his cockpit seat, he placed new pages for an enroute chart/approach plate holder on the center pedestal then put the pages into the holder on his lap. Meanwhile, a captain from Pan American World Airways, who was flying as a non-revenue passenger, entered the cockpit and sat down facing crosswise on the auxiliary jump seat behind the captain's seat. This captain said another person from USAir entered the cockpit and gave the crew a single-sheet weather chart that was eventually placed on the center pedestal. Several other persons were also in the cockpit at various times before departure. The captain returned to the cockpit as the last of the passengers were boarding, and the entry door was closed. After the jetway was retracted, the passenger service representative. told the captain through the open cockpit window that he wanted to open the door again to board more passengers. The captain refused, and flight 5050 left Gate 15 at 2252. During the initial interview with the Safety Board, the flight crew described starting the engines and taxiing out to runway 31 as uneventful. They said six to eight airplanes were ahead of them on the taxiway awaiting takeoff clearance. Two minutes after push-back, the ground controller told the crew to hold short of taxiway GOLF GOLF. However, the captain failed to hold short of that taxiway and received modified taxi instructions from the ground controller at 2256. The captain then briefed takeoff speeds as V : ft 125 knots, VR: 128 knots, and V : 139 knots. The captain had flown t e BHI-LGA segment, and the first officer was to be the flying pilot on the LGA-CLT segment. No company or Federal regulations govern flying pi 1 ot choices. As the flying pilot, the first officer's departure briefing consisted of his reciting to the captain his turn and altitude clearance and the LaGuardi a 3 departure clearance . About 2 minutes later, the first officer announced "stabilizer and trim" as part of the before-takeoff checklist. The captain responded with "set" and then corrected himself by saying: "Stabilizer trim, I forgot the answer. Set for takeoff .I' According to USAir' s B-737-300/400 normal procedures checklist, "set for takeoff" was the correct response, although the captain's words "stabilizer trim" failed to restate the correct challenge. The captain said during the public hearing that he had no specific recollection of checking trim settings on the accident flight but that his normal procedure would be to do so. The first officer said during the hearing that he did not check the trim settings himself while he was running the checklist during taxi-out. USAir procedures did not require him to do so. The last item on the before-takeoff checkl ist was AUTO-BRAKE. When challenged on this item, the captain responded "is off," and the first officer called the checkl ist complete. Flight 5050 was cleared into position to hold at the end of the runway at 2318:26 and received takeoff clearance at 2320:05. The cockpit voice recorder (CVR) disc1 osed the sound of increasing engine noise, and shortly thereafter the first officer pressed the autothrottle disengage

button instead of the takeoff/go-around (TO/GA) button. He l a t e r said t h a t he then pressed the TO/GA button, but "noted no t h r o t t l e movement. He then advanced the t h r o t t l e s manually t o a "rough" takeoff-power setting. The captain then said: "Okay, that's the wrong button pushed" and 9 seconds l a t e r said: "All r i g h t , I'll set your power." The captain l a t e r said he thought he had rearmed and reengaged the autothrottles and had advanced the t h r o t t l e s t o the N1 target setting o f 95 percent while depressing the TO/GA button. The f i r s t o f f i c e r l a t e r explained t h a t "I'll set your power" meant t o him t h a t the captain was "fine-tuning" the setting t o takeoff power. Both crewmembers agreed t h a t the airplane then began tracking t o the l e f t during the takeoff r o l l . About 18 seconds a f t e r beginning the r o l l , the CVR recorded a "bang" followed shortly by a loud rumble. The captain l a t e r said t h a t during t h i s time the airplane continued tracking t o the l e f t and t h a t he was becoming concerned about the unidentified bang and rumble. The f i r s t o f f i c e r l a t e r said he believed he had stopped the leftward tracking and the airplane "began t o para1 1 e l the runway center1 i ne. " A t 2320:53, the CVR recorded the captain saying "got the steering." The captain l a t e r t e s t i f i e d t h a t he had said, "You've got the steering." The f i r s t o f f i c e r t e s t i f i e d t h a t he thought the captain had said: "I've got the steering." When the f i r s t o f f i c e r heard the captain, he said "Watch it then" and began releasing force on the r i g h t rudder pedal but kept h i s hands on the yoke i n anticipation o f the V l and r o t a t i o n callouts. A t 2320:58.1, the captain said: "Let's take it back then" which he l a t e r t e s t i f i e d meant t h a t he was aborting the takeoff. According t o the captain, he rejected the takeoff because o f the continuing l e f t d r i f t and the rumbling noise; he said t h a t he used d i f f e r e n t i a l braking and nose wheel steering t o return toward the centerline and stop. The sound o f t h r o t t l e levers h i t t i n g t h e i r i d l e stops was recorded a t 2320:58.4. According t o data from the d i g i t a l f l i g h t data recorder (DFDR), indicated airspeed a t t h a t time was 130 knots. The sound o f engine noise decreasing was recorded a t 2321:00.9. The f i r s t o f f i c e r then t o l d the tower about the rejected takeoff. I n l a t e r testimony, the f i r s t o f f i c e r said t h a t he was unaware o f the reason f o r the captain's decision t o abort. Increasing engine sound indicating employment o f reverse t h r u s t was heard on the CVR almost 9 seconds a f t e r the abort maneuver began. The airplane d i d not stop on the runway but crossed the end o f the runway a t 34 knots ground speed. It came t o r e s t i n the water supported by the p i e r t h a t holds runway 13's approach l i g h t s . The sound o f impact was recorded a t 2321:Zl.g. Both p i l o t s agreed t h a t the farthest the airplane tracked t o the l e f t during the rejected takeoff (RTO) was about halfway between the centerline and the l e f t side o f the runway; both said t h a t during the RTO they thought the airplane could be stopped on the remaining runway. Neither p i l o t could r e c a l l noting the airspeed a t i n i t i a t i o n o f the RTO, and the CVR recorded no standard airspeed cal louts.

The accident occurred in darkness at 40°56'36 north, 73O52'24" west. Both pilots and the four cabin crewmembers had minor injuries. Two of the 57 passengers were killed and 15 were injured. Passengers included a 5-year-old child and an 8-month-old baby held by its mother. Neither the infant nor the child was injured. 1.2 Injuries to Persons 1n.iuries Q&J Passenuers Others W Fatal 0 2 0 2 Serious 0 3 0 3 Minor 6 12 0 18 None 0 3 7 0 3 7

Unknown*

0

3

0

3 Total 6 57 0 63 *Hospi ta1 records were not avai 1 able for three passengers. 1.3 Damage to the Aircraft The airplane was destroyed. The insurance agent handling the claim said that the hull loss of a Boeing 737-400 in this configuration was $35,000,000. 1.4 Other Damage The cost of replacing the pier and approach lighting destroyed during the accident was $150,000, according to the Port Authority of New York and New Jersey. 1.5 Personnel Information 1.5.1 General Piedmont Airl ines originally hired both pilots, but USAir trained them using a "mirror image" transition training concept in anticipation of a corporate merger, which occurred on August 5, 1989. This concept was to make Piedmont flight training and flight operations identical to that of USAir by the time of the merger. 1.5.2 The Captain The captain, 36, held Airl ine Transport Pi lot certificate 24378065 with endorsements for the deHavilland DH-4 and the B-737. He also had mu1 tiengine commercial and single engine land ratings, along with a turbojet flight engineer certificate. The Federal Aviation Administration (FAA) issued him a first class medical certificate with no limitations on May 17, 1989.

The captain received his initial flight training in the United States Air Force (USAF) in 1979. His first military line flying assignment was in USAF Reserve Lockheed C-130 transport airplanes. In 1987, he upgraded to aircraft commander in the C-130 and held the rank of Major at the time of the USAir accident. He failed his first C-130 aircraft commander check ride in part because of poor check1 ist usage. Piedmont Airlines hired the captain on July 9, 1984, and he satisfactorily completed B-727 fl ight engineer ground school on July 13, 1984, and served as a B-727 flight engineer until August 1985. He completed B-737-200 ground school on August 9, 1985, and B-737-200 flight training on August 27, 1985, with 34 simulator hours and 1.7 hours in the aircraft. He completed B-737-300 differences flight training as a first officer on September 19, 1986, and B-737-400 differences ground training on May 19,

1. He said that he believed he had "between 5 and 10" RTO's

in the B-737 simulator, a1 1 after simulated engine anomalies. He had experienced one low-speed RTO in the B-737 after a takeoff warning sytem alarm had sounded. The captain began his B-737-300/400 training as a captain candidate in June 1989 and completed initial qua1 ification ground school on June 28, 1989. He completed flight training in the B-737-300 with 22 flight hours plus 4 hours of line oriented flight training (LOFT) in a simulator on July 9, 1989. His initial operating experience in the B-737-300/400 consisted of 14 hours with 11 takeoffs and landings followed by a 9.2-hour FAA-observed line check with 6 takeoffs and landings completed on July 20, 1989. His captain's training was interrupted twice, once by a USAF Reserve deployment and once by minor illness. Supervisory USAir pilots generally described the captain's performance during upgrade training as "average." The pi1 ot who supervised the captain's initial operating experience said the captain had no problems making decisions. The captain had no formal training in cockpit resource management. The captain had total estimated flying time of 5525 hours, 1500 hours of which were in the USAF and USAF Reserve. Ninety-seven of the military hours were in command of the C-130. He accumulated about 2625 hours in all models of the Boeing 737. His 30, 60 and 90 day flying hour totals at USAir were 23, 72 and 121.5 hours, respectively, all in B-737-300/400 aircraft as captain. His total flying time as a B-737-400 captain was about 140 hours. His last B-737 flight prior to September 20th was on September 3rd, the last leg of a three-day trip. He flew the C-130 on September 8th for 0.3 hours and again on September 18th for 2.0 hours. During the 24 hours preceding the accident, he flew 0.9 hours on the BWI-LGA leg. 1.5.3 The F i r s t Officer The first officer, 29, held Airline Transport Pilot certificate 572317704 with commercial multiengine land and single engine land and sea ratings. Piedmont Airlines hired him in May of 1989. He completed B-737 ground school on July 14, 1989, and 8-737 first officer flight training on

August 8, 1989, with 24 hours i n the simulator and 1.1 f l i g h t hours. His i n i t i a l operating experience consisted o f 14.2 f l i g h t hours and the observation o f 12 landings from the jump seat. He a1 so performed 2 takeoffs and two landings. His l i n e check on August 12, 1989, consisted o f 3.1 f l i g h t hours and three takeoffs and landings, which was the l a s t time he flew p r i o r t o the BWI-LGA f l i g h t o f September 20, 1989. He had 3,287 f l y i n g hours, 8.2 o f which were i n the B-737-300/400. He had flown 8.3 hours i n the previous 90 days and 0.9 hours i n the previous 24 hours. The f i r s t o f f i c e r had no formal i n s t r u c t i o n i n cockpit resource management. His p r i o r experience had been attained i n small and commuter turboprop-type a i r p l anes . 1.6 A i r c r a f t Information On December 23, 1988, The Boeing Company delivered t o Piedmont Aviation the B-737-400, U.S. registration N416US. A t the time o f the accident, USAir owned and operated the a i r c r a f t , which was powered by two CFM I n t e r n a t i o n a l CFM-56-32B engines. Registration and airworthiness c e r t i f i c a t e s were valid. By t h e accident date, the airplane had 2,235 hours. and 1,730 cycles. I t s "C" maintenance check was i n four phases conducted i n intervals o f 1,050 operating hours. The l a s t major check was a "C2" on August 3, 1989, a t Greensboro, North Carolina, that showed no noteworthy maintenance discrepencies. Maintenance 1 ogbooks showed rep1 acement o f main 1 anding gear t i r e s a t regular intervals because o f normal tread wear, which also prompted replacement o f the two nose wheels and t i r e s on August 28, 1989. No nose wheel, main landing gear, o r main landing gear brake malfunctions were reported w i t h i n 3 months p r i o r t o the accident. Also, the logbooks contained no open write-ups on the date o f the accident. The takeoff weight o f the airplane was 107,900 pounds, and maximum allowable gross weight was 129,600 pounds. The center o f gravity was 18 percent mean aerodynamic chord and w i t h i n l i m i t s . According t o the cockpit voice recorder, the crew based takeoff speeds on a gross weight o f 105,000 pounds. Correct VJ, VR, and V2 speeds for t h i s weight were 125 knots, 128 knots, and 139 knots respectively. 1.7 Meteor01 ogical Information 1.7.1 Surface Observations The Weather Service Contract Meteorological Observatory a t LaGuardi a issued the f o l 1 owing observation: Time--2334; type--local ; c e i l ing--estimated 500 f e e t overcast; v i s i b i l i t y - - 5 miles; w e a t h e r ~ l i g h t r a i n and fog; temperature--73O F.; dew point--73O F.; wind--210 degrees a t 4 knots; altimeter--30.20 inches; remarks--aircraft mishap.

The Low-Level Windshear A l e r t System (LLWAS) located near the departure end o f runway 31, showed average wind a t the time o f the accident from 207O a t 5.4 knots. 1.7.2 Rainfall On September 20th, 1.72 inches o f r a i n f e l l , 0.01 inches between 2100 and 2200, 0.01 inches between 2200 and 2300, and 0.08 between 2300 and 0000. Interpretation o f the recording from a weighing r a i n gage a t LaGuardia showed accumulation o f 0.03 inches from 2300 t o 2315 and 0.01 inches between 2315 and 2330. Around 2330, 0.02 inches accumulated rapidly, and from 2330 t o 2345 a trace o f less than 0.01 inch f e l l . The cockpit crewmembers said that they d i d not use the windshield wipers during the rejected takeoff. 1.8 Aids t o Navigation Navigational aids were not a factor. 1.9 Communications No communications problems were reported between the crew and any a i r t r a f f i c control f a c i l i t y before o r during the accident sequence. 1.10 Aerodrome Informati on The Port Authority o f New York and New Jersey operates LaGuardia Airport under lease from the C i t y o f New York. Runway 31 i s 7,000 feet long by 150 feet wide with a 100-foot overrun a t the departure end (figure 1). The surface i s asphalt w i t h saw-cut transverse grooves 1 1/2 inches apart and 1/4 inch wide and deep. About the l a s t 900 feet i s concrete with similar, but not uniform, transverse grooves averaging 1/8 inch deep. The concrete portion, including a 100-foot ungrooved and heavily painted overrun before the threshold, i s on an elevated deck above Bowery Bay. Runway 31's slope increases from 7 feet msl a t the threshold t o 13 feet msl a t the runway 13 threshold. The surface between taxiways X and L received a rubber-removal treatment on September 3, 1989. Runway 4/22 also i s 150 feet wide and crosses runway 31 about 1,300 f e e t from the departure end. Runway 31 has a three-bar visual approach slope indicator (VASI), centerline and edge lighting, and runway end i d e n t i f i e r l i g h t s . The National Aeronautics and Space Admini s t r a t i on (NASA) tested runway 31's drainage and f r i c t i o n using a sel f-wetting Saab F r i c t i o n Tester owned by the Port Authority of New York and New Jersey. Figure 2 i s an evaluation of the rejected takeoff i n terms o f speed, 1 ateral displacement from runway center1 ine, and the f r i c t i o n coefficient. The report NASA furnished the Safety Board said:

Rejected Takeoff Braking Levels Approved AFM braking coefficient for a dry runway Braking coefficients available at the time of the accident 112 of the dry runway braking coefficient Braking coefficients attained by flight 5050 . Figure 2.--NASA Evaluation o f B-737-400 a i r c r a f t rejected takeoff on runway 31 a t LaGuardia Airport on September 20, 1989.

Based on runway surface characteristics, crown, and texture depth values, the drainage analysis indicates that runway 31 had excellent water drainage capabil ity (excluding the painted nongrooved bl ast pad [overrun] area) part i cul arl y for the rainfall rate occurring at the time of the accident (-008 in./hr.). With the transverse grooving, and the good tread condition of the main gear tires, hydroplanning was not a signficant factor. Except for approximately 1,200 feet near runway 4/22 intersection, the accident aircraft RTO track was established by the white tire erasure marks found on both the asphalt and concrete deck surfaces of the runway. In terms of tire friction performance, the Saab friction tester results indicate that the lateral displacment of the aircraft left of centerline actually provided better friction performance compared to that measured closer to runway centerline. 1.11 Fl i ght Recorders 1.11.1 The Cockpit Voice Recorder The Fai rchi 1 d Model A-100 Cockpit Voice Recorder (CVR) survived intact with a recording of excellent quality. The CVR recording started at 2249~30 just as the airplane was pushed back from the terminal at LaGuardia and continued for 31 minutes and 41 seconds until 2321:22. 1.11.2 The Flight Data Recorder The digital flight data recorder (DFDR), a Fairchild Model F800, was also undamaged, and the qua1 ity of the data was generally good. Printouts of selected DFDR parameters are in Figure 3. As the engines were shut down at the gate after the flight from BWI to LGA, an oil pressure sensor in the left engine tripped power to the DFDR; the rudder position was recorded at 00 deflection. After engine start at the gate, the DFDR began recording the accident flight. The airplane's heading was 357.2O, and the rudder was 15.g0 left, essentially the position equating to full left rudder trim. Subsequent excursions in rudder position, elevator position, and ai 1 eron position were those normally associated with a flight control check. Rudder position returned to 15.g0 left following the excursions. The first indication of the takeoff start was the increasing Nl values for both engines. During the early part of the takeoff, the airplane's heading deviated nearly 20 left of the runway heading, rudder position varied from 0.44O right to 6-90 left, ground speed increased to 91 knots, and Nl values for the left and right engines increased to 91.5 and 94.5 percent, respectively. The airplane's heading was nearly 5O to the left of the runway

USAir Flight #5050 - Accident at LaGuardia Airport, Flushing NY Time Distance Airs~eed Event ANL - , I ANR (feet) , (knots) ANR + ANL - 46 - C A M I - C A M I -

( ( s o u n d o f c r a s h ) I %

w e ' r e g o i n g o f f

w e ' r e g o l n g o f f a h w e ' r e g o i n g o f f ( ( sound o f l n c r e a s i n g e n 1 n e n o I s e 11

!

u s a l r f i f t y f i f t y ' s a b a r l n g

Tire Erasure Marks ' C A M - f 114= R D 0 2 - t125- D F D R - ( ( t h r u s t r e v e r s e r s d e p l o y e d I I

138- C A M - ( ( s o ~ n d o f e n g i n e noise d e c r e a s i n g I )

136- C A M - ( ( r u n b l e sound I n c r e a s e s I n amp1 I t u d e I)

130-- C A M - ( ( s o ~ , n d s l m i l a r t o t h r o t t l e 8 h i t t i n g i d l e ] ) -

128- C A M I - l e t ' s t a k e I t b a c k

119- C A M 2 - w a t c h It t h e n

110- C A M 2 - okay

106- C A M I - g o t t h e s t e e r l n g

91 - C A M - ( ( e o b n d o f l o u d r u m b l e e t a r t e l l

looof 62 - C A M - ( ( s o i ~ n d o f b a n g I)

C A M I - a l l r i g h t I ' l l e a t y o u r p o w e r

t

D F D R - ( ( TOGA b u t t o n p u a h e d I I

C A M I - i t ' e t h a t one u n d e r n e a t h t h e r e C A M 2 - o h yctah I knew t h a t e r C A M I - o k a y t h a t ' s t h e w r a n a b u t t o n p u s h e d 3 10 315 20 10 0 10 20 Runway 31 ~ i a g r a m Magnetic Heading Rudder Deflection (Distorted Horizontal scale) (degrees) (degrees) C A M 2 - o k a y C A M I - I got t h e s t e e r l n g t l l l y o u a n C A M - ( ( a o i ~ n d o f l n c r e a a l n g e n g i n e noise)) Figure 3. --DFDR/CVR information. Lateral Longitudinal Acceleration Acceleration (GIs) (GIs) ANLA - Aircraft Nose Left or Right

heading when an engine power reduction to idle power was recorded. The rudder was nearly centered and the airspeed was about 130 knots. In the next five seconds, before thrust-reverser deployment, the heading began swinging to the right 3O, ground speed peaked at 143 knots and then decreased to 124 knots, and the rudder averaged 3O left; Nl decreased to its lowest values of 42.12 percent for the left engine and 43.5 percent for the right engine. The longitudinal acceleration transitioned from positive to negative during this time. Brake hydraulic pressure was not a recorded parameter. In the final 17 seconds of recording, #round speed decreased steadily to 34 knots, heading swung right to 316.17 (0.8O right of runway heading) for one second and then swung back to the left ending at 311.13O. Thrust reversers remained deployed and Nl held steady between 88 and 89 percent. Rudder position varied from 13O left to Z0 right and longitudinal deceleration peaked at -.41g 8 seconds after the first power-reducti on indication, then decreased to - .2g. 1-12 Wreckage and Impact Information 1.12.1 Main Wreckage The airplane collided with a wooden approach lighting stanchion or pier as it went off the end of the overrun. The fuselage separated into three sections with the forward section resting on part of the elevated light stanchion and the aft section partially submerged (see figures 4 and 5). All fuselage fractures were due to overstress. The bottom of the nose aft of the nosewheel well' had heavy impact damage. Fragments of the pier penetrated the cockpit floor near the captain's rudder pedals. The nose gear was extended, and both nosewheel tires were attached to their wheel rims but were deflated and worn away to expose carcass plies near the center of the tread. More wear was on the left sides of both nose tires. The left and right wings and engines were intact. Leading edge flaps one and two on the left wing had some impact damage. The trailing edge flaps were 50 down. The tires on both main landing gears were inflated and showed normal wear. The vertical stabil iz.er, its control surfaces, the horizontal stabilizer and its control surfaces were undamaged. The rudder and elevator moved freely when manual 1 y operated. 1.12.2 Marks on the Runway The surface of runway 31 had scrub marks from both main landing gear tires and the nose wheel tires. Pneumatic tire braking or cornering on wet pavements leave such marks as the tires remove residue from the runway leaving a clean surface. These marks started left of the centerline 3,735 feet from the runway threshold and extended to 5,400 feet from the

Figure 4. --N416US a t low t i d e .

runway threshold. About 5,000 feet from the threshold, the two nose gear scrub marks merged into one wider mark for a short distance before they disappeared. The scrub marks on the overrun reappeared at the end of the runway near the centerline and extended onto the overrun. The location of the tire marks is depicted in figure 2. 1.13 Medical and Path01 ogical Informati on The captain's medical insurance claims for the 12 months prior to the accident showed nothing relevant to flight status. The captain described his health as "good" and recalled no major changes just before the accident. He said he drank alcohol occasionally and his last drink was about four days prior to the accident. He said he was not on prescription medication and had no drug exposure in the 72 hours prior to the accident. He awoke about 0900 on the day of the accident after 12 hours of sleep and ate a light breakfast. The captain stated that his eating on the day of the accident consisted of two light meals before beginning duty and fruit from a crew meal later in the day. The afternoon fol 1 owing the accident, medical personnel asked him for toxicological samples, but he refused upon the advice of an Air Line Pilot's Association (ALPA) representative who accompanied him. He gave a urine sample to investigators on September 22 between 1855 and 1950, 44 hours after the accident, but upon the advice of an ALPA attorney refused to give a blood sample. Two police officers trained in detecting alcohol abuse spoke to the captain during the rescue operation and saw no signs of intoxication. Toxicological testing of the captain's urine detected orphenadrine, a muscle relaxant in the commercial product Norgesic. Norgesic is a drug obtainable only through a physician's prescription, however, the captain stated that a fellow pilot gave him the drug after the accident to treat his injuries. All other substances tested, including alcohol, were negative. The first officer awoke about 0930 on the day of the accident after eight hours of sleep. He ate a light breakfast that morning and a crew meal 1 ater in the day. He described his health as "average" and recalled no major changes just before the accident. The first officer said he did not drink alcohol, did not take prescription medicine, and had no drug exposure the previous 72 hours. The first officer also provided a urine sample 44 hours after the accident, and all substances tested were negative. His ALPA counsel advised the Safety Board that only a urine sample would be forthcoming. Two passengers in seats 21A and 21B died of mechanical asphyxiation (suffocation from being crushed and unable to breathe). Seat damage and floor disruption delayed the evacuation of passengers seated in 21F and 22A. 1.14 Fire No fire occurred during or after the accident.

1. 15

Survival Aspects 1.15.1 SeatDamage Timber from runway 1 ighting stanchions penetrated the l e f t side of the cockpit. A length of wood penetrated the forward cockpit bulkhead, damaged the captain's r i g h t rudder pedal, s p l i t around the pedal, passed on both sides o f the captain's r i g h t leg, and caused minor i n j u r y t o him. The f i r s t o f f i c e r ' s side o f the cockpit showed no damage, and the one forward and two a f t f l i g h t attendant seats had no damage. The wreckage was not secure on the wooden p i l i n g s and i n the water, so t i d a l movements made on-site examination o f the wreckage unsafe. Salvage and transport t o a secure a i r c r a f t hangar damaged the wreckage. Therefore, determining the presalvage condition o f the passenger seats was impossible. Deceleration was not high enough t o dislodge o r overstress any seats o r t o separate any seat b e l t s o r shoulder harnesses. Separation and subsequent crushing o f the fuselage caused the most severe seat damage i n rows 21 and 22. Massive crushing o f one seat and the f l o o r occurred i n row 21 on the l e f t side o f the airplane. 1.15.2 Emergency E x i t Damage The airplane e x i t configuration consisted o f the L-1 main boarding door, the R-1 forward galley door, four Type I11 overwing exits, the L-2 a f t entry door, and the R-2 a f t galley door. A l l the exits, except the L-1 door and L-2 door were used f o r evacuation. T h e lead f l i g h t attendant could not open the L-1 door a f t e r the airplane came t o a stop. The f l i g h t attendant seated nearest the R-1 door opened t h a t door w i t h the help o f the lead f l i g h t attendant. The evacuation s l i d e a t R-1 deployed; the R-2 s l i d e was disarmed before the door was opened because the f l i g h t attendant believed that the s l i d e would f l o a t upward and block the e x i t because o f the closeness o f the water. The L-2 door was opened and then closed when water entered the cabin. Both r i g h t overwing e x i t s operated normally and the l e f t overwing e x i t s were not available f o r inspection; however, several passengers stated t h a t they used the l e f t overwing e x i t s t o evacuate successfully. 1.15.3 Evacuation Immediately following the impact the captain performed the Passenger Evacuation checklist. He verbalized the steps o f t h i s checklist as he was s i t t i n g i n h i s seat. The captain, the f i r s t o f f i c e r , the o f f duty Pan American captain, f l i g h t attendants, and an a i r p o r t pol i c e o f f i c e r , who jumped i n t o the water from the runway deck, assisted then passengers during the evacuation. Depending upon where the passengers were seated, t h e i r evacuations were impeded by darkness, cabin separations a t seat rows 4 and 21, and the unavailable f l o o r level e x i t s on the l e f t side.

About 20 passengers stood on the left wing, which was out of the water. Someone unstowed the fabric ditching line from above a left overwing exit and tied it to its wing fitting. These 20 passengers, including the woman with the 5 year old child and the 8-month old infant, held onto the line as they awaited rescue. The ditching line was unstowed from its right overwing exit opening but evacuees did not know it needed to be tied to the right wing fitting. The forward portion of the right wing was out of the water and passengers held onto the ditching line so they could stay out of the water. Passengers who egressed at the two floor-level exits entered the water and because of the 1 knot current some persons drifted away from the airplane and under the runway deck. Crewmembers threw floatation seat cushions and crew life preservers, which were held by passengers and crewmembers, some of whom could not swim. Several persons complained that they could not hold onto the cushions or that the cushions did not keep them afloat. Some clung to pilings under the deck and floating debris. Some passengers also swallowed fuel that was on the water surface. Several complained that waves from boats and downwash from a rescue helicopter hampered staying afloat with their heads out of the water. One passenger said that she sustained.a fractured right ankle and a lacerated hand when a rescue boat backed over her. The captain and the lead flight attendant were the last crewmembers to leave the cabin after assisting rescue workers, who were attempting to extricate the passengers trapped in seats 21F and 22A. These passengers estimated that their extrication was completed 90 minutes after the accident. According to U.S. Coast Guard records, all persons had been removed from the airplane by 0102. Problems were experienced with one hand-held, battery powered cabin megaphone~the other megaphone was not used. The lead flight attendant stated that he attempted to use it to give evacuation commands, but subsequently his commands were "squelching," [feedback] and it became more effective to simply yell the commands. Also, this megaphone ceased operating completely after it became wet 1 ater during the evacuation. During the investigation, it was discovered that the megaphone used at the USAir training center had a volume knob that turned to the left to increase the volume. The lead flight attendant could not specify which way he operated the volume knob, or whether he operated it at all during the rescue sequence. The magaphone he used was not recovered following the accident. A1 though crewmembers had 1 i fe preservers, FAA regulations do not require life preservers for passengers aboard this flight. Flight attendants had not received ditching training in the water. It was not required by the FAA.

1. 15.4

Emergency Response A i r T r a f f i c Control tower personnel stated t h a t they observed the airplane apparently t r a v e l l i n g too fast t o stop and they used the crash phone and activated the crash alarm before the airplane departed the runway. The New York City F i r e Department (NYCFD) and the U.S. Coast Guard were also n o t i f i e d by the controllers. The 12 Port Authority a i r c r a f t rescue and f i r e f i g h t i n g (ARFF) personnel responded with 5 ARFF trucks, 3 o f which were positioned a t the end of the runway deck within 90 seconds. Shortly thereafter, a Port Authority police o f f i c e r jumped i n t o the water with a large i n f l a t a b l e l i f e r i n g from one o f the ARFF trucks. A t t h i s time, some o f the airplane occupants had begun t o d r i f t under the deck and vehicles were positioned t o shine t h e i r headlights and spot l i g h t s on persons i n the water; additional 1 i f e rings were thrown t o those i n the water. Also, about t h i s time an attempt was made t o launch the Port Authority's 19 foot boat but the pickup truck that towed the b o a t - t r a i l e r could not develop t r a c t i o n over a dike next t o the launching ramp and the boat was not launched. />. The f i r s t boat t o a r r i v e (about 10 minutes a f t e r the accident) was from the New York City Police Department (NYCPD) Harbor Unit; it was joined shortly by U.S. Coast Guard boats, boats from other agencies, and the f i r s t o f two Coast Guard helicopters. Passengers and crewmembers were taken t o one of the three triage/assembly areas a t the a i r p o r t o r d i r e c t l y t o area hospitals. Rescue personnel and persons who were i n the water informally estimated t h a t the l a s t person was taken onshore well over 30 minutes a f t e r the f i r s t boat arrived. The search and rescue a c t i v i t i e s were hampered by darkness and f l o a t i n g debris. Further, rescue personnel d i d not know how many persons were onboard the airplane, how many were i n the water, and how many had been taken from the scene. About 12 minutes a f t e r the accident, a NYCFD tower ladder truck arrived and, using a combination o f the tower ladder and other ladders, rescue personnel climbed down t o the airplane. These personnel assisted persons who were standing on the wings, treated the passengers who were trapped i n the cabin, and began extrication. The Port Authority Operations Supervisor and the Tour Commander served as the Port Authority command post from t h e i r automobiles, which were positioned away from the edge o f the deck so that ARFF vehicles and o f f a i r p o r t vehicles could be close t o the edge. However, Port Authority o f f i c i a l s found t h a t the command post was not t o t a l l y e f f e c t i v e because the command post automobiles could not be seen among the much larger f i r e f i g h t i n g and rescue vehicles. The U.S. Coast Guard Vessel "HAWSER" arrived on scene a t 0039 and was designated as the On-Scene Coordinator vessel. Although the Coast Guard reported t h a t a l l persons were out o f the airplane a t 0102, the search continued f o r possible missing persons because they d i d not have the f l i g h t manifest. A t 0252, the Coast Guard was n o t i f i e d o f the number o f persons onboard, but not the number o f persons who had been rescued. A t 0709, the next day, the Coast Guard was informed by the Port Authority t h a t a l l persons had been accounted f o r and the search was concluded.

Agencies involved in the rescue operation included the Port Authority of New York and New Jersey, the New York Police Department, the New York City Fire Department, including the Harbor Unit, the United States Coast Guard, the New York City Harbor Patrol, and the Rikers Island Emergency Response Unit of the New York City Department of Corrections. The New York Pol ice Department Aviation Unit was notified of the accident but was unable to launch any of its helicopters because of poor weather conditions. Critiques were held on September 23 and 27, 1989, to examine the emergency response by airport ARFF and off -ai rport agencies. Appendix E contains a synopsis of the rescue agencies' critiques and actions taken by LaGuardia Airport since the accident. 1.16 Tests and Research 1.16.1 Powerplant Examination Both CFM International CFM-56-32B engines were immersed in sea water for about 80 hours. After being removed to an aircraft hangar at LaGuardia, they were examined externally and internally but were not torn down completely. Certain components were tested or disassembled, or both. The number 1 engine's thrust reverser cowls were 2 inches from full deployment, and the number 2 engine's cowls were fully deployed. Low pressure rotors on both engines could be rotated by hand. Thirty four of 38 fan blades on the number 1 engine had hard object damage, such as nicks, gouges, and tip curls. This engine had ingested its total air temperature probe during impact. All the number 2 engine's fan blades were intact, but water impact had deformed some of them to varying degrees. Low pressure turbines on both engines were not visibly damaged, and no metallic particles were in either engine's tailpipe. Since the DFDR showed that the number 1 engine did not reach full takeoff thrust during the takeoff attempt, mechanical and electric components of its control system were tested or disassembled. These tests and di sassembl ies showed that a1 1 the mechanical components were capable of normal operation during the accident. The testing of electrical components showed anomalies, such as several shorts to ground and below minimum insulation resistances and signal voltages. Sea water and salt deposits were inside power management controls and transformers. The first electrical test of the main engine control turned up voltage anomalies in the rotary variable di fferenti a1 transformer (RVDT) that could have hampered engine power management, but the RVDT operated normally after appropriate components were baked in an oven to remove all traces of moisture. 1.16.2 Rudder Trim Examination On-scene examination of the rudder trim system showed that the rudder trim control knob rotated freely in both directions with no evidence of binding or sticking. This control is located on the aft end of the center pedestal. The trim indicator, which is also on the center pedestal, showed an "off" flag, and there was no evidence of sticking. Extension of the

rudder trim actuator rod was 10.5 inches, corresponding to a trim position of 16O left deflection of the rudder. Examination of the fol 1 owing components of the rudder trim system occurred at the Boeing facility in Seattle, Washington: 1. The rudder trim module from the center pedestal containing the rudder trim control and the trim indicator; 2. The rudder trim actuator including the rudder position transmitter; 3. The rudder centering unit; 4. The rudder pedal actuator; 5. The rudder power control; 6. The auxiliary rudder power control package; 7. The rudder trim indicator and control circuit breakers. All components worked normally when initially tested. The rudder trim actuator failed, however, after one and one-half cycles. Disassembly revealed an electrical short circuit at a solder terminal inside the power supply module. The terminal was corroded. Rudder-trim components that could be functionally tested against a specification control drawing were within acceptable limits, except the rudder trim indicator circuit breaker. This device needed more current than specified before it would trip. 1.16.3 Brake and Anti -skid Examination On-scene examination of the anti -skid system revealed no major anomalies. The front metal pulltab on the anti-skid control was bent slightly, but all electrical connections appeared normal. A1 so, the inboard and outboard anti-skid valves in the left and right wheelwells were in good condition. Investigators loosened. the "B" nuts from all four valves and saw hydraulic fluid run out from the lines. All anti-skid hydraulic lines, fittings, fuses, and plugs were intact, as were the safety seals. Left and right main-landing-gear brakes had no apparent damage, fluid leakage, or overheating. The left gear's outboard brake wear pins measured 1.5 inches and the inboard pins 1.2 inches unpressurized. The right gear's outboard brake wear pins measured 1.4 inches and the inboard pins 0.375 inch. Linings of the inboard brake had worn to approximately 0.0625 inch without evidence of delining. All four brakes were functionally tested after they were rebuilt 4 months after the accident. All heat stacks, bolts and other steel hardware had heavy oxidation. All running clearances were within 1 imits, and a1 1 adjusters operated satisfactorily

between cycles. During functional tests, one brake cylinder on each o f two brakes leaked hydraulic f l u i d . Wear p i n measurements d i f f e r e d s l i g h t l y from those taken shortly a f t e r the accident, with the p i n extended 0.15 inch on the most worn r i g h t inboard assembly. 1.16.4 Simulation Studies Applying specific t h r u s t and rudder data from f l i g h t 5050's DFDR, several situations were examined i n a B-737 engineering simulator a t Boeing i n Renton, Washington. Programmed i n t o the simulations were basic accident parameters, such as runway length, airplane weight, winds, and RTO i n i t i a t i o n speed. The simulations used coefficients o f f r i c t i o n equal t o t h a t expected on a dry runway surface and one-half that of a dry runway, referred t o herein as a "1/2 dry" surface. P i l o t s who flew the simulations included a Boeing production/ engineering t e s t p i l o t , the Pittsburgh F l i g h t Standards D i s t r i c t Office (FSDO) 19 Aircrew Program Manager, the USAir Senior Director o f Qua1 i t y Assurance and F l i g h t Safety, a U S A i r l i n e captain and a Safety Board a i r safety investigator. They simulated a l l takeoff runs and RTO's from the captain's seat, and t h e i r conclusions were: 1. A 4 1/4-inch d i f f e r e n t i a l displacement o f the rudder pedals made f u l l l e f t rudder t r i m r e a d i l y discernable. 2. The nose wheel steering t i l l e r alone could o f f s e t the DFDR dynamic rudder values when taking o f f from a dry runway. 3. The nose wheel steering t i l l e r alone could not o f f s e t f u l l l e f t rudder t r i m o r the DFDR dynamic rudder values with 1/2 dry coefficient o f f r i c t i o n programmed. 4. Rejected takeoffs were successful with about 2,500 feet remaining a f t e r the stop on a dry runway and 1,200-1,700 feet remaining a f t e r the stop on the 1 / 2 dry" runway. A second series o f simulations used the USAir B-737-400 simulator with the USAir l i n e captain (not the accident p i l o t ) serving as f i r s t o f f i c e r and the other p i l o t s acting as captain. During these t e s t takeoffs, the f i r s t o f f i c e r controlled the rudder u n t i l about 90 knots when the captain took over. The captain aborted between 120 and 130 knots sometimes using the RTO feature o f the autobrake. A l l the p i l o t s agreed upon the following f o r the circumstances o f fl i g h t 5050. 1. The f i r s t o f f i c e r could have taken o f f successfully with f u l l l e f t rudder t r i m . 2. Confusion i n the cockpit between 80 and 110 knots adversely affected the captain's actions i n the RTO and lengthened the distance required t o stop.

The transfer of command degraded control and used up runway theoretically available for braking.

The RTO autobrake feature aided stopping.

The RTO would have been successful if normal RTO procedures had been fol 1 owed. 1.17 Other Information 1.17.1 Aircraft Systems Descriptions 1.17.1.1 The Nosewheel Steering System The B-737 has a hydraulically actuated nosewheel steering system. Steering angles up to 78O left or right of center can be attained using a nosewheel steering tiller on the left sidewall of the cockpit. Additionally, either pilot can turn the nose wheel up to 7O left or right of the center position by using the rudder pedals. However, the nosewheel steering tiller overrides any steering command by the pedals. For example, if the first officer is attempting to turn left using the pedals, the captain can override the pedal command and turn right using the tiller. Neither the position of, nor the force required on, the rudder pedals for a given rudder position will change as a result of the tiller position. 1.17.1.2 The Rudder Trim System Figure 6 shows the B-737-400 rudder trim control knob at the rear of the cockpit center pedestal. The knob is spring-loaded to its center position and electrically activates the rudder trim actuator motor only when held away from center. The motor repositions the neutral point of a hydraulic servo actuator to position the rudder up to 16O either side of center. Regardless of the trim setting the pilots' force on the rudder pedals can still move the rudder to its full deflection of 26O either side of center. A horizontally scaled indicator forward of the control knob shows rudder trim settings to the crew. Out-of-neutral rudder trim also changes the position of the rudder pedals and the steering angle of the nosewheel when on the ground. For example, full left rudder trim will move the nosewheel 4O left, producing an offset between the rudder pedals of 4 1/4 inches. That is, the left rudder pedal will be displaced about 2 inches forward and the right pedal 2 inches aft, which affects the position of the pilot's feet correspondingly. This trim condition will cause the airplane to turn to the left during taxi or takeoff, and right tiller or pedal force must be used to straighten the ground track. Overhead View Bear View Oblique View Figure 6.--The B-737-400 cockpit a i s l e stand.

1. 17.1.3

The Autothrottle System The Boeing 737-400 has an autothrottle system that automatically advances to takeoff power when armed and engaged at the start of a takeoff roll. The arm switch is on the autopilot flight-director-mode control panel and holds the arm position magnetically. Once armed and then engaged by the TO/GA switch below the thrust levers, the auto throttle system will advance the thrust to N1 values preset into the limit annunciators. However, if indicated airspeed reaches 64 knots prior to completion of the thrust-setting cycle, the throttles will stop at an intermediate position and manual advancement is required to obtain takeoff thrust. Autothrottle disengage switches are on each thrust lever; once disengaged, the arm/TO/GA cycle must be repeated to reengage. If reengagement is completed before reaching 64 knots takeoff thrust will be attained automatically. An airplane can be dispatched with its autothrottle inoperative. 1.17.1.4 The Autobrake System When armed for takeoff, the autobrake system wi 1 1 provide maximum braking consistent with the antiskid function in the event of a rejected takeoff. Autobraking begins when thrust levers are pulled back to their idle stops if wheel speed exceeds 90 knots. Manual braking disengages the autobrakes, which wi 1 1 not reengage once deceleration begins if interrupted by manual braking. The accelerate-stop distances derived during certification are based on manual braking . 1.17.2 USAir B-737-300/400 P i lots Handbook Excerpts: The following information is contained in the USAir B-737-300/400 Pilots Handbook: Rejected Takeoff A rejected takeoff is a maneuver performed during the takeoff roll to expeditiously stop the airplane on the runway. As the airplane accelerates during the takeoff roll, energy increases rapidly. The energy increase is in proportion to the square of the increase in speed. This energy must be dissipated to stop the airplane. At low speeds, up to approximately 80 knots, energy developed is not sufficient to cause difficulty in stopping the airplane. As airspeed approaches Vl for the balanced field condition, the effort required to stop the airplane on the runway for an RTO approaches maximum. After Vl, it may not be possible to stop the airplane on the runway. The decision to reject the takeoff must be made prior to Vl so that the maneuver can be initiated no later than V and must be accompanied by immediate accomplishment of t ft e rejected takeoff maneuver.

Prior to V , a takeoff should be rejected in the event of an engine fai \ ure, engine fire, unsafe ' configuration, or any adverse condition significantly affecting the safety of flight. The captain makes all rejected takeoff decisions. When alerted to the abnormal situation, the captain should call "reject" and simultaneously close the thrust levers (disengage the autothrottle, if required) and apply maximum brakes. If RTO autobrakes are selected, monitor system performance and apply manual wheel brakes if the AUTO BRAKE DISARM light illuminates or deceleration is not adequate. Rapidly raise the speed brakes and apply maximum reverse thrust consi stant with conditions. Maintain reverse thrust and braking until runway length remaining permits transition to normal 1 anding roll procedures. USAir recommends arming the RTO feature on all takeoffs as it will ensure brake application early in the rejected takeoff. Departure Briefing The departure briefing shall include at least the initial heading and intial altitude restriction (i .e., Runway heading and maintain 5,000) as a standard briefing. No two takeoffs are identical. The Captain is responsible that crews are aware of the many situations which could occur during this phase of flight that might present a non-routine situation. Normally, the Pilot flying will brief the Pilot not flying when any portion of the takeoff is anticipated to be other than routine. Items to be included in the briefing could include, but are not 1 imited to, runway contamination, unique noise abatement procedures, presence of hazardous terrain adjacent to the flight path, or any items which may necessitate special flight or crew procedures or crew responsibilities. 1.17.3 FAA Oversight of USAir From April 10-14, 1989, FAA Flight Standards District Office (FSDO) 19 inspected Piedmont Airlines to gauge progress of the merger between Piedmont and USAir and to determine if the airlines were adhering to their "mirror image" transition plan. According to the manager of FSDO 19, FAA aviation-safety inspectors made more than 75 enroute inspections, 25 station inspections, and numerous manual checks, checkrides, and training reviews. He stated, "The overall results of this inspection were excellent. Throughout the inspection, [Piedmont personnel] demonstrated an excellent know1 edge of USAir pol icies and procedures and effective1 y util ized those procedures during all phases of 1 ine operations." Piedmont Air1 ines and USAir merged on August 5, 1989.

From September 18 t o October 6, 1989, the FAA conducted "special surveil 1 ance" o f USAir proficiency checks and training, cockpit enroute inspections, fl ight-crew and fl ight-attendant manuals, recurrent crew training, and f l i g h t dispatch procedures. Two other incidents involving USAir f l i g h t s prompted a series o f FAA reviews beginning about September 8, 1989, and ending with publication o f the report: USAir. Inc. Aircrew Desianated Examiner/Fl i a h t Trainina Proaram Assessment i n October. The findings were c r i t i c a l o f USAir's cockpit resource t r a i n i n g program, company pol i c y on f l i g h t crew approach briefings, lack o f crew coordination between p i l o t s and f l i g h t attendants, sterotyped fl i g h t t r a i n i n g and checking, monitoring o f adverse t r a i n i n g trends, d e f i c i e n t international dispatcher training, and several fl i g h t attendant t r a i n i n g and equipment matters. USAir o f f i c i a l s disagreed with the report by saying that the programs and procedures under c r i t i c i s m were a11 approved by the FAA and i n most cases exceeded basic FAA requirements. The author o f the report t e s t i f i e d a t the Safety Board's public hearing that: "We recommended some technique changes. They are changes t h a t could take place i n a r e l a t i v e l y short period o f time with[in] the company. They have the q u a l i t y people and equipment t o accomplish a job. It i s a matter o f changing techniques i n a few areas [and they are doing t h a t ] a t a rapid pace a t t h i s moment." 1.17.4 Airplane Performance By modifying the acceleration and t r a n s i t i o n phases o f longitudinal acceleration using DFDR data, investigators predicted how s i x d i f f e r e n t conditions would have altered the ground r o l l distance during f l i g h t 5050's rejected takeoff. Predictions of accelerate-stop distance i n t h i s study used acceleration and deceleration evident on the F l i g h t 5050 DFDR rather than the more general values contained i n the B-737 f l i g h t manual. The variables used t o examine the s i x conditions were: 1. Speed when t h r o t t l e s are retarded t o i d l e stops. F l i g h t 5050's t h r o t t l e s were retarded a t 130 KIAS, whereas the appropriate V l speed was 125 KIAS. 2. Engine t h r u s t during acceleration. F l i g h t 5050 had attained t h r u s t o f only 93.1 percent N1 on the l e f t engine and both engines took longer t o reach peak thrust than normal. Calculation o f f u l l t h r u s t assumes 94.9 percent N1 speed on both engines. 3. Time t o brake. F l i g h t 5050 reached maximum deceleration 5 1/2 seconds a f t e r the t h r o t t l e s were retarded t o i d l e thrust. The calculations assumed 2 1/2 seconds as the basis f o r " f a s t braking."

The calculated ground r o l l distances f o r the examined conditions, the f i r s t o f which approximates USAir F l i g h t 5050, are as follows: Case Conditions 1. Sl ow/reduced takeoff thrust, 130 KIAS abort, slow braking 2 . F u l l takeoff thrust, 130 KIAS abort, slow braking 3. S l ow/reduced takeoff thrust, 130 KIA abort, f a s t braking 4. F u l l takeoff thrust, 130 KIAS abort, f a s t braking 5. Slow/reduced thrust, 125 KIAS abort, slow braking 6. F u l l takeoff t h r u s t 125 KIAS abort, f a s t braking Di stance-Feet (from s t a r t o f runway) 7,100 ( t o end o f RWY 31) 7,286 ( t o airplane stop) 1.17.5 Inadvertent Rudder Trim Anomal i e s The Safety Board collected about 90 reports o f rudder t r i m anomalies f o r the Boeing 737-300/400 series airplane. The majority o f these reports were received a f t e r the accident and were from p i l o t s who had heard o r read about the accident i n various publications. Because many accounts omitted such i d e n t i f i c a t i o n as dates and places of occurrence, o r were anonymous, dupl i c a t i on precluded an exact anomaly count. For instance, records f a i l e d t o show whether a captain and a f i r s t o f f i c e r on the same f l i g h t had turned i n separate reports on the same incident. The FAA and Boeing received most of these incident reports a f t e r the accident. Boeing knew o f only s i x anomalies before September 20, 1989, and the FAA's maintenance d i screpency reports showed none. The National Aeronautics and Space Admini stration's (NASA) Aviation Safety Reporting System (ASRS) data base contained one from before the accident and one after. Many reports described the inadvertent setting o f rudder t r i m by the foot o f a jumpseat occupant behind the captain's seat. The reports imply t h a t casual v i s i t o r s t o the cockpit d i d not strap in, sat sideways and used

the end of the center pedestal as a footrest for their right foot. This allowed their shoe sole to push the trim knob counterclockwise and set left rudder trim. The Pan American captain who had visited the cockpit before departure of flight 5050 said that he did not rest his foot on the center pedestal at any time. Other reports show that placing objects on the center pedestal can inadvertently turn the rudder trim knob. While the Pan American captain said that he believed the first officer placed his chart holder on the pedestal during prestart activities, the first officer did not recall having done so. Many pilots reported rudder trim knobs sticking out of neutral after intentional activation. A knob with debris underneath or a mechanical anomaly found later on some airplanes can keep driving trim after release, in spite of it being spring-loaded to the neutral position. Several reports show that even when trim operates properly, the trim indicator can either remain centered or show an erroneous indication. The Air Line Pilots Association provided the Safety Board with one pilot report of a rudder trim system that on February 8, 1990, activated without operator input and "ran away" in flight. Several of the reported inadvertent rudder trim settings were discovered by the flightcrew only after takeoff. The pilots in those incidents at first suspected engine failure as the cause of the yaw encountered and only later detected the mistrimmed rudder. They described the mistrinnned airplane as controllable in flight using the rudder. 1.17.6 Corrective Actions On October 3, 1989, USAir's Senior Director for Quality Assurance and Flight Safety issued USAir Safety Alert (89-2) asking pilots to watch for unusual rudder trim indications or unexpected settings. It continued: "The BEFORE TAKEOFF checkl i st item 'STABILIZER & TRIM.. .SET FOR TAKEOFF' is the appropriate item on the checklist to remind us to check all three trim indications (stabil izer, aileron and rudder) one 1 ast time before takeoff .'I Also, the airline modified its B-737-300/400 BEFORE TAKEOFF checklist to require use of the RTO autobrake function on all takeoffs. On December 11, 1989, a Boeing Operations Manual Bulletin about inadvertent rudder trim on B-737-300/400/500 series aircraft recommended that the stabilizer trim item on the BEFORE TAKEOFF checklist read: RUDDER, AILERON & STABILIZER TRIM.. ..ZERO, ZERO, UNITS. USAir so modified its checkl ist on February 7, 1990. In May 1989, Boeing began to study design improvements to curtail inadvertent disturbance of rudder trim controls. On January 17, 1990, Boeing stated that it would replace the current blade-type trim knob with a round knob having finger grips around its circumference. This design change will apply to the B-737-300/400/500, the B-747-400, the B-757, and' the B-767. Boeing also designed a raised shield to protect the aileron and rudder trim

controls on the B-737-300/400/500 cockpit center pedestal. Crew acceptance testing and design approval from the FAA are pending. Also, Boeing is designing an improved rudder trim indicator and has made preinstallation screening of current models more rigorous. An FAA Notice of Proposed Rulemaking issued on January 31, 1990, proposed to require retrofit installation of the newly designed rudder trim knob and the pedestal protective shield. FAA has evaluated the rudder trim system and found no evidence of uncommanded rudder trim movement. While no further action is planned to modify the basic system, the FAA is still evaluating the need for action to prevent binding of the trim control knob or sticking of the trim indicator. 1.17.7 FAA Drug and Alcohol Post-accident Testing Requirements Specific requests to USAir and ALPA to have the pilots of flight 5050 submit toxicological samples were made about 10 hours after the accident and again about 20 hours after the accident. At the time of the accident, the FAA had yet to require post-accident toxicological testing of flight crews. On December 18, 1989, post-accident drug testing became mandatory for pilots involved in accidents. However, the rule requires urine samples only and permits a delay of up to 32 hours following the accident for samples to be taken. The manager of FAA's Drug Abatement Program testified during a pub1 ic hearing that she did not know why the FAA selected 32 hours as the time limit for submission of samples. There are no federal regulations requiring pilots to be tested for alcohol following an accident, although some state authorities can request such tests. On December 5, 1989, the Safety Board issued recommendations to the U. S. Department of Transportation regarding the development of uniform regulations to be adopted by the regulatory agencies of a1 1 transportation modes. The recommendations were as follows: A-89-4 throuah A-89-7 Develop post-accident and post-incident testing regulations that are separate from the pro-employment, random, and reasonable suspicion testing regulations in a1 1 modal agencies. (Class 11, Priority Action) (A-89-4) Adopt uniform regulations for a1 1 drug and alcohol testing, other than post-accident and post-incident testing, in all transportation modes, including U.S. Department of Transportation employees who are in safety-sensitive positions. Adopt uniform regulations on post-accident and post-incident testing of private sector employees for alcohol and drugs in a1 1 transportation modes. Use the Federal Railroad Admini stration's (FRA) current regulation as a model

regulation for all transportation modes except for the permissible blood alcohol level of less than 0.04 percent. Using the FRA regulation as a model for other transportation modes refers only to the collection of blood and urine and the screening and confirmation of positives in blood. As a minimum, the drugs identified in FRA screen should be used in the other modes. Reference to the FRA model does not refer to the administration or implementation of the regulation. The Safety Board recognizes that the implementation of the regulation may be different in the various transportation modes. The regulations for all modes should provide: o for the collection of blood and urine within 4 hours following a qualifying incident or accident. When collection within 4 hours is not accomplished, blood and urine specimens should be collected as soon as possible and an explanation for such delay shall be submitted in writing to the administrator. o testing requirements that include alcohol and drugs beyond the five drugs or classes specified in the Department of Health and Human Services (DHHS) guidelines and that are not limited to the cutoff thresholds specified in the DHHS guidelines. Provisions should be made to test for illicit and licit drugs as information becomes available during an accident investigation. 1.17.8 Pub1 ic Hearing Testimony on Accident-Related Subjects ~lthough the captain did not mention any abnormal rudder pedal condition during initial post-accident interviews, when asked about such a condition at the public hearing, he stated: Yes. I had some degree of awareness that the rudder pedals were not even. This did not present any particular problem to me, I believe due to the military transport experience that I have where it would not be uncommon at all to taxi this airplane [the C-1301 and the rudder pedals be uneven during taxi. And I was also not having any problem during the taxi stage. 1.17.9 Pilot Experience and pairing After the Continental Airlines Flight 1713 accident on November 15, 1987, at Denver, Colorado, the Safety Board issued Safety Recommendation A-88-137 asking the FAA to specify minimum experience for each pilot-in-command and second-in-command and to prohi bit the pairing of pilots on the same flight who have less than the minimum experience at their respective positions.

The FAA responded with an Air Carrier Operations Bulletin on January 21, 1988, urging its principal operations inspectors to promote minimum experience criteria for pilot pairing. In the summer of 1988, an FAA survey showed that 41 percent of the 14 CFR Part 121 carriers had policies on crew pairing. Based upon this survey and the "expected degree of voluntary compliance with [crew pairing] scheduling practices" the FAA determined that rulemaking was unnecessary and planned no further action. The Safety Board called this response an "Open-Unacceptable Action." Notwithstanding its earlier disagreement with this Safety Board recommendation, after the USAir accident, the FAA informally asked the Air Transport Association-hosted Joint Government/Industry Task Force on Flight Crew Performance to examine the crew pairing issue and to develop proposed industry guide1 ines for air carriers. A special Crew Pairing Committee was formed, composed of government and industry representatives, which has met several times since December 1989. The Committee has developed prel iminary recommendations that call for more structured initi a1 operating experience for newly trained pilots and more timely completion of it; impose operating restrictions under specified weather and other conditions; and prohibit the pairing on the same flight of pilots who have less than a specified minimum experience in their respective positions. In addition to restrictions on crew pairing, the Committee's recommendations stressed the importance of a concerted, uninterrupted period of 1 ine operating time, including Initial Operating Experience (IOE) to foster the consolidation and stabilization of pilots' newly-acquired know1 edge and ski1 1 s. The Committee recommended that the consol idation period begin at the initiation of IOE, consist of 100 hours of line operating time, and be completed within 120 days. Failure to complete consolidation within this time would require observation of two satisfactory cycles by a 1 ine check airman before continuation of the program. Additionally, with regard to crew pairing restrictions, the FAA initially suggested to the Committee that an initial pilot-in-command and an initial second-in-command pilot not be paired together if both have less than 150 hours, including IOE, in the position on the airplane in which they have most recently qua1 ified. The Committee has recommended less than 150 hours. The Committee is currently revising and refining its recommendations based on comments received from the FAA. The FAA has informally advised the Committee that it intends to initiate a proposed rulemaking project, based in part on these recommendations, to amend its air carrier fl ight crew operating experience regulations. 1.17.10 Rejected Takeoff Special Investigation On February 27, 1990, the Safety Board issued Special Investigation Report SIR-90-02: Runway Overruns Followinq Hiqh Soeed Re.iected Takeoffs. Although this Special Investigation had begun before the accident at LaGuardia, the report made recommendations on proper definition of Vl speed, dissemination of Vl aircraft certification data to 14 CFR 121 operators, crew coordination during rejected takeoffs, and fleet standardization of rejected

takeoff procedures among airplanes of the same type. FAA response is pending . 1.17.11 Runway Safety Areas The Safety Board expressed its concern about runway safety areas following a Texas International Airlines DC-9 accident at the Stapleton International airport, Denver, Colorado on November 16, 1976. The airplane overran the runway during a rejected takeoff. Subsequent to the accident, the Safety Board recommended that the FAA: Amend 14 CFR 139.45 to require, after a reasonable date, that extended runway safety area criteria be applied retroactively to all certificated airports. At those airports which cannot meet the full criteria, the extended runway safety area should be as close to the full 1,000-foot length as possible. The FAA's initial response, dated July 11, 1977, stated that this recommendation would place an economic burden on airport operators. They did propose, however, an amendment to 14 CFR Part 139 that would require extended safety areas concurrently with construction of new airports, runways, and major runway extensions at existing airports. On October 23, 1985, the FAA published Notice of Proposed Rulemaking (NPRM) No. 85-22, "Revision of Airport Certification Rules," published at 50 FR 43094. In its response to the NPRM, the Safety Board supported the proposed section 139.307, "Safety Area," which would require that safety areas conform to the criteria in effect at the time of an expansion of a runway, or at the time of certification. While the Safety Board continued to stress that criteria for runway safety areas should be made mandatory at a1 1 certificated airports regardless of the date of construction, it was sensitive to the practical and economic difficulties of implementing such a requirement. On October 16, 1987, as the result of an accident at the Charlotte Douglas International Airport, Charlotte, North Carolina, in which a Piedmont Airline B-737 overran the end of runway 36R and struck a concrete culvert 318 feet beyond the departure end of the runway, the Safety board issued another recommendation to the FAA concerning runway safety areas:

Required airport managers to repair areas and/or remove obstacles, such as concrete culverts, that are adjacent to airport operating areas. Such repairs should be performed at t h e earliest opportunity. (class 11, priority action) (A-87-107) Also, on October 16, 1987, the Safety Board issued a recommendation to the American Association of Airport Executives (AAAE) and the Airport Operators Counci 1 International , (ACI) Inc. : Inform its members of the circumstances of the aircraft accident at Char1 otte Doug1 as International Airport on October 25, 1986, and request its membership to repair areas and/or remove obstacles, such as concrete culverts, that are adjacent to airport operating areas. Such repairs should be performed at the earl iest opportunity. (Class 11, Priority Action) (A-87-112) On November 17, 1987, the FAA revised 14 CFR 139 in response to comments on its NPRM of October 23, 1985. With regard to Safety Recommendation A-77-16, on March 29, 1990, the Safety Board replied to the FAA : "In Safety Recommendation A-77-16, the Safety Board recommended that the FAA amend 14 CFR 139.45 to require, after a reasonable date, that the extended runway safety area criteria be applied retroactively to all certificated airports. At those airports that cannot meet the full criteria, the extended runway surface area should be as close to the full 1,000-foot length as possible. While we note that the revised regulations call for safety areas to meet current dimensional criteria, to the extent practicable, if construction, reconstruction, or significant expansion of runways/taxiways began on or after January 1, 1988, we are concerned that there is no retroactive requirement for upgrading existing safety areas to the new dimensional criteria. Based on the lack of a retroactive requirement, the Safety Board has classified Safety Recommendation A-77-16 as "Closed--Unacceptabl e Action. " With regard to Safety Recommendation A-87-07, on January 28, 1988, the Safety Board placed it in a "Closed--Acceptable Action" status based on the FAA's November 18, 1987, amendment to 14 CFR 139 that extends the runway safety area and on the FAA's willingness to instruct its Airport Certification Inspectors to encourage Airport operators to remove, to the extent practical, all objects outside the designated runway safety area but within the dimensions of an extended runway safety area defined by the FAA's current design standards.

Also, on March 23, 1989, the Safety Board classified Safety Recommendation A-87-112 as "Closed--Acceptable Action based on ACI ' s and AAAE's actions to inform their members of the need to remove hazards adjacent to airport operating areas. 1.17.12 Overwater Emergency Equipment The Safety Board's Special Study entitled "Air Carrier Overwater Emergency Equipment and Procedures", (NTSB-SS-85-02) dated June 12, 1985, stated in part: All air carrier aircraft which operate under 14 CFR 121, 125, or 135 operations should be required to carry certain basic water survival equipment : approved flotation seat cushions and, for each occupant on board (including infants), an approved 1 ife preserver. As discussed below, the Board considers this equipment to be essential when overwater operations are involved. The FAA staff study found that at least 179 fully certificated airports in the U.S. are located within 5 miles of a body of water of at least one-quarter square mile surface area (certificated airports in A1 aska were not included, although a high percentage are near water). Virtually all aircraft used by Parts 121, 125, and 135 operators use one or more of these 179 airports (or may need to use one of them in an emergency). Thus, many passengers are exposed to risk of inadvertent water impact near an airport, whether or not their flight is classified as an "extended overwater" flight. The Safety Board's Special Study made three safety recomendations to the Federal Aviation Administration: Amend 14 CFR 121 to require that a11 passenger-carrying air carrier aircraft operating under this Part be equipped with approved 1 i fe preservers meeting the requirements of the most current revision of TSO-C13 within a reasonable time after the adoption of the current revision of the TSO; ensure that 14 CFR 25 is consistent with the amendments to Part 121. Amend 14 CFR 125 to require that all passenger-carrying air carrier aircraft operating under this Part be equipped with approved life preservers meeting the requirements of the most current revision of TSO-C13 within a reasonable time after the adoption of the current revision of the TSO; amend Part 125 to require approved flotation-type seat cushions (TSO-C72) on all such aircraft; ensure that 14 CFR 25 is consistent with the amendments of Part 125.

Amend 14 CFR 135 to require that all passenger-carrying air carrier aircraft operating under this Part be equipped with approved life preservers meeting the requirements of the most current revision of TSO-C13 within a reasonable time after the adoption of the current revision of the TSO; amend Part 135 to require approved flotation-type seat cushions (TSO-C72) on a1 1 such aircraft; ensure that 14 CFR SFAR No. 23 is consistent with the amendments to Part 135. The Federal Aviation Administration responded on December 23, 1988: "On June 27, 1988, the FAA issued NPRM No. 88-11 (Docket No. 25642). The comment period ended November 28, 1988. This NPRM addresses the issues of these safety recommendations and proposes new requirements for water survival equipment carried aboard airplanes and rotorcraft. The requirements would apply, after specified dates to U.S. certificate holders that conduct common carriage operations with airplanes and rotorcraft. 'I On November 28, 1988, the Safety Board responded to NPRM-88-11: I . . . The Safety Board is pleased that a requirement for flotation-type seat cushions would be required on Parts 121 and 135 aircraft as was called for in Safety Recommendation A-85-37. However, the Safety Board is concerned that the proposed rul emaking does not include passenger-carrying aircraft operating under 14 CFR 125 and strongly recommends that the FAA extend the same protection to passengers on board 125 operators as called for in Safety Recommendation A-85-36. Further, the Safety Board supports Safety Recommendation A-85-35 through -37 to amend 14 CFR 121, 135, and 23 to require air carriers to install life preservers that meet TSO-C13e within a reasonable time. ''The proposed rulemaking states: A passenger life preserver must be located at each passenger seat or in the immediate vicinity of the seat. Although the proposed rule does not prohibit the under seat storage of life preservers, the Safety Board urges the FAA to encourage unique and innovative ways to store the life preservers to avoid the problems as cited in our Special Study. The Safety Board remains concerned that under seat storage is not a desired location for life preservers based on its accident investigation experience. 'The Safety Board notes that the proposed Parts 121.571 and 135.117 are parti a1 1 y responsive to Safety Recommendation A-85-89 dealing with pre-departure passenger briefings and should be part of the final rule. However, we continue to

believe that Part 125 should also be amended as called for in this safety recommendation. Also, it is noted that the FAA has not addressed the differing requirements for and standardization of survival equipment/tool s in this proposed rulemaking. The Safety Board believes that these requirements need to be included in the proposed rulemaking action and urge that the provisions of Safety Recommendation A-85-40 be included in the rulemaking.. . " On February 21, 1989, the Safety Board responded to the FAA response to these recommendations " . . .We await the Federal Aviation Administration's regulatory action to make our further evaluation. These recommendations are classified as Open--Acceptable Action." On July 2, 1985, the Safety Board recommended that the FAA: Amend relevant emergency training sections of 14 CFR 121, 125, and 135 to require the cockpit and cabin crewmembers on aircraft being operated under these Parts be given periodic training, including hands-on "wet" drills, in the skills relevant to inadvertent water impact which may increase the chances of post-crash survival. On January 23, 1989, the FAA responded: I . . . Because of the diversity of the comments received, the FAA has decided to incorporate some of the subject areas discussed in the AC into an Air Carrier Operations Bulletin (ACOB). One of the subject areas that will be addressed in the ACOB is "hands-on" drills. It is anticipated that the ACOB will be issued in the fall of 1989. Until the Safety Board has the opportunity to review this ACOB, the status of this recommendation is "Open-Acceptable Action."

ANALYSIS 2.1 General The investigation showed that the flight and cabin crew were qua1 ified to perform their duties under Federal and company regulations. The pilots were well rested prior to their crew-duty day and recalled no personal matters that would have hindered their flying. Maintenance and operation of N416US complied with Federal and company specifications, and no evidence suggested that pre-existing structural discrepancies or fl ight-control system or engine anomalies contributed to the accident. The evidence indicates that the takeoff attempt with full left rudder trim precipitated the accident. The investigation also showed that the airplane was controllable with full left rudder trim and could have been flown with the appropriate operation of available flight controls. Lastly, the investigation showed that the airplane could have been stopped on the runway after the takeoff was rejected. The Safety Board analyzed: o The activation of the rudder trim to position. o The flight crew's failure to detect rudder. o The rudder trim control design. o The fl ightcrew's directional control diffi~ o The RTO decision. the full trim the mistrimmed culties. o The B-737-400 braking performance and the use of autobrake system. o The fl ightcrew' s performance and coordination. o The post accident survival factors. 2.2 Activation o f the Rudder Trim Data from the DFDR showed that rudder trim on N416US was neutral after arrival at the USAir gate at LGA. The DFDR subsequently shut down. When repowered after engine start for flight 5050, the DFDR showed that the rudder had moved to the full left trim position. Electrical and hydraulic power from the Auxiliary Power Unit (APU) were available during the intervening period to change the rudder trim position, if commanded. The time to run trim from neutral to full left is about 30 seconds, so momentary knob rotation would not have produced full left trim. The raised-blade design of the knob and i t s unguarded location a t the edge o f the center pedestal made it vulnerable t o inadvertent actuation by a person i n the jump seat who could have pushed the knob counterclockwise with h i s o r her foot. Although the v i s i t i n g captain said t h a t he d i d not use the center pedestal as a footrest, e i t h e r he o r other individuals not i d e n t i f i e d during the investigation had the opportunity t o r o t a t e the knob inadvertently. Also, an object placed on the center pedestal could have wedged against and rotated the knob t o drive the t r i m out o f neutral. Although the v i s i t i n g captain said that the f i r s t o f f i c e r may have had a chart binder on the console, the f i r s t o f f i c e r disagreed. It i s possible t h a t the rudder t r i m knob was momentarily moved and jammed out o f neutral e i t h e r because o f debris underneath o r an internal malfunction. The Safety Board be1 ieves t h a t e i t h e r occurrence i s unl i kely since the knob operated s a t i s f a c t o r i l y a f t e r the accident. Finally, a USAir B-737-300/400 p i l o t said t h a t he had encountered an uncommanded e l e c t r i c a l runaway o f rudder t r i m about 4 1/2 months a f t e r the accident. However, investigators could not p o s i t i v e l y determine the findings o f maintenance a f t e r the occurrence. The Safety Board does not be1 ieve t h a t an uncommanded t r i m runaway occurred on F l i g h t 5050 because circumstances t h a t would lead t o such an event have not been substantiated. The Safety Board concludes t h a t a person o r object inadvertently moved the rudder t r i m knob while the airplane was between f l i g h t s , and the crew f a i l e d t o note the mistrimmed condition during preparations f o r f l i g h t 5050's departure. 2.3 Crew Failure t o Detect the M i s t r i m e d Rudder The captain could have noticed the misset rudder t r i m almost immediately a f t e r engine start, even before he began t a x i i n g away from the gate, because the rudder pedals were o f f s e t from each other by 4 1/4 inches. He d i d not mention the offset t o investigators 2 days a f t e r the accident. However, a f t e r the DFDR evidence indicated the t r i m anomaly, he said that he had noticed the offset pedals, adding that the o f f s e t d i d not bother him because he was used t o t a x i i n g with o f f s e t pedals i n the C-130. The C-130 rudder control system i s reversible because a i r loads acting on the rudder surface w i l l cause rudder movement that w i l l feed back through the control system t o move the rudder pedals. Thus, it i s normal when t a x i i n g a C-130 f o r the rudder pedals t o move as a crosswind o r j e t b l a s t acts on the rudder. However, the B-737 control system i s irreversible; a i r loads on the rudder w i l l not cause rudder o r rudder pedal movement. While the captain was re1 a t i v e l y inexperienced i n h i s position, the Safety Board be1 ieves t h a t he should have been aware of these different airplane characteristics. Even i n a C-130, it would be unusual for the pedal position t o remain a t a constant o f f s e t as the airplane changed direction during t a x i . Although the captain had more than 2,600 f l i g h t hours i n the B-737, he had only about 140 hours i n the l e f t seat. Since t a x i i n g i s performed only from the l e f t seat, h i s t a x i experience was somewhat limited. However, the f u l l rudder t r i m would also have turned the nose wheel about 4O l e f t ,

requiring the captain to make a constant correction with the nosewheel steering tiller to stay on a straight taxiway. The Safety Board does not understand the captain's failure to react to these cues. The captain checked rudder control during the BEFORE TAKEOFF checklist. The B-737 rudder trim is designed so that the full 26O rudder deflection in either direction is always obtainable regardless of trim setting or airspeed. Boeing estimated that full deflection of the rudder left and right with full left trim in the system would have required about 56 lbs. of force on the left pedal and 71 lbs of force on the right, respectively. At zero trim, full rudder deflection forces are equal at approximately 68 lbs. Data from the DFDR show that the flight control check included full rudder deflections left and right and therefore full pedal travel in both directions. Again, the captain apparently did not notice or consider significant the different pedal deflections or the different forces required during the control check. The BEFORE TAKEOFF checklist also requires the captain to look at trim indicators for the stabilizer, the rudder, and the aileron in response to the first officer's challenge, "STABILIZER and TRIM." The intent of this checklist step is to detect misset trim. Although the captain said he looked at all three indicators during taxi-out, his response: "Stabilizer trim, I forgot the answer. Set for takeoff," suggests not only that he was unfamiliar with this memory response, but also that he may have been unfamiliar with what items to check. The words "stabilizer trim" instead of "stabilizer and trim" suggests he looked at the stabilizer trim only instead of all three settings. Certainly, this was a critical opportunity to notice the misset rudder trim, but the captain failed to do so. USAir challenge- and-response procedures did not require the first officer to verify the rudder trim position as he called out the checklist. The possibility that the captain looked at the rudder trim indicator and saw a stuck marker reading "0" is remote because the indicator worked when tested later. Thus, the Safety Board believes the captain should have noticed the mistrimmed rudder when he first rested his feet on the offset pedals, during taxi when he had to move the rudder pedals or nosewheel steering tiller to correct the left turning tendency, or during the rudder-control freedom-of-movement check. The first officer would have been unlikely to notice the offset pedals until he took control for the takeoff run. He testified that he noticed the pedal offset while on the runway and needed more right pedal to maintain runway heading as the airplane accelerated. According to the CVR neither pilot mentioned the pedal offset. The Safety Board believes that the first officer's inexperience in the B-737-400 may explain his failure to have recognized and acted upon the anomaly in time to change the outcome. USAir flight crews operationally check the rudder trim knob and other such controls only once during the acceptance preflight at the beginning of each day. No operational checks follow absences of flight crew

from the cockpit or after crew changes. Long delays between flights and crew changes may mean that the cockpits of USAir airplanes are out of direct observation by flight crews for extended periods of time. Consequently, visitors have ample opportunity to inadvertently misposi tion switches and knobs. The Safety Board therefore believes that a modified aircraft acceptance checklist should be performed instead of through-flight or intermediate checklists whenever the cockpit is vacated by the flight crew. 2.4 Rudder Trim Control Design Earlier Boeing aircraft such as the B-707, B-727, early B-737, and early B-747 had larger, rather stiff, trim wheels that positioned the rudder controls by cable. However, the B-737-300/400 series and other new designs have electrical/hydraulic trim controls with smaller, easier-to-manipulate, knobs. Boeing design engineers used elements of good ergonomics on the current rudder trim knob; its raised blade-li ke shape resembles a rudder and its location is in the appropriate relationship to the other trim controls. Designers should give more consideration to how shape and position can contribute to mistakes in operation. Operating experience has demonstrated that the B-737-400's rudder trim knob is vulnerable to inadvertent rotation. The aileron trim control, just 2 inches from the rudder trim knob on the B-737-400, consists of two toggle switches guarded against inadvertent activation by raised metal flanges. Both of these switches must move in the same direction at the same time to set aileron trim. The Safety Board believes that the same type of human engineering evaluation should have been applied to the rudder trim control on the B-737-400 during its initial design when it might have been foreseen that the control knob was vulnerable to inadvertent operati on. Before this accident, Boeing designers were in the early stages of a redesign because they knew about six inadvertent rudder trim missettings on the B-737-300/400. The Safety Board is convinced that some 90 episodes that surfaced after the accident would have accelerated redesign if Boeing had known about them. Boeing is changing the shape of the knob and putting a raised guard behind it, which the FAA is expected to make mandatory. This action should curtail inadvertent knob rotation. The B-737's takeoff configuration warning system does not include an alarm for rudder mistrim. The Safety Board believes this is proper because misset rudder trim does not make the airplane unflyable. Pilots only need warning of catastrophic configuration anomalies, such as misset flaps or elevator trim. Pilots cannot immediate1 y correct these during a takeoff run, but full command of rudder movement, even with full trim deflection, allows pilots to correct the effect of misset rudder trim immediately. 2.5 Directional Control Difficulty Full rudder trim during takeoff does not make an accident inevitable. Pilots are trained to maintain directional control during takeoff under adverse conditions, such as yaw from an engine failure. Furthermore, rudder trim on the B-737 can be overpowered by the pilot.

Yawing moments caused by rudder deflection w i l l increase with increasing airspeed; but even with f u l l t r i m , the rudder can be deflected t o a position f u l l y opposite t o t r i m by the application o f force on the rudder pedals. Upon reaching a speed a t which the rudder i s aerodynamically effective, the rudder pedals alone can be used t o keep the airplane r o l l i n g straight. A t 1 ower speeds, the nosewheel steering must be used. According t o the B-737's Airplane F l i g h t Manual (AFM), use o f the nosewheel t i l l e r a f t e r receipt o f takeoff clearance i s only f o r a1 ignment o f the airplane with the runway. After alignment, rudder pedal steering should be used t o maintain directional control during takeoff. On the B-737, rudder pedals give the nose wheel up t o 7O o f steering t o assist during the early part o f the takeoff r o l l . But the captain t e s t i f i e d that he t r i e d t o use the steering t i l l e r t o maintain runway alignment u n t i l he rejected the takeoff. According t o Boeing's Chief B-737 Test P i l o t , the nosewheel steering i s e f f e c t i v e only u n t i l the rudder gains aerodynamic authority. Afterward, the nosewheel t i r e s cannot produce s u f f i c i e n t cornering force t o r e d i r e c t the airplane i n opposition t o the aerodynamic force resulting from rudder deflection. Using Fl i g h t 5050's gross weight, an engineering simulator showed that, a t more than 81 knots on a dry runway and 64 knots on a wet runway, nosewheel steering alone could not t u r n the airplane i n opposition t o 16O o f rudder deflection. Data from f l i g h t 5050's DFDR confirms that the f i r s t o f f i c e r applied some force on the r i g h t rudder pedal while the airplane accelerated f o r takeoff; but t h i s pedal force was i n s u f f i c i e n t as the rudder became more aerodynamically effective, and a t 91 knots the nose veered l e f t . A t 106 knots, the CVR recorded the captain saying "got the steering." He l a t e r t e s t i f i e d t h a t he said "you got the steering," advising the f i r s t o f f i c e r t o correct with r i g h t rudder. However, the f i r s t o f f i c e r t e s t i f i e d t h a t he thought t h a t the captain said: "I got the steering" and t h a t he expected the captain t o take control o f the rudder. The f i r s t o f f i c e r then said "okay" and a t 110 knots relaxed force on the r i g h t pedal gradually t o prevent rapid veering t o the l e f t . The rudder deflection changed from about lo l e f t t o 80 l e f t , consistent with the f i r s t o f f i c e r ' s statement that he relaxed force on the pedal. The f i r s t o f f i c e r t e s t i f i e d t h a t he never f e l t the captain overpower h i s rudder pedal force. A t 119 knots and fewer than 3 seconds a f t e r the captain's comment "got the steering," the DFDR l a t e r a l accelerations show t h a t the airplane swerved t o the l e f t . Apparently, neither p i l o t was f u l l y i n control o f the airplane, as both o f them seemed t o expect the other t o steer. The captain t e s t i f i e d that he t r i e d t o h a l t the leftward track o f the airplane by using both rudder pedal and the nosewheel steering t i l l e r p r i o r t o r e j e c t i n g the takeoff. But the DFDR data refutes such an occurrence because it indicates a maximum rudder deflection o f only 1 degree r i g h t during the 4 1/2 seconds from "got the steering" t o the captain's signalin h i s r e j e c t i o n o f the takeoff by saying " l e t ' s take it back." Although 1 !

nose-right rudder required about 58 l b s on the r i g h t pedal, neither p i l o t applied the 71 lbs. o f force needed f o r f u l l r i g h t rudder. When the captain took control o f the airplane t o i n i t i a t e the RTO, he faced an unknown and compl icated directional control situation. The f i r s t officer had been reacting t o the nose-left tendency by depressing the r i g h t pedal, but the captain does not remember the f i r s t o f f i c e r ' s warning about this. Therefore, the need f o r a large amount o f force on t h ~ wight rudder pedal probably was a complete surprise t o the captain a t a c r i t i c a l time i n the takeoff. His testimony, DFDR rudder data, the rumble sound on the CVR indicating extreme nosewheel deflection, and the physical evidence on runway 31 indicate that the captain was r e l y i n g on the nosewheel steering t i l l e r f o r directional control instead of the rudder pedals. The combination o f the captain's use o f the t i l l e r , and h i s f a i l u r e t o detect the f i r s t o f f i c e r ' s rudder commands apparently l e d the captain t o f a l s e l y believe t h a t the t i l l e r was e f f e c t i v e l y maintaining directional control. Consequently, instead o f applying force t o the r i g h t rudder pedal, he continued t o depend on the nose wheel steering t i l l e r , and the airplane veered further t o the l e f t complicating the captain's subsequent actions t o stop the airplane. 2.6 The RTO Decision History has shown t h a t most o f the RTOs t h a t have resulted i n runway overrun accidents have been i n i t i a t e d f o r reasons other than engine f a i l u r e and, i n many cases, the RTO's were not necessary because the airplanes could have taken off safely. The awareness o f these occurrences has prompted the a i r l i n e industry t o emphasize the philosophy t h a t a f t e r reaching high speeds (generally accepted as 100 knots), fl ightcrews should r e j e c t takeoff only when an engine f a i l s before V l o r there are clear indications t h a t a condition exists t h a t w i l l s i g n i f i c a n t l y a f f e c t the safety o f f l i g h t . USAir provided such guidance i n t h e i r t r a i n i n g program and the USAir B-737-300/400 Pi 1 ot's Handbook. The captain o f f l i g h t 5050 had several indications o f a problem during the takeoff r o l l before the airplane reached 100 knots. First, he must have been aware o f the f i r s t o f f i c e r ' s d i f f i c u l t y i n maintaining runway heading as more and more nosewheel steering commands were applied by the t i l l e r ; second, the sound of the "bang" occurred a t 62 knots and the subsequent rumble was heard a t 91 knots. The Safety Board believes t h a t the captain should have decided t o r e j e c t the takeoff immediately. Having f a i l e d t o do so, he must have been aware that the airplane was accelerating and r a p i d l y approaching the Vl speed, even though he f a i l e d t o make the 80 knots and Vl callouts. With such awareness, the captain should have given h i s t o t a l attention t o control of the airplane with the rudder pedals and continued the takeoff. Either p i l o t was physically capable o f but d i d not use substantial r i g h t rudder t o maintain directional control. The Safety Board concludes that because the p i l o t s had f u l l rudder authority, a safe takeoff was possible, and t h a t the p i l o t s could have corrected the mistrim condition a f t e r l i f t i n g o f f . Successful takeoffs have been accomplished four times

with full rudder trim and five times with partial rudder trim, according to reports from B-737-300/400 pilots located during this investigation. The investigation showed that the captain had not experienced a tire failure or non critical event at high speed during takeoff in either simulator training or 1 ine flying operations. The Safety Board's Special Investigation of Runway Overruns Following High Speed Rejected Takeoffs found that USAir RTO training was not unique in this regard, that most airlines present only engine failure situations during simulator training. Moreover, the critical safety margin of the RTO may not be readily apparent to the trainee as he succeeds without difficulty in stopping the simulator with runway remaining because the RTO scenario or the simulator characteristics were not representative of the most critical line operations. The Safety Board addressed these issues in its Special Investigation Report and in safety recommendations contained in Section 4.0. 2.7 Braking Performance The B-737-300/400 AFM shows that flight 5050 could have departed from a runway of 4,460 feet. The VJ reject speed for this balanced field (accelerate to V and stop) takeoff is 125 knots, the same as specified for flight 5050. A F ~ distances assume a dry runway, stopping without the use of reverse thrust, thrust slightly less than the average production engine, and an additional distance equivalent to 2 seconds at VB to account for in-service variation of pilot response. The V speed is the speed when full ^ braking is achieved, which happens to equal Vi or flight 5050. The Safety Board has had a longstanding concern that the AFM stopping performance is based upon dry runway tests without allowance for the reduced friction coefficient on wet surfaces. To compare the stopping performance of flight 5050 with that achievable on the wet runway, investigators measured runway friction under conditions similar to those existing on September 20, 1989, and applied an appropriate correction to airplane stopping performance calculations. A coefficient of friction equal to 1/2 of the dry runway coefficient of friction was considered conservative based upon the results of the NASA tests. The Boeing calculations showed that a B-737-400 should have stopped after an RTO initiated at a 125 knot Vl speed using 4,050 feet on a dry runway and 5,670 feet on the "1/2 dry" runway, both without consideration for reverse thrust. That flight 5050 failed to stop on a 7,000 foot runway is of concern to the Safety Board. In fact, an extrapolation of OFDR acceleration data when the airplane left the runway shows that flight 5050 would have used about 7,280 feet to come to a full stop, assuming that the deceleration rate was maintained. In addition to variations in the runway friction, several other factors affect the airplane's braking performance and extend the distance required to stop the airplane beyond that demonstrated or theoretically derived from certification tests. Among these factors are the distance used to accelerate the airplane, the RTO initiation speed, and the distance used

because of variations in pilot response times to apply maximum braking and reconfigure the airplane. The Safety Board considered each of these factors to determine why flight 5050 did not stop on the available runway surface. The first factor considered was the distance used for acceleration. Although flight 5050 accelerated rapidly, the evidence showed that full takeoff thrust was not achieved and the thrust used was attained with some delay. Safety Board studies indicate that flight 5050 would have reached the speed at which the RTO was initiated using 320 feet less runway had the thrust advanced normally with use of the autothrottle. More significantly, the captain delayed his action to reject the takeoff until the airplane had accelerated to, or beyond, the prescribed V l speed. The DFDR data showed that the throttles were retarded to idle thrust at 130 knots, 5 knots above the speed for which AFM stopping distance was based. The Safety Board's study showed that, other factors notwithstanding, the 5 knots of additional speed increased the required stopping distance by 494 feet. The order of actions in a rejected takeoff are full braking, throttle reduction, extending the spoilers, and applying reverse thrust when available. Such actions are considered the full braking configuration. Wheel braking develops most of the decelerating force, and full wheel braking at high speed depends on rapid spoiler deployment. The spoilers serve two purposes: to increase drag for deceleration and to place weight on the tires for braking by reducing wing lift. If the pilot does not extend the spoilers, automatic deployment comes with reverse thrust. Flight 5050's DFDR data shows that the thrust reversers unlocked 5 1/2 seconds after the rejected takeoff started and about 4,800 feet from the beginning of the runway. The captain testified that he could not remember extending the spoilers or if the selection of reverse thrust automatically extended them. Spoiler position was not recorded on the DFDR. Thus, the Safety Board could not determine whether 1 ate deployment of the spoi 1 ers delayed the attainment of full braking force. When the captain took control to reject the takeoff, he needed to correct the leftward tracking and apply maximum braking without delay. The evidence shows that maximum braking was not achieved immediately. The DFDR thrust and rudder position data indicate that the captain relied only on the differenti a1 braking and nosewheel steering to correct the airplane's heading. The captain's testimony confirmed that he attempted first to correct the leftward track. As a result, the DFDR data showed that the maximum deceleration was not achieved until 5 1/2 seconds after the initial RTO action was taken, whereas the AFM data assumed an increment of only 1 second from brake appl ication to achieve maximum deceleration. In analyzing the captain's performance, the Board assumed a reaction time of 2 1/2 seconds from brake application to achievement of maximum deceleration as being reasonable. The Safety Board's study indicated that the additional 3 seconds of delay added 786 feet to the theoretical stopping distance required. Based upon these calculations, the Safety Board concludes that flight 5050 could have been stopped on the 7,000 foot runway had the captain taken more timely actions to achieve maximum braking after his decision to

reject the takeoff. Further, the Safety Board observed that maximum braking would have been achieved sooner, irrespective of the captain's actions or his directional control problems, if he had used autobrakes. The captain chose not to use the RTO feature of the autobrake system during the accident takeoff run, despite recommendations from both Boeing and USAir. The first officer's observation that he never took off without selecting the RTO autobrake function during his recent training suggests USAir actively encourages using autobrakes on takeoff. Boeing personnel said that during aircraft certification testing under near-perfect conditions, a pilot expecting a rejected takeoff might manually brake as fast as the autobrake. However, such an occurrence is unl i kely during 1 ine operations. The Safety Board believes the captain should have used autobrakes and his failure to do so suggests that its use may not have been appropriately emphasized during line operations. The lack of autobraking was a factor in this accident. The captain said that he believed steering the airplane back to the centerline was necessary prior to applying full brakes. Manually applying full brakes and full rudder is possible during a high-speed abort but borders on being an unnatural action because the pilot's feet are in slightly different positions for braking and for rudder. Use of the autobrake would have freed the pilot to concentrate on maintaining directional control with the rudder while still achieving maximum braking. The Board has heard the argument that autobrakes may throw passengers against seatbacks during low-speed aborts. This logic is spurious since the B-737-400's autobrakes are not active until ground speed reaches 90 knots. Moreover, serious injuries and deaths during unsuccessful high-speed aborts far outweigh the few, if any, minor injuries that might occur during low-speed rejected takeoffs. 2.8 Engine Performance While rudder mistrim was the precipitating factor in this accident, other disparities appeared in some DFDR engine parameters. Fan speed ( N l ) increased slowly and differently on each engine during acceleration for takeoff. The number one fan never reached targeted N1 speed, but engine performance appeared normal and balanced during reverse thrust. Examination at the scene and during teardowns showed no pre-existing engine damage. Also, the DFDR's N1 values as a function of fuel flow closely matched those for an average engine. The loud "bang" on the CVR could have been a compressor surge, but engine parameters had no sharp discontinuities. A1 so, parameters recorded during the accident airplane's 10 previous takeoffs showed both engines accelerating together with standard autothrottle characteristics.

The Safety Board believes that the captain either did not rearm the autothrottle after the inadvertent disengagement or he did not rearm and press TO/GA before 64 knots was reached. In either case, the autothrottles did not engage. The first officer did a "rough manual power set," but the captain did not make final adjustments to the left throttle. The left engine never reached its targeted N1, explaining substandard engine performance compared to a typical autothrottle thrust application. 2.9 The "Bang" and Rumble on the CVR The tire marks on the runway suggest that the captain's continued attempt to steer using the nosewheel caused the "bang" and rumble noises that prompted the RTO. Rumbling began when Flight 5050 reached 95 knots ground speed 1,736 feet from the start of runway 31. The "bang" was most likely caused by the left nosewheel tire suddenly coming off the rim allowing the air to escape violently. The CVR shows that 23 seconds elapsed after the takeoff started before the rumble started. During this period, the rudder was deflected to the left much of the time. The Safety Board be1 ieves that Flight 5050 stayed on the runway, instead of running off the left side of the runway, because the captain was overpowering the rudder by commanding the nosewheel to steer right with the tiller. Erasure marks on the runway and damage to the nose tires confirm this. 2.10 Crew Coordination 2.10.1 Cockpit Resource Management Training The Safety Board views the absence of a comprehensive departure briefing, the absence of airspeed callouts, the failure of the first officer to clearly communicate his directional control problem, and the non-assertive manner in which the captain communicated his intent to reject the takeoff as indications of poor cockpit coordination. That the pilots of flight 5050 were ineffective as a team is probably the result, in part, of their lack of any formal training on cockpit resource management (CRM). Both of the flight crewmembers were hired and trained by Piedmont Airlines before the merger with USAir had been completed. Piedmont Airlines did not provide formal CRM management training to either pilot involved in this accident. FAA Advisory Circular 120-51 issued on December 1, 1989, states that CRM training should consist of (1) definition and discussion, (2) practice and feedback especially by 1 ine-oriented flight training (LOFT) and (3) continuous reinforcement as part of the airline's culture. At the time of the accident, USAir had 1 1/2 days of CRM training spent mostly on awareness. Out of 6,000 pilots about 1,800 had been exposed to this training, and neither the captain nor the first officer of Flight 5050 were among them.

The following are crew coordination problems evident i n the accident sequence: the captain's f a i l u r e t o provide an extended briefing, o r an emergency briefing, before the takeoffs a t BWI and LGA o r a t any time during the 9 hours the crewmembers spent together before the accident; the decision o f the captain t o execute the takeoff a t LGA with autobrakes disengaged, contrary t o company and manufacturer recommendations ; the f a i l u r e o f the crew t o detect the improper rudder t r i m setting i n response t o the checklists; the f a i l u r e o f the crew t o detect the improper rudder t r i m setting by means o f rudder pedal displacement information during t a x i i n g and holding f o r takeoff; the f a i l u r e o f the a i r c r a f t t o hold a t taxiway GOLF GOLF during t a x i i n g as directed by ATC ( t h i s error, an obvious v i o l ation, had no e f f e c t on the accident sequence) ; the f a i l u r e o f the f i r s t o f f i c e r t o push the correct button t o engage the autothrottles a t the beginning o f the takeoff r o l l ; the f a i l u r e o f the captain, during the takeoff r o l l , t o take control o f the a i r c r a f t and transfer control back t o the f i r s t o f f i c e r i n a smooth and professional manner, with the r e s u l t o f confusion as t o who was i n control; the f a i l u r e o f the captain t o make speed c a l l outs and t o consult airspeed before i n i t i a t i n g an abort; the f a i l u r e o f the captain t o announce the abort decision i n standard terminology, with the r e s u l t o f confusion by the f i r s t o f f i c e r as t o what action was being taken; The f a i l u r e of the captain t o execute the abort procedure i n a rapid and aggressive manner. The Safety Board believes t h a t giving CRM t r a i n i n g o f the sort described by the FAA Advisory Circular t o a l l p i l o t s can prevent the type o f cockpit coordination and communication d i f f i c u l t i e s evident on f l i g h t 5050. Although the c i r c u l a r was only advisory and was issued a f t e r the accident, the Safety Board believes t h a t agreement on the value o f CRM was widespread enough t h a t USAir should have had better CRM t r a i n i n g i n place.

According t o the author o f the. FAA's report o f i t s l a t e s t inspection o f USAir, USAir was making changes recommended by the FAA t o improve the communication, coordination, and the adherence t o required procedures by i t s fl ightcrews. 2.10.2 Pre-takeoff Emergency Procedures' Briefings The Safety Board concludes that the captain's b r i e f i n g on departure and emergency procedures was not adequate for the circumstances o f t h i s takeoff. Before boarding the airplane a t BWI, he learned t h a t the f i r s t o f f i c e r was on h i s f i r s t t r i p a f t e r obtaining i n i t i a l operating experience i n the B-737. Having never flown with the f i r s t officer before, the captain could not have been f u l l y aware o f h i s capabilities. Thus, the captain should have given more than the minimal briefing t h a t he provided p r i o r t o departure from BWI. A t LaGuardia, the captain should have been even more aware t h a t the f i r s t o f f i c e r needed a discussion o f emergency procedures, such as rejected takeoffs. LGA was t o be the f i r s t o f f i c e r ' s f i r s t non-supervised takeoff i n 1 ine operational status. Conditions included darkness, low ceiling, and a wet runway t h a t was also r e l a t i v e l y short with no appreciable overrun, having water a t i t s end. The Safety Board believes t h a t these factors categorized the takeoff as nonroutine and should have prompted the captain t o review rejected takeoff procedures with the f i r s t o f f i c e r . U S A i r does not require a discussion o f emergency procedures during departure briefings. I n t h i s case, however, good airmanship dictated such a discussion. The captain might even have accomplished the takeoff himself since the f i r s t o f f i c e r lacked experience i n the B-737 under such conditions. 2.10.3 Crew Coordination During the Takeoff Run C r i t i c a l lack o f crew coordination was obvious when the a i r c r a f t began t o veer l e f t as it accelerated f o r takeoff. The CVR recorded the captain t a l k i n g about steering twice during the takeoff. According t o the captain, h i s f i r s t statement meant that he was taking charge o f directional control using the nosewheel t i l l e r , and the second meant t h a t he was giving responsibility f o r directional control back t o the f i r s t o f f i c e r . According t o the f i r s t o f f i c e r , the f i r s t statement meant t h a t the captain was taking over steering and the second was t o confirm t h i s and t o remind the f i r s t o f f i c e r t o leave the rudder pedals alone. The expression "got the steering" was probably ambiguous t o the f i r s t o f f i c e r because the captain might have been taking charge o f the e n t i r e takeoff o r j u s t the steering. I n any case, data from the DFDR make clear that both p i l o t s were attempting t o maintain directional control a t one time and neither was steering a t another. Also, no one was making required speed callouts; consequently, the captain may not have realized t h a t he had reached Vl speed when he decided t o r e j e c t the takeoff. The a i r c r a f t was accelerating so rapidly that although the decision t o r e j e c t the takeoff may have been a t o r below V , slowing o f the a i r c r a f t + d i d not begin u n t i l f i v e knots over the maximum sa e RTO speed.

The Safety Board believes that the captain should have used his command authority to take full control as soon as the first officer's control difficulty became apparent. Then he could have made an informed decision to either reject or continue the takeoff. Being aware of the first officer's inexperience and his own inexperience as a captain, he should have been mentally prepared to assume full control early, rather than to merely assist the first officer. When the captain finally rejected the takeoff, he used the phrase "let's take it back,*' a non-standard expression not recognized by the first officer as announcement of a rejected takeoff. The first officer expected to continue the takeoff up until the captain retarded the throttles. USAir calls for the captain to announce an abort with the word "reject." The ambiguous "let's take it back" could mean many things. High-speed rejected takeoffs are statistically one of the most dangerous maneuvers ever faced by captains and demand clear, concise communications. 2.10.4 Pilot Experience and Pairing The facts, conditions, and circumstances of this accident further reinforce the Safety Board's be1 ief that the pairing of pilots with limited experience in their respective positions can, when combined with other factors, such as an aircraft anomaly, be unsafe and is not acceptable. The Safety Board believes that although the pilots of flight 5050 had previously demonstrated competence in their duties, compromises in the captain's decision-making processes and management of the flight, and the first officer's improper operation of aircraft controls occurred as a result of inexperience in their respective positions. The Safety Board a1 so continues to believe that an operational safeguard to reduce the effect of these circumstances would be to establish a requirement prohibiting the scheduling or pairing on the same flight of crewmembers with limited experience in their respective positions. Although the FAA originally disagreed with an earlier Safety Board recommendation (A-88-137) calling for such crew pairing requirements, the Safety Board is encouraged by the FAA's efforts to solicit industry recommendations on the subject. However, it remains concerned that repeated accidents over several years have shown current Federal regulations on air carrier crew operating experience to be inadequate. Given the normal time required to amend these regulations, it is 1 i kely to be several more years before suitable requirements are in effect. Therefore, the Safety Board continues to believe that the FAA should initiate rulemaking, on an expedited basis, to establish experience levels for each pilot-in-command and second-in-command pilot, and to prohibit the pairing on the same flight of pilots who have less than the specified minimum experience in their respective positions. Based on FAA's recent actions and apparent commitment to work toward rulemaking on this issue, the Safety Board has classified Safety Recommendation A-88-137 "Open-Acceptable Action.''

The Safety Board supports the intent of the Crew Pairing Committee recommendations concerning the cons01 idation of pi1 ots' recently-acquired training. However, it is concerned that completion of the specified of line operating time over a 120-day period may not provide a regular and concentrated exposure to achieve the desired effect. Moreover, new1 y-trained air carrier pilots normally are initially scheduled on "reserve" or on an "on-call" basis and, as a result, may not fly at regular and frequent intervals. This irregularity of exposure also could detract from the intended cons01 idation of learning. Accordingly, the Safety Board be1 ieves that the FAA should urge air carriers to schedule newly-trained captains and first officers on regular trip sequences immediately following the training session, until they accrue a prescribed amount of line operating time in their respective positions, in order to consolidate their recently-acquired training. In view of the circumstances of this accident, the Safety Board believes that the crew pairing minimum flight hour limitation, including IOE, should not be less than 150 hours. Furthermore, the Safety Board believes operators should be required to pair not only a captain who has a relatively high level of experience with a first officer of relatively low level of experience, but also should require that a captain with relatively low level of experience be scheduled with a first officer with relatively high level of experience. In this manner, flight crewmembers' re1 ative experience levels would complement and compensate one another rather than counteract one another, as illustrated by this accident. Therefore, the Safety Board believes the FAA should amend the air carrier regulations to specify a combined experience level for initial pilot-in-command and initial second- in-command pilots which would preclude the pairing of two pilots, each of whom has relatively low experience in his or her respective position. 2.11 Making Runway Overruns Safer While strongly advocating runway safety areas and paved overruns where practical, the Safety Board does not cite the lack of a sufficient overrun or safety area as a factor in this accident because flight 5050 could have legally taken off from a runway less than 5000 feet long. Runway 31 is 7,000 feet long. So the effective overrun, then, was more than 2,000 feet. Nonetheless, other airplanes routinely depart LGA under conditions that require the entire 7,000 feet of runway surface for acceleration and stop in event of a takeoff rejected near Vl speed. Although the overrun safety area for runway 31 at LaGuardia was only 100 feet long and extended over Bowery Bay on a pier, it met FAA certification standards because the rules in effect when runway 31 was extended in 1965 and 1966 did not require runway overrun safety areas. Further, rule changes made since.the extension of runway 31 have exempted existing runways at FAA-certi ficated airports from requirements for overrun safety areas unless significant extension of a runway is planned and construction of the safety area is economically feasible and practical. Furthermore, the Safety Board is concerned that with recent emphasis on improving and del ethal i zing areas beyond the runway, including

the replacement of rigid supports for approach 1 ight systems with frangible supports, more attention was not given to runway 31 at LaGuardia. For N416US, conditions included a precipitous drop of about 15 feet into the water of Bowery Bay followed by collisions with the massive wood and concrete stanchions that supported the approach lights for runway 13. Although the provision of a longer overrun safety area northwest of the departure end of runway 31 may not be economically feasible or practical under the existing circumstances, the Safety Board believes that it might be possible to eliminate some of the existing hazards. For example, it might be feasible to provide a gradually sloping ramp from the end of the overrun to the water and to replace the existing approach light stanchions with less massive or frangible stanchions. The impact from the existing elevated platform and the massive stanchions ruptured the fuselage of N416US, killing the occupants of seats 21A and 2lB and trapping two other passengers nearby. Moreover, had the airplane contained the number of passengers it was capable of accommodating, it is likely that many more serious injuries and deaths would have occurred. Therefore, the Safety Board believes that the Port Authority of New Jersey and New York should consider improvements in the area beyond the departure end of runway 31, and the areas beyond the departure ends of the other runways at LGA containing similar hazards, to reduce the risk to passengers of airplanes that leave the end of the runways at low to moderate speeds. 2.12 Survival Factors The impact of the airplane with the pier and water generated minor overall forces because of the low speed when the airplane departed the runway. However, at seat rows 4 and 21, the fuselage received localized severe vertical forces where the approach light pier structure penetrated and separated the lower fuselage. The floor crushed upward at seat rows 21 and 22 and trapped four passengers. The passengers in 2lA and 2lB were trapped in seats that were crushed against the. ceiling; they died of asphyxia from compression of their chests. Only immediate extraction and life support would have saved them. The other two passengers, in seats 22F and ZlA', sustained serious multiple injuries. Meaa~hones.--Megaphones are required safety equipment aboard aircraft and should be capable of operating after a survivable accident, including those in the water. In this case, although the megaphone was not recovered, it may have been a model on which the volume knob rotated opposite to conventional volume knobs. This could explain the feedback experience by the lead flight attendant. In addition, it failed after it got wet. The FAA has no Technical Standards Order (TSO) or other standard for the design, construction, and operation of megaphones, and the Safety Board believes that the FAA should develop such a TSO. Flotation Eaui~ment. --Fl ight 5050 was not equipped for extended overwater operations ,defined by 14 CFR 1.1 because it was never to be more than 50 nautical miles from the nearest shoreline. Passengers had to make use of flotation seat cushions, even though the flight and cockpit crewmembers had life preservers. Although no water-related fatalities

resulted from this accident, flotation cushions are inadequate substitutes for 1 ife preservers, especially for infants, handicapped persons, and other injured persons. On June 12, 1985, the Safety Board recommended that the FAA require life preservers on flights that operate under 14 CFR 121, 125, and 135. The FAA answered with a Notice of Proposed Rulemaking, and on November 28, 1988, the Safety Board determined that the proposed rule would satisfy its intent. The Safety Board now urges the FAA to expedite final rulemaking. Fliaht Attendant Training.--Water survival training for the flight attendants did not include, and the FAA did not require, hands-on "wet" drills. In response to Safety Board recommendation A-85-49 on July 2, 1985, the FAA issued an Air Carrier Operations Bulletin promoting but not requiring "wet" drills. The Safety Board believes that an ACOB falls far short of what will correct this shortcoming in flight attendant training. Unless required to do so, airlines are highly unlikely to develop and use water training facilities, given the initial expense, maintenance costs, and additional training time. Because regulation is needed, the Safety Board reiterates recommendation A-85-49. F l i ~ h t Attendant Activities.--The four flight attendants performed in an outstanding manner following the impact and during and after the evacuation. They assessed the outside conditions, threw seat cushions to passengers, and gave commands that resulted in a timely evacuation. Assessing outside conditions proved to be quite difficult because of darkness. The, fl ight attendants immedi ate1 y reacted when they real ized that the take-off was deteriorating. As the airplane deparated the runway's deck, they told the passengers to brace. As soon as the airplane came to rest, they independently assessed their assigned exit and initiated, as appropriate for their exit, an evacuation. The B and D flight attendants assessed 2L and 2R and saw that water was at those exits but less water was at 2R. The B flight attendant knew that an inflated slide would float, rise into the door opening, and block the exit. Her quick thinking and ability to take the initiative under very trying circumstances resulted in her decision to disarm the slide at 2R prior to opening the door. She prevented the exit from becoming unusuable and thereby expedited the evaucation. During the time that passengers were in the water, flight attendants remained in control of the situation by instructing everyone to stay in groups and to help each other. In spite of the strong water current that made it difficult for survivors to stay afloat, flight attendants B and C linked arms to support two passengers who could not swim. Emergency Res~onse and Water Rescue 0~erations.--The rescue and f irefighting response was timely and effective overall ; however, several deficiencies were noted; most of which have been corrected. Appendix E contains a synopsis of actions taken by the LGA airport since the accident.

The Safety Board believes that after an accident the airline involved should be responsible for providing rescue officials a timely and accurate list of the numbers of all persons on board. Further, the airline should provide assistance in determining the disposition of persons rescued, killed, or injured. 2.13 Postacci dent Toxicological Testing Because the FAA's rules requiring post-accident toxicological testing of flightcrews was not in effect at the time of the accident, the flightcrew was not required to provide any specimens for testing for drugs. Even if the rules had been in effect, they do not require testing for alcohol. Further, because current FAA rules require the collection of urine specimens only, and allow up to 32 hours for the collection, rules for post- accident testing are inadequate to determine if a flightcrew was impaired and if drugs were causal to an accident. The Safety Board has made recommendations to the Secretary of the U.S. Department of Transportation to set consistent rules for a11 modes of transportation. Such rules would provide for the postaccident/postincident collection of blood specimens within 4 hours and for tests for a wider group of drugs, including alcohol. Moreover, they would facilitate a determination of the role (or non-role) of drugs and alcohol in accidents and incidents. The Safety Board will continue to seek cooperation from the Department of Transportation in achieving this important goal. 2.14 Postaccident Aircrew Avai 1 abi 1 i ty The Safety Board is extremely concerned that no federal investigators were allow to speak to the pilots of flight 5050 until almost 40 hours after the accident. Specific requests to USAir and ALPA to interview the pilots and to have them provide toxicological samples were made about ten hours and again about 20 hours after the accident. USAir representatives stated they did not know where the pilots were sequestered. The Air Line Pilots Association representatives initially stated that they also did not know where the pilots were, then later stated that their location was being withheld so they could not be found by the media. This complicated the investigative process to a great degree. The sequestering of the pilots for such an extended period of time in many respects borders on interference with a federal investigation and is inexcusable. More importantly however, is the fact that the pilots may have had safety-related information concerning the Boeing 737-400 that needed to be disseminated to all operators and the Boeing company immediately. This was not the case in this particular accident, but until the pilots were interviewed 40 hours later, only the pilots and their union representatives knew this to be a fact. The Safety Board believes that all parties to an accident investigation have a duty to assure that the safety of the travelling public is given top priority in the earliest phases of the investigation and that they cooperate fully in making those individuals who might possess essential information available as soon as possible. No single party is able to determine whether the information possessed by crew members,

air traffic controllers, witnesses, or others associated with an accident can contribute to the identification of urgently needed corrective actions.

1. CONCLUSIONS
2. 1

Findings 1. The flight and cabin crews were properly certificated and qualified for the flight. 2. The airplane was certificated, equipped, and maintained in accordance with Federal regulations and approved procedures. 3. Rudder trim moved full left while the airplane was parked with engines off at LGA. 4. The captain could have detected the mistrim rudder condition during taxi, during the flight control freedom-of-movement check and during the response to a checklist challenge. He failed to do so. 5. The captain did not use the autobrake system during the takeoff roll, as recommended by Boeing and USAir management. His failure to do so delayed the onset of maximum braking and extended the airplane's stopping distance. 6. Both pilots were relatively inexperienced in their respective positions. The captain had about 140 hours as a B-737 captain, and the first officer was conducting his first non- supervised line takeoff in a B-737, and also his first takeoff after a 39-days non-flying period. 7. Early in the takeoff attempt, the first officer inadvertently disarmed the autothrottle. He then manually advanced the throttles; the resultant delay and the slightly low thrust set on the left engine lengthened the airplane's ground roll and added to the directional control problem. 8. The captain's use of the nosewheel steering tiller during the takeoff roll was not proper and may have masked the initial directional control problem created by the mistrimmed rudder. 9. Because of poor communication between the pilots, both attempted to maintain directional control initially and neither was fully in control later in the takeoff, compounding directional control difficulties.

1. Neither pilot was monitoring

indicated airspeed and no standard airspeed call outs occurred.

The captain should have been aware of the directional control problem and should have initiated an RTO before accelerating to high speed. Unusual noise and vibration from the cocked nosewheel, and the leftward veer, led the captain to reject the takeoff. Computed Vl speed was 125 knots and action by the captain to reject the takeoff began at 130 knots. After initiating the RTO, the captain used differential braking to steer the airplane. This delayed the attainment of effective braking until 5 1/2 seconds after the takeoff was rejected. Braking during the RTO was less than the maximum braking achievable on the wet runway; the airplane could have been stopped on the runway. The airplane departed the end of the runway at about 34 knots. The pilots did not submit urine samples for toxicological testing until 44 hours after the accident. They refused to submit blood samples upon the advice of their attorney, in spite of requests to do so by the NTSB. FAA requirements for post-accident toxicological testing were not in effect at the time of the accident and the flightcrew was not required to provide specimens for such testing. However, the FAA rules later adopted are inadequate to determine impairment from drugs and alcohol because they permit up to 32 hours for specimen collection and do not include requirements for a1 coho1 tests. The low-impact velocity resulted in very low longitudinal acceleration, a1 though high 1 ocal i zed vertical forces were experienced at seat rows 4 and 21 where the fuselage crushed when it came to rest on top of the approach light piers. The accident was not survivable for the occupants of seats 21A and 21B because of the massive upward crush of the cabin floor. The B flight attendant quickly assessed the situation and disarmed the R-2 slide because she anticipated that the inflated slide would have floated on the water and blocked the exit.

Because the airplane was not r e q u i r e d t o be equipped with passenger l i f e preservers, crewmembers threw l i f e preservers and f l o t a t i o n seat cushions t o persons i n the water. However, the f l o t a t i o n cushions were d i f f i c u l t t o hold and d i d not provide adequate f l o t a t i o n . The portable cabin megaphone was not waterproof, and it may have had a volume control knob t h a t operated contrary t o establ i shed ergonomic principles; the FAA has no Technical Standards Order regarding the design, construction and operation o f portable cabin megaphones. The FAA d i d not require the f l i g h t attendants t o receive 'hands-on" water ditching training, which would have b e t t e r prepared them f o r an unplanned water landing. The airport's boat could not be launched, and the f i r s t boats d i d not a r r i v e u n t i l about 10 minutes a f t e r the accident a t which time passengers had d r i f t e d under the dark runway deck, further hampering t h e i r rescue. The f l i g h t attendants performed admirably i n warning passengers o f the impending impact, maintaining control d u r i n g t h e evacuation, throwing f l o t a t i o n devices t o passengers i n the water, and holding passengers who could not swim and who had d i f f i c u l t y staying afloat. 3.2 Probable Cause The National Transportation Safety Board determines t h a t the probable cause o f t h i s accident was the captain's f a i l u r e t o exercise h i s command authority i n a timely manner t o r e j e c t the takeoff o r take s u f f i c i e n t control t o continue the takeoff, which was i n i t i a t e d with a mistrimmed rudder. Also causal was the captain's f a i l u r e t o detect the mistrimmed rudder before the takeoff was attempted.

RECOMMENDATIONS As a result of this investigation, the National Transportation Safety Board made the fol 1 owing recommendations : --to the Federal Aviation Administration: Develop standards for the design, construction, operati on, and performance of megaphones. (Class I I, Priority Action) (A-90-104) Require air1 ines to provide airport crash/fire rescue personnel accurate and timely numbers of all persons aboard an accident/incident aircraft, and to provide assistance in determining the disposition of persons who have been recovered from the scene of an accident. (Class 11, Priority Action) (A-90-105) Require air carriers to adopt procedures that would result in the completion of a modified or full acceptance check1 ist whenever the fl ightcrew has vacated the cockpit. (Class 11, Priority Action) (A-90-106) Issue an Air Carrier Operations Bulletin directing all Principal Operations Inspectors to urge air carriers to schedule newly-trained captains and first officers on regular trip schedules immediately following completion of training, until they accrue a prescribed amount of line operating time in their respective positions in order to consolidate their recently-acquired training. (Class 11, Priority Action) (A-90-107) Amend 14 CFR 121.385 to specify a combined experience level for initial pilot-in-command and initial second-in- command pilots which would preclude the pairing of two pilots, each of whom has relatively low experience in his or her respective position. (Class 11, Priority Action) (A-90- 108) --to the Port Authority of New York and New Jersey: Survey the 1,000 foot by 500 foot surface area contiguous to the departure ends of the runways at the LaGuardia Airport in order to minimize hazards to airplanes that do not stop on the runways. (Class 11, Priority Action) (A-90-111) The Safety Board r e i t e r a t e d the following recommendation t o the Federal Aviation Administration: Amend 14 CFR 121, 125, and 135 t o require t h a t cockpit and cabin crewmembers on a i r c r a f t being operated under these Parts be given periodic training, including hands-on "wet" d r i l l s , i n the s k i l l s relevant t o inadvertent water impact t h a t may increase the chances o f post-crash survival. (Class 11, P r i o r i t y Action) (A-85-49) As a r e s u l t o f the Safety Board's Special Investigation Report SIR-90-02: Runway Overruns Fol 1 owina Hidh Speed Re.iected Takeoffs, the Safety Board issued the following recommendations pertinent t o t h i s accident: Redefine V l i n 14 CFR 1.2 and 14 CFR 25.107 (2) t o c l e a r l y convey t h a t it i s the takeoff commitment speed and the maximum speed a t which rejected takeoff action can be i n i t i a t e d t o stop the airplane w i t h i n the accelerate-stop distance. (Class 11, P r i o r i t y Action) (A-90-40) Require Principal Operations Inspectors t o review the accuracy o f information on V l and rejected takeoffs t h a t 14 CFR 121 operators provide the flightcrews t o assure t h a t they provide correct information about p i l o t actions required t o maximize the stopping performance o f an a i r p l a n e d u r i n g a h i g h speed rejected takeoff. (Class 11, P r i o r i t y Action) (A-90-41) Require 14 CFR 121 operators t o present t o flightcrews the conditions upon which f l i g h t manual stopping performance i s predicated and include information about those f a c t o r s which adversely a f f e c t stopping performance. (Class 11, P r i o r i t y Action) (A-90-42) Require t h a t simulator t r a i n i n g f o r flightcrews o f 14 CFR 121 operators present, t o the extent possible, the cues and cockpit warnings o f occurrences other than engine f a i l u r e s t h a t have frequently resulted i n high speed rejected takeoffs. (Class 11, P r i o r i t y Action) (A-90-43) Require t h a t simulator t r a i n i n g o f 14 CFR 121 operators present accurate1 y the stopping distance margin available f o r a rejected takeoff i n i t i a t e d near o r a t V on runways where the distance equals o r j u s t exceeds ba 1 anced f i e l d conditions. (Class 11, P r i o r i t y Action) (A-90-44)

Require t h a t simulator t r a i n i n g f o r flightcrews o f 14 CFR 121 operators emphasize crew coordination during rejected takeoffs, p a r t i c u l a r l y those rejected takeoffs t h a t require transfer o f control from the f i r s t o f f i c e r t o the captain. (Class 11, P r i o r i t y Action) (A-90-45) Require 14 CFR 121 operators t o review t h e i r p o l i c i e s which permit f i r s t officers t o perform takeoffs on contaminated runways and runways t h a t provide minimal rejected takeoff stopping distance margins, and encourage the operators t o revise those p o l i c i e s as necessary. (Class 11, P r i o r i t y Action) (A-90-46) Require t h a t the takeoff procedures o f 14 CFR 121 operators are standardized among t h e i r airplane types o f the extent possible, and that the procedures include appropriate cal l o u t s t o a l e r t fl ightcrew members c l e a r l y and unambiguously when the airplane i s entering the high speed takeoff regime and when a rejected takeoff i s being i n i t i a t e d . (Class 11, P r i o r i t y Action) (A-90-47) Require 14 CFR 121 operators t o require p i l o t s t o adopt a policy t o use the maximum brake capability o f autobrake systems, when i n s t a l l e d on the airplane, f o r a l l takeoffs i n which runway conditions warrant and where minimum stopping distances are available following a rejected takeoff. (Class 11, P r i o r i t y Action) (A-90-48) BY THE NATIONAL TRANSPORTATION SAFETY BOARD /s/ James L. Kolstad Chairman /s/ Susan Couqhlin Vice Chairman /s/ John K. Lauber Member /s/ Jim Burnett Member Jim Burnett, 'Member, f i l e d the following concurring and dissenting statement: Although I concur with the probable cause as adopted as f a r as it goes, I would have added the following as a contributing factor: Contributing t o the cause o f the accident was the f a i l u r e o f USAir t o provide an adequate1 y experienced and seasoned fl i g h t crew. July 3, 1990

APPENDIX A INVESTIGATION AND HEARING 1. Investigation The National Transportation Safety Board was notified of the accident at about 0100 on September 21, 1989. An investigation team was dispatched from Washington, D.C., at about 0600 and arrived on scene about 1 hour later. Investigative groups were formed for operations, air traffic control, meteorology, human performance, survival factors, structures, systems, powerpl ants, and maintenance records. Groups were 1 ater formed for aircraft performance and for readout of the CVR and DFDR in Washington, D.C. Parties to the investigation included USAir, Inc., the FAA, CFM International/General Electric Aircraft Engines, the Boeing Aircraft Group, the Air Line Pilots Association, the Association of Flight Attendants, the International Association of Machinists, and the Port Authority of New York and New Jersey. 2. Pub1 ic Hearing A public hearing on this accident was held in New York City on February 13-16, 1990.

APPENDIX B PERSONNEL INFORMATION Captain Michael Martin Captain Martin, 36, held Airline Transport Pilot certificate 243378065 with endorsements for the deHavilland DH-4 and the Boeing 737. He also had multiengine commercial and single engine land ratings, along with a turbojet flight engineer certificate. He was issued an FAA first class medical certificate with no "imitations on May 17, 1989. The captain was hired by Piedmont Airlines on July 9, 1984. He had a total estimated flying time of 5,525 hours, 1,500 hours of which were in the USAF and USAF Reserve. First Officer Constantine Kl ei ssas First Officer Kleissas, 29, held Air1 ine Transport Pilot certificate 572317704 with commercial mu1 tiengine land and single engine land and sea ratings. He was issued an FAA first class medical certificate with no limitations on April 12, 1989. He had a total flying time of 3,287 hours. Fl i ght Attendant Wayne Reed Flight Attendant Wayne Reed, 34, was the senior flight attendant. He was employed by USAir on April 30, 1985, and had been a full time flight attendant for 4 years and 4 months. His most recent recurrent training was successfully completed on April 25, 1989. He occupied the jumpseat at door 1-Left (1-L) Flight Attendant Kelly Donovan Flight Attendant Kelly Donovan, 31, was employed by USAir on July 2, 1987, and had been a full-time flight attendant for 2 years and 2 months. Her most recent recurrent training was successfully completed on June 6, 1989. She occupied the jumpseat at door 2-Left (2-L). Flight Attendant Susan Harelson Flight Attendant Susan Harelson, 24, was employed by USAir on July 2, 1987, and had been a full-time flight attendant for 2 years and 2 months. Her most recent recurrent training was successfully completed on June 6, 1989. She occupied the jumpseat at door 1-Right (1-R). Fl ight Attendant Jol ynn Galmi sh Flight Attendant Jolynn Galmish, 23, was employed by USAir on June 14, 1987, and had been a full -time flight attendant for 2 years and 3 months. Her most recent recurrent training was successfully completed on June 24, 1989. She occupied the jumpseat at door 2-Right (2-R).

APPENDIX C AIRPLANE INFORMATION Boeing 737-400, N416US, was delivered t o Piedmont Aviation on December 23, 1988. At the time o f the accident, the airplane was owned and operated by USAir, Inc. The airplane had accumulated 2,236 hours and 1,730 cycles. It was equipped with two CFM International CFM-56-32B engines.

APPENDIX D COCKPIT VOICE RECORDER TRANSCRIPT TRANSCRIPT OF A FAIRCHILD MODEL A-100 COCKPIT VOICE RECORDER S/N 6128 REMOVED FROM A USAIR AIRLINES BOEING 737-400 WHICH WAS INVOLVED I N A TAKEOFF ACCIDENT ON SEPTEMBER 20, 1989 AT NEW YORK LAGUARDIA INTERNATIONAL AIRPORT, NEW YORK CAM RDO PA INT

• 1
• 2
• 3

-? TWR GND OPS UNK * @

% 0

(0)

Cockpit area microphone voice o r sound source Radio transmission from accident a i r c r a f t A i r c r a f t Public Address System Source Cockpit t o Ground Intercom System Voice i d e n t i f i e d as Captain Voice i d e n t i f i e d as F i r s t O f f i c e r Voice i d e n t i f i e d as Ground Mechanic Voice unidentified Laguardia Local Controller (Tower) Laguardia Ground Controller USAir Operations a t Laguardia Unidentifiable Radio Transmission U n i n t e l l i g i b l e word Nonpertinent word Expletive deleted Break i n continuity Questionable t e x t E d i t o r i a l insertion Pause NOTE: A l l times are expressed i n Eastern Daylight Savings Time. Only radio transmissions t o o r about the accident a i r c r a f t were transcribed.

I r n - C O C K P I T TINE & SOURCE CONTENT Start o f recording 2249:30 CAM-1 okay I ' m t i r e d o f à around 2249:31 CAM-2 a l l r i g h t 2249:33 CAM-1 we're supposed t o be out o f here a t ah 2249:35 CAM-2 oh you mean on the original printed schedule 2249:38 CAM-1 f i v e six seven eight nine 2249:41 CAM-1 i t ' s almost eleven now 2249:43 CAM-2 that's correct ten t o eleven 2249:45 CAM-1

we couldn't wait any longer

2249:47 CAM-2 ah I don't know what they're thinking 2249:52 CAM-2 okay 1 AIR-GROUND COMMUNICATIONS TIHE & SOURCE COKTEWT 2250:OO CAM-2 okay packs o f f f o r t y PSI

TIRE & SOURCE CONTENT 2250:07 CAM-1 you know sorry about the people i n Greensboro but # it man I j u s t can't go stop i n Greensboro 2250:14 INT-1 you s t i l l on 2250: 16 INT-3 okay * 2250:24 CAM-1 you got a push back i n there 2250:25 CAM-2 ah yes s i r and we're gonna be towed forward t o spot one 2250:31 CAM-1 oh god 2250:32 CAM-2 yeah 2250:36 CAM-2 American behind us 2250:40 INT-3 you're cleared t o s t a r t now 2250:41 INT-1 okay we need t o go t o spot one 2 AIR-GROUND COHWINICATIONS TIME & SOURCE 2250:43 INT-3 understand spot one

CONTENT 3 AIR-GROUND COMMICATIONS TIME Ã SOURCE 2250:45 INT-1 turning two 2250:SO CAM-1 go ahead 2250:52 CAM-2 start valve's open 2250:56 CAM-1 time is really qettin' ** bad we were due out at sixteen fifty five right 2250:58 CAM-2 ah originally 2251:02 CAM-1 that's seventeen hundred that's five o'clock my watch says now 2251:05 CAM-2 you're loo- comin' UD on six hours late yes sir 2251:OE CAM-1 see we're runnin' out of time too we

couldn't wait a minute lonaer we miqht

not even get to Lansing 2251:12 CAM-2 naw not at this rate TIME 1 SOURCE c m

2251 : 20 CAM-1 we might get t o Lansing 2251:21 CAM-2 ((sound o f laugh)) gotta think positive 2251:22 CAN-1 we're gunna be # haulin' # 2251:27 CAM-1 as long as it gets smooth enroute I ' m gunna run your speed up 2251:29 CAM-2 what ever you say f i f t y f i v e * 2251 : 55 CAM-1 da t a da clear one 2252:06 CAM-2 okay 4 AIR-GROUND COWUNICATIONS TIME 1 SOURCE CONTENT 2252:07 CAM-2 f i v e seventy seven 2252:09 CAM-1 another thing too I don't know i f they taught you - 2252: 10 INT-3 brakes set please 2252:15 INT-1 brakes are set

TIME k CONTENT 2252: 16 INT-3 thank you 2252:25 CAM-1 make sure also ah Connie that when you ah you note the pressure when you s t a h i s the same as it i s when you finish at least the same 2252:32 CAM-2 oh okay 2252:34 CAM-1

• you're lookin' for that t o go back t o forty

two or so because occasion all^ you'll qet one

• -

o f these - 2252:36 CAM-2 uh huh 2252:37 CAM-1 - the l i g h t stays on and the only way - just a second - only way t o verify i f this i s t e l l i n ' you the truth or- not is- 2252:44 CAM-1 -did that go back t o where it started out at 5 AIR-GROUND CONUHICATIONS TIME & SOURCE

6 INTRA-COCKPI T AIR-GROUND COMMUNICATIONS TINE & TINE & SOURCE CONTENT SOURCE COIfTEIIT 2252:46 CAM-1 and ah you might save yourself some g r i e f i f you're able t o t e l l the captain you f l y i n ' with hey we did get starter cut out I know because it went r i g h t back t o where it started you always j u s t 2253:05 CAM-2 r i g h t 2253:06 CAM-1 look a t the Airbus over there 2253:07 CAM-1 t a da 2253:08 CAM-2 f o r t y f i v e f i f t y ah --*** 2253:30 CAM-1 after s t a r t 2253:39 CAM-2 electrical panel 2253:41 CAM-1 checked set 2253:42 CAM-2 okay hydraulics 2253:44 CAM-1 on pressure 2253:45 CAM-2 engine anti-ice

IIITIIA-COCKPIT TIME & SOURCE 2253 : 46 CAM-1 o f f CONTENT 7 AIR-GROUND COWUNICATIONS TIME & SOURCE CONTEXT 2253:47 CAM-2 a i r conditioning pressurization 2253:49 CAM-1 set 2253 : 50 CAM-2 radar 2253:51 CAM-1 standby aux 2253:53 CAM-2 okay and door lights and locked 2253:54 CAM-1 checked 2253: 55 CAM-2 okay 2254:Ol RDO-2 ground USAir f i f t y f i f t y taxi 2254:06 GND USAir fifteen f i f t y eight 2254:08 RDO-2 ah f i v e zero f i v e zero spot one with Zulu

TIME & SOURCE CONTENT 8 AIR-GROUND COMMUNICATIONS 2254: 10 GND ah USAir f i f t y f i f t y turn ah r i g h t on the inner hold short a t double g o l f f o r runway three one 2254:17 ROO-2 okay r i g h t on the inner hold short o f g o l f 2254:30 CAM-1 a11 right 2254:40 CAM-1 okay you need t o c a l l 'em back inside and t e l l 'em that our numbers that we got on our papers shows zero passengers they need t o re-figure with f i f t y f i v e passengers 2254:52 CAM-2 okay that's our ops 2254:53 CAM-1 yeah 2254:55 CAM-2 I ' m o f f 2254:57 ROO-2 ops f i f t y f i f t y 2255: 16 CAM-2 how many people 2255:17 CAM-1 f i f t y f i v e

Irn-COCKPIT TIME & SOURCE 9 AIR-GROUND COWUNICATIONS TIME 1 SOURCE CAM-2 okay 2255:22 RDO-2 ops f i f t y f i f t y 2255-43 ROO-2 operations USAir f i f t y f i f t y 2256:OO GND ah USAir f i f t y f i f t y you missed double move up on the inner t a x i way and hold o f lima now go1 f short 2256:07 RDO-1 o k a y s h o r t o f l i m a n o w f i f t y f i f t y f i v e o h 2256:14 RDO-2 operations USAir f i f t y f i f t y 2256: 19 OPS f i f t y f i f t y stand-by one 2256:32 UNK f i f t y f i f t y 2256:42 RDO-2 ops USAir f i f t y f i f t y 2256:51 CAM-2 why doesn't t h i s sucker answer

INTRA-COCKPIT TINE 6 SOURCE CONTENT 10 AIR-GROUND COMWNICATIONS TIME 6 SOURCE c m E N T 2257:20 RDO-2 operations USAir f i f t y f i f t y 2257:43 CAM-2 I can't g e t anybody t o answer he's t a l k - I mean he t a l k s but he j u s t doesn't answer 2257:56 RDO-2 operations USAir f i f t y f i f t y how do you hear 2258:20 RDO-2 operations USAir f i f t y f i f t y 2259:OO RDO-2 operations i s anybody home f i f t y f i f t y 2259:05 OPS f i f t y f i f t y go ahead t h i s i s ops 2259:07 ROO-2 h e l l o there ah we're gonna need some new numbers sent out here t h e numbers you gave us show us as ah zero pax on board we have f i f t y f i v e 2259: 13 OPS okay I understand you need new numbers stand-by f i f t y f i f t y 2259: 16 RDO-2 thank you 2259:23 OPS ah f i f t y f i f t y d i d you copy

Irn-COCKPIT TINE 6 SOURCE CONTENT 11 AIR-GROUND COtHUNICATIONS TIME 6 SOURCE CONTENT 2259:26 ROO-2 ah yes I understand that we're gunna be standin' by f o r new numbers 2259:29 OPS okay I'll send them r i g h t out t o you s i r 2259:32 RDO-2 thank you 2300:29 CAM-1 d i d you ever get 'em 2300:30 CAM-2 yeah he's gonna send them out now I ' m back up 2300:39 OPS USAir f i f t y f i f t y you copy * 2302: 06 CAM-2 I ' m g e t t i n ' it 2302:07 CAM-1 okay 2302:25 GND USAir f i f t y f i f t y hold short o f taxiway whiskey 2302: 28 RDO-2 okay we'll hold short o f whiskey f i f t y f i f t y

12 AIR-GROUND COMWNICATIOHS 2303:Ol GND USAir f i f t y fifty departure w i l l be one twenty point eight remain with me tentatively number eight 2303:06 RDO-2 roger twenty point eight we copy 2303:11 CAM-1 l e t ' s see what d i d we do with the Charlotte weather 2303: 17 CAM ((sound o f s i x ACARS a l e r t tones)) 2303:30 CAM-1 good that's us next page a hundred and seven I was o f f a l i t t l e b i t 2303 :49 CAM-2 here you go 2303: 55 CAM-1 ah well we burned down a l i t t l e fuel 2305:Og CAM-1 what did that guy say do hold short 2305:lO CAM-2 he said hold short o f whiskey stay with him 2305: 16 CAM ((sound o f whistling and humming))

TIME & SOURCE COWTEHT 2306: 14 CAM-2 i s there a scheduled departure time on t h i s you know the estimated time enroute --- 1 guess it r e a l l y doesn't matter 2306;30 CAM-1 d i d you put the f l i g h t number i n there 2306:31 CAM-2 ah I believe I d i d l e t ' s see here 2306:40 CAM-1 yeah here it i s 2306: 43 CAM-2 ah it screwed up the push back 13 AIR-GROUND COMMUNICATIONS TIHE 6 SOURCE 2306:45 CAM-1 okay no problem 2306: 46 GND ah USAir f i f t y f i f t y hold short o f mike u n t i l advised the setup sequence i s the Airbus on the inner monitor tower one one eight seven ATIS now i s alpha 2306: 54 RDO-2 okay we'll go over t o tower a t alpha ah go behind the Airbus a t mike 2307:21 CAM-1 how long have we been here 2307:22 CAM-2 holding

TIME 6 SOURCE COIITENT 2307:39 CAM-1 hah we're suppose t o be a t Lansing i n t h i r t y minutes 2307:41 CAM-2 no problem 2307 : 42 CAM-1 hah 2309:OO CAM-1 say we're s i x hours l a t e 2309:Ol CAM-2 affirmative so i t ' s f i v e o'clock now 2309:06 CAM-1 we had a nine hour t h i r t y minute day 2309:08 CAM-2 yeah I think we're gonna follow him up i n front there 2309:09 CAM-1 yeah 2309:15 CAM-1 okay nine hour t h i r t y minute day plus six i s what - 2309: 18 CAM-2 ah fifteen t h i r t y a. AIR-GROUND CCTHUNICATIONS TIME 6 SOURCE CAM-1 f i f t e e n t h i r t y

TIME & SOURCE CONTENT 2309:21 CAM-1 good I think we might be inside o f sixteen hours 2309:31 CAM-1 i f they jack us around i f they t r y t o make us get there w- we'll try t o make it i f they jack us around we'll we'll slow it down and not make it we'll stop i n Dayton -- they'll j u s t have t o get somebody else t o ah -- 2310:21 CAM-1 you have a choice t o qo three hundred o r two hundred 2310:23 CAM-2 ah yeah and ah by the time they got down t o us I was number f o r t y i n the class a l l the F-28s went ah senior so ah a few slots l e f t 'em two three hundred slots one two hundred s l o t the r e s t a11 IP's 2310:46 CAM-1 what's happenin' with the hurricane 2310:48 CAM-2 I don't know 2310:49 CAM-1 okay ah but t o answer your question I don't know about the ah time -- 15 AIR-GROUND COMMNICATIONS TIME & SOURCE CONTENT 2310:55 CAM-2 screw it on here

16 AIR-GROUND COMMUNICATIONS INTKA-COCKPIT TIKE 6 SOURCE CONTENT 2311:21 CAM-1 what's it show an hour and eighteen minutes enroute 2311:22 CAM-2 that's correct s i r 2311:26 CAM-1 I'll b e o f f f o r a second 2311:27 CAM-2 okay 2311:29 CAM ((pa announcement by the captain t o the cabin starts)) 2312:43 CAM ((end o f PA announcement)) 2312:51 CAM-1 back with ya 2312:52 CAM-2 okay 2312:58 CAM-1 l e t ' s do the before takeoff 2313:04 CAM-2 fuel quantity 2313:06 CAM-1 ah checked TIME 6 SOURCE COIfTEIIT

INTRA-COCKPIT TIME 6 SOURCE CONTENT 2313:07 CAM-2 shoulder harness 2313:08 CAM-1 fastened l e f t 2313:09 CAM-2 takeoff data 2313: 10 CAM-1 okay i t ' s a hundred and f i v e thousand pound machine -at twenty f i v e twenty eight and t h i r t y nine 2313:13 CAM ((sound o f ACARS a l e r t beep)) 17 AIR-GROUND COMMUNICATIONS TIME & SOURCE 2313:27 CAM-2 ah it says somthin' about - 2313:31 CAM-1 i t ' s s t i l l on the ground t e l l him we're gonna be about another ten minutes 2313:35 RDO-2 operations i t ' s f i f t y f i f t y yes it w i l l be about another ten minutes 2314:13 RDO-2 USAir f i f t y f i f t y i s s t i l l on the ground we'll be another ten minutes before departure

Ã

v m 2314:18 SZ 0 PS okay copy that f i f t y f i f t y thanks f o r the 0 c a l l x

TIME 1 SOURCE 2314:30 CAM - 2 2314:38 CAM-1 2314:43 CAM-2 2314:50 CAM-2 2314:51 CAM- 1 2314:53 CAM- 2 2314:55 CAM- 1 2314:58 CAM- 2 2314:59 CAM- 1 2315:OO CAM-2 CONTENT 18 AIR-GROUND COMMUNICATIONS TIME & SOURCE CONTENT 2314:Zl ROO-2 you bet okay I'm back up with you takeoff data yeah speed's checked set twenty five twenty eight thirty nine okay stabilizer and trim - I got it stabilizer and trim set flight and stand-by flight instruments stabilizer trim I forgot the answer set for takeoff okay what was the other one flight and stand-by flight instruments

INTRA-COCKPIT TIME 1 SOURCE CONTENT 2315:02 CAM-1 they're set CAM-2 HSI switches 2315:03 CAM-1 I got nav up here 2315:05 CAM-2 okay ah ice protection 2315:07 CAM-1 i t ' s o f f 2315:OE CAM-2 p i t o t heat 2315:09 CAM-1 on and checked 2315:lO CAM-2 yaw damper CAM-1 on and checked 2315:ll CAM-2 okay f l i g h t controls 2315:12 CAM-1 checkin' 2315:14 CAM-2 there you go ah flaps 19 AIR-GROUND COMMUNICATIONS TIME & SOURCE COWTENT 2315:15 CAM-1 f i v e f i v e green detent

CONTENT 2315: 16 CAM-2 APU 2315:17 CAM-1 leave i t runnin' 2315:18 CAM-2 okay recall 2315: 19 CAM- 1 checked 2315:ZO CAM-2 departure briefing 2315:21 CAM-1 your takeoff your brief 2315:22 CAM-2 okay so it's ah runway heading right turn three five zero fer five thousand feet Laguardia three departure down to the line 2315:32 CAM-2 fifty five on board 2315:35 CAM-1 okay 2315:40 CAM ((sound of ACARS alert beep)) 20 AIR-GROUND CONWNICATIONS TIME 6 SOURCE COtlTBtT

IlfTBA-COCKPIT TIME 1 SOURCE CONTENT 2315:49 CAM-1 see what that i s 2315:53 CAM-1 new release time 2316:Ol CAM-1 what t h i s 2316:14 CAM-2 we can ah want tower 21 AIR-GROUND COHUNICATIONS TIRE Ã SOURCE CONTENT 2316:17 CAM-1 I don't exactly remember what he said about tower * what ever 2316:20 CAM-2 he said ah monitor tower a t ah - 2316:22 CAM-1 yeah yeah 2316:33 CAM-1 what I usually do too Connie on that release time i s j u s t write it on the release I usually j u s t write it ah release time ah i s zero three f i f t e e n Shore - the new release time and the dispatcher's name ( ( f l i g h t switched t o tower frequency))

I r n - . C O C K P I T TINE & SOURCE CONTENT 22 AIR-GROUND CONWNICATIONS TIME & SOURCE cairm 2316:55 CAM-1 but now what what are they t e l l i n ' you hav- what paper work are they t e l l i n ' you you have t o turn i n 2316:58 CAM-2 ah - just the ah you know the individual f l i g h t l o g f o r each f l i g h t number and then a t the end o f the t r i p the ah that's it 2317:04 TWR USAir f i f t y f i f t y give way t o the Eastern Airbus goin' i n t o position and hold short caution wake turbulence 2317:ll RDO-2 USAir f i f t y f i f t y 2317:13 CAM-1 they're sayin' j u s t t u r n i n that f l i g h t log that's a11 2317:16 CAM-2 yeah 2317:17 CAM-1 you don't have t o t u r n i n t h i s other s t u f f 2317:18 CAM-2 no 2317:19 CAM-1 okay that that's a11 changed then 2317:20 CAM-2 oh what

TIME 1 SOURCE CONTENT 2317:23 CAM-1 that that's the new way 2317:25 CAM-1 with Piedmont we always had t o turn i n a11 that other s t u f f and you you put down t h the remarks well you put down dispatch release time and a11 that gets - the f l i g h t manual said you know had t o be released every so often - 2317:38 CAM-2 r i g h t 2317:39 CAM- 1 2318:Ol CAM

• and you didn't have any record o f it now we got

ACARS so it'll stay i n here so I guess you're probably legal without just w r i t i n ' it down j u s t a carry over a l o t o f t h i s s t u f f you're gunna f i n d i s a carry over 23 AIR-GROUND CONUNICATIONS ((sound o f whist1 ing)) TIME 1 SOURCE

TIME S SOURCE CONTENT 2318: 13 CAM-1 I don't know how my fuel keeps getting out of balance it doesn't make any sense at a11 2318:26 TWR USAir fifty fifty caution wake turbulence preceding heavy jet departure taxi into position and hold runway three one 2318:31 RDO-2 position and hold three one fifty fifty 2318:34 PA-? ladies and gentlemen cleared onto the active runway we'll be departing momentarily flight attendants please be seated 2319:40 CAM-1 okay below the line 2319:41 CAM-2 okay got ah start switches are ah 2319:46 CAM-1 continuous 2319:47 CAM-2 on continuous out there transponder 24 AIR-GROUND COMMICATIONS TINE S SOURCE COIfTENT 2319:51 CAM-2 and the auto-brake

1m-COCKPIT TIME 6 SOURCE 2319:53 CAM-1 i s o f f CONTENT 25 AIR-GROUND COMUMICATIONS TIME & SOURCE coin'EKr 2319:54 CAM-2 okay takeoff check1 i s t i s complete 2320:05 TWR USAir f i f t y f i f t y runway three one cleared f o r takeoff caution wake turbulence preceding heavy 2320:09 RDO-2 cleared for takeoff USAir f i f t y f i f t y 2320: 13.3 CAM-1 okay 2320:15.9 CAM-1 you ready f o r it guy 2320:16.7 CAM-2 oh here goes nothin' 2320:18.9 CAM-1 here goes the brakes- lookin' f o r one ah - - n o wait a minute what was the # weather again -- 2320:26.0 CAM-1 a l l r i g h t make a r i g h t turn as soon as you can 2320:27.8 CAM ((sound o f increasing engine noise)) 2320:29.7 CAM-1 I got the steering till you ah

Irn-COCKPIT TIME & SOURCE 2320:32.1 CAM-2 okay CONTENT 2320:32.6 CAM-1 okay that's the wrong button pushed 2320:34.1 CAM-2 oh yeah I knew t h a t er 2320:35.5 CAM-1 I t ' s t h a t one underneath there 2320:41.8 CAM-1 a l l r i g h t I'll set your power 2320:46.2 CAM ((sound o f bang)) 2320:50.8 CAM ((sound o f loud rumble sound s t a r t s ) ) 2320:53.6 CAM-1 g o t the steering 2320:54.4 CAM-2 okay 2320:56.2 CAM-2 watch it then 2320:58.1 CAM-1 l e t ' s take it back 26 AIR-GROUND COWDNICATIONS 2320:58.4 CAM ((sound s i m i l a r t o t h r o t t l e s h i t t i n g t h e i d l e stops))

CONTENT 27 AIR-GROUND COWMNICATIONS TIKE 1 SOURCE 2321:OO.l CAM ((rumble sound increases i n amp1 i tude)) 2321:OO.g CAM ((sound o f engine noise decreasing)) 2321 :07 RDO-2 USAir a i r f i f t y f i f t y ' s aborting 2321:07.2 CAM ((sound o f increasing engine sound)) 2321:OE TWR USAir f i f t y f i f t y roger l e f t turn a t the end 2321:18.7 CAM-2 ah we're goin' o f f 2321:20.2 CAM-2 we're goin' o f f 2321:21.6 CAM-2 we're goin' o f f 2321:21.9 CAM ((sound o f crash)) 2321:22.8 ( (end o f recording) )

APPENDIX D F l i g h t Crew's Comments and Additions A. SUMMARY The f l i g h t crew reviewed the Cockpit Voice Recorder (CVR) t r a n s c r i p t on November 16, 1989 i n the audio laboratory o f the National Transportation Safety Board. The following are t h e i r additions and comments t o the CVR group's transcript. B. DETAILS OF INVESTIGATION Page 1. Page 2. Page 3. Page 4. Page 5. Page 6. Page 8. At time 2249:52 change CAM-2 t o CAM-1. Change comment a t time 2250:31 t o "oh gosh". Change comment a t time 2250:56 to: CAM-1 time i s r e a l l y get yourself h i t bad we were due out a t sixteen f i f t y f i v e r i g h t Change comment a t time 2251:29 to: CAM-2 what ever you say f i f t y p o s i t i v e N1 Add two comments between time 2251:29 and time 2251:55 CAM-1 cutout f o r t y PSIG CAM-2 ** Delete "da t a da" on comment a t time 2251:55. Change word "note" t o "know" i n comment a t time 2252:25 Change words " j u s t a second " t o " f i f t y seconds" i n comment a t time 2252:37 Add comment CAM-2 affirmative a f t e r time 2252:37. Change comment a t time 2253:07 t o CAM-1 cut out. Change comment a t time 2253:44 t o CAM-1 A systems pressured. Change CAM-1 t o CAM-2 a t time 2254:30

APPENDIX D Page 11. Change CAM-2 t o CAM-1 a t time 2302:06. Change CAM-1 t o CAM-2 a t time 2302:07. Page 12. Delete f i r s t two (2) words i n the comment a t time 2303:ll. Change "six" t o "seven" i n e d i t o r i a l comment a t time 2303:17. Page 13. Change comment a t time 2306:40 t o read: CAM-1 yeah it i s Delete word "it" form comment a t time 2306:43. Add word holding t o end o f comment a t time 2307:21. Delete comment a t time 2307:22. Page 15. Change word "IP's" t o "FE's" i n comment a t time 2310:23. Page 20. Add words "with ah" t o the beginning o f comment a t time 2315:32. Page 21. Change word "what" t o "what's" i n comment a t time 2316:Ol. Page 25. Change word " i s " t o " i t ' s " i n comment a t time 2319:53. Page 26. The Captain thought t h a t the comment'at time 2320:53.6 should read: CAM-1 you got the steering (The F i r s t O f f i c e r agreed with the statement as printed) Page 27. Change CAM-2 t o CAM-1 f o r the comments a t times: 2321 :18.7 2321 :20.2 2321:21.6

APPENDIX E SYNOPSIS OF FIRE AND RESCUE CRITIQUES AND POST-ACCIDENT IMPROVEMENTS The following summarizes topics that were raised during c r i t i q u e s conducted by the Port Authority o f New York and New Jersey on September 22, 1989, and by the New York Police Department on September 27, 1989. A serious lack o f a i r p o r t vehicles t o escort NYPD and NYFD vehicles from Security Post 3 t o the runway. NYPD o f f i c e r s were disoriented because they were not f a m i l i a r with the airport. The Port Authority responded t h a t they would explore the p o s s i b i l i t y of new signs t o d i r e c t emergency vehicles and have updated a i r p o r t maps sent t o commands. Port Authority also encouraged agencies t o arrange f o r a i r p o r t nighttime f a m i l i a r i z a t i o n tours. NYFD said that too many people were allowed access t o the deck. NYPD Emergency Services questioned why they d i d not have a re1 i a b l e passenger manifest and why infants and dead-heading crewmembers were not l i s t e d on f l i g h t 5050's manifest. A Port Authority representative suggested t h a t the gender o f each passenger be l i s t e d t o help rescuers t o account f o r everyone. On the topic o f communications, a NYPD representative asked about using a mobile communications van t o assist with interagency communications. A Port Authority captain suggested t h a t i n the future each agency should send one person t o the on-scene command post and another t o the secondary command post i n the police garage. A U.S. Coast Guard representative said t h a t h i s agency needed more guidance on using i t s boats and helicopters and t h a t the Coast Guard lacked communication w i t h other agencies. The Coast Guard offered t o assist i n any way possible, including demonstrating f l o t a t i o n devices. The a i r p o r t manager thanked the Coast Guard f o r i t s assistance and said t h a t the agency would be included i n future emergency d r i l l s a t the airport. The Deputy Chief o f Operations f o r Emergency Medical Services said t h a t the EMS staging area a t 81st Street and Ditmars Boulevard experienced no d i f f i c u l t y but t h a t there were serious problems t r y i n g t o stage a t the Post 3 security gate. A1 so, h i s organization had problems 1 earning where the rescue boats brought people. The Port Authority advised t h a t the problems a t Post 3 would be corrected and t h a t updated maps would be provided t o the EMS.

Intentionally Left Blank in Original Document

FD07152 ｜ 1990_美国_HAR9003.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1990 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

PB90-916203 111U1111~111II111111I11111I milII' PB90-916203 NTSBjHAR-90j03 Nft~l~I0 NAL TPJiNSPORTATION SAFETI' BOARD HIGI-IVvfi~Y ACCIDENT REPORT COLLAPSE OF THE I-lARRISON ROAD BRiDGE SPANS ~~/1IAl\IITO\VN, OHIO IVL\Y 26, 1989 REPRODUCED BY: NJ:lI u.s. Department of Commerce National Technical Information Service Springfield, Virginia 22161

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable cause of accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Copies of these documents may be purchased from the National Technical Information Service, 5285 Port Royal Road, Springfield, Virginia 22161. Details on available publications may be obtained by contacting: National Transportation Safety Board Public Inquiries Section,RE-51 800 Independence Avenue, S.W. Washington, D.C. 20594 (202)382-6735

TECHNICAL REPORT DOCUMENTATION PAGE

1. Report No.
2. Government Accession No.
3. Recipient's Catalog No.

NTSB/HAR-90103 PB90-916203

1. Title and Subtitle

Highway Accident Report·-

1. Report Date

Collapse of the Harrison Road Bridge Spans, Miamitown, November 20, 1990 Ohio, May 26, 1989

1. Performing Organization

Code

1. Author{s)
2. Performing Organization

Report No.

1. Performing Organization Name and Address
2. Work Unit No.

5137B National Transportation Safety Board

1. Contract or Grant No.

Office of Surface Transportation Safety Washington, D.C. 20594

1. Type of Report and

Period Covered Highway Accident report

1. Sponsoring Agenc¥ Name and Address

May 26,1989 NATIONAl TRANSPORTATION SAFETY BOARD

1. Sponsoring Agency Code

Washington, D.C. 20594

1. Supplementary Notes
2. Abstract

This report explains the collapse of a section of a temporary bridge over the Great Miami River in Miamitown, Ohio, on May 26, 1989. The safety issues discussed in the report are temporary and permanent bridge design and procedures for closing temporary and permanent bridges. Safety recommendations addressing these issues were made to the Hamilton County (Ohio) Engineer's Office, the Ohio Department of Transportation, the Federal Highway Administration, the American Association of State Highway and Transportation Officials, and the United States Geological Survey.

1. Key Words
2. Distribution Statement

This document is available to the public through the National Technical Information Service, Springfield, Virginia 22161

1. Security Classification
2. Security Classification
3. No. of Pages
4. Price

(of this report) (of this page) UNCLASSIFIED UNCLASSIFIED 45 NTSB Form 1765.2 (Rev. 5/88)

EXECUTIVE SUMMARY CONTENTS v INVESTIGATION Events Prior to the Collapse 1 The Accident 3 Emergency Response and Search 5 VE7hi~le and Occupant Information 5 InJunes 5 Highway Information 5 Bridge Information 7 History of Bridge Site 7 GOP's Temporary Bridge Design Plans 7 Selection Process for the Replacement and Temporary Bridges 9 NECC's Temporary Bridge Design Plans 11 Bridge Design Considerations 11 Temporary Bridge Construction...... 12 Bridge Wreckage Documentation 18 Bridge Design Standards 18 AASHTO Guidelines 18 ODOT Requirements.. . 22 Hamilton County Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 23 Geologicallnformation 23 Meteorological Information 23 Rainfall 23 Flood Warning/Flood Watch. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 26 River Gauge Readings 26 Hydrology Information 26 Riverbed Elevations 27 Construction of the Temporary Bridge. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 27 Postcollapse 28 Tests and Research 28 Metallurgical Information 28 Underwater Inspection of Wreckage and Riverbed. . . . . . . . . . . . . . . . . . . . .. 29 FHWA Engineering Analysis of Collapsed Bent 29 NECC Engineering Analysis of Collapsed Bent 30 University of Maryland Engineering Analysis of Collapsed Bent 30 Survey of Temporary Bridges 31 ANALYSIS General 32 Failure Mode Sequence 32· Superstructure 32 Substructure 33 Adequacy of the Bridge Design 34 Oversight of the Bridge Project 34 The Role of Scour. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 35 Bridge Design Specifications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 36 AASHTO 36 State of Ohio. 37 iii

CONCLUSIONS Findings 37 Probable Cause 38 RECOMMENDATIONS 39 APPENDIXES Appendix A--Investigation 41 Appendix B--Abbreviated Injury Scale 43 iv

EXECUTIVE SUMMARY On May 26, 1989, about S:2S p.m. eastern daylight time, a 140-foot section of the SS6-foot Harrison Road temporary bridge over the Great Miami River fell about 40 feet into the rain-swollen river after a pile bent collapsed. Seven witnesses reported that a passenger car and a pickup truck fell into the river.. However, only a passenger car and the bodies of the car's two occupants have been recovered from the river. No other vehicles were found in the river nor are any persons reported missing in the Miamitown area. Witnesses reported an unusual amount of debris floating down the river and striking the pile bents of the bridge prior to the collapse. Although the weather was clear and dry, flooding conditions existed at the time of the collapse and the river had overflowed its banks onto the flood plain. The National Transportation Safety Board determines that the probable cause of the temporary bridge collapse was the selection by the Hamilton County Engineer's Office of a design by the National Engineering and Contracting Company that did not consider lateral loads and the failure of the Hamilton County Engineer's Office to promptly close the bridge when it became subject to significant debris loading. Contributing to the cause of the collapse was the failure of the Hamilton County Engineer's Office to submit the bridge design plans to the Ohio Department of Transportation for review as required by State law. The primary safety issues raised by this accident are the adequacy of the temporary bridge design, the adequacy of procedures for closing temporary and permanent bridges under conditions that exceed bridge design criteria, and the adequacy of current design guidelines and specifications for highway bridges, particularly for debris loading. Safety recommendations addressing these issues were made to the Hamilton County Engineer's Office, the Ohio Department of Transportation, the Federal Highway Administration, the American Association of State Highway and Transportation Officials, and the u.S. Geological Survey. v

NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 HIGHWAY ACCIDENT REPORT COLLAPSE OF THE HARRISON ROAD BRIDGE SPANS IN MIAMITOWN, OHIO MAY 26,1989 INVESTIGATION Events Prior to the Collapse About 4:20 p.m. on May 26, 1989, a project superintendent employed by National Engineering and Contracting Company (NECC), the designer and contractor of the one-lane temporary bridge over the Great Miami River at Miamitown, Ohio (the Harrison Road bridge), stopped at the bridge 1 site on his way home from another work project. He had heard that construction workers at the bridge site had moved a large crane away from the river because of high water, and he wanted to make certain that it had been moved to a safe location. While there, he checked the river gauge, noticed debris coming down the river, walked out on the temporary bridge, and looked down between the pickup holes in the mats2 to see the accumulation of debris at the pile bents.3 He stated that he saw two refrigerators and large trees floating down the river. He also saw a telephone pole with a tree leaning against it on the east bank north (upstream) of the bridge. The superintendent sighted the upstream bridge curb line and noted no deflection. He walked to the west bank, went underneath the bridge, looked around, and observed debris wedged against the pile bents in the river. He noticed a tree about 18 inches in diameter on the east side of pile bent 2 (parallel to it) with the roots upstream and the limbs downstream and saw a floating pole strike the roots of the tree. While underneath the bridge, he felt the steel beams but did not detect any vibration. The superintendent then walked back onto the bridge and noticed a telephone pole that was embedded in the ground but leaning toward the bridge with a phone cable suspended over the traveled portion of the bridge. (See figure 1.) He again read the river gauge. He stated that although he had heard a news broadcast that the river was supposed to crest at 20 feet, the gauge indicated almost 21 feet. About 4:48 p.m., the superintendent went into the NECC field office, a construction trailer on the east bank, and notified his supervisor by telephone about the river level and the leaning telephone pole. He also called the hydrologist at the River Forecast Center (RFC) in Cincinnati, Ohio, and was advised that the river crest was being revised to 23 feet. He again called his supervisor and told him that he was going to call the Hamilton County Engineer's (HeE's) Office; he was concerned that 1A temporary bridge had been constructed before the old truss bridge was closed and removed; a new permanent bridge was being constructed. 2Large hardwood timbers (10" x 10" x 24') joined together in 4-foot sections that made up the bridge deck. 3 A pile bent is a pier composed of driven piles. This particular pile bent consisted of four steel piles and was capped at the top with a steel beam to form a bridge seat. .

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3 the telephone pole and line would fallon the traffic crossing the bridge and believed that the bridge should be closed as a precautionary measure. In addition to notifying the telephone company, he directed an NECC carpenter foreman to report to the site to build a brace to keep the telephone pole from falling onto the bridge. The superintendent then called the HCE bridge engineer to obtain approval to close the bridge. The HCE bridge engineer, who had just returned from vacation, was lying down because he was suffering from a migraine headache. He said that he took the call between 5:00 and 5: 15 p.m. The bridge engineer stated that he told the superintendent, "I will take the authority for you to close the bridge down." He added, "I said to him, I will call [the HCE], tell him that I have authorized the closure of this bridge, just to notify him, because I knew the press would be calling [the HCE]." The bridge engineer was unable to reach the HCE but was able to contact the Chief Deputy HCE. The deputy received the bridge engineer's telephone call concerning closure ofthe bridge at 5: 17 p.m. The superintendent stated that when he called the bridge engineer and explained the problem, the bridge engineer said: ... he guessed he could give me the authority or I could call the police or he said you would have to talk to [an HCE employee] about getting the signs to close the bridge. Then he said let me call [the HCE] and then I'll call you back. About 5:25 p.m., the bridge engineer returned the superintendent's call; while the superintendent was talking on the telephone in the construction trailer, he heard a loud bang, looked out a trailer window, and saw part of the west deck of the bridge go straight down. He called "911" and reported the bridge collapse. A witness on the west bank stated that about 5·: 15 or 5:20 p.m. he saw a huge amount of debris, including a boat, part of a dock, and many large trees with roots attached, coming down the river. He said the pile of debris was about 10 feet high and that he saw it strike pile bent 2. (See figure 2.) About the same time, another witness at the same location saw the same debris and estimated that the trees that had accumulated on pile bent 2 were "back upriver about 30 to 40 feet." Both witnesses saw the debris strike pile bent 2, heard a loud noise, and saw two spans fall into the river. The Accident Two spans and pile bent 2 fell into the rain-swollen Great Miami River, which had risen above its flood stage and had extended onto the adjacent flood plain. Traffic was traveling westbound on the one-lane bridge at the time of the collapse. A blue 1977 Mercury Cougar, with a driver and one passenger, fell into the river. The driver of the passenger car following the Mercury observed the car and bridge spans fall together into the river. She stated that she immediately put her car in reverse and backed up as far as she could while motioning for the drivers of vehicles behind her to back up. She stated that as she backed up, the wooden mats making up the bridge deck were dropping in sections in front of her. Another motorist stated that she was almost three-quarters of the way across the bridge when she heard a noise and her car started swaying back and forth. She thought that her tires were going flat, so she accelerated to get off the bridge. As she reached the west end of the bridge, she looked in her rearview mirror and saw the Mercury fall in the river.

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5 Seven witnesses (five on the bridge and two on the west bank) reported that a passenger car and a pickup truck fell into the river. Only the passenger car (the Mercury) was recovered from the river, and no other persons have been reported missing in the Miamitown area. Several witnesses commented about the height and turbulence of the river in their statements to the police. Emergency Response and Search The Hamilton County Communications Center received several "911" calls, and emergency response units were dispatched at 5:27 p.m. from the Hamilton County Sheriff's Office (HCSO), the Whitewater Township Fire Department, and the Colerain Township Fire Department. Following the collapse, many witnesses searched the river for signs of the car, the pickup truck, and their occupants, but no one saw the vehicles after they entered the water. By 6:30 p.m., an Ohio Highway Patrol helicopter, as well as mounted and foot patrol emergency response personnel, were searching for the victims along both banks downriver of the bridge. The river level and the water velocity prevented boat patrols and divers from searching until 2 days later. The search and recovery efforts lasted 9 days and included 60 to 80 volunteers, 4 fire engines, 3 emergency medical service units, 6 boats, 6 divers, 1 helicopter, and sonar equipment. Vehicle and Occupant Information One body (passenger car driver) was recovered 4 days after the collapse approximately 5 miles downstream. Eight days after the collapse, with the aid of a sonar device, the submerged passenger car was located about 300 feet downstream of the temporary bridge and 15 feet from the west bank. The roof of the car was substantially crushed and both car doors were jammed shut. (See figure 3.) The passenger's body was found in the rear passenger compartment of the car. The medical examiner found no blunt trauma injuries and ruled that the cause of both deaths was" asphyxia due to drowning." Injuries4 Fatal Serious Minor None Total Drivers 1oooT Passengers 1oooT Total 2ooo2 Highway Information Harrison Road is a two-lane asphalt roadway that runs east-west parallel to Interstate 74 (1-74). It is the main route between Whitewater Township and Colerain Township serving Miamitown, Ohio. The road had been designated U.S. Route 52 until 1974, when the State turned over the road and the existing bridge to Hamilton County and the roadway was redesignated County Route 457. The posted speed limit for the road was 45 mph; however, near the bridge, construction signs were 4See appendix Bfor the Abbreviated Injury Scale.

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7 posted and the speed limit had been reduced to 25 mph. Advisory signs indicated: "ONE-LANE BRIDGE," "TRAFFIC SIGNAL," and "NO TRUCKS, 4-WHEEL VEHICLES ONLY, EXCEPT EMERGENCY VEHICLES." The approach roadways were delineated with solid white edgelines and a solid double yellow centerline, and the roadway curved to the left for westbound traffic. The average daily traffic count for Harrison Road was about 3,000 vehicles. (See figure 4.) Traffic signals were installed at both ends of the temporary bridge to manage the alternate one-way traffic flow. The signals changed on a fixed time cycle, with 20-second green indications for each direction of traffic and red indications for opposing traffic. Each green indication was followed by a 3-second yellow and a 22-second all-red interval, which permitted the bridge traffic to clear. The traffic control box and the police emergency box were located on the west end of the bridge. Neither the HCE, nor the county bridge engineering staff, nor NECC personnel had keys to either box. Personnel from the county's traffic engineering section had keys to both boxes. The sheriff's department had keys to the police emergency box. Bridge Information History of Bridge Site.--In 1894, the King Bridge Company built a 440-foot, s.ingle-span, through-truss bridges over the Great Miami River at Miamitown, Ohio. In 1974, major repairs and modifications were made to the bridge, and later that year, the State of Ohio turned the highway and the bridge over to Hamilton County. According to the Miamitown Businessman's Association (MBA), when the truss bridge was closed for repairs for 16 months in 1974 and 1975, many businesses faltered and some went bankrupt. In 1987, because of the deteriorated condition of the truss bridge, the HCE decided to replace it with a new bridge at the same location. On May 6, 1987, the HCE hired a consultant, Graham, Obermeyer & Partners, Ltd. (GOP), to design a replacement bridge. Harrison Road was scheduled to be closed for approximately 1 year during construction of the replacement bridge, and a proposed detour for local traffic involved traveling about 2 miles farther west on 1-74 and exiting at Route 128, then traveling about 1/2 mile north to Miamitown. This detour takes about 10 minutes. Because of the financial hardship anticipated owing to the closure of the Harr-ison Road bridge, the MBA petitioned the HCE to build a temporary bridge. The HCE agreed to do so to accommodate local traffic until the permanent bridge was open to traffic. GOP's Temporary Bridge Design Plans.--On April 6, 1988, the HCE signed an agreement with GOP to design a temporary bridge for the site.6 The plans prepared by GOP indicated multiple simple spans (concrete box beam girders) supported by five tower-frame bents and two abutments. Each tower bent was to consist of ten HP 12 x 74 steel sections arranged in two rows of five each. The six inside HP sections were to be battered longitudinally, and the four corner piles were battered both sA jointed structure with an open web construction so arranged above the roadway that the frame is divided into a series of triangular figures with its component straight members stressed axially only. 6According to the HCE, consultants hired by the HCE's office perform 90 percent or more of the work on bridges and large roadway projects

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9 longitudinally and laterally. (See figure 5.) The piles were to be connected using diagonal and horizontal bracing with bolted connections. The bottom horizontal brace was to be placed as close as possible to the water level for pile bents 1 and 2. From 2 feet above the bottom horizontal brace to 2 feet above the riverbed, cable bracing positioned in an "X" configuration was to be attached in both the lateral and longitudinal directions. The piles were to be driven to refusal on bedrock and embedded at the top in a reinforced concrete pile cap. The box beam spans would later be transferred from the temporary bridge to the replacement bridge for use as spans in the replacement bridge. Other than a partial cross section of the riverbed, the GOP site plans for the permanent and temporary bridges depicted no hydrological or hydraulic information. The GOP design calculations did determine lateral loads due to stream flow using a stream velocity of 10 feet per second (fps). Selection Process for the Replacement and Temporary BridSes.--ln August 1988, seven contractors submitted sealed bids to erect a temporary ridge based on the GOP design, dismantle the truss bridge, and construct a replacement bridge over the Great Miami River. The HCE estimate for the bridge project was $2,438,284.56. NECC submitted the lowest bid, $2,297,141.20, and was awarded the contract, which specified that the contractor "shall start work on the temporary bridge within 10 days after signing the contract and that the temporary bridge shall be open to traffic within 200 days of signing the contract." The contractor had 500 calendar days from the inception of the contract to completion, including completion of the replacement bridge and removal of the temporary bridge. The contract between the HCE's office and NECC had no provisions for monitoring or closing the temporary bridge. In September 1988, NECC submitted an alternate design for the temporary bridge different from the one developed by GOP. The alternate design and construction project had an anticipated cost savings to the HCE's office of about $48,000 and a time savings of about 6 months for completion of the permanent bridge. In a letter dated October 5, 1988, NECC offered to accept liability for design of the temporary bridge if the HCE approved use of the NECC alternate temporary bridge design. The HCE retained GOP to review these alternate design plans. A pre-construction meeting on October 6, 1988, included representatives of the HCE, NECC, and GOP; the designer of the NECC temporary bridge was not present. The GOP engineer responsible for reviewing the NECC plans testified at the Safety Board's public hearing that he expressed concern at the pre-construction meeting about the lack of lateral load considerations in the design. He stated that at this meeting he asked about both the lateral design criteria for the bridge and the lateral load transmission for wind and for longitudinal loading because there was no evidence of horizontal cross bracing in a direction parallel with the deck. He said that the NECC representatives told him that this design had been used on at least one other occasion by the contractor and that they had confidence in it but would review his concerns. GOP raised these same concerns in an October 10, 1988 letter to the HCE. The consultant stated: (a) National [NECC] has responded that substructure lateral loads are transferred to the abutments and to soil without any formal longitudinal bracing. (b) Anticipated bearing elevations may need to be adjusted in field, and National seems to understand this.

10 RIVERBED EL. VARIES / CABLE BRACING ATTACHEO TO AND DRIVEN WITH PILING. LOOP CABLE THROUGH PLATES AND CONNECT ENDS WITH TURNBUCKLE. ,. G·h 19 STANDARD WIRE ROPE. MINIMUM BREAKING STRENGTH 10 • WATER LEVEL EL. VARIES ¥ NOTE: CONNECTIONS ARE 80LTED :'-- BOTTOM OF PILE CAP PIER NO.1 EL. 514.46 PIER NO.2 EL. 513.82 NORTH ELEVATION 2'0' MIN. OR AS REC:D FOR CABLE CLR. ;:c en c "' !. ~ 0 en... in c:> N 0 "''" '"c :E ~ EAST ELEVATION 2·L'sSx3x5/1I TYPICAL PILES HP 12.74 TYPICAL t PIER NO.1 EL. 518.78 I 8 •° .1..--=8:.,..--=0:..-__] /IER NO.1 EL. 518.53 PIER NO.2 EL. 518.15 '" - ..---=---=-----<~ .. V PIER NO.2 EL. 517.90 PIER NO.2 EL. 448.0 PIER NO.1 EL. 455.0 CONSULTANT'S DESIGN. TEMPORARY BRIDGE, PILE BENTS 1 AND 2 Figure 5.--Schematic of tower bents 1 and 2 as designed by consultant.

11 (c) Ice, flood, and stream flow (read debris) criteria are not specifically designed into this bridge and National agrees. I guess this is why it's temporary. (d) Possibly making some of that east end piers closer to the east abutment and potential effects: I've asked H.C. Nutting Co. [geotechnical and testing engineers] to check into this based on forthcoming distance information. The HCE did not require NECC to make any changes to the design plans for the temporary bridge as a result of the concerns expressed by GOP. On October 19, 1988, the HCE approved the NECC temporary bridge design, and the contractor began work. In December 1988, the temporary bridge was open to traffic. NECC's Temporary Brid3e Design Plans.--The temporary bridge constructed by NECC was designed for dea loads,? which consisted of the weight of the H-piles, W-beams, the cross bracing, the timber deck, ice loads on the deck, and the asphalt deck surface. According to the NECC design plans, the temporary bridge was also designed for live loads in accordance with the HS20-448 vertical loading. The plans did not indicate that the bridge was designed for lateral loads, nor did they show calculations for lateral loads. The NECC design plans specified cross bracing of the piles to reduce the effective length of the columns, but they included no calculations or details for the cross bracing connections. The plans indicated that the cross bracing was to be placed approximately down to the riverbed; however, the bridge was constructed with the lowest point of the cross bracing 12 feet above that shown on the plans. Also, the upper cross bracing of pile bent 2 did not extend up to the pile cap; instead, it began 3 feet 2 inches below the bottom of the pile cap. (See figures 6 and 7.) Bridge Design Considerations.--At the Safety Board's public hearing, the NECC designer of the temporary bridge (a registered professional engineer who had 10 years experience with NECC) testified that the temporary bridge was designed in accordance with ASSHTO specifications for HS20-44 vertical loading. In addition to using the AASHTO vertical load criteria, the NECC designer testified that he also referred to the Ohio Department of Transportation (ODOT) Construction and Material Specifications, specifically Item 502. (See section on ODOT Requirements.) When asked by Safety Board investigators whether he had designed the temporary bridge for either impact or lateral (wind, stream flow, or debris) loading, he replied, "I don't believe so." He explained that he had determined that there was a substantial margin of safety for vertical loads (3.5 to 1) in using the 12 x 539 H-piles and that he believed this margin of safety allowed for any lateral loading to which the bridge would be subjected. He also stated that he did not consider debris 7A static load from the weight of the structure itself. 8The standard American Association of State Highway and Transportation Officials (AASHTO) designation for the live or moving loads to be applied on the deck for determining highway load limits. An HS20-44 vehicle load is a 3-axle, 36-ton tractor-semitrailer with a gross weight of 72,000 pounds. 9The first number indicates 12-inch-wide flanges; the second number indicates that the section weighs 53 pounds per linear foot.

12 loading or the effects of scourlO in the design of the temporary bridge because he did not consider them major factors. He also testified that he designed the bridge so that the flanges of the H-piles were parallel to the stream flow and said that he did so to provide a surface for bracing the four piles together. He explained that he was not involved in the construction of the temporary bridge and was not aware of any discrepancies between the design plans and the actual construction. Although his design indicated that the bracing for pile bent 2 was to be attached to the battered piles just above the riverbed, he said that he expected the attachment to be made just above the water level, which he anticipated would be 4 or 5 feet above the riverbed. Because this distance was less than the shortest unbraced length that he used in calculating the safe column loads, he believed the piles would still safely carry the vertical loading for which they were designed. According to testimony by the NECC designer, soundings of the river to establish riverbed elevations and the mean river flow data were the only hydraulic or hydrologic information used by NECC in the design and construction of the temporary bridge. Temporary Bridge Construction.--The Harrison Road temporary bridge, which opened for local traffic in December 1988, consisted of nine simple spansll that were supported by eight pile bents and two concrete abutments. The abutments on both ends of the bridge consisted of reinforced concrete spread footings supported by soil embankments. The temporary bridge was 68 feet north of the old truss bridge centerline and had a curved section at the east end transitioning toward the existing alignment of Harrison Road. (See figure 8.) The pile bents consisted of four steel H-piles in a plane, two vertical and two battered.12 The plans called for each pile to be driven to refusal 13 in the riverbed. The H-piles were erected with the web14 perpendicular to the flow of the river, and the end piles were battered at a slope of six vertical to one horizontal. Two levels of cross bracing had been used to reduce the unbraced length of the piles. The upper level of bracing consisted of two 4-inch x 4-inch x 3/8-inch steel angles with one angle welded to the east flanges of the piles and the other to the west flanges. The lower bracing consisted of two 7-inch x 4-inch x 3/8-inch steel angles with one angle welded to the east flanges and the other to the west flanges. The pile caps consisted of HP 14 x 117 steel sections. (See figure 9.) Each of the nine spans, ranging in length from 54.75 to 70.75 feet, consisted of 36-inch deep steel girders (W-shape), which overlapped slightly over the supports and were welded to the pile caps. The bridge deck was made up of hardwood mats and the wearing surface was covered with asphalt. The mats were lOAn erosion of a river, stream tidal inlet, lake, or other water bed area by a current, wash, or other water in motion, producing a deepening of the overlying waterway or a widening of the lateral dimension of the flow area. llA superstructure span having, at each end, a single unrestraining bearing or support and designed to be unaffected by stress transmission to or from an adjacent span. l2A pile driven in an inclined position to resist forces that act in other than a vertical direction. 13Driven to bedrock or until 1 inch or less penetration is achieved with 20 or more blows or impacts of the pile driving hammer. l4That part of an H-pile located between and connected to the flanges.

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12 I~ 6·0 12 6··0 • ~ EAST ELEVATION o" N ELEV. = 522.67 ELEV. = 522.50 =~=t=;;;;====~;;::;:=~---10·· HARDWOOD MATS ELEV. = 521.67 I ELEV. = 518.67 --+--~....L..~......,..",...-,----:-:---'-...&....L---i ELEV. = 517.49 ELEV. =453.00 ELEV. = 480.00 - CONTRACTOR'S DESIGN, TEMPORARY BRIDGE, PILE BENT 2 Figure 7.--Front view of NEC('s pile bent 2 as designed.

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17 ELEV.453.6± Pile blner (typ.) STREAMFLOW ~ PILE LOCATIONS 8'·0"± BEAM 1'.3"± (typ.) LOCATIONS 10 -0 '± 6' ·3"± 520 Elev. 517.5" See Note 2 515 C .2., 510 I:.. E'6 I: +1 ~ ~ 505 .. in ~ N '"... ,..; '" 500 495 490 t= ww!:. 485 Z 0 ti>' W ...I W 475 470 B 465 ... ... !! !! ~ ~ 0 0 " " .. 460 .. a: a: "0 "0 z z 455

ELEV. 453.8± Elevation based on 450 45.0' below Iplil:e (typ.) EAST ELEVATION OF PILE BENT 2 (As Constructed) Notes: 1) This drawing based on measurements of salvaged materials. 2) Pier cap elevation based on construction plans. 3) B = Location of bend Figure 9.--East elevation of NECC's pile bent 2 as constructed.

18 wedged to the top flange of the W-beams with bolts and angle irons. W-beam guardrails spanned the bridge on both sides of the asphalt lane. Bridge Wreckage and Documentation.--On June 9,10, and 11, 1989, the bridge wreckage was documented as it was found on the riverbed. The four 36 x 170 W-beams of span 2 were found near the west bank of the river. One beam rested on the riverbed upstream, away from the other beams. The two 36 x 230 W-beams of span 3 were found near the second pier of the replacement bridge. The remaining sections of each span were still joined together and were partially buried in the loose granular riverbed material. (See figure 10.) Pile bent 2 was found approximately where it had been constructed. The pile cap was facing and parallel to the west bank, and the four piles were bent with the bottom ends still buried in the riverbed. The pile cap was undamaged, and all welds between the piles and pile cap were intact, as were the welds on the upper cross bracing. The lower brace on the east face fell off as the bent was removed, and the brace was never recovered. The brace on the west face remained welded to piles 3 and 4 (piles numbered from upstream to downstream). However, the welds connecting the west brace to piles 1 and 2 were fractured. (See figure 11.) Trees and branches were wedged within and on top of the piles. The pile cap was 1 to 2 feet above the riverbed, and the splice plates15 of each pile were intact. The second and third piles were parallel to each other and about 1 foot apart, but twisted so that the web of one of the piles was parallel to the riverbed. The flange was slightly bent where the third pile entered the riverbed. The fourth pile was found about 3 to 4 feet above the riverbed and bent acutely so that it entered the riverbed in an almost perpendicular fashion. The flange was torn at the pointed bend. The pile bent was removed from the river and inspected on June 12, 1989. Two of the piles were bent approximately 90 degrees, the pile located farthest upstream (pile 1) was bent approximately 50 degrees, and the pile located farthest downstream (pile 4) was bent slightly more than 90 degrees. Burn holes16 and tears in the flange were noted on piles 2 and 3 slightly below the area where the lower cross bracing was attached. Bridge Design Standards AASHTO Guidelines.--The AASHTO "Standard Specifications for Highway Bridges" are intended to serve as a standard or guide for the preparation of State specifications and for reference by bridge engineers. The AASHTO specifications are referenced in the Federal Highway Administration (FHWA) Federal Aid Program Manual 6-2-1-1, dated September 1987 and entitled "Design Standards for Highways," for use on Federal-aid highway projects. The State of Ohio has adopted these standard specifications and uses them in conjunction with additional State specifications. 15A splice plate is a piece of metal welded to a structural elemen.t to cover a joint to provide strength and stability. 16Holes cut into the pile flange with a torch during construction to aid in placing the piles.

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21 The AASHTO specifications do not differentiate between permanent bridges and temporary bridges; consequently, there are no separate criteria specifically relating to temporary bridges. Sections of the AASHTO specifications that govern the design of bridge structures address dead loads, live loads, impact loads, longitudinal forces, centrifugal forces, wind loads, stream current, floating ice, drift (debris), and additional forces under particular conditions. A bridge may be subjected to several of the above mentioned loads at the same time and theAASHTO specifications therefore establish combinations of loads (group loading criteria) that can be considered as acting on a structure simultaneously. By using combination loading, only a percentage of the sum of the maximum effects is considered, since the likelihood of the peak value of these events occurring simultaneously is remote. AASHTO specification section 3.7.4 (Minimum Loading) states: Bridges supporting Interstate highways or other highways which carry, or which may carry, heavy truck traffic shall be designed for HS20-44 Loading.... AASHTO specification section 3.15 (Wind Loads) states: A wind load of the following intensity shall be applied horizontally at right angles to the longitudinal axis of the structure. For girders and beams... 50 pounds per square foot. The total force shall not be less than 300 pounds per linear foot on girder spans. AASHTO specification section 3.18 (Force from Stream Current, Floating Ice and Drift) states: All piers and other portions of structures that are subject to the force of flowing water, floating ice, or drift shall be designed to resist the maximum stresses induced thereby. AASHTO specification section 3.22 (Combination of Loads) states: Each component of the structure... shall be proportioned to withstand safely all group combinations of... forces that are applicable to the particular site or type [of structure]. AASHTO specification section 1.3 also states that: Hydraulic studies of bridge sites area necessary part of the preliminary design of a bridge and should include (a) maps, stream cross sections, aerial photographs, (b) complete data on existing bridges, including dates of construction and performance during past floods, (c) available high water marks with dates of occurrence, (d) information on ice, debris, and channel stability, (e) factors affecting water stages such as high water from other streams, reservoirs,

22 flood control projects, and tides. Hydrologic analysis should include (a) flood data applicable to estimating floods at site, including both historical floods and maximum floods of record, (b) flood-frequency curve for site, (c) distribution of flow and velocities at site for flood discharges to be considered in design of structure, (d) stage-discharge curve for site. Hydraulic analysis should include (a) backwater and mean velocities at bridge opening for various trial bridge lengths and selected discharges, (b) estimated scour depth at piers and abutments of proposed structure. ODOT Reguirements.--The ODOT has its own bridge design manual that gives detailed instructions regarding bridge plan preparations as practiced in ODOT's Bureau of Bridges. Directions, provisions, and requirements for construction and materials are promulgated in ODOT's "Construction and Materials Specifications." Although this publication is not a design manual, item 502.02 in the 1987 edition addresses temporary structures and states in part: The temporary structure shall have an adequate waterway opening, but generally not less than 75 percent of the effective waterway opening of the proposed structure or may be designed to provide for a five-year frequency flood as a minimum. The contractor shall be responsible, however, for any damages caused by upstream flooding due to insufficient temporary structure size or the accumulation of debris or sediment in the channel. ... The temporary structure shall be designed for a loading of HS20-44 at unit stresses not to exceed 136.5 percent of those specified by pertinent sections of AASHTO "Standard Specifications for Highway Bridges." The chairman of the AASHTO Highway Subcommittee on Bridges and Structures testified at the public hearing that he interprets "pertinent sections" to mean that the designer should reference the type of material to be used for the structure. He stated: ...if you have a steel structure, you use the portions of the specifications relative to steel structures. If you have a concrete structure, you use those, and not try to apply timber and so on and so forth.. If you're dealing in a structure over waterways, you deal with the items that deal with waterways. If it's over a highway, then you deal with those. To me, that's what pertinent means. He also stated that "pertinent sections" refers to those sections dealing with loads and stresses, including vertical loads (dead, live, and impact loads) and lateral loads (wind, stream flow, ice, and debris loads). No Federal or State funds were used in the design and construction of either the temporary or the permanent bridges. Therefore, there was no State or Federal review of the design plans. However, the county was required to submit the plans to the State for review, according to an Ohio law (Ohio Revised Code, Section 5543) that states:

23 No contract for the construction or repair of a bridge, the entire cost of which construction or repair exceeds fifty thousand dollars, shall be entered into by the county unless the plans are first approved by the state director of transportation. The HCE's office did not submit any design plans to OOOT for review. According to testimony from an OOOT bridge engineer, of 88 counties in the State of Ohio, about 20 comply with this law. He also testified that had the bridge design been submitted for review, the OOOT would have reviewed the temporary bridge plans for structural adequacy, including adequacy for lateral loads, wind loads, and impact loads. He stated that if the design plans did not include provisions for lateral loading, OOOT would not have approved the plans. Hamilton County Guidelines.--HCE representatives stated that they adhere to the OOOT Bridge Oesign Manual and "Construction and Materials Specifications" when designing various projects, and the OOOT specifications were referenced in the contracts with the consultant. The HCE representative testified at the Safety Board's public hearing that his office did not submit the plans for approval as required by the Ohio Revised Code, Section 5543, because it did not have the plans available to send to OOOT for prior approval when the contractor submitted the alternate bid and because it was concerned about the time consumed by the process of sending plans to OOOT. Geological Information The Great Miami River Valley has a 3/4-mile-wide flood plain surrounding the Great Miami River. The Great Miami River and its tributaries drain more than 3,900 square miles across southwest Ohio. (See figures 12 and 13.) In the vicinity of the Harrison Road bridge, the soil is glacial till underlain by sand, gravel, and cobbles and, in some areas, clay layers. The bedrock is soft shale. Meteorological Information On May 26, 1989, the Cincinnati weather was mostly cloudy with a visibility of 20 miles. The temperature was 80 degrees Fahrenheit with a westerly wind of 10 mph. In Miamitown, witnesses stated that when the bridge collapsed, skies were clear and sunny a'nd the temperature was about 80 degrees Fahrenheit. Rainfall.--In the Great Miami River basin on May 26,1989, rainfall ranged from a high of 3.37 inches to a low of 0.78 inches. Many of the water basins that drain into the Great Miami River had received rainfall of approximately equal or greater magnitude 3 days earlier. Rainfall data records indicate that most of the rain fell on May 26,1989, between 3 a.m. and 5 a.m. The average total amount of rainfall in the 24-hour period in the Miami Conservancy Oistrict (MCO}17 amounted to 2.08 inches. According to the National Weather Service (NWS), this amount had an approximate recurrence interval of about 2 years. Oaily rainfall records are collected at more than 17A public corporation that was formed in 1915 to protect the major cities along the Great Miami River from floods. After the 1913 flood, during which 300 people died and more than $100 million of damage occurred, the Ohio legislature passed the Ohio Conservancy Act, which allowed for the creation of conservancy districts, Hamilton County is not included in the MCD.

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26 40 stations, and stream flow measurements are recorded at 30 locations by MCD staff. Flood Warning/Flood Watch.--On Thursday, May25, 1989, at 3:48 p.m., the NWS issued a flood watch for all but extreme northern and northeastern Ohio for that night and the next day. A flood watch is issued when a flood threat exists in the areas indicated, and the purpose of the watch is to advise citizens to keep informed and to be ready for quick action if flooding is observed or a warning is issued. This watch included Hamilton County, as well as the surrounding counties in the southwest part of the State. Flood watches and warnings are disseminated on the National Oceanographic and Atmospheric Administration Weather Wire, the National Distribution Circuit to the Family of Services, and the Ohio Highway Law Enforcement Automated Data System circuit. The flood waUh on May 25 stated: A large complex system of thunderstorms will be moving through Ohio tonight and Friday. Two to four inches of rain are possible in the Watch Area by Friday evening. Many rivers and streams in the Watch Area are already above normal levels and this additional rain may cause them to flood. On Friday, May 26, 1989, the NWS issued several flood warnings for the Great Miami River. The 11 :30 a.m. and 2:20 p.m. flood warnings predicted the river would rise to 20 feet; the 5:20 p.m. warning predicted 23 feet; and the 9:40 p.m. warning predicted 24 feet by Saturday morning, May 27. The flood warnings advised that a heavier concentration of rain was falling north of Hamilton, Ohio, and that the flooding of the Great Miami River would continue. River Gauge Readings.--Water level readings obtained from a person monitoring the river gauge located at the Harrison'Road temporary bridge were reported to the Ohio River Forecast Center. This river gauge had been installed on pile bent 6 on the east end of the bridge. The gauge is numbered from 13 feet (elevation 495.15 feet) to 33 feet (elevation 515.15 feet). At this location the flood stage is considered to be 16 feet (elevation 498.15 feet). Readings from this gauge taken shortly before and after the temporary bridge collapse about 5:25 p.m. were used to estimate the flood stage at the time of the collapse. The acting hydrologist-in-charge at the RFC stated that the sheriff's office was notified of the potential for flooding at 11 :34 a.m. on May 26. The hydrologist said that a record flood of about 34 feet was recorded in Miamitown in 1959. Hydrology Information· The Safety Board requested that the u.S, Geological Survey (USGS) gather information and evaluate the hydrologic and hydraulic conditions that existed during the May 26 flood and bridge collapse. One week after the collapse, from May 31 through June 2, the USGS measured the high water marks on both sides of the river along a reach extending approximately 1,000 feet upstream and downstream of the Harrison Road bridge site. Approximately 500 feet upstream and 500 feet downstream of the bridge site, high-water marks indicated water-surface elevations of about 507.0 feet and 503.4 feet, respectively. The data from two MCD discharge measurement gauges (the Hamilton and Indian Creek gauges, which were approximately 15 and 19 miles, respectively, upstream from the Harrison Road bridge) were used to estimate the conditions at

27 the bridge site. A hydrograph 18 of the river reach at the bridge was similar to a hydrograph of the river reach in the area of the gauges; therefore, the USGS was able to estimate conditions at the bridge site. The discharge at the time of the bridge collapse was about 46,700 cubic feet per second (cfs), and the peak discharge at 1 a.m. on May 27 was 67,000 cfs. The May 26 peak discharge of 64,600 cfs at the Hamilton gauging station has been exceeded in magnitude (on an annual basis) eight times during the period from 1922 to 1988, most recently in 1968. USGS-gathered data, including water discharge, water-surface elevations, and riverbed material roughness coefficients, were used to estimate water velocities. The velocities at pile bent 2 for the preflood and postflood geometries were estimated to have been 10.7 and 9.2 fps, respectively, for the peak discharge of 67,000 cfs. The velocities at pile bent 2 for the preflood and postflood geometries were estimated to have been 9.1 and 7.6 fps, respectively, for the discharge estimated to have occurred at the time of the bridge collapse, 46,700 cfs. Return periods19 indicate that the flood during the time of collapse, 46,700 cfs, would have a recurrence frequency of about 2 to 3 years and that the peak flood, 67,000 cfs, would have a recurrence frequency of about 9 years. The following table lists flood frequencies estimated from the flood frequency curve for the Hamilton County gauging station.2o Table 1. Flood Frequency for Hamilton Gauqinq Station (1922-1988) NTSB Estimate from USGS Annual Exceedance Probability 0.50 (2 years) 0.20 (5 years) 0.10 (1 0 years) 0.02 (50 years) Riverbed Elevations Flood Frequency Curve (cfs) 39,000 57,000 68,000 87,500 Construction of the Temporary Bridge.--In June 1987, a consultant (CDS Associates) for the HCE's office surveyed the riverbed at the old truss bridge and found that in the 28-foot-wide channel, at a point 50 feet downstream of pile bent 2 ofthe temporary bridge, the riverbed elevation was 470.5 feet. In July 1987, another consultant (H.C. Nutting Co.) to the HCE conducted a geotechnical investigation of the site. Seven soil boring samples21 were taken at the existing truss bridge abutments, and three boring samples were taken at the proposed permanent bridge pier locations. Only one boring hole was drilled in the riverbed, approximately 30 feet from the west bank and 50 feet downstream of the proposed temporary bridge. The water level was at an elevation of 483 feet; concrete rubble was encountered at an elevation of 478 feet. Medium-dense sand and gravel were l8The characteristics of the response of the stream during a storm event. 19The average interval during which a flood of a given size is exceeded as an annual maximum. 20Derived by the USGS following the Interagency Advisory Committee on Water Data Bulletin 17B entitled "Guidelines for Determining Flood Flow Frequency" published by the U.S. Department of Interior. 21Measured cylindral samples of soil extracted from the riverbed by means of a drilling tool.

28 encountered at elevation 475, very soft shale bedrock was encountered at elevation 457, and the boring was terminated at 97 blows per 6 inches at elevation 453. NECC's temporary bridge design plans, dated September 1988, showed that the riverbed elevation at pile bent 2 was 480 feet and that the lowest riverbed elevation was 472.5 feet at a point 40 feet west of pile bent 2. The water surface elevation was shown on the plans as 484.4 feet. A construction platform (a finger road constructed of gravel dredged from the riverbed) was placed from the east bank downstream of the temporary bridge in late October 1988 to drive the piles on both the temporary and permanent bridges. The superintendent testified that the platform was 5 or 6 feet deep, which would be at an elevation of 485 or 486 feet based on the riverbed elevation of 480 feet listed on NECC's design plans. Neither the HCE project engineer nor the NECC recorded the number of blows required to drive the piles of pile bent 2 into the ground. Postcollapse.--In June 1989 (after the collapse), a consultant hired by HCE surveyed the riverbed elevations. He 'found that the riverbed elevation on the upstream side of pile bent 2 was 471.5 feet and that the riverbed elevation on the downstream side of pile bent 2 was 471 feet. The lowest riverbed elevation on the upstream side was 468.5 feet (30 feet west of pile bent 2), and on the downstream side the lowest elevation was 471 feet (85 feet west of pile bent 2). In July 1989, the consultant also measured the lengths of the recovered piles, and the Safety Board used those measurements to calculate the following riverbed elevations for each of the piles of pile bent 2 (numbered from upstream to downstream beginning with pile 1); the piles were cut off at the riverbed: Pile 1 - 469 feet Pile 2 - 468 feet Pile 3 - 466 feet Pile 4 - 468 feet Tests and Research Metallurgical Information.--A Safety Board metallurgist examined the bridge wreckage from pile bent 2 on the river bank on June 19, 1989. Four cross braces had been welded to the flanges of each of the piles. The cross braces had been attached directly to the flanges of each pile by welds running along the edges of the braces. In most cases, the welds ran continuously across the flange face along one edge of the brace, and intermittent welds ran along the other edge of the brace contacting the flange face. The portion of pile 1 where brace 3 had been attached was recovered after the Safety Board's initial wreckage examination. An examination of this pile by a consultant for HCE indicated that it had not bent at this location but that distortion was significant. Of the 16 cross brace weld attachment areas on the 4 piles, 6 areas were found to have separated. At these 6 locations the welds had fractured either directly through the weld fusion zones or immediately adjacent to the fusion zones. Very little weld penetration into the base metal was noted on those welds that broke along the edge of the fusion zone. In the immediate area of each of these separations, local deformation in the form of buckling, twisting, or bending was noted in either the pile or the brace or both. A significant amount of local deformation was noted in the members at several of the intact weld locations.

29 A 13.5-inch segment from the lower end of the lower west face cross brace was flame cut and removed for examination. This cross brace section was found to be cracked along a line of transverse welds 10.25 inches from the lower end. Underwater Inspection of Wreckage and Riverbed.--In June 1989, Collins Engineers, Inc. (CEI), under contract with the FHWA and the HCE, performed an underwater inspection of the submerged portions of the bridge wreckage and took soundings of the riverbed. The main purpose of this work was to determine the configuration and location of the submerged bridge components and to determine the condition of the riverbed. Soundings were taken along lines approximately parallel to the centerline of the temporary bridge from the upstream face to approximately 200 feet downstream of the temporary bridge. The soundings were made with a recording-type fathometer using a 192-KHz, 20-degree transducer. Low-frequency sonar, with a 14-KHz tuned transducer, was used to produce subbottom profiles to determine whether there were any scour holes, whether infilling of scour holes had occurred at the site, and whether there were any differences in the density of the riverbed material. Sounding data just upstream and downstream of the collapsed temporary bridge provided evidence of infill material 22 in the low-water channel (approximately 30 feet west of pile bent 2), as well as infill material to the east side of pile bent 3. Infilling was not apparent in the vicinity of pile bent 2. Neither CEI nor the USGS were able to determine from this data whether scour at pile bent 2 had occurred. FHWA Engineering Analysis of Collapsed Bent.--The FHWA performed a limited linear two-dimensional frame analysis of pile bent 2, using a computer program called STRUDL23 to determine the loading conditions that would precipitate a failure of a primary structural member in pile bent 2. A computer model was developed to simulate the pile bent structure as it was designed and as it was constructed. The secant formula 24 was used to determine stresses in the piles. The analysis by FHWA showed that the substructure failure could have occurred when pile bent 2 was subjected to the forces of dead load, a live load of one passenger car, stream flow, and a debris force of 5 tons. Under the 5-ton debris load, pile 4 could have failed from compression flange buckling in flexure, general column buckling from axial loads, or buckling from combined flexure and axial loads.25 As the bent was displaced sideways by the debris and stream flow forces, 22Aher a flood, when river velocities decrease, material is redeposited in scour holes. This is referred to as "infilling." Since infill material ohen has a different density than the adjacent unscoured material, scour can be measured by determining the interface where the density change occurs. 23STRUDL is an acronym for Structural Design Language; it is a series of computer programs for solving problems in structural engineering and was used in this accident to perform a linear elastic, static analysis of pile bent 2. 24The secant formula is one of many equations available for structural analysis that is used to determine the safe load with eccentric loading parallel to the axis of the column. Its use in forensics in this collapse is limited to determining the stresses at yield. 25Buckling, which is the kinking, wrinkling, bulging, or otherwise loss of shape of a structure, occurs when loads exceed the structural strength of the member.

30 moments in all four piles would have been increased dramatically, thus increasing their susceptibility to buckling failure. NECC Engineering Analysis of Collapsed Bent.--On April 6, 1990, NECC submitted a structural analysis of pile bent 2 that was performed using the computer program EZFEAT26 and the interaction formula. 27 The NECC analysis indicated that if the bracing remained attached, a lateral force from stream flow and debris of about 20.5 tons would cause pile 4 to fail and that if the lower west face brace failed first, a lateral force from stream flow and debris of about 13.5 tons would cause pile 4 to fail. At the request of the Safety Board, the FHWA performed further analyses. The calculations with fixity at 471 feet indicated that a lateral force from debris of about 11 tons would cause pile 2 to fail from lateral buckling if the lower east face brace failed first and that a lateral force from debris of about 13 tons could have caused a lateral buckling failure in pile 4 with all the bracing attached. In addition, the FHWA concluded that the yielding of pile bent 2 could have occurred at debris loads as low as 5 tons based on the secant formula analysis with or without the bracing intact. Moreover, according to FHWA, an interaction analysis (combined column and axial loads and flexure) indicated that allowable design stresses are exceeded at debris loads as low as 5tons without the bracing. University of Maryland Engineering Analysis of Collapsed Bent.--In May 1990, the Safety Board contracted with the University of Maryland (UMD) to conduct structural calculations to determine the lateral load capacity of the collapsed structure and the ability of the bridge to meet AASHTO lateral load specifications. Two types of computer analysis were carried out to determine the lateral load capacity and the sequence of failure from both elastic buckling 28 and an elasto-plastic29 type failure. The UMD concluded that the results of the elastic buckling analysis did not correspond with the physical evidence and that an elasto-plastic failure (or formation of plastic hinges30 on the H-piles) was the probable mode of failure. The UMD calculated that the formation of plastic hinges began at a lateral debris load of about 7.5 tons and that overall collapse would occur between 11 and 12.5 tons. These loads assumed an initial failure at the connection between the lower west face brace and pile 1. The UMD estimated that had the connection not failed, the bent could have withstood a lateral load in excess of 15 tons. In addition, the most 26EZFEAT is an acronym for Easy Finite Element Analysis; it is a series of computer steps for solving problems in structural engineering and was used in this accident to perform a linear elastic, static frame analysis of pile bent 2. 27A method of approximating the ultimate strength when a structural member is subjected to combined loading, such as bending and axial compression. 28Elastic buckling analysis is a method used to determine the upper bound of the load-carrying capacity of a structure before buckling occurs. 29Elasto-plastic analysis is a method used to determine the upper bound of the load-carrying capacity of a structure before plastic deformation occurs. 30A plastic hinge occurs when the loads on a structure exceed the elastic limit, causing deformation of the structure.

31 probable characterization of the debris that actually struck the pile bent and caused it to fail was a combination of impact and accumulated debris forces. The UMD analysis also indicated that an object, such as a 50-foot, 7- to 14-inch-diameter floating log, striking the pile bent head-on at a stream flow velocity of 9 fps, was capable of providing the lateral impact force required for collapse of the pile bent. AASHTO specifications require a safety factor of 2.12 when designing long columns used in bridge structures. The UMD applied this safety factor to the NECC temporary bridge design. Using the results of the elasto-plastic analysis, the UMD calculated that the NECC temporary bridge could sustain a safe lateral load of about 3.5 tons. The UMD also calculated that the NECC temporary bridge would had to have been designed to withstand a safe lateral load of about 23 tons in order to conform with AASHTO's group loading specifications for stream flow, ice, and wind. In August 1990, the Safety Board asked the UMD to conduct an engineering analysis of the GOP temporary bridge design using the elasto-plastic analysis method to determine the bridge's lateral load capacity and its ability to meet AASHTO group loading criteria. The UMD concluded that the GOP-designed bridge would experience an initial formation of plastic hinges at a lateral debris load of about 39 tons. According to the UMD estimate, a lateral load greater than 65 tons31 would have caused the overall collapse of the structure. The analysis indicated that the GOP design would have withstood the calculated lateral loads that collapsed the NECC bridge and that the GOP design met the AASHTO provisions for group loadings. . Survey of Temporary Bridges On August 22, 1989, the Safety Board sent letters to 56 States and territories and to 1,100 of the 3,042 counties in the United States asking for information concerning the number of permanent and temporary bridges within those jurisdictions, whether the design criteria for temporary bridges differ from those specified for permanent bridges, and if so, in what way. The Safety Board received responses from 44 States, which reported 1,037 temporary bridges32 representing 92 percent of the bridges in the National Bridge Inventory (NBI).33 Of the 44 responding States, 14 reported no temporary bridges, 18 reported 1 to 9 temporary bridges, 8 reported 10 to 100 temporary bridges, and 4 reported more than 100 temporary bridges. 31The high degree of redundancy, the resistance to lateral loading of the GOP design, the complex interconnection of cable elements, and the three-dimensional behavior of the bent necessitated computer time beyond the scope of the project. Thus, the UMD did not calculate the value of the collapse load. 32The 1988 FHWA designation "temporary structure(s)" applies to those at which conditions require measures to facilitate traffic flow. It is used (1) when bridges are shored up, (2) when temporary repairs are made to keep a bridge open, and (3) when temporary structures, temporary runarounds or bypasses, and other temporary measures, such as barricaded traffic lanes, are in place to keep the bridge open. 33As of June 30, 1988, there were 577,710 bridges in the FHWA-maintained NBI that includes 50 States, Puerto Rico, and the District of Columbia. Of these bridges, 274,583 are on the Federal-aid system and 303,127 are not.

32 Of the 1,100 local jurisdictions, responses were received from 645 counties, reporting 97,510 permanent bridges (16 percent of those in the NBf) and 105 temporary bridges. Of the 35 States that were represented by counties responding, 17 reported no temporary bridges. Some temporary bridges were reported by both counties and States. Many States and counties reported that they used Acrow or Bailey bridges as temporary bridges. Both are prefabricated modular steel panel bridge spans that can be used as replacement spans on existing supports. The majority of the States and counties responding to the survey question regarding design criteria indicated that they used the same standards for permanent and temporary bridges. Those using different criteria cited "legal loads," "10-ton loading," and "HS-15" and "HS-20" loading as the major criteria to which temporary bridges wou Id be designed. Some indicated that geometric standards and hydraulic criteria for temporary bridges would be less stringent than those for permanent bridges. Most respondents cited AASHTO or State De.partment of Transportation specifications as the criteria used when constructing a temporary structure. Other respondents indicated that they do not use temporary bridges but close the route until permanent replacement bridges are constructed or until repairs have been made to the existing structure. ANALYSIS General The performance of the passenger car driver before the collapse did not affect the outcome of this a"ccident. The span on which the driver was traveling collapsed before she had an opportunity to make an evasive maneuver. The passenger car driver directly behind the car that fell into the river was attentive and reacted appropriately. She immediately began backing her car off the bridge and motioned other drivers behind her to back up. Another passenger car driver, traveling in front of the car that fell into the river, also was attentive. She initially thought her tires were going flat because her car was swaying from side to side. She accelerated to get off the bridge, looked in her rearview mirror, and saw the blue passenger car fall into the river. Although seven witnesses stated that they saw a pickup truck fall into the river, the HCSO never found a pickup truck and has no reports of missing persons that are thought to be related to the bridge collapse. The initial call about the collapse was received by the Hamilton County Communications Center at 5:27 p.m. Three minutes later, a sheriff's deputy and the fire chief arrived at the scene of the collapse. Search and rescue efforts were seriously hampered because of the rapid river flow, depth of the river, and debris in it. Witnesses at the site sought to locate the vehicles or their occupants in the river but were unsuccessful. The Safety Board concludes that the response of emergency personnel was timely and that their actions were appropriate under these conditions. Failure Mode Sequence Superstructure.--Based on all available evidence, the Safety Board concludes that no preexisting defects in the superstructure caused the bridge collapse. There were no cracks, physical deformities, or misalignments reported by either the HCE bridge engineer or the NECC superintendent who observed the superstructure just

33 before the collapse. A postaccident inspection ofthe bridge wreckage did not reveal any superstructure defects. Furthermore, based on the witnesses' descriptions of the vehicles on the bridge, the superstructure was not overloaded at the time of the collapse. The physical evidence and witnesses' statements indicate that the spans and the pile bent fell rapidly during .the collapse sequence, suggesting that failure of a substructure element may have initiated the collapse. Substructure.--Examination of the bridge wreckage following the collapse revealed that the welds connecting the cross bracing to the piles of pile bent 2 were of poorquality. However, the Safety Board metallurgical examination indicated, and the UMD analysis concurred, that the welds connecting the lower east brace to piles 1, 2, 3, and 4 failed during the collapse and not because of preexisting defects. Results of the NECC and UMD analyses showed that the weld connecting the lower brace to the west flange on pile 1 failed before the collapse. The NECC and UMD analyses also indicated that the failure of this weld substantially reduced the pile bent's resistance to lateral loads. However, the cross bracing members were not designed to accommodate lateral loads; they were used to reduce the effective length of the columns and thus increase the vertical load-carrying capacity of the bridge. Examination of the bridge wreckage revealed burn holes in the west flanges of piles 2 and 3 just below the lower bracing. The burn holes slightly reduced the strength of each affected pile and created potential stress raisers.34 Although plastic hinges began to form in the piles at the bracing points, bending occurred at the burn holes just below because of the reduced section. Nonetheless, bending would have occurred in the absence of burn holes, which are unlikely to have significantly reduced the lateral load-carrying capacity of the pile bent. The Safety Board concludes that the burn holes did not significantly reduce the lateral load capacity of the bridge. . The FHWA, NECC, and the UMD performed independent engineering analyses to determine the most likely mode of failure and the magnitude of debris loading needed to precipitate a failure of pile bent 2. The FHWA and NECC assumed that failure may have resulted from elastic buckling and performed further analyses to determine the loading conditions that would precipitate a structural failure of a member in the pile bent. Although the FHWA and NECC used different methodologies to analyze the structure and to determine the magnitude of debris loads needed to cause a failure, they both concluded that a buckling failure of the piles had occurred, causing pile bent 2 to collapse. Nonetheless, after performing the elastic buckling analysis, the UMD concluded that this type of failure could not explain the formation of the plastic hinges indicated by the physical evidence. In performing its analysis, the UMD assumed that the pile bent failure resulted from some type of elasto-plastic yielding that led to the formation of plastic hinges. The UMD analysis indicated that at a combined impact and accumulated debris load of 7.5 tons, plastic hinges would begin to form. The UMD also concluded that collapse would occur when a critical number of plastic hinges35 had developed 34Stress raisers are changes in contour or discontinuities in structure that cause local increases in stress. 35When the number of plastic hinges formed exceeds those required for elastic stability, the overall collapse of the pile bent occurs.

34 throughout the substructure, at a combined impact and accumulated debris loading between 11 and 12.5 tons. Based on UMD's engineering analysis and the physical evidence, the Safety Board concludes that the collapse of pile bent 2 resulted from the formation of plastic hinges due to a combination of impact and accumulated debris loading on the upstream side of the pile bent. Adequacy of the Bridge Design The Safety Board's review of the NECC temporary bridge design indicates that the bridge was designed in accordance with AASHTO (HS20-44) vertical loading and with the ODOT waterway opening specifications for temporary structures. At the Safety Board's request, the UMD reviewed the NECC temporary bridge to determine whether it would have met AASHTO specifications for group loading combinations and found that it did not. According to the UMD report, if the NECC temporary bridge had been designed to conform with AASHTO lateral load specifications, pile bent 2 would have had a safe load capacity of about 23 tons instead of its actual safe load capacity of about 3.5 tons. The designer of the NECC temporary bridge believed that the bridge's substantial vertical load design factor of safety (3.5 to 1) would also accommodate any lateral loads that the bridge would experience. As illustrated by this collapse, an increase in the vertical load capacity of a bridge may not result in a similar increase in its lateral load capacity. Therefore, the Safety Board concludes that it was inappropriate for NECC to assume lateral load capacity for the temporary bridge simply by providing a substantial vertical load factor of safety in its design calculations. Furthermore, the Safety Board concludes that had the NECC temporary bridge been designed for lateral loads such as those specified by AASHTO, the bridge would have withstood the combined debris loads that caused the collapse. The UMD analysis of the GOP temporary bridge design concluded that this design met all applicable AASHTO group loading combinations for highway bridges. According to UMD estimates, the GOP design would have withstood a lateral load of about 39 tons before the formation of the first plastic hinge, and collapse probably would not have occurred until debris loading reached at least 65 tons. Thus, the Safety Board concludes that the GOP temporary bridge design would have withstood the combined debris loads that caused the collapse of the NECC bridge. However, because the maximum amount of debris during the flood is not known, the Safety Board could not determine whether the GOP design would have withstood all lateral debris loads during the entire flood. Oversight of the Bridge Project The HCE's office uses consultants in the design, construction, and review of county projects because it does not have a sufficient engineering staff for these functions. Although the HCE reviewed NECC's temporary bridge design plans for construction purposes, GOP was retained to perform a design review of the proposed alternate bridge plans. During the review, GOP raised questions about NECC's design, noting that it included no calculations for lateral loading. The HCE did not require NEeC to make lateral load calculations or design modifications to address GOP's concerns. As a result, the NECC temporary bridge was constructed with little consideration for lateral loads. Had the HCE's office required NECC to perform lateral load calculations, the office would have discovered that the NECe temporary bridge design had a low lateral load capacity. The Safety Board concludes that HCE's approval of the NECC design without requiring design calculations for lateral loads resulted in the construction of a bridge that was inadequate for the lateral loading conditions imposed on it.

35 Also, the HCE did not submit the temporary or permanent bridge design plans to ODOT for review and approval as required by Ohio law. If the HCE had done so, the absence of lateral loading calculations might have been questioned by an engineer reviewing the plans. AnODOT bridge engineer testified during the Safety Board's public hearing that the NECC temporary bridge design would not have been approved. Although the construction crew was not at the site on the day of the accident, the Hamilton County assistant bridge engineer stopped by to check the work status. While he was at the site, the water level increased from 13 feet to 18 feet on the gauge. He stated that he was not alarmed by this because earlier in the week (3 days before the collapse) the river gauge had read 21 feet. He testified at the Safety Board's public hearing that there were no written procedures or policies for closing bridges. An NECCsuperintendent stopped by to check the construction site about 4:20 p.m. He did not notice anything unusual about the bridge but was alarmed by a telephone pole leaning precariously toward it. According to testimony at the Safety Board's public hearing, the superintendent apparently believed that he needed to get permission from the HCE's office before taking action to close the bridge. In addition, HCE employees testified that they expected to be contacted regarding a decision to close the bridge. Even though the superintendent's actions were not in response to a potential collapse of the bridge, had a procedure been in place that provided the superintendent with the authority to close the bridge, he could have closed it before the collapse. At the time of the collapse, the HCE knew that lateral loads had not been calculated in the design of the temporary bridge and was aware of the flood conditions during the week preceding the collapse.. Because the lateral design capacity of the bridge was not known, the HCE should have initiated procedures for monitoring the bridge during the flood conditions. During the initial contractual arrangements, the HCE's office and NECC should have agreed on procedures for monitoring and closing the temporary bridge structure. The Safety Board concludes that the HCE's failure to establish a policy and to develop procedures for monitoring and closing the temporary bridge during flooding conditions contributed to the severity of this accident. The Safety Board believes that the HCE should establish policies and develop procedures for bridge closure. Furthermore, the Safety Board believes that all States should require that any bridges susceptible to hydraulic and debris loading be monitored during flood events to ensure that they are closed when lateral loads exceed the design loads. The Role of Scour The Safety Board obtained riverbed elevations ranging from 466 feet to 480 feet from several different sources taken at different times and at various locations surrounding pile bent 2. These differences in elevations suggest that some form of scour may have occurred at or close to pile bent 2 before its collapse, at the time of its collapse, or after its collapse. However, attempts to examine the riverbed for scour where pile bent 2 was constructed were unsuccessful. The riverbed material consisted primarily of dense sand, gravel, and silt, and it was not possible from the subbottom profiles to differentiate between material that had been there before the collapse and the material that may have infilled after the flood subsided. Therefore, the Safety Board was not able to determine whether scour occurred at

36 pile bent 2 before it collapsed. The FHWA, NECC, and UMD analyses indicated that even allowing for the possibility of scour during the flood, differences in the unsupported length of piles had little effect on the lateral load capacity of pile bent

1. Thus, if scour had occurred, it would not have been a factor in this collapse.

Bridge Design Specifications AASHTO.--According to the testimony from the chairman of the AASHTO Subcommittee on Bridges and Structures, AASHTO specifications for bridge design address all the forces a bridge is expected to safely withstand during the life of the structure. AASHTO does not differentiate between permanent and temporary bridges and thus, according to AASHTO, all temporary bridges should be designed in accordance with the same AASHTO loading specifications that are applicable to permanent structures. Based on the UMD analysis, the Safety Board concludes that had NECC considered AASHTO lateral loads in the design of its temporary bridge, the bridge would have withstood the debris loading that caused the collapse. Moreover, the UMD noted that the GOP temporary bridge design met AASHTO lateral group loading specifications, indicating that it is reasonable to design temporary bridges in accordance with these specifications. Therefore, the Safety Board believes that all public bridges should be designed and built in accordance with AASHTO vertical and lateral loading specifications. Se~ion 3.18 of AASHTO standard specifications for highway bridges states that all piers and portions of structures that are subjected to flowing water are to be designed to resist the maximum stresses induced by stream flow, floating ice, wind, and debris. The specifications provide detailed criteria for calculating the maximum expected loads and stresses for each of these conditions except debris. The specifications do not provide any guidance for calculating impact and accumulated debris loads. According to testimony provided by the chairman of the Subcommittee on Bridges and Structures, debris loading is partly accounted for by the safety factor incorporated into the design and may also be estimated based on bridge site visits or historical data on river debris. Most structures that are built in accordance with AASHTO loading specifications for allowable working stress have a factor of safety of about 2 to compensate for .unanticipated loads. However, this factor of safety is based on the assumption that the designer has tried to consider all known forces (vertical, lateral, and so forth) that may be imposed on the bridge during its service life. The factor of safety is intended to provide for variations in the different types of loads that are specifically considered. Many permanent bridges are built with massive substructures to support the weight of the superstructure and, as a result, far exceed AASHTO criteria for lateral loads. These bridges are protected from debris loading by the inherent nature of the massive substructures. However, those bridges that do not have massive piers in the water, such as this bridge, are susceptible to being overstressed from loads caused by debris impact and accumulation. Therefore, it is imperative that all significant lateral forces, including debris loading, be considered in the design process. Because no specifiC guidance is provided by AASHTO for calculating debris loads, the Safety Board believes that AASHTO, in cooperation with the FHWA and the USGS, should conduct research to develop methods for estimating maximum debris loads, that is, frequency, size, and magnitude, for design purposes. The Safety Board believes that once these methods are developed, AASHTO should include in the "Standard Specifications for Highway Bridges" detailed criteria for calculating the maximum

37 expected debris loads and should specify analytical methods for determining the stresses imposed by impact and accumulated debris loads on highway bridges. State of Ohio.--The OOOT has adopted AASHTO bridge specifications; however, AASHTO specifications do not differentiate between temporary and permanent bridges. Temporary structures are addressed in Section 207 of the OOOT bridge manual and in Section 502.2 of the Ohio "Construction and Materials Specifications." Section 502.2 specifies that temporary bridges "shall be designed for a loading of HS20-44 at unit stresses not to exceed 136.5 percent of those specified by pertinent sections of AASHTO 'Standard Specifications for Highway Bridges.'" According to OOOT, these specifications were promulgated so that temporary bridges are not designed to lesser AASHTO loadings, such as H-15, H-20, or HS-20. However, Section 502.2 does not similarly define lateral load requirements for temporary bridges. The OOOT bridge engineer testified at the Safety Board's public hearing that the OOOT specifications require that temporary bridges be designed to the lateral loading specifications of AASHTO. Also, GOP calculated lateral loads when developing its temporary bridge design. The Safety Board believes that the AASHTO lateral load criteria should have been applied to the design of the NECC temporary bridge. However, the NECC did not use AASHTO lateral loading criteria for the design of the temporary bridge. The NECC and HCE stated that the AASHTO bridge specifications for lateral loads did not apply to the design of temporary bridges in Ohio. The Safety Board concludes that NECC and HCE may have misinterpreted section 502.2 of the ODOT "Construction and Materials Specifications" as not requiring the application of AASHTO lateral load specifications to temporary bridges in Ohio. To avoid misinterpretation, the Safety Board believes that ODOT should clarify the lateral load requirements for temporary bridges in its "Construction and Materials Specifications." Furthermore, the Safety Board believes that all States should require all AASHTO design loading specifications as minimum standards for all temporary, as well as permanent, bridges. CONCLUSIONS Findings 1. The performance of the passenger car driver before the collapse did not affect the outcome of this accident. 2. No preexisting defects in the superstructure caused the bridge to collapse. 3. The response of emergency personnel was timely and their actions were appropriate under the conditions. 4. The burn holes used for pile installation in piles 2 and 3 did not significantly reduce the lateral load capacity of the bridge. 5. The failure of the weld connecting the lower brace to the west flange on pile 1 substantially reduced the pile bent's resistance to lateral loads. 6. The collapse of pile bent 2 resulted from the formation of plastic hinges due to a combination of impact and accumulated debris loading on the upstream side of pile bent 2.

38 7. 9. 8. 11. NEee inappropriately assumed lateral load capacity for the temporary bridge by providing a substantial vertical load factor of safety. Had the NECC temporary bridge been designed for lateral loads such as those specified by AASHTO, the bridge would have withstood the combined debris loads that caused the collapse. The GOP temporary bridge design would have withstood the combined debris loads that caused the collapse of the NECC bridge. HCE's approval of the NEce design without requiring design calculations for lateral loads resulted in the construction of a bridge that was inadequate for the lateral loading conditions imposed on it. Had a procedure been in place that provided the superintendent with the authority to close the bridge, he could have closed the bridge before the collapse. 12. The HCE did not comply with the Ohio requirement for the submission of bridge design plans to ODOT for review. 10. 13. The HCE's failure to establish a policy and to develop procedures for monitoring and closing bridges during flooding conditions contrib~ted to the severity of this accident. 14. Whether scour occurred at pile bent 2 -before its collapse could not be determined; however, if scour did occur, it would not have been a factor in this collapse. 15. Current AASHTO specifications do not provide criteria for calculating combined debris loads in the bridge design process. 16. The NEee and HCE may have misinterpreted section 502.2 of the ODOT "Construction and Materials Specifications" as not requiring the application of AASHTO lateral load specifications to temporary bridges. Probable Cause The National Transportation Safety Board determines that the probable cause of the temporary bridge collapse was the selection by the Hamilton County Engineer's Office of a design by the National Engineering and Contracting Company that did not consider lateral loads and the failure of the Hamilton County Engineer's Office to promptly close the bridge when it became subject to significant debris loading. Contributing to the cause of the collapse was the failure of the Hamilton County Engineer's Office to submit the bridge design plans to the Ohio Department of Transportation for review as required by State law.

39 RECOMMENDATIONS As a result of its investigation of this accident, the National Transportation Safety Board made the following recommendations: --to the Hamilton County Engineer's Office: Require that bridge design capacities be determined and establish policies and procedures for monitoring and closing public highway bridges when conditions exceed the design capacity of the structure. (Class II, Priority Action) (H-90-98) --to the Ohio Department of Transportation: Require that bridge design capacities be determined and establish policies and procedures to close bridge structures when conditions exceed the design capacity of the structure. (Class II, Priority Action) (H-90-99) Clarify the lateral load requirements for temporary bridges in the Ohio "Construction and Materials Specifications." (Class II, Priority Action) (H-90-1 00) Disseminate the facts and circumstances of this accident to each county and municipal engineer responsible for bridge design and construction in the State of Ohio. (Class II, Priority Action) (H-90-101) Develop and implement procedures to ensure enforcement and monitoring of the Ohio law (Ohio Revised Code, Section 5543) that states: No contract for the construction or repair of a bridge, the entire cost of which construction or repair exceeds fifty thousand dollars, shall be entered into by the county unless the plans are first approved by the State Director of Transportation. (Class II, Priority Action) (H-90-102) --to the Federal Highway Administration: Undertake a research program in cooperation with the American Association of State Highway and Transportation Officials and the U.S. Geological Survey to develop methods for estimating maximum debris loads for bridge design purposes. (Class II, Priority Action) (H-90-103) Establish, in cooperation with the American Association of State Highway .and Transportation Officials, standard analytical methods to determine loads imposed by debris impact and by debris accumulation on bridge substructures. (Class II, Priority Action) (H-90-1 04)

40 Encourage the States to determine bridge design capacities and to establish policies and procedures to close bridges when conditions exceed the design capacity. (Class II, Priority Action) (H-90-1 05) Encourage all States to require the American Association of State Highway and Transportation Officials loading specifications as minimum design criteria for all bridges open to the public. (Class II, Priority Action) (H-90-1 06) --to the American Association of State Highway and Transportation Officials: Cooperate with the Federal Highway Administration and the U.S. Geological Survey in a research program to develop methods to estimate maximum debris loads for bridge design purposes. (Class II, Priority Action) (H-90-1 07) Cooperate with the Federal Highway Administration in establishing standard analytical methods to determine loads imposed by debris impact and by debris accumulation on bridge substructures. (Class II, Priority Action) (H-90-108) Following the development of debris loading design methodologies, include detailed criteria for calculating the maximum expected debris loads and stresses in the "Standard Specifications for Highway Bridges." (Class II, Priority Action) (H-90-1 09) --to the U.S. Geological Survey: Cooperate with the Federal Highway Administration and the American Association of State Highway and Transportation Officials in a research program to develop methods to estimate maximum debris loads for bridge design purposes. (Class II, Priority Action) (H-90-11 0) BYTHE NATIONAL TRANSPORTATION SAFETY BOARD /s/ James L. Kolstad Chairman /s/ Susan M. Coughlin Vice Chairman /s/ Jim Burnett Member /s/ John K. Lauber Member /s/ Christopher A. Hart Member November 20, 1990

41 APPENDIXES APPENDIXA INVESTIGATION Investigation The National Transportation Safety Board was notified of this accident by the news media, and highway accident investigators were launched from the Safety Board headquarters in Washington, D.C. The investigation team arrived on scene about 7 p.m. on May 28, 1989. Participating in the investigation were representatives from the Whitewater Township Fire Department, the Hamilton County Engineer's Office, National Engineering and Contracting Company, the Miami Conservancy District, the Ohio Department of Transportation, and the Federal Highway Administration. Hearing The Safety Board convened a public hearing in Cincinnati, Ohio, on October 3 and 4, 1989, to inquire further into the collapse of the temporary bridge. The Safety Board was concerned that State specifications governing the construction of bridges were not being adhered to and that no procedures were in place for monitQring and closing the temporary bridge during flood conditions.

Preceding page blank 43 APPENDIXB ABBREVIATED INJURY SCALE* Drivers Passengers Total Unsurvivable (AIS-G) Critical (AIS-5) Severe (AIS-4) Serious (AIS-3) Moderate(AIS-2) Minor (AIS-O) Unknown (AIS-9) Total ooooo 1** o,. ooo oo 1** o,. ooooo 2o2 * ** Abbreviated Injury Scale refers to the abbreviated injury scale (1985) of the American Association for the Advancement of Automotive Medicine. Drowning is not considered an injury under the Abbreviated Injury Scale.

• u.s. G.P.O.:1991-281-626:20030

FD07153 ｜ 1991_美国_MAR9104.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1991 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

PB91·916404 1111111111111111111111111111111111111 . ----- -- ..- _. ---- -- .- . _.- NTSBjMAR·91j04 NATIONAL TRANSPORTATION SAFElY BOARD WASHINGTON, D.C. 20594 MARINE ACCIDENT REPORT EXPLOSION AND FIRE ABOARD THE U.S. TANKSHIP JUPITER BAY CITY, MICHIGAN SEPTEMBER 16, 1990 ....- .-.~.' -~-----::.:---- ,---------- u.s.D~~~CD~~;"erce~..__ 54_26_A__J National Technical Information Service Springfield, Virginia 22161

The. National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable cause of accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Information about available publications may be obtained by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 L'Enfant Plaza East, S.W. Washington, D.C. 20594 (202)382-6735 Safety Board publications may be purchased, by individual copy or by subscription, from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (703)487-4600

NTSB/MAR-91/04 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 MARINE ACCIDENT REPORT PB-91-916404 FIRE AND EXPLOSION ABOARD THE U.S. TANKSHIP JUPITER BAY CITY, MICHIGAN SEPTEMBER 16, 1990 ADOPTED: OCTOBER 29, 1991 NOTATION 5426A Abstract: This report explains the fire and explosion aboard the U.S. Tankship JUPITER, Bay City, Michigan, Septe.mber 1~, 1990., .T~e_saf~ty. issues discussed in the report are the adequacy of the ship berthing facilities at the Total Petroleum, Inc., terminal at Bay City; the adequacy of the mooring procedures aboard the JUPITER and at the Total Petroleum pier;-the speed and track of the BUFFALO as it passed the moored JUPITER; the lack of a communications system to notify a vessel moored at a bulk fuel discharging terminal that another vessel was approaching in the channel; the adequacy of the disaster contingency plans for the area; and the installation of the flame screens in the ullage pipes aboard the JUPITER. The National Transportation Safety Board made safety recommendations addressing these isssues to the U.S. Coast Guard, Total Petroleum, Inc., Cleveland Tankers, Inc., the Lake Carriers Association, the State of Michigan, and the Bay County Emergency Services.

EXECUTIVE SUMMARY CONTENTS v INVESTIGATION Events Preceding the Accident 1 JUPITER 1 BUFFALO 5 Accident 6 Action Aboard the JUPITER 6 Action Aboard the BUFFALO 13 Action at the Total Petroleum Terminal 13 Injuriesto Persons........................................................ 15 Damage................................................................. 15 JUPITER 15 BUFFALO 15 Total Petroleum Terminal 15 Crew Information 15 JUPITER. 15 BUFFALO 17 Toxicological Testing 18 Vessel Information 18 JUPITER 18 Cargo Operations Aboard the JUPITER. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 22 Automatic Constant-Tensioning Mooring Winches 25 BUFFALO 26 Terminal Information 28 Wreckage ;.............................................. 32 JUPITER 32 BUFFALO 32 Total Petroleum 32 Waterway Information 35 Meteorological Information 36 Medical and Pathological Information 36 Survivors'lnjuries 36 Fatal Injuries 36 Survival AspeCts 36 JUPITER 36 Terminal Response 37 Search and Rescue 38 Fire Department Response 39 Michigan State Police Response 41 State Fire Marshal's Division 41 Bay County Sheriff's Department 41 Medical Response 41 Critique ofthe Emergency Response 42 Critique of the BMC Emergency Preparedness Procedures 43 Disaster Preparedness 43 Tests and Research 44 Wood Mooring Pile 44 Hydrodynamic Studies 44 /r------- ...... I

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Other Information 46 ANALYSIS General 46 Accident 47 JUPITER's Mooring at the Total Petroleum Facility 47 Responsiveness of the JUPITER's Crew ;.............................. 49 Line Handling 49 Precautionary Measures Taken Aboard the JUPITER 50 Arrival of the BUFFALO 51 Speed of the BUFFALO 52 Total Petroleum's Inspection of Its Pier 53 Spread of the Fire 54 Total Petroleum's Operating Manual 54 Terminal Responsibility for Tankships Moored at the Facility 55 Survival Factors/Search and Rescue 55 Coast Guard Response 55 Abandon Ship Procedures 56 Response by Local Authorities 56 Toxicological Testing 57 CONCLUSIONS Findings 58 Probable Cause 59 RECOMMENDATIONS 59 APPENDIXES Appendix A--Investigation 63 Appendix B--Personnellnformation 65 Appendix C--Declaration of Inspection Prior to Bulk Cargo Transfer 69 Appendix D--U.S. Coast Guard Certificate of Inspection, JUPITER 71 Appendix E--U.S. Coast Guard Certificate of Inspection, BUFFALO 73 Appendix F--Emergency Station Bill, JUPITER 75 Appendix G--USDA Forestry Laboratory's Report on Wood Pile Sample 77 Appendix H--Excerpts From CFR PART 164-Navigation Safety Regulations. 79 iv

EXECUTIVE SUMMARY \ . ~\ On Sunday, September 16, 1990, the 392-foot-long u.S. tankship JUPITER was moored at the Total Petroleum, Inc., terminal (Total Petroleum) on the Saginaw River in Bay City, Michigan, discharging a cargo of unleaded gasoline. While the JUPITER lay moored at Total Petroleum's pier, the 635-foot-long bulk carrier BUFFALO entered the Saginaw River en route to a bulk materials handling facility at Midland, Michigan, to discharge a cargo of coal. As the BUFFALO passed the JUPITER, the tankship broke away from .its berth and its stern swung out into the river, rupturing the discharge hose to the pier and damaging the pipeline on the pier. Gasoline spilled on the pier and onto the deck of the JUPITER. The electrical cables to two motor-operated valves that closed off the pipelines at the end of the pier were torn apart, causing sparks that ignited the spilled gasoline. Fire spread to the deck of the JUPITER, causing a series of explosions in the cargo tanks that destroyed the entire midship section of the vessel. One crewmember died during abandonment of the vessel. The JUPITER, valued at $9 million, was declared a total loss and later sold for scrap. <__--- The safety issues discussed in the report are: • The adequacy of the ship berthing facilities at the Total Petroleum, Inc., terminal at Bay City; • The adequacy of the mooring procedures aboard the JUPITER and at the Total Petroleum pier; • The speed and track of the BUFFALO as it passed the moored JUPITER; • The lack of a communications system to notify a vessel moored at a bulk fuel discharging terminal that another vessel was approaching in the channel; . • The adequacy of the disaster contingency plans for the area; and • The installation of the flame screens in the ullage pipes aboard the JUPITER. The National Transportation Safety Board determines that the probable cause of the fire and explosions aboard the tankship JUPITER was the failure of Total Petroleum, Inc., to provide adequate mooring facilities for tankships such as the JUPITER, which allowed the vessel to break away from the pier because of surging caused by a passing vessel. Contributing to the accident were the inadeq uate procedures used aboard the JUPITER for managing the mooring lines and winches while other ships passed nearby and the fact that the BUFFALO was navigated to pass closer to the JUPITER than normal. Contributing to the severity of the accident were the lack of a reliable and timely alerting system that would have given the JUPITER's crew adequate time to take additional precautions to safeguard the vessel and the failure of the owners of the JUPITER and the U.S. Coast Guard to ensure that flame screens were properly fitted. As a result of this investigation, the Safety Board made recommendations to the U.S. Coast Guard, Total Petroleum, Inc., Cleveland Tankers, Inc., the Lake Carriers Association, the State of Michigan, and the Bay County Emergency Services. .'-:----'"' /

NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 MARINE ACCIDENT REPORT FIRE AND EXPLOSION ABOARD THE U.S. TANKSHIP JUPITER BAY CITY, MICHIGAN SEPTEMBER 16, 1990 INVESTIGATION Events Preceding the Accident JUPITER.--At 0145, eastern standard time, on September 16, 1990, the 392-foot-long u.S. tankship JUPITER arrived at the Total Petroleum, Inc., (Total Petroleum) facility in Bay City, Michigan, loaded with 56,000 barrels of unleaded gasoline. (See figure 1.) Originally loaded at a Sun Oil Company refinery in Sarnia, Canada, the entire cargo was to be discharged at Total Petroleum s Bay City terminal. By 0205, the crew had secured the JUPITER, starboard side to the pier heading upstream, and had rigged a boarding ladder. They moored the tankship as they had done before at the Total Petroleum facility, with six lines that consisted of two polypropylene lines and one wire rope cable from each of four constant-tension winches. (See figure 2.) The winches were numbered 1 through 4 from forward. (For this report investigators have numbered the mooring pile clusters in similar order for reference.) The vessel's parallel midbody (straight sides of the hull) lay against Nos. 2 and 3 pile clusters. Nos. 1 and 4 mooring wires led fore and aft, respectively, to the Nos. 1 and 4 pile clusters, which were set back and made no contact with the vessel's hull. The No.2 mooring wire was led aft as a spring line 1 and secured to the No.2 pile cluster. Similarly, the No.3 mooring wire was led forward as an after spring line to the No.3 pile cluster. The two polypropylene mooring lines were led from the bow and stern to Nos. 1and 4 pile clusters, respectively. The No.3 pile cluster, shown in figure 3 after the accident, is typical of the pile clusters at Total Petroleum's terminal. After securing the JUPITER to the Total Petroleum pier, the crew prepared to discharge its gasoline cargo. They connected the cargo hose and the bonding cable and gauged the tanks before they began discharging. It was expected that the cargo transfer would be completed during the morning and that the vessel would sail at 1200. lA mooring line that leads in a fore and aft or diagonal direction from a ship's side to ashore to constrain the ship's motion in a fore and aft direction when moored. Also used to draw a vessel alongside by the athwartship component of force exerted when the line is in tension and the vessel is in motion. .Preceding page blank :

,tate Park o t N 2 G "31" G"7" ESSEXVILLE CG Station Saginaw River Saginaw Bay Yacht Club ... ,~--R"10" R "14" BAY CITY SCALE I V2 . 3/4 Statute Miles Figure 1.--Saginaw River at Bay City, Michigan.

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5 BUFFALO.--At 0655 on September 16, the 635-foot-long bulk carrier BUFFALO entered the entrance channel to the Saginaw River. The master, the first mate, and the wheelsman were on the bridge. The master was conning the vessel, giving orders to the wheelsman, and operating the engine controls himself. The first mate had broadcast a "security" call over VHF-FM channel 16, advising that the BUFFALO was inbound in the Saginaw River, bound for Midland. About 0700, he called Coast Guard Station Saginaw River (Station Saginaw River) for a tide reading. Station Saginaw River advised him that the height of the tide was ( +) 33 inches. (A reading was taken later that indicated a height of [ + ] 28 inches). The BUFFALO's cargo, 13,585 tons of coal, gave the vessel a draft of 15 feet 6 inches forward and 18 feet 11 inches aft, for a displacement of 17,500 long tons. At 0730, the third mate relieved the first mate as watch officer. The BUFFALO's master testified that he continued at full speed (approximately 11-12 knots according to the third mate) until 0800, when he reduced speed to 9 feet of pitch 2 (approximately 6-7 knots) as the vessel passed buoys 27 and 28. (Vessel operators consider these buoys the entrance to the Saginaw River.) According to the BUFFALO's log, wind velocity in Saginaw Bay was 20 knots from the northeast. Visibility was about 3 miles in light rain. At 0800, Station Saginaw River radioed the BUFFALO and asked whether the vessel was inbound or outbound. The master radioed back that he was inbound en route to the Midland Contracting pier. Shortly thereafter, the master broadcast a second security call, advising of his position and destination. As the BUFFALO entered the narrow section of the river, the master reduced speed to 6 feet of pitch (approximately 4-5 knots). The master later testified that the bridge watch kept no record of the vessel's position in the river, the time of engine maneuvers, or the time of passing bridges, nor is it customary to do so on the Great Lakes. Deck log entries only indicated when the vessel entered the river and when it arrived at the pier in Midland. The master testified that he maintained 6 feet of pitch while the BUFFALO passed the marinas near Station Saginaw River. He said, "I have no knowledge of how to equate that to knots. I just know that it's a safe speed to handle the ship without doing damage. II As the BUFFALO started turning slowly to starboard toward the Detroit & Mackinaw (D&M) railroad bridge, he sighted the JUPITER moored at the Total Petroleum terminal. According to the master, he immediately reduced the pitch to 4 feet before adjusting the vessel's heading to pass through the right-hand draw (opening) of the swing bridge. The master testified that '4 feet of pitch was the minimum speed at which he could operate the BUFFALO and still maintain control. Lowering the pitch control another position would have placed the propeller at zero pitch and caused the engines to idle. He said that at the reduced speed, the wind had some effect on the vessel's handling. The wheelsman testified that he had to apply extra rudder to compensate for the wind, but he had no difficulty steering. As the BUFFALO approached the railroad bridge on a westerly heading, the master stated that the northeasterly breeze caused the vessel- to set to port toward the center span of the bridge. The BUFFALO passed through the draw with about 12-14 feet of clearance 2Theoretical advance of a propeller in one revolution measured in feet. The BUFFALO was equipped with a controllable-pitch propeller with pitch settings from 0 to 16.5 feet in the ahead position.

6 on each side.3 The BUFFALO's chief-engineer also testified that the vessel's pitch was at 4 feet going through the D&M railroad bridge. . As the BUFFALO was passing, a local yacht owner, was preparing to leave the Saginaw Bay Yacht Club pier, which was on the east side of the river about 1/4 mile upstream of the Coast Guard station. He testified that he ·waited until the bulk carrier went by and then maneuvered his 40-foot sailboat out into the river, following astern of the BUFFALO at a distance of about 300 feet through the" D&M railroad bridge. He testified that after the BUFFALO was lined up to enter the draw, the propeller wash seemed to increase until the vessel passed clear of the railroad bridge and then the wash decreased, but the vessel did not appear to create any significant wake. When the BUFFALO was about to enter the draw, the master sounded a whistle signal 4 to alert the bridge tender to open the Independence Bridge, a bascule-type highway bridge, 3/4 mile ahead. As the vessel's stern cleared the railroad bridge, the master ordered the wheelsman to steer to the right until the vessel was headed for the right-hand pier of the Independence Bridge. The wheelsman said that because of the BUFFALO's slow speed, he used hard right rudder to start the vessel swinging. The BUFFALO's third mate testified that the vessel's loran showed a speed of 2.85 knots about this time. The master testified that the BUFFALO was on the channel's centerline, but was favoring the "green," or left side. He estimated that the BUFFALO was 60-65 feet away when it passed abeam of the JUPITER. Because of the wind on his starboard quarter, he passed closer to the JUPITER than he otherwise would have. He stated, "Had there been no wind, we would have been further left." He testified that it was his belief that the passing of the BUFFALO did not cause the JUPITER to break away from the pier. He stated that he had piloted the BUFFALO in and out of the Saginaw River on four or five occasions during the current year without incident. Accident Action Aboard the JUPITER.--Aboard the JUPITER, cargo discharging continued while the BUFFALO continued its transit upstream. Shortly before 0800, the third mate (the 8-12 watch officer)5 relieved the first mate.(the 4-8 watch offiter).6 The two 8-12 watch able seamen (ABs) also relieved the two 4-8 watch ABs on deck. The third mate ordered the ABs to gauge the tanks to determine how much cargo remained aboard. The JUPITER's pumpman, who had been on duty since-the vessel arrived at the terminal, was also on deck. About 0830, just as the·JUPITER crew had 3The right hand draw had a clear width of 96 feet (6 U.S Coast Pilot-198, 20th edition). The BUFFALO's beam was 68 feet. 4The Independence Bridge tender notifies 911 Central Dispatch whenever the bridge will' be opened for marine traffic so that emergency vehicles can be rerouted if necessary. The bridge tender's clock and the 911 Central Dispatch time were not synchronized. The bridge tender's records show that the BUFFALO's whistle was sounded at 0833, that the bridge was opened at 0834, and that it was closed at 0840. The records of the 911 Central Dispatch show that the telephone call from the bridge tender was placed at 0831 :41, answered at 0831 :43, and completed at 0831 :54. The bridge tender called 911 Central Dispatch at 0841 :14 and reported the bridge closed. 50800- 1200, 2000-2400 watch. 60400-0800, 1600-2000 watch.

7 completed gauging the tanks, the third mate saw a vessel (later determined to be the bulk carrier BUFFALO) approaching the D&M railroad bridge, which was 0.35 mile downstream of the Total Petroleum terminal. He testified that as the BUFFALO passed through the railroad bridge opening, he heard the sound of its whistle signaling to open the Independence (highway) Bridge, located about 0.4 mile upstream of the Total Petroleum terminal. Three cargo pumps were operating at the time. The third mate ordered an AB to shut down the NO.2 cargo pump and attend to the forward mooring winch controls for Nos. 1 and 2 winches. He ordered the other AB to the after mooring winch controls for Nos. 3 and 4 winches.? The third mate testified that he then shut down Nos. 4 and 6 cargo pumps and went amidships with the pumpman to the valve manifold platform and started the hydraulic pump for the hose boom winch. The pumpman told the third mate that a ship was coming"awfully fast." He testified that he waved his arms in the direction of the BUFFALO as a signal to slow down. The AB at the after mooring-winch controls testified that the BUFFALO appeared to be closer to the JUPITER than he had observed in previous passages. The third mate testified that the flame screens were in place in the ullage 8pipes at all 12 cargo tanks but the covers on the ullage pipes were left open. He testified: It's standard procedure for us to shut down the cargo transfer operation and to have people standing by the winches in this river and in other rivers whenever a boat is going to be passing or there's going to be a ship passing. According to the terminal operator, as the BUFFALO approached the moored JUPITER, the level of the river rose about 4 feet, imparting a slight forward motion to the JUPITER. The tankship then surged aft about 8 to 12 feet as the water receded. He testified that as the BUFFALO passed abeam of the JUPITER, the tankship again surged forward with increased velocity until the NO.4 mooring wire cable grew taut and broke the center piling on the NO.4 pile cluster (see figure 4), releasing both the wire cable and the after polypropylene line. Both lines fell into the water. The AB assigned to the after mooring winch controls testified that when he went to the winch control platform, he saw that the pile cluster that held the stern lines was leaning toward the JUPITER, pulled over by the tension on the NO.4 wire cable. The AB testified that he had time only to depress the start buttons for the Nos. 3 and 4 winches when the piling broke. He thought he saw the NO.3 mooring cable go slack and "splash" into the water. He did not know whether the line had parted or whether the NO.3 pile cluster had also broken. (Investigators later determined that neither the wire nor the piling had broken. The NO.3 wire mooring cable had slackened. When asked, the AB gave no explanation for the slack wire.) The AB testified that he did not heave on the NO.3 tension winch because it would have pulled the tankship forward. He testified that when he left the winch controls, the motors were off and the control levers were in the neutral position. The first mate testified that when he took over the NO.3 winch controls from the AB in an 7Each winch had both port and starboard controls at four control consoles on each end of the main deck that were secured to the port and starboard bulwarks over an elevated platform, enabling the operator to see over the bulwarks to observe the wire cables. 8Distance between the liquid's surface in a tank and the reference point at the top of the tank. Crewmembers use this measurement to determine the amount of liquid in a calibrated tank.

8 .- ( : . . .. , .,....... .. .:.' ""-1,,-,------c",---,---::-: -.,--~--,------:,-"--"-.-.-.----.---. _...----- l ...' .,..'.. r.,""'", Figure 4.--No. 4 pile cluster showing the broken mooring pile. attempt to pull the JUPITER back to the pier, the winch motor was on and the control lever was in the neutral position. He pulled some slack out of the NO.3 wire cable with the winch, but because the wire was leading forward, he abandoned the attempt and left the NO.3 winch control lever in the neutral position. Meanwhile, the other AB manned the forward winch controls for the Nos. 1 and 2 winches. The third mate stated that as the vessel surged forward, he believed that the center piling on the NO.2 pile cluster also broke. (A photograph taken shortly thereafter showed that the NO.2 center piling did not break but that iater it burned almost to the water. See figure 5.) Because he was unable to use the NO.2 mooring cable to control the motion of the vessel, the AS glanced at the third mate

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10 and threw up his hands, as if indicating that he believed he could do nothing more to stop the JUPITER from surging ahead. Several witnesses stated that as the NO.1 pile cluster leaned toward the vessel, the polypropylene line stretched tight and pulled clear of the piling to which it was secured. The line catapulted into the air and partially landed on the vessel's foredeck. The stern of the BUFFALO had already cleared the JUPITER's bow when the tankship stopped moving astern and started to surge forward again. With no aft moorin~ lines to hold it, the vessel's stern then swung out into the river. The JUPITER s third mate and pumpman were amidships at the hose boom controls. When the hose stretched tight, the third mate and the pumpman lowered it to the deck to relieve the stress. The JUPITER's forward motion pulled the 12-inch pipeline off its foundation on the wooden pier, bending it in the upstream direction until it touched the upstream valve. (See figure 6.) The force of the motion caused a nitrogen purge line9 to break where it entered the top of the pipe, spilling gasoline onto the deck of the pier. Even with the additional slack in the cargo hose, nonetheless, it pulled apart from the stress and spilled gasoline on the pier and on the tankship's deck. An electrical conduit to a junction box fastened to the pier that powered the motor-operated valves pulled apart. The pumpman testified that he twice saw sparks flash on the pier from the damaged electrical wires. He said that the second flash ignited the spilled gasoline. . The fire on the pier spread along the hose, onto the JUPITER's deck, and ignited gasoline retained by a spill containment rail. The third mate testified that as he ran forward to the vessel's bow, he looked back and saw the entire midships area engulfed in flames. Using his handheld radio, he called the terminal to ask that the motor-operated valve be closed but did not wait for a reply. Instead, he continued running to the bow; the AB who had been at the forward winch controls joined him. The third mate stated that he intended to use the bow telephone to report the fire and to let go an anchor if the JUPITER started to drift into the river. Before he got to the bow, however, an explosion occurred (see figure 7), followed by a loud roar of fire from the burning gasoline. The third mate believed that more explosions were imminent. He stated that when he looked aft, the entire main deck was on fire. He turned to the AB and said, "Let's get out of here." Without taking time to don the Iifejackets stowed forward or to take a ring buoy hanging on the forward bulwarks, both men jumped overboard from the bow. The JUPITER's master testified that he had awakened at 0825 and gone to the ship's galley to give the cook instructions concerning some mail and the purchase of groceries. While he was in the starboard passageway, he heard the sound of a constant-tension winch operating. He described it as "groaning," or working hard. He ran to the after passageway door and saw the BUFFALO going by and the JUPITER moving away from the pier. The master testified that he then ran toward the pilothouse to call the BUFFALO to caution the master about speed in the river. As he approached the pilothouse, he saw that the forward and after winch controls and the cargo hose boom were manned according to "standard procedure." When he got to the pilothouse, however, he saw the pier breaking up and the cargo hose stretching taut despite his crew's efforts to lower it. He radioed the Coast Guard at 9Nitrogen under pressure is used to clear the pipeline of product at the completion of a transfer.

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-I ~.~- '" --. :~;i~f~~;~ , -1 .;--." 'I; Figure 6.--Pipelines and valves on the Total Petroleum pier. Station Saginaw River and reported that the JUPITER had been "sucked" off the pier and that the pier was breaking up. During his testimony, the master said that the events that followed happened so quickly that he had difficulty keeping them in chronological order. He did recall maintaining radio contact with the Coast Guard. He also remembered starting up the fixed foam generator; however, because the foam lines on deck were damaged, pressure in the lines was too low to have any effect on the fire. The master ordered the crew to the stern of the vessel for an accountability check. Both first mates checked that crewmembers had donned either life jackets or exposure suits. After accounting for the crew, the master searched the crew quarters to ensure everyone

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13 was on deck and then ordered the crew to abandon ship. At 0850, he notified the Coast Guard that men were in the water. Action Aboard the BUFFAlO.--When the BUFFALO's master was piloting the vessel, the third mate, who had only limited duties, was monitoring the vessel's wake from time to time from the starboard side of the pilothouse. When the BUFFALO's stern was about 500-600 feet beyond the JUPITER's bow, the third mate noticed the JUPITER's stern swinging away from the pier. Almost immediately, he saw afire start on the pier next to the JUPITER. He brought the fire to the attention of the master, who was conning the BUFFALO at the front windows of the pilothouse. The master walked over to the starboard side, looked back at the JUPITER, and saw the fire spread from the pier to the tankship. He testified that in a matter of seconds, the fire spread fore and aft along the deck of the JUPITER. He estimated that 30 seconds to 1 minute later, an explosion occurred. He overheard a voice, which he believed was the JUPITER's master, on his VHF-FM radio reporting the fire. Meanwhile, when the bridge tender at the Independence Bridge heard the BUFFALO's whistle signal, he called 911 (at 0831 :41) to inform the authorities that he would be opening the bridge. He testified that he routinely informed the 911 operator whenever he was about to open the bridge so that 911 personnel could reroute any emergency vehicle if necessary. He observed the JUPITER's stern swing away from the pier when the BUFFALO passed the tankship. He testified that as the BUFFALO approached the Independence Bridge, he radioed the vessel to check whether it had any problems. The BUFFALO replied that it had no problems. After the fire started on the JUPITER, the bridge tender called 911 again (at 0837:43) to inform them of the fire and that he would close the bridge as soon as possible after the BUFFALO went through in order to allow emergency vehicles to cross. The bridge tender's log showed the bridge was closed at 0840. He stated that the BUFFALO appeared to be traveling at the same speed that he had observed on previous passages of the vessel up the Saginaw River. Action at the Total Petroleum Terminal.--After the JUPITER started discharging its cargo, the terminal operator remained in the vicinity of the pier and the tank farm. He carried a handheld radio and was available at all times to answer any call from either the terminal office or the vessel. About 0800, the operator, the terminal manager, and assistant manager went aboard the JUPITER and had breakfast. After dining, the two managers returned to the terminal office, and the terminal operator went to the pump building near the head of the pier. (See figure 8.) While looking out the pump building's window, the terminal operator heard a whistle signal and saw a ship coming from the direction of the D&M railroad bridge. He stated that he recognized it as the BUFFALO and as it came closer, he became concerned about the speed of the vessel. Because he thought that the BUFFALO might be moving "too fast," he left the pump building and went out on the pier toward the JUPITER to watch the mooring lines. When he was about 100 feet out on the 396-foot pier, the BUFFALO was passing abeam of the JUPITER. He saw the tankship surge aft and then forward. He testified that when the boarding ladder fell away from the vessel, he turned and hurried back up the pier to close the valves. As he turned, he saw the 12-inch pipe on the downstream side of the pier being pulled over by the strain on the cargo hose from the JUPITER. He testified that he saw a "big flash of fuel" that quickly ignited and spread over two-thirds of the vessel's foredeck. As he ran up the pier, he shouted "Fire, fire" into his handheld radio. He

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15 ran to the valve that isolated the 12-inch pipe on the pier from the tank farm and quickly closed it. The fire, fueled by gasoline trapped on deck by a spill containment rail, quickly engulfed the deck of the JUPITER. Eyewitnesses reported three explosions, two on the port side and one on the starboard side, immediately following the spreading fire. The explosion tore away sections of the main deck and caused part of the deck on the forward starboard side to fold over the side of the vesseL The flames forced the 18 crewmembers into the water, where all but one were rescued by Coast Guard and civilian boats. One crewmember drowned when he jumped into the water from the tankship's bow without a lifejacket. His body was recovered several days later. The fire continued throughout September 16 and the next day. Professional fire fighting teams were hired to extinguish the blaze, assisted by several Coast Guard vessels and the Coast Guard Atlantic Strike Team. Because the JUPITER settled to the bottom and blocked the channel, the Saginaw River was closed to all marine traffic until a salvage team removed the remaining gasoline and moved the vessel clear of the channel. The tankship was later refloated and towed to a scrapping facility upstream. Until October 21, when the JUPITER was moved clear of the channel, all vessels upstream of the accident site, including the BUFFALO, were prevented from entering or leaving the river. Injuries to Persons Injuries Crew Other Total Fatal 1 0 1 Serious 3 0 3 Minor 3 *1 4 None 11 0 11 Total 18 1 19 *A Dow Chemical employee suffered from smoke inhalation. Damage JUPITER.--The explosions and fire aboard the JUPITER damaged the vessel's entire midsection. The vessel, valued at $9 million, was declared a constructive total loss and sold for scrap. The lost cargo was valued at $55,000. BUFFALO.--The BUFFALO sustained no damage as a result of this accident. Total Petroleum Terminal.--The Total Petroleum pier sustained damage from the surging motion of the JUPITER and the ensuing fire. (See figure 9.) The estimated damage to the pier was $276,000. Crew Information JUPITER.--The 1a-man crew of the JUPITER comprised 1 Coast Guard-licensed master, 3 Coast Guard-licensed mates, 4 Coast Guard-licensed engineers, 4 AB watchmen, 2 deckhands, 1 pumpman, 1 engine utilityman, 1 steward, and 1 porter. All unlicensed crewmembers held Coast Guard Merchant Mariner's documents. Each

16 Figure 9.--Damage to Total Petroleum's pier. of the three deck watches--12-4, 4-8, and 8-12-- was under the supervision of a mate who was responsible for cargo loading or discharging while in port and for navigation of the vessel while under way. The master had overall charge of the vessel. During cargo activity in port, the mate on watch supervised the pumpman. At other times, the chief engineer supervised the pumpman. The master of the JUPITER had been sailing as a licensed officer since 1973. Before his assignment as master, he had sailed on deck in various ratings, including AB seaman. Except for one voyage offshore, he had gained his experience on Great Lakes vessels. He started working for Cleveland Tankers, Inc., owners of the JUPITER, in 1976 as a relief mate, serving aboard four of the company's vessels at various times. He had been master of the JUPITER for approximately 2 1/2 months during the current season. He testified that since 1976, he had averaged 3-5 calls per year at the Bay City terminal. The first mate had been employed by Cleveland Tankers, Inc., for 10 1/2 years and each year had served some time aboard the JUPITER. He also had served on two other company tankships while employed with Cleveland Tankers. He graduated from the Great Lakes Maritime Academy in 1979 and held a Coast Guard license as master of Great Lakes vessels. He had served as first mate on the JUPITER since July 1990. The morning of the JUPITER accident, the regular first mate was

17 scheduled for vacation and had been relieved by another first mate at 0800 but had not yet departed the vessel when the accident occurred. The replacement first mate had held a mate's license for Great Lakes vessels since 1980. He had been employed by Cleveland Tankers, Inc., since 1983, during which time he had served aboard the JUPITER intermittently. He had sailed on the JUPITER earlier in the year. In June, he transferred to the GEMENI, another company tankship, until his return to the JUPITER on the day of the accident. He reported aboard several hours earlier and had exchanged vessel information with the regular first mate. The second mate had served 7-8 months aboard the JUPITER before the accident. A 1987 graduate of the Great Lakes Maritime Academy, he held a Coast Guard license. as mate aboard Great Lakes vessels. He previously worked on the vessels of U.S. Steel's Great Lakes Fleet. He had been employed by Cleveland Tankers, Inc., since 1989, during which time he served aboard three of its vessels. The third mate joined the JUPITER crew on June 10, 1990, shortly after graduating from the "Great Lakes Maritime Academy. He had made two previous trips into Bay CitY, one of which was to the Total Petroleum ter·minal. He normally stood the 8-12 watch. He held a Coast Guard license as mate on Great Lakes vessels . The JUPITER's pumpman had 35 y,ears experience salling as a merchant seaman both 'offshore and on the Great Lakes. Employed by Cleveland Tankers, Inc, since 1981,-the pumpman had sailed on several vessels in its fleet but mostly on the JUPITER . " The surviving 8-12 AB/watchman had sailed on seagoing vessels since 1957. He had been employed by Cleveland Tankers, Inc., aboard Great Lakes tankers since 1979, during which time most of his experience had been aboard the JUPITER. BUFFALO.--The master of the BUFFALO received his first Coast Guard license in 1971 and started sailing as third mate in 1972. In 1982, he started sailing as master aboard Great Lakes vessels. He had prior experience as a master piloting vessels in the Saginaw River. During the current season, he had piloted the BUFFALO in the Saginaw river on five occasions. As part of his training, he had attended a 2-week shiphandling course at a special simulator school in Port Revel, France. Hisemployer, American Steamship Company, also required him to observe shiphandlers on other company vessels before he was assigned as master. " On the day of the accident, the BUFFALO's master had slept 5 hours when he was called to the bridge at 0730. He testified that he felt rested and was not fatigued.' He said that he followed his normal routine, that is, he did not eat breakfast and consumed "lots of coffee." He did not smoke or take medicine, alcohol, or drugs. He stated that he had no health problems and generally considered himself healthy. . . The third mate, who served as watch officer during the BUFFALO's passage in the Saginaw River, had held a mate's license for the Great Lakes since 1979. He had worked aboard the BUFFALO since March 1990, usually as second mate rather than third mate. He started sailing on Great Lakes vessels at age 17 and worked his way up to AB and mate. During the current season, he had made 20-30 trips into the Saginaw River.

18 The AB/wheelsman at the BUFFALO's helm on the day of the accident had sailed on the BUFFALO since 1982. He had held a Coast Guard merchant mariner's document as AB since 1969. He had 13 years experience as a wheelsman and had made six or seven trips into the Saginaw River during 1990. His other duties aboard the BUFFALO included operating the conveyor belt and the cargo discharge boom. Toxicological Testing The Coast Guard regulations at 46 CFR 4.06--Mandatory Chemical Testing Following Serious Marine Incident Involving Vessels in Commercial Service--and at 33 CFR 95--0perating a Vessel While Intoxicated--require that the marine employer take all practicable steps to have individuals directly involved in a serious marine accident undergo a chemical test for drugs and alcohol. A law enforcement officer may order the marine employer to have additional individuals tested if, in the officer's opinion, they also were directly involved in the accident. On September 16, the day of the accident, a Coast Guard boarding officer visited the BUFFALO at the Midland Marine pier to conduct a preliminary investigation of the accident and to ensure that chemical tests were performed on those crewmembers that were directly involved in the operation of the vessel. A representative of the marine employer stated that tests had been ordered for nine members of the BUFFALO's operating crew. Using the testing kits aboard the vessel, urine specimens were taken and sent to an independent laboratory where tests for drugs were performed. The results of the tests showed the specimens to be "drug- free" under the current Coast Guard regulations. Since the BUFFALO had berthed several hours before and some of the crew had already gone ashore and returned, it was decided that any results of a test for alcohol on the individuals concerned would not be conclusive since much time had elapsed. Therefore, testing for alcohol was not performed. Immediately' after the rescue of the JUPITER's crewmembers from the water, they were treated and released by the local hospital before any drug or alcohol tests were ordered. A company representative arranged hotel accommodations for them in Bay City. Later, four of the crewmembers who were on duty at the time of the accident were ordered to a local medical facility where they were tested for drugs, but not alcohol.lO Testing for drugs was performed by an independent laboratory. The test results for drugs were reviewed by the testing facility's medical review officer (MRO), who determined that they were negative. During the autopsy of the AB who drowned during the evacuation of the JUPITER (2 1/2 days earlier), blood specimens were tested for drugs and alcohol. Medical records indicated that no drugs were found. The blood was found to have an alcohol concentration of 0.02 percent. Vessel Information JUPITER.--In 1976, S.B.A. Shipyards in Jennings, Louisiana, built the JUPITER, a chemical tanker, for Cleveland Tankers, Inc., a division of the Ashland Petroleum Company. The tankship was documented by the Coast Guard in Wilmington, Delaware. The vessel had received its most recent Coast Guard inspection before the accident on March 21, 1990, in Milwaukee, Wisconsin. (See appendix D.) The Coast 10Exact times ofthe events were not available.

19 Guard completed the vessel's last hull inspection on drydock on April 7,1987. Coast Guard records for both inspections show no outstanding discrepancies. The Safety Board's investigation found no deficiencies on the vessel except for the flame screen installation. The American Bureau of Shipping (ABS) classed the vessel *(Maltese Cross) A1 Oil Carrier,1 1 Great Lakes and St. Lawrence River Service.· The ASS classed its machinery *(Maltese Cross) AMS.12 The following list shows the JUPITER's principal characteristics: Length overall Length between perpendiculars Beam Molded depth Maximum draft Gross tonnage Net tonnage Deadweight tonnage Horsepower 392 feet 382.42 feet 60 feet 25 feet 19.1 feet 4,263 3,764 10,932 4,200 The JUPITER's main propulsion plant consisted of two General Motors diesel engines with Falk reduction gears coupled to two shafts, each of which was fitted with a stainless steel propeller. The vessel was equipped for bridge control of the engines. Three 300-kw diesel generators furnished electrical power. The crew quarters were on the port and starboard sides of the main deck aft, over the engineroom. The galley and the messroom were located between the port and starboard passageways. The wheelhouse, situated over the crew quarters, had an unobstructed view overthe bow. (See figure 10.) The JUPITER's cargo tank section was divided into 12 tanks, 6 port and 6 starboard, separated by a single longitudinal bulkhead and 5 transverse bulkheads. (See figure 11.) Each of the JUPITER's port and starboard cargo tanks were interconnected by pipelines and valves to one of six electrically driven deepwell pumps.13 Through a series of bypass valves, one or two pumps could discharge the cargo from a four-tank group. For example, a pump could discharge Nos. 1 and 2 port and starboard while another pump could discharge Nos. 2 and 3 port and starboard. Each pump discharged into a common manifold at the discharging/loading station amidships. A nonreturn valve on the discharge side of each pump prevented product backflow after the pump was secured. Each tank had a pressure/vacuum (PN) valve fitted with a flame screen. The center of each tank had a 20-inch-diameter clean-out hatch through which an 8-inch ullage pipe was installed. (See figure 12.) 11This classification indicates that the vessel has been built to the full requirements of the ABS Rules for Great Lakes service at the assigned freeboard as an oil carrier and that the equipment aboard the vessel, such as anchors and chains, complies with the rules. 12This classification indicates that the machinery has been built in accordance with the ABS rules. 13A fixed submersible pump installed at the bottom of a tank driven by a vertical shaft from a power source on deck.

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--392 Feet-------- --- NQl NQ2 NQ3 PUMP CONTROLS PUMP CONTROLS PUMP CONTROLS NO.5 NO.6 PUMP CONTROLS PUMP CONTROLS #3 STBD -"_ ---N -' STERN CAPSTAN DECK HOUSE CREW QUARTERS BElOW WHEELHOUSE #5 PORT #5 STBD NO.4 PUMP CONTROLS DOUBLE HULL o #4 PORT MANIFOLD PIPING AND VALVES 40 FOOT CARGO HOSE #2 PORT ( ( TENSION WINCHES BOW M'vJUPITER Figure 11.--JUPITER's tank arrangement.

22 The top of each ullage pipe was equipped with a closed gauging system and a flame screen. Four 1/2 x 1/2 x 1-inch pieces of steel stock, equally spaced and welded to the inner surface of the ullage pipe, supported the flame screens. (See figure 12.) The flame screen installation precluded the use of the closed gauging system. The JUPITER did not use the closed gauging system when carrying Grade B cargo because it was not required and because crewmembers found the gauge mechanism unwieldy and the gauging tape difficult to read through the heavy glass viewing port. Instead, crewmembers swung the gauge covers open and lowered handheld measuring tapes into each tank between the edge of the flame screen and the inside of the ullage pipe. They then left the tapes hanging with the gauge covers open. (The JUPITER was not equipped with an inert gas system.) The flame screen support did not provide a complete seal around the periphery of the screen. Cleveland Tankers, Inc., purchased the Coast Guard-approved 12-unit closed gauging system from the Petroleum Gauging and Appliance Company, Houston, Texas, and had it installed during construction of the vessel. Investigators could not determine whether the flame screen installation in the ullage pipes was part of the original purchase or whether the Coast Guard had approved it. Coast Guard construction standards for flame screens are contained in 46 CFR 30.10-25. A Coast Guard spokesman stated that a "common sense item" is that Coast Guard inspectors are expected to check to ensure that the flame screen provides a complete seal around the screen periphery. The vessel was double-hulled with side tanks and double bottom tanks used exclusively for ballast water. The JUPITER had a separate ballast piping system with a dedicated ballast pump to fill or dewater the ballast tanks as necessary, usually during loading or discharging. Each ballast tank had goose-neck-type vent pipes along the port and starboard sides of the main deck. To prevent any product spilled on deck from running over the side, each side of the main deck had a 6-inch high steel plate fitted along the edge as a containment rail. The JUPITER had the following safety equipment aboard: 3 20-man liferafts, 24 lifejackets, 23 immersion suits, 12 ring buoys (6 equipped with lights), an emergency position indicating radio beacon (EPIRB), fire hose, 5 fire axes, and 18 portable and semiportable fire extinguishers. On the main deck, the vessel had a fixed foam extinguishing system with four monitors, two aft over the crew quarters and two forward of the cargo tanks. A fixed halon fire extinguishing system protected the engineroom. Cargo Operations Aboard the JUPITER.--After the crew secured the JUPITER at the pier, the second mate (the 12-4 watch officer)14 met with the terminal representatives to exchange required cargo documents and to supervise the gauging of the cargo tanks to determine the amount of cargo aboard. The crew took the gaugings or ullages through the open ullage pipes. Because the cargo had been loaded in Canada, a cargo manifest had been prepared to obtain the necessary clearance by U.S. Customs before the vessel could begin discharging. At 0240, the second mate and terminal personnel completed their document exchange, including the execution of the Declaration of Inspection Prior to Bulk Cargo Transfer as required by Coast Guard regulations, 33 CFR 156.20, 156.150, and 46 CFR 35.35-30. (See appendix C.) Discharging commenced. 140000-0400, 1200-1600 watch.

pat ~. IH ~ .'.- t ' r 23 . , Figure 12.--Tank gauging device in open position. ._-.....,.........---. .. ~}.~j ... "i, • ., -~~ ~-' ....." .~. - ... ~: . .... .. "'~; ~ .~''': : ~

24 Immediately after the vessel was made fast, a crewman passed a bonding cable to a terminal employee on the pier; the employee electrically grounded the vessel to shore by connecting the cable to the pipeline. The 8-12 watch (third mate and two ASs) rigged an 8-inch flanged cargo hose from the vessel to the pier. The vessel's hydraulically operated cargo hose boom supported the hose. The watch bolted the flanged ends to the cargo manifold on the vessel and to one of two pipelines on the pier. Terminal personnel removed a blank flange from the connection on the pier and, assisted by one of the 8-12 ASs, connected the JUPITER'S hose. After they made the connection, they opened the cargo tank valves and the valve at the loading/discharge manifold. Terminal personnel opened a motor-operated valve on the pier and the valves ashore to the receiving tanks. They tested a remote emergency shut-off switch that was connected to the motor-operated valve by an electrical cable and looped the cable over the railing at the gangway. In an emergency, the tankship's personnel could close (but not open) the motor-operated valve from the deck of the vessel. The terminal lent a VHF-FM handheld radio to the ship's watch officer for communicating with the terminal operator and the terminal office. After the third mate and the two ASs finished connecting the cargo hose, the 12-4 watch (second mate and two ASs) took over the duties on deck. In addition to the regular watch, the JUPITER'S pumpman was also on duty to help the second mate open valves, start pumps, and take on ballast as required. The pumpman testified that he opened the NO.2 tank valves, port and starboard, and started the No.2 pump. As the discharge pressure increased, he checked the connections. The second mate testified that he found no leaks. He stated that terminal personnel said that the shoreside valves were properly set and they were receiving the product. Sefore crewmembers started additional pumps aboard the JUPITER, the watch officer ordered the discharging operation stopped from 0300 to 0335 while an outbound vessel, the 638-foot-long IRVIN L. CLYMER, passed in the river. A watch AS had sighted the outbound vessel approaching and notified the watch officer. The officer ordered the cargo pump stopped and the forward and after tension winch controls manned until the vessel passed clear. At 0400, the first mate relieved the second mate and the 4-8 ASs relieved the 12-4 ASs. The JUPITER'S pumpman remained on duty. The JUPITER's six deep well pumps were each powered by a separate electric motor with separate controls in individual pump houses on the main deck. After 0400, crewmembers opened the Nos. 4 and 6 tank valves, port and starboard, and started Nos. 4 and 6 pumps. The pumpman testified that it was customary aboard the JUPITER to pump Nos. 2, 4, and 6 cargo tanks down 10 feet before opening the crossover valves to the remaining tanks. According to the JUPITER's pumping record, during the first mate's watch (0400-0800), power failures aboard the vessel caused the pumps to stop on two occasions, from 0510 to 0525 and from 0600 to 0615. The 4-8 watch opened the remaining tank valves during its watch. Sy that time, three cargo pumps, Nos. 2,4, and 6, were pumping from all cargo tanks. The JUPITER's cargo piping system was configured so that a series of cross connections enabled them to pump from all 12 tanks simultaneously. The third mate testified that when he ordered the two ASs to gauge the cargo tanks at 0815 to determine the amount of cargo remaining aboard, he wanted to establish a pumping rate. to ascertain when discharging would be completed. As the men gauged the tanks, the third mate recorded the ullages. Shortly thereafter, the third mate determined that 22,268 barrels of unleaded gasoline remained to be discharged.

25 Automatic Constant-Tensioning Mooring Winches.--The JUPITER had four: electrohydraulic constant-tensioning winches located on the main deck, two forward and two aft. The forward winches were paired and numbered 1 and 2 port and starboard, respectively; the after winches were paired and numbered 3 and 4 port and starboard, respectively. Each winch drum was rove with approximately 400 feet of 7/8-inch diameter wire rope cable that could be led to either side of the vessel. Each pair of winches was electrically interlocked so that crewmen could control direction of drum rotation, speed, and tension from either the port or the starboard console. The winches on the JUPITER were operated in the following manner. To activate the winch, an operator had to have the control handle in the neutral position. (See figures 13 and 14.) After starting the electric motor by depressing the start button on the control panel, the operator moved the control handle outboard to the "payout" position, allowing the wire to unreeve from the drum. He controlled payout line speed by moving the control handle away from or back to the neutral position. To stop the wire movement, the operator returned the control handle to the neutral position. To heave in on the wire cable, the operator moved the control handle inboard to the heave position. Again, he controlled line speed by moving the handle away from or back to the neutral position. At the maximum setting with no load on the wire cable, light line speed was 350 feet per minute. Th"e rated line pull was 22,000 pounds at 55 feet per minute. To stop heaving the cable, the operator returned the control handle to the neutral position. The position of the winch control handle for maximum heave is in the same direction as the standby position. The operator used this position to maintain constant tension on the wire cable and to hold the vessel alongside the pier. The winch could also be operated in this position unattended. When the control handle was in the standby position and the winch sensed full line tension," the brake set automatically. After 8 seconds, the electric motor stopped and did not restart for 105 seconds. After 105 seconds elapsed, the electric motor restarted to heave in any slack in the wire cable if necessary. The operator could cancel this mode of operation by moving the control handle out of the standby position or by depressing the stop button. An internal adjustment in the winch could be preset for the desired maximum holding tension in the standby mode. Maximum holding tension was 25,000 pounds. A note of caution in the operating manual for the winch states: " As [when] unusual conditions are present which will cause rapid and extreme changes in line tension, this [standby] mode is not recommended. " The JUPITER's third mate testified that when the JUPITER's crew operated the constant tension winches, they moved the controls to the payout position so that they could run enough wire off the drum to reach the mooring pile on the pier. (Full payout speed was approximately 350 feet per minute.) They then moved the winch controls to the heave position to remove the slack from thewire. When the wire was tight, they placed the control handle in the standby position to automatically heave until the preset tension was reached. The brake set automatically when full line tension was reached and the electrohydraulic motor stopped. They then depressed the stop button to maintain the brake setting and placed the control handle in the

26 /---- ------------., Reproduced from best available copy. ---------_/ .........--:.--,. ."!'~ ' ,.' .. .. . . . •.:1- .... ".... "" ' ...... _ • '., ," '.,;" ""-.'11 of<' J- !II- ••,.... ~- 'j. ~ '~ • '1 .. • ._ fF.. ' ... '

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',. ~ . Figure 13.--Nos. 1 and 2 constant-tension winch controls, starboard side, forward. neutral position. The third mate explained that with the winch in this mode, the crew could start it immediately when required. A manufacturer's representative pointed out, however, that when an operator started the winch motor with the control handle in the neutral position, the brake was automatically released. Investigators found most of the wire from the NO.3 winch payed out with no tension on it on the river bottom. The eye of the wire was over the mooring pile, and turns of wire were still on the winch drum. (This was the wire the third mate heard "splash" in the water.) BUFFALO.--In 1978, the Bay Shipbuilding Corporation in Sturgeon Bay, Wisconsin, built the BUFFALO, a self-unloading bulk carrier, for the American Steamship Company. The vessel was documented by the Coast Guard in Philadelphia, Pennsylvania. Its last Coast Guard inspection before the accident was on March 20, 1989, in St. Ignace, Michigan. (See appendix E.) The Coast Guard's last hull inspection of the vessel on drydock was on March 23,1988. The Safety Board's

27 eproduced from best available copy. 0 Figure 14.--Nos. 3 and 4 constant-tension winch controls, starboard side, aft. investigation revealed no mechanical deficiencies. The ABS classed the vessel *(Maltese Cross) A1 (E) Great Lakes and St. Lawrence River Service and its machinery *(Maltese Cross) AMS. The BUFFALO's principal characteristics were: Length overall Length between perpendiculars Beam Molded depth Maximum draft Gross tonnage Nettonnage Deadweight tonnage Horsepower 634.89 feet 617feet 68 feet 40 feet 27.3 feet 11,619 8,036 28,770 7,200

28 The BUFFALO's main propulsion plant consisted of two General Motors B-20-645-E7 diesel engines with Falk reduction gears coupled to a single shaft fitted with a stainless steel controllable-pitch propeller that was controlled from the bridge. Three General Motors 670-kw AC generators furnished electrical power to the vessel. The BUFFALO was equipped with bow and stern thrusters. The single deckhouse, located aft over the engineroom, contained the navigating bridge, crew quarters, galley, messroom, and conveyor machinery. (See figure 15.) The conveyer boom had an outreach of about 220 feet. Twenty hatches provided access for loading to the BUFFALO's five cargo holds, which varied in length from 72 to 120 feet. Bulk cargos were discharged by means of two conveyor belts that transported the material to the discharge boom. When the BUFFALO had no cargo aboard, it could carry 14,154 tons of water ballast in 12 double bottom tanks, 6 port and 6 starboard, and the forepeak and afterpeak tanks. The BUFFALO had the following safety equipment aboard: a 30-person lifeboat, 4 inflatable liferafts with a total capacity of 90 persons, 36 lifejackets, 32 immersion suits, 24 ring buoys (12 equipped with lights), a portable lifeboat radio, an EPIRB, fire hose, 8 fire axes, and 34 portable and semiportable fire extinguishers. A fixed halon fire extinguishing system protected the engineering spaces, and a fixed C02 system protected the emergency generator room. Terminal Information Located on the west side of the Saginaw River in Bangor Township, Bay County, Michigan, the Total Petroleum terminal was a wholesale petroleum facility. The terminal received most of its products by pipeline and stored them in above-ground tanks that had a total capacity of about 600,000 barrels. Terminal personnel loaded products into customer's trucks through loading racks at the north end of the terminal. The oil transfer facility, adjacent to the waterway, gave the terminal the ability to transfer products to and from vessels moored at the end of the 390-foot-long pier. According to the terminal operator, vessels berthed at the facility infrequently. He stated that the JUPITER was its "best customer" and recalled that the tankship averaged two to eight calls a season at the terminal. The JUPITER's master could not recall any prior problems from passing vessels while moored at the Bay City terminal. . The pier was a wood structure, built in 1986 by William W. Stender, Inc., Marine and General Contractor, Bay City, to replace a previous structure that dated from

1. The deck of the pier, on which the two pipelines were mounted, was 6 feet

wide. On the upstream side, a 1O-inch welded steel pipe was used to transfer light heating oil products. On the downstream side, a 12-inch welded steel pipe was used to transfer gasoline products. Both pipelines were elevated approximately 2 feet above the deck at the river end of the pier to enable terminal personnel to clear the pipe of product after they completed transfer operations. Personnel cleared the pipelines using pressurized nitrogen from a 1 1/2-inch purge pipe installed on the pier and connected to the outer ends of the pipes. The terminal stored the nitrogen bottles in the firepump building near the head of the pier. Valves controlling the nitrogen were located in the pump building and on each branch line to the 10-inch and 12-inch transfer pipelines at the end of the pier.

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30 Manually operated gate valves adjacent to the pump building isolated the pier pipelines from the tank farm. When the fire started on the JUPITER, the terminal operator closed the 12-inch valve to isolate the pier from the rest of the facility. (See figure 8.) He also stated that the storage tanks were fitted with a flapper-type nonreturn valve that could be opened manually when product was to be transferred from the tank. According to Total Petroleum's area general manager, there are no check (nonreturn) valves between the pier and the pump building. The river end of each pipeline was fitted with an 8-inch motor-operated nonrising stem gate valve. The valves were elevated to allow clearance for a drip tub under each outer flange connection in the event some product was unintentionally released while the transfer hose was being connected or disconnected. The outer flange at each valve had a 90° 8-inch elbow mounted in a vertical position to which a vessel's hose was bolted. A weathertight metal box with exterior control buttons housed the controls for the motor-operated valves. A small portable metal box fitted with an electric wire long enough to reach a vessel's deck while it was moored at the pier contained a remote kill switch. When placed aboard a vessel, the single-button kill switch enabled vessel personnel to simultaneously close the motor-operated valves and stop the shoreside pump when the vessel was loading. The motor-operated valve could only be closed from the controls on the pier or by the kill switch aboard the vessel. However, terminal personnel could control the pumps from the pump building. The four mooring pile clusters were positioned so that moored vessels lay against the two center clusters. Vessels such as JUPITER secured their mooring lines to the wood center pile of each cluster that extended above the other piles in each of the 12-14 pile clusters. The pilings were "Class B" size, at least 13-inches in diameter, approximately 55-feet long, and driven 20 to 21 feet into the river bottom. The pilings were spaced about 1 foot apart at the river bottom. The upper portions of the pilings were wrapped together with galvanized wire held in place with wire staples. The pile clusters (dolphins) were of the flexible type; the cluster will return to its original upright position after leaning due to a horizontal load. According to an industry guide, Design and Construction of Ports and Marine Structures written by Alonzo DeF. Quinn, pile clusters are used for mooring small vessels, generally under 5,000 deadweight tonS. 15 Quinn includes industry standards for different sizes of pile clusters, as well as recommended leads for mooring vessels, in this publication. 16 The owner of the marine construction company that built and repaired the pier and pile clusters stated that his company built the original pier in 1943, probably to the standards used during that period, and replaced the pier in

1. Records indicate that in 1985 Total Petroleum had the NO.3 cluster replaced.

The company also had the NO.2 cluster upgraded by adding six additional white oak piles because it was subject to additional force when vessels were maneuvering 15Design and Construction of Ports and Marine Structures by Alonzo DeF. Quinn, McGraw- Hill Book Company, 1972. 16The publication illustrates a method of mooring a vessel to a pier using six mooring lines that lead to six individual pierside mooring devices: a bow line leading ahead of the vessel, a forward breast line leading approximately 90° to the center line of the vessel, a forward spring line leading aft, an after spring line leading forward, an after breast line leading approximately 900 to the center line of the vessel, and a stern line leading aft ofthe vessel.

31 alongside when berthing. The contractor also believed that he installed the NO.4 cluster between 1983 and 1987. He stated that the average life of a 14-pile cluster is 15 to 20 years and that the average life of the center mooring pile is 10 to 12 years. In May 1989, his company installed a fifth 21-pile cluster, about 50-80 feet upstream of the NO.1 pile cluster, specifically to moor a large" Amoco barge" that had its cargo valve manifold located at the after end of the vessel. This mooring device consisted of three 12-inch steel pilings driven in the center of a 21-pile cluster. Filled with concrete, these steel piles extended above the wood piles to which the barge's mooring lines were fastened. The 1989 improvements to the pier were authorized under a permit issued by the U.S. Army Corps of Engineers (USACE) on November 17, 1988, valid after authorization by State and local jurisdictions. A USACE review of a permit application and site is normally limited to determining a structure's location in the waterway and the potential environmental impact of the construction. The USACE review does not determine the adequacy of a structure for the mooring of vessels. The facility owner has the responsibility for identifying the scope of his needs and customarily employs a civil engineer to design an adequate structure. In an affidavit dated March 4, 1991, the marine contractor stated that before each shipping season began, he visually inspected the pier and mooring pile clusters for signs of damage that may have occurred over the winter. The affidavit does not mention probing or similar tests to check for deterioration in the wood. No repairs or alterations had been made to the pier or the pile clusters since the May 1989 installation. The facility's Terminal Operations Manual, dated October 1986, conforms to the Coast Guard regulations at 33 CFR Part 154, Oil Pollution Prevention Regulations for Marine Oil Transfer Facilities. This manual contains no instructions that require a vessel in the process of transferring a product at the facility to shut down loading/discharging operations when another vessel of significant size passes in the river. The decision whether to secure is left to the vessel personnel. The Coast Guard regulations do not specifically address when, or for what reason, transfer operations should shut down. However, 33 CFR 154.550 and 155.780 do address how to effect a shutdown between a vessel and the pier using the remote kill switch aboard the vessel. Total Petroleum met the communication requirements outlined at 33 CFR 154.560 and 155.785 by providing handheld radios to terminal and vessel personnel. The most recent inspection took place on April 4, 1990, when Coast Guard inspectors from the Marine Safety Office in Detroit visited the Bay City Total Petroleum facility to check for compliance with Federal regulations pertaining to liquid bulk transfer facilities as outlined at 33 CFR 154. The terminal manager accompanied the inspectors during the inspection. The report prepared following this inspection indicated that the terminal was in compliance with the regulations, and inspectors found no discrepancies or hazardous conditions. However, the report did not address the terminal's mooring arrangements. Coast Guard regulations at 33 CFR 156.120--0il Pollution Prevention and Hazardous Material Transfer Operations-- address only the vessel's mooring arrangements. On August 23, 1990, Coast Guard inspectors conducted a "spot" inspection of the pier that included an examination of the valve arrangements; they noted no discrepancies.

32 Wreckage JUPITER.--The 6-inch spill containment rail trapped burning gasoline on the deck of the JUPITER. At Nos. 1 and 2 port, at No.3 starboard, and at Nos. 4 and 5 port cargo tanks, sections of the main deck were blown off, exposing the gasoline remaining in the tanks. Photographs taken by an eyewitness on the Independence Bridge indicate that the first explosion probably occurred on the port side of the vessel, possibly at Nos. 4 and 5 tanks, followed by explosions at NO.3 starboard and Nos. 1 and 2 port. A postaccident view of the vessel from the air showed the extent of the explosions. (See figure 16.) The longitudinal bulkhead separating the Nos. 1 and 2 port and starboard tanks had ruptured and pulled away from the tank's bottom plating, exposing the double bottom tanks below. (See figure 17.) The after bulkhead between Nos. 2 and 3 starboard tanks had split, and the surrounding steel area appeared to have been burned. The hull buckled in two places at Nos. 3 and 5 tanks. The entire midships section sagged and settled to the bottom. However, a diving team found the bottom of the hull intact. Although distorted, both sides of the double hull remained intact and watertight. (See figure 18.) On the main deck, the explosions tore off pipelines and other deck equipment, including the pipelines that were part of the fixed foam fire fighting system. (See figure 19.) Damage to the foam lines caused the pressure in the system to fall. As a result, the foam did not reach the cargo manifold area. The intense heat distorted the remaining portions of the main deck. The force of the explosion caused a section of deck plating at NO.1 port cargo tank to drape over the vessel's side. The blasts also blew away the foremast. A section was found on the bow of the tankship. The fore and aft catwalks and manifold platform at the loading/ discharge station were bent, and some parts were missing. The NO.2 constant-tension winch, originally located over NO.1 cargo tank near the centerline, was blown overboard and remains missing. Safety Board and Coast Guard investigators found the NO.1 winch control partially in the payout position and the NO.2 winch control partially in the heave position. (See figure 13.) Investigators found the Nos. 3 and 4 winch controls in the neutral position. (See figure 14.) The positions of the winch controls may have been disturbed by firefighters, salvors, and others before investigators boarded the vessel. The bow section forward of the cargo tank section remained intact. Except for minor smoke damage, the storeroom forward was intact. The stern section, which included the engineroom, crew quarters, galley, storerooms, and messroom, was undamaged. After firefighters extinguished the fire, they found that the generators in the engineroom were still running. Salvage crews removed the remaining gasoline from the cargo tanks before the vessel was refloated, and they towed the JUPITER to a ship breaking facility in Bay City. BUFFALO.--The BUFFALO sustained no damage as a result of this accident. Total Petroleum.--The 12-inch pipeline was bent and pulled loose from its foundation (see figure 6). When the pipeline pulled loose, the 1 1/2-inch nitrogen purge line to the pipe broke. The aluminum walkway on the upstream side of the pier leading to the Nos. 1 and 2 mooring pile clusters was damaged. The fire damaged the motor-operated valves at the end of the pier and burned the NO.2 mooring pile cluster almost down to water level. The JUPITER's wire broke the center piling of the NO.4 cluster. The estimated cost of the repairs to the Total Petroleum pier was $276,000.

,----~ i

.

ego au ~G1 '0:0 GlIll u= llll '0> o III '"- 11... alGI a:,Q i I II·I It l- f.. ; i--- II fJ.I i. ; . , - i - 33

34 Figure 17.-- Damage to the bulkheads in No.2 starboard cargo tank. Figure 18.--Damage to No.1 port cargo oil tank showing the double hull.

35 Figure 19.--View of the damage on the main deck. Waterway Information The Saginaw River is at the head of Saginaw Bay on the west side of Lake Huron. Vessels enter the river through a 350-foot-wide channel that is dredged to 27 feet and extends 13.5 miles. Channel buoys and a centerline range mark the channel. At the mouth of the Saginaw River, the channel width narrows to 200 feet. At Bay City, the channel depth is 26 feet. In the upper sections of the 22-mile-long river, depths decrease to about 15 feet at the south end of Saginaw City. Bay City is about 2 miles from the mouth of the Saginaw River. The Total Petroleum terminal is on the west side of the river, about 1 1/2 miles farther upstream. Numerous wharves and waterfront facilities line both sides of the river. The BUFFALO's intended destination, the Midland Contracting Company pier, is approximately 6 1/2 miles from the river entrance. Vessels in the Bay City/Saginaw port area mainly transport commercial commodities, such as petroleum products, grain, limestone, coal, sand, gravel, and cement. Bay City/Saginaw is a designated customs port of entry.

36 The Saginaw River's mean monthly water level varies about 3 feet from the highest to the lowest. Heavy rains and flooding may cause unusually high water levels. Considerable fluctuations in the Saginaw's water level can occur during several hours of violent northeast or southwest winds. Vessels have grounded in the dredged channel during periods of unusually low water in Saginaw Bay. According to a USACE survey conducted in September 1990, at mean low water, the water depth in the dredged channel opposite the Total Petroleum berth was 26.8 feet. At the Total Petroleum pier, the depth at mean low water varied from 24 to 26 feet. The JUPITER, as moored, did not extend into the dredged channel, according to charts furnished by the USACE. Meteorological Information At 0800 on September 16, Coast Guard Station Saginaw Bay recorded the following weather observations: cloudy; visibility, 7 miles; easterly wind at a speed of 7 knots; air temperature 53°F; water temperature 71°F; barometer 29.82, rising. At 1000 on September 16, the station log entry indicated a 12-knot wind from the northeast. According to the sailin~ Directions for Lake Huron and Saginaw Bay region of Michigan, southerly throug westerly winds prevail in the early autumn. From spring through fall, thunderstorms can produce short periods of high winds. Total Petroleum's terminal manager testified that cargo transfer operations between vessels and the terminal are usually suspended during thunderstorms. Medical and Pathological Information Survivors' Injuries.--Information in Bay City Medical Center's (BMe's) Emergency Disaster Flow Sheet/Log indicated that medical personnel examined 17 crewmembers from the JUPITER. Six men sustained injuries, three of whom were treated and released, and three were admitted to BMC. Medical records show that injuries sustained included burns to the face and hands, head injuries (closed), mild cold exposure, contusion on the lumbar spine, chest pains, headaches, ringing ears, a forehead laceration, and an abrasion on the lower leg. A Dow Chemical employee suffered smoke inhalation. Fatal Injuries.--A 46-year-old male AB on board the JUPITER was reported missing on September 16. His body surfaced on September 19 at the Total Petroleum pier and was recovered by terminal personnel. An autopsy performed on September 20 at the BMC showed death was caused by asphyxiation due to drowning. Survival Aspects JUPITER.--A station bill posted in the JUPITER's crew quarters listed the fire and emergency duties and the abandon-ship stations for each crewmember, including any additional persons on board. (See appendix F.) The Coast Guard Marine Inspection Office at Toledo, Ohio, had approved this station bill on June 15, 1977. The document stated that the master was in command of all emergency operations. An emergency squad consisted of the mate and the crew on watch and three additional AB seamen. In the event of an emergency, each squad member was assigned specific items of emergency gear to bring to the scene. The third mate stated that the JUPITER had placards and notices posted in each room and throughout the vessel that were clearly visible to the crew. The placards

37 and notices gave directions on how to don survival gear, as well as instructions in emergency procedures, including abandon-ship instructions. The third mate also stated that fire and boat drills were held weekly aboardthe JUPITER. During the drills, crewmembers activated one of the vessel's emergen.cy systems to ensure that it was functioning properly. They pumped water through the foam lines to ensure the lines were clear and operational. At times, the crew donned survival gear, including exposure suits, to make sure the zippers and the battery-operated lights worked properly. At each weekly drill, weather permitting, the crew concentrated on a different aspect of an emergency procedure. Terminal Res~onse.--Because it had been raining on the day of the accident, the JUPITER'S thir mate and the AB who manned the forward controls were wearing rain gear and heavy clothing. Neither man wore a lifejacket or an exposure suit when he jumped from the starboard bow into the water. While in the water, the third mate looked around and saw the AB about 10 feet away. The third mate stated that another explosion, which he believed emanated from the No.1 tank, followed the first explosion. Fire spread on the surface of the water around the bow from gasoline that had splashed out of the tank. Both men swam toward the shoreline, about 300 feet away. The third mate recalled that the AB was behind him. While he looked for something to swim to, he heard the AB yell, II Help me! II He saw the AB's arms go up in the air. The third mate believed that the man was tired and could not swim any farther. He swam back to the AB and put his right arm around his neck. The third mate was floating on his back. He stated that when he tried to pull him to safety, the AB kept sinking and dragging him down too. Each time the AB went under water, the third mate pulled him up to the surface. For a while, the third mate held onto the AB while he swam. He then held him by the collar and tried to pull him along, but the AB's weight was too much for him and he let him go. The AB disappeared under the water and was not seen alive again. The third mate swam to an old section of wood breakwater, crawled up on it, and lay there. The terminal manager said that he was sitting in his office when he heard a whistle signal, which he knew came from a ship. He heard the terminal operator radio the fire alert and heard the JUPITER's mate radio that they were having a problem. The terminal manager called 911 (at 0835:45, according to the records of the911 central dispatch) to report the fire on the JUPITER. From his office window, he could see fire on the forward end of the tankship. He testified that the fire equipment arrived about 5 to 10 minutes after he called 911. After closing the valve ashore, the terminal operator ran back to the head of the pier. The assistant manager from the terminal office joined him. Both men noticed someone clinging to an old section of wood breakwater adjacent to the u'pstream side of the Total Petroleum pier. They ran to where a small open outboard motorboat was tied to the pier. Cutting loose the line holding the boat, .they motored over to the third mate and pulled him into the boat. . They then went to the port side of the JUPITER to look for the AB but did not see him. They continued around the stern of the JUPITER and picked up the first assistant engineer and another crewmember. They attempted to pick up the cook but were unable to get him into the boat because of his size. They were able to drag the cook to shallow water, where he walked ashore. The boat put the three survivors ashore at the Total Petroleum dock.

38 Search and Rescue.--At 0837, a controller at the Coast Guard's 9th District Rescue Coordination Center (RCC) in Detroit, Michigan, heard a distress calion VHF-FM channel 16 from the JUPITER stating that the deck was engulfed in flames at the Total Petroleum dock about 2 1/2 miles from the mouth of the Saginaw River and that persons were in the water. At 0838, the RCC contacted Station Saginaw River and ordered a utility boat dispatched to the accident site as soon as possible. Meanwhile, at 0845, the officer on duty (ODD) at Station Saginaw River received a call on VHF-FM channel 16 from the master of the JUPITER stating that the JUPITER and the Total Petroleum pier were on fire. The 000 sounded the Search and Rescue (SAR) alarm and briefed the coxswain of the 41-foot utility boat (CG 41466). At 0848, with five Coast Guardsmen aboard, CG 41466 got under way and proceeded to the Total Petroleum pier. About the same time, a Coast Guard auxiliarist, who was monitoring VHF-FM channel 16, heard an unidentified voice from the MN JUPITER saying, "Help us! Help us! We are on fire!" Within minutes, another voice, believed to be that of the master, stated, "The BUFFALO's coming to us...we've severed our mooring lines and are engulfed in flames. Get us help immediately!" A husband and wife team who were Coast Guard auxiliarists donned their exposure suits and proceeded to their boat, USCG auxiliary boat No. 073 (CGA 073), located about 1/4 mile from the Coast Guard Station. At 0849, the station recalled other Coast Guard personnel to provide assistance. The ODD broadcast the following marine advisory message on VHF-FM channel 16: "This is the Coast Guard Saginaw River. The Saginaw River has been closed due to a fire on board the MN JUPITER." At 0851, CG 41466 and CGA 073 arrived at the scene. CG 41466, equipped with a 2 1/2-inch fire monitor on the bow, attempted to fight the fire but stopped when people on the stern began climbing over the side of the tankship. Some used a mooring line and others jumped into the water. The fire appeared to be more intense toward the bow. Coast Guard personnel stated that everyone jumping into the water from the JUPITER's stern was wearing a life preserver or an exposure suit. Both Coast Guard boats took survivors aboard. At 0856, the JUPITER's master radioed that about 2/3 of the deck was on fire and that seven crewmen and an unknown number of dock workers were on board. He later said that at least 15 people were on board. At 0858, CGA 073 contacted Station Saginaw River and reported that they had rescued five survivors who would need an ambulance when the boat arrived at the station. CG 41466 initially recovered seven survivors. They requested an ambulance for one survivor, whose hands were burned, and for others who were in shock. The burned person was treated aboard the CG 41466 before being transported to a hospital ashore. After the ambulances arrived, CGA 073 returned to the scene. At 0910, the Coast Guard dispatched CG 224310 to the scene with three Coast Guardsmen on board. At 0912, the master informed the station that he had to leave the vessel. Coast Guard personnel on the rescue boats recalled that they yelled to the master to abandon ship and maneuvered the CG 41466 around to the JUPITER's stern to pick him up. As the master climbed down the mooring line from the stern and entered" the water, another explosion occurred on board the JUPITER. He swam to CG 224310, which had arrived on scene at 0915. Later, CG 41466 transferred five other survivors to CGA 073, which transported them to shore for medical treatment.

39 At 0920, Station Saginaw River was informed that one person from the JUPITER was missing. The Coast Guard ordered all on-scene personnel to conduct a search in the immediate area. The search was unsuccessful. At 0928, Station Saginaw River called the RCC in Detroit to brief them on SAR activities. They also advised the RCC that one person was still missing. At 0935, CG 224310 maneuvered close to the D&M railroad bridge and found three more survivors from the JUPITER in waist-deep water near the shore. Two men were wearing exposure suits; the other man was wearing a yellow rain coat. At 0940, the CG 224310 transferred the three crewmen to the CGA 073, which took them to Station Saginaw River. At 0945, the RCC requested that Station Saginaw River make another radio broadcast announcing that the Saginaw River was closed to all traffic. The RCC broadcast the same message. At 0955, the Coast Guard ordered all units to stand by and move 600 feet away from the JUPITER because by then the fire was too hot to get near. At 1000, the Coast Guard officially closed the Saginaw River to all traffic and established a safety zone in the area. CG 224310 reported that only one line was holding the tankship to its mooring. At 1600, on September 17, 1990, Ashland Petroleum Company, parent company of Cleveland Tankers, Inc., requested that Coast Guard Group Detroit search for the body of the missing crewmember. Group Detroit lacked the trained divers and specialized equipment necessary to do a search. The Coast Guard ordinarily does not conduct body searches. Moreover, Group Detroit informed Ashland Petroleum Company that in this case, it could not conduct a search because its personnel were fatigued from the rescue effort. At 1610, RCC was advised of the request for a body search from Ashland and concurred with Group Detroit's decision not to comply. Coast Guard personnel later picked up the third mate and the other two crewmen at the terminal and transported them to Station Saginaw River. Aher the third mate changed into dry clothes, he returned to the accident scene and provided information to the firefighters concerning the cargo aboard the JUPITER. He later went to the BMC, where doctors examined him and determined that he had not sustained any injuries. In summary, the CG 41466 rescued seven persons, the CG 224310 rescued five persons (including the three whom Total Petroleum recovered and brought ashore near the D&M bridge), and CGA 073 rescued five persons. The Coast Guard closed the SAR case on September 19, 1990, but ordered its Atlantic Strike Team to maintain a 24-hour safety and security zone patrol until salvors removed the remaining gasoline from the JUPITER. Fire Deaartment Response .--At 0835, the Bangor Township fire department's fire chief an assistant fire chief responded to a fire alarm at the Total Petroleum facility for the fire aboard the JUPITER. Aher being advised of conditions aboard the ship, the assistant chief ordered a second fire alarm sounded. The BMC also dispatched two ambulances to the accident site. Aher discussing the situation with one of his firefighters, the Bangor Township fire chief decided to let the JUPITER burn to avoid risking the safety of the

40 firefighters until officials could obtain more information about the tankship. At least eight local fire departments provided mutual aid under the direction of the Bangor Township fire chief, who was named incident commander. The firefighters established command posts (CPs) at the Total Petroleum terminal and across the river opposite the oil terminal. To contain spilled gasoline, the incident commander ordered oil containment booms deployed in the river between the tankship and the D&M railroad bridge. Local authorities determined that to stretch one boom across the river would require a 1,500-foot length of oil boom. Because the local area lacked enough lengths of boom to contain the existing spill, the authorites had to obtain additional booms from outlying areas. By 1111, 3,000 feet of oil boom had been gathered and delivered to the site. By afternoon, the Coast Guard had 6,000 feet of boom available. It rigged four oil booms across the river, two upstream and two downstream of the JUPITER. The Midland fire department and the Midland Dow Company furnished foam later to fight the fire on the JUPITER. The fire department set up two 5-inch fire monitors on the Total Petroleum pier to keep the pier cool and to direct water on the mooring line and pile cluster holding the tankship. The fire pump at the terminal operated for more than 30 hours. The local officials were concerned that the JUPITER might drift across the river because only one mooring line held the vessel. They obtained a 300-foot length of wire cable from a local power company and a large bulldozer from a local contracting company. After several attempts, they secured the wire cable between the JUPITER's anchor and the blade of the bulldozer on shore. By backing up the bulldozer, they pulled the JUPITER about 135 feet closer toward shore. At 2345, Williams, Boots, and Coots, Inc., a commercial fire fighting firm from Texas, arrived on scene and began preparing for fire fighting operations the next day. The Coast Guard ordered its cutter, the BRAMBLE, a buoy tender, to assist in the fire fighting operation. The BRAMBLE was to be used as a platform from which firefighters could battle the JUPITER blaze. At 0815 on September 17, they loaded the necessary foam and equipment aboard the buoy tender. At 1230, the BRAMBLE got under way and proceeded to the scene of the fire. Firefighters performed foaming operations until 1645, when they declared the fire out. At 2112, however, the fire rekindled and burned throughout the night. At 1332 on September 18, the BRAMBLE got under way again and returned to the JUPITER. In less than 1 hour, firefighters extinguished the fire. The Coast Guard's on-scene commander (OSC), using personnel from the Atlantic Strike Team, monitored the JUPITER's status until workers offloaded all remaining gasoline. The Coast Guard's responsibility concerning waterfront and shipboard fires is addressed in the Marine Safety Manual, volume VI, chapter 8, paragraph B, which states in part: Although the Coast Guard clearly has an interest in fighting fires involving vessels or waterfront facilities, local authorities are principally responsible for maintaining necessary firefighting capabilities in U.S. ports and harbors. The Coast Guard renders assistance as available, based on the level of training and the adequacy of equipment. The Commandant intends to maintain this traditional "assistance as available"

41 posture without conveying the impression that the Coast Guard is prepared to relieve local fire departments of thei r responsibilities .. " Michi an State Police Res onse.--The Michigan State police emergency management ivision EMD is Mic igan's emergency/disaster agency. In this accident, the EMD coordinated the State agency response and interfaced with Federal and local efforts. It arranged for State troopers to assist local law enforcement officers in securing the area affected by the explosion and fire. Additionally, the EMD provided the State police command trailer for use as a CP by all responders and provided personnel to staff the CP communications equipment. The EMD made arrangements for Department of Public Health personnel to sample and monitor air and water quality and for the Department of Natural Resources to deal with any issues concerning the environment, wildlife, and water quality to ensure compliance with State laws. The EMD provided helicopters for overflight assessment and videotaping of the emergency response activities. Eight divers searched for mooring lines and other evidence pertaining to the tankship fire. In addition, the divers were to search for the missing person if the body had not been recovered before the gasoline dissipated on the surface of the water. The assistant division commander stated that emergency personnel encountered no serious problems and that he believed that all agencies worked very well together in facing a serious threat to the community. State Fire Marshal's Division.--At 0900, the commander of the hazardous material section notified the Michigan State fire marshal about the fire aboard the JUPITER. Accompanied by two officers from the fire marshal's division to assist him, he reported to the accident site to coordinate the fire fighting efforts. Bay County Sheriff's Department.--At 0836, the Total Petroleum terminal manager notified the Bay County sheriff's department that a tankship was on fire at the terminal. The first sheriff's department unit arrived on scene at 0845. The sheriff's department dispatched four additional units to provide traffic control on the Independence Bridge and surrounding areas. They also dispatched three marine units (patrol boats), first to assist the Coast Guard with the search and rescue and then to assist in controlling traffic on the Saginaw River. At "800 on the day of the accident, the sheriff's department dispatched personnel to the Bay Harbor Marina, Sunset Shores, Bay City Yacht Club, and local waterfront residences to notify people that they might have to evacuate their property if the situation became worse. Medical Response.--According to their records, the BMC received a call from the 911 central dispatch at 0837 stating that a tanker had exploded near the bridge. At 0840, BMC dispatched a paramedic unit to the accident scene, which was about 1 1/2 miles away. Upon arrival at 0846, the unit set up a triage area west of the command center. After the medical technicians had set up their facilities, the Coast Guard advised them that the Coast Guard personnel had picked up numerous survivors from the explosion and that the emergency medical technicians (EMTs) would meet them at the Wirt Stone pier south of the Independence Bridge. The paramedic unit moved its triage ambulance to the Wirt Stone pier. About this time, Coast Guard personnel brought seven survivors to the triage area to be treated.

42 Shortly thereafter, the paramedic unit requested that more ambulances and additional assistance be sent to the scene. When the Coast Guard brought the JUPITER's master ashore, the EMT in charge questioned him about his crew, and he stated that, in addition to himself, 17 men were on the ship. He refused treatment and went to the nearby CPo The EMTs also went to the CP to treat the other survivors and to obtain the exact number and names of all crewmembers. They determined that all crewmen had managed to abandon ship and were in the water. At 0920, the BMC ambulance supervisor and additional ambulances were dispatched to the scene. Medical personnel from other area emergency services were called to provide assistance as necessary. After conferring with the BMC ambulance crew and Coast Guard personnel, the technician in charge of the first paramedic unit determined that one person was missing. He then advised the incident commander and the Coast Guard's CSC of the situation. By this time, EMTs had either examined and treated the other survivors at the scene or transported the injured to BMC for further examination. The emergency technician convinced the master to join the rest of his crew at the BMC for further examination. The EMT-in-charge assigned another emergency technician to accompany a Coast Guard helicopter crew and to obtain an aerial overview of the fire. The EMT searched for the missing crewmember near the shoreline and in the river but was unsuccessful. Critique of the Emergency Response.--Representatives of all agencies involved in the accident held an overview meeting of the incident at the Bay City city hall on December 6 to review the emergency response measures taken by the local authorities. They discussed problems that they encountered and proposed solutions to avoid similar difficulties in the future. A synopsis of the suggestions and observations made at the meeting is presented below: • Emergency response agencies need additional communications equipment with compatible frequencies. Participants proposed using the 911 emergency center as a central dispatch. • An organization chart should be developed that lists all emergency response agencies and appropriate points-of-contact to avoid the type of problems that occurred at the CP during the JUPITER incident. • The fire burned for an extended period of time because of the lack of equipment and available trained personnel to extinguish it. In view of the limited amount and type of equipment and personnel devoted to the effort, the hazard abatement was handled well. • The accident had minimal environmental impact because of the proper handling of the incident, the rapid cleanup, and the type of product involved.

43 • Approximately 300 persons from 35 agencies and industry interacted in an excellent manner. Critique of the BMC Emergency Pre1 aredness Procedures.--On September 20, officials of the BMC met to review t e medical center's external disaster preparedness and to discuss several areas in which improvements could be made. The participants suggested the following: • The medical center did not use the designated area for news media control. An accident of this nature required that the center reasonably accommodate the news media, as well as maintain adequate security. • No one initially notified the switchboard of the potential for a "Code Red"17 situation. • In addition to social services staff, the hospital staff should have been available to counsel survivors and their families. • The medical center should consider whether it can provide a more suitable area for discharged survivors and their families. • A television set and possibly a cellular telephone should be bought for the control center so that center personnel have an improved means of communication with the accident scene and are better able to anticipate requirements in emergency situations. The critique participants scheduled these issues for resolution by the Emergency Preparedness Subcommittee. Disaster Preparedness.--At the time of the accident, Bay County Emergency Services activated its hazardous materials contingency plan. At 1000, the Governor proclaimed a state of emergency and implemented the Michigan State contingency plan. According to a representative from the Michigan State police EMD in Saginaw, Michigan, neither the State nor the county had guidelines for fighting shipboard fires, even though some government agencies had identified a need for such. The incident commander responsible for fire fighting activities stated that local firefighters had not participated in any shipboard fire fighting training. In this accident, they implemented their standard operating procedures for fighting hazardous materials fires. The incident commander and the Coast Guard's port safety officer from the Detroit (Michigan) Marine Safety Office concurred that local authorities and the Coast Guard had an unwritten agreement to provide mutual aid during accidents or disasters. They conceded that no fire fighting contingency plan included the Bay City port area. 17The BMC's highest level of response to an external disaster, as stated in the center's Emergency Preparedness Manual.

44 The Coast Guard's Marine Safety Manual states in part: Paramount in preparing for vessel or waterfront fires is the need to integrate Coast Guard planning and training efforts with those of other responsible agencies, particularly local fire departments and port authorities. Just 2 weeks before this accident, the Coast Guard and local agencies had held a disaster drill involving an oil spill. The Coast Guard and those agencies on the county's disaster plan periodically hold drills using different accident scenarios. Tests and Research Wood Mooring Pile. --Investigators sent a wood sample from the broken center mooring pile of the NO.4 pile cluster at the Total Petroleum's tanker berth to the U.S. Department of Agriculture's (USDA's) Forest Products Laboratory in Madison, Wisconsin, for examination. In its reply to the Safety Board (see appendix G), the USDA laboratory identified the species of the wood and concluded that decay was present. The report further stated that "characteristics of the wood cells at the fracture zone .indicate that the wood was subject to brashness. 18 " The USDA laboratory could not specify the percentage of strength loss in the wood as a result of decay. Hydrodynamic Studies.--Total Petroleum engaged a naval architect at the Massachusetts Institute of Technology in Cambridge, Massachusetts, to study the hydrodynamic interactions between the BUFFALO and the JUPITER.19 In the course of his study, the naval architect analyzed factors that would affect the motion of the ships in the waterway. Using a computer program, he generated a simulation of the accident events as the BUFFALO passed the JUPITER. (See figure 20.) The American Steamship Company (ASC), owners of the BUFFALO, engaged a consulting naval architect from Ann Arbor, Michigan, to conduct a separate study of the hydrodynamic interaction between the vessels. 20 The ASC's consultant used a different computer program to predict the interaction forces and moments that occurred during the passage of the BUFFALO. laUnder certain conditions, wood fails abruptly, with minimal deflection and at lower than expected loads. These failures are characterized by cross breaks that lack the usual evidence of fibrous or splintering separation. Such brittle and weak behavior in wood is ca~led brashness.... and fungal decay causes brashness in wood. [Strength of Wood, Chapter 6). 19Preliminary Analysis of Hydrodynamic Interactions between the Motor Vessels JUPITER and BUFFALO in the Saginaw River, Bay City, Michigan by Professor J.N. Newman, Wayland, MA, 8 March, 1991, with addendum, July 18,1991. 20Preliminary Report, the Interaction Between the MN JUPITER and athe MN BUFFALO and the Total Oil Terminal, Bay City, Michigan, on September 16,1990 by Robert F. Beck. Report No. 91-1, March 15, 1991.

CJUPITER J FIGURE ZO. NO INTERACTION LOW PRESSURE BUFFALO LOW PRESSURE FIGURE ZOd MAXIMUM ATTRACTION FORCE Small Surlle Force Large Auraclive Side Force Small Yaw MomenlS LOW PRESSURE INDUCED ~ ATIllACflON FORCE ~r:.:) ~ .l=- V1 FIGURE 20e MAXIMUM POSITIVE SURGE rORCE AND YAW MOMENT Near Muimum Upslream Surllc Force Very Small Side Fon:c LUlc Bow-Io Yaw Momenl LOW PRESSURE INDUCED BOW·IN MOMENT ol UPsnEAM SURGE FORCE BUFFALO FIGURE ZOb START or INTERACTION Small Upsll'nJII Surle Force Small Repulsive Force Small Bow-In Vaw Momenl HIGH PRESSURE INDUCED HlOH PRESSURE INDUCED BOW·IN MOMENT -""" .r- REPULSION FORCE '" UPSTIlEAM SURGE FORCE FIGURE zoe MAXIMUM NEGATIVE SURGE FORCE AND YAW MOMENT Nnr Muimum DoWIIIUeam Surle Fon:e Very Small Side Fon:e LUle Bo",-Oul Ya'" Momenl HIOH PRESSURE INDUCED BOW.oIJT MOMENT BUFFALO FIGURE 20f SEPARATION PHASE Small Downstream Surlc Fon:c Small Repulsive Side Fon:e Small Bow-Oul Momenl HlOH PRESSURE INDUCED IlEPULSION FORCE &: DOWNsnEAM SUROE FORCE LOW PRESSURE INDUCED BOW~ MOMENT &: DOWNSIllEAM SUROE FORCE HIGH PRESSURE INDUCED BOW.QIJT /lfOMEm" &: )()WNS'TP-EAM SlJaOE FORCE Figure 20.--Hydrodynamic interaction diagrams from Total Petroleum's report by Professor J. N. Newman.

46 In his report, the ASC's consultant explained the interaction forces that resulted at the following instances: when the larger vessel (the BUFFALO) approached the smaller vessel (the JUPITER), when the larger vessel passed abeam of the smaller vessel, and when the larger vessel cleared the smaller vessel. Other Information As a U.S. tankship, the JUPITER was subject to Coast Guard regulations at 46 CFR Parts 30-40, Subchapter D--"Tank Vessels." The regulations require that tank vessels be inspected biannually or more often if the local officer-in-charge marine inspection (OCMI), deems it necessary in order to determine whether a vessel is suitable to carry hazardous or flammable liquid cargo in bulk. The inspection covers the hull, cargo tanks, fuel tanks, ballast tanks, pressure vessels, piping, machinery, and equipment. Inspection of safety equipment is to include liferafts, lifejackets, exposure suits, all fire extinguishing equipment, and other required safety equipment. The Coast Guard regulations require that the vessel receive a drydock inspection every 5 years for examination of the underwater hull, through-hull fittings, sea valves, sea chests, and sea strainers. ANALYSIS As a result of its investigation of the fire and explosions aboard the JUPITER, the Safety Board found no mechanical deficiencies on the two vessels or in their equipment other than the design of the flame screen installation in the JUPITER's cargo tank ullage pipes. Investigators questioned vessel crews about their experience, work/rest cycles, and training, which were found not to have contributed to the accident. In determining the probable cause, the Safety Board considered the following factors: • The adequacy of the JUPITER's mooring arrangement. • The adequacy of Total Petroleum's mooring devices. • The precautions that the JUPITER's crew took in anticipation of hydrodynamic forces that a passing vessel might generate. • The BUFFALO's speed and position in the river. • The adequacy of procedures that Total Petroleum's and JUPITER's operating manuals contained for alerting vessels moored at the Total Petroleum facility of an approaching vessel. • The adequacy of the flame screen installation in the cargo tank ullage pipes. General A mooring system that limits vessel motion, thereby preventing momentum buildup, is essential to the safe transfer of liquid bulk cargoes between tankships and shoreside terminals. To prevent damage and possible spillage, the motion of a tankship along and away from a pier cannot exceed the limit of slack provided by the cargo transfer hoses. Crewmembers can restrict vessel movement along the

47 berth by running spring lines ashore from each end of the vessel to the terminal's mooring devices. To restrict vessel movement away from the pier, the crew should also run breast lines ashore as close to 90 0 as possible. Additional head lines and stern lines further secure the vessel against excessive motion. The use of steel wire cables to moor vessels lessens the possibility of undue vessel motion along the pier because steel wire has limited elasticity compared with polypropylene or other fiber lines. When used with constant-tensioning winches, steel wire cables are the preferred method, particularly when used as spring lines, for mooring vessels. In addition, piers and mooring devices must be designed and constructed to accommodate the size of vessels expected to berth at a facility. Accident As the BUFFALO moved through the water, it generated an hydrodynamic pressure field that interacted with nearby shore structures and other vessels. The hydrodynamic effects are determined by the length, beam, and drafts of the ships, their lateral separation, water depths, and speed of the moving vessel. The forces produced can increase exponentially. In this case, the hydrodynamic forces affected the moored JUPITER and caused it to surge. According to an eyewitness, as the BUFFALO approached the JUPITER, it generated the initial upstream surge force that caused the water level to rise about 4 feet. (See figure 20b.) This force imparted a slight forward motion to the tankship, which was restricted mainly by the No.2 and 4 mooring cables. As the BUFFALO continued past the smaller vessel, the direction of the hydrodynamic forces reversed. This downstream surge force caused the JUPITER to move aft with considerable force, placing a great stress on the No.3 mooring cable. (See figure 20c.) Because the forward polypropylene line and the No. 1 mooring cable were used as breast lines, they offered little or no resistance to the aft surge. Only the NO.3 cable provided resistance to the JUPITER's aft motion. However, the NO.3 cable did not slow the aft motion because the winch brake was released when the AB started the winch motor and presumably payed out the cable to relieve the stress. When the JUPITER surged aft, the NO.2 and 4 wire cables became slack. Whether the AB on the forward winch controls removed the slack in the NO.2 mooring cable at this time and shut off power to the winch in order to set the brake is not known. Moreover, if the AB manning the after winch controls was operating the NO.3 winch, he probably failed to notice the slack in the No.4 cable. At this point in the passing, the BUFFALO generated near maximum upstream surge force which caused the JUPITER to quickly reverse its direction to a forward motion. (See figure 20e). As the JUPITER moved forward, only the NO.2 mooring cable offered resistance to the force. However, because it led aft as a spring line, the No.2 cable caused the JUPITER's stern to swing away from the pier. As the BUFFALO's stern cleared the bow of the JUPITER, the interaction forces imparted a yawing or turning motion forcing the JUPITER's bow toward the shore, which caused the tankship's stern to swing out into the river. (See figure 20F.) When the No.4 mooring cable became taut, the sudden shock-loading of the No.4 mooring pile broke the pile. Both the No.4 cable and the polypropylene line fell into the water, and the JUPITER's stern swung unchecked out into the river. JUPITER's Mooring at the Total Petroleum Facility When the JUPITER arrived at the Total Petroleum pier, the crewmembers moored the tankship at the facility as they had done on prior voyages. They led steel

,, . 48 wire cables from the·four constant-tension winches to the center mooring pile of each of the four pile c1u.sters adjacent to the pier, together with polypropylene lines from the bow and stern. They used the JUPITER'S No.2 and 3 mooring cables as spring lines and ran the lines to the Nos. 2 and 3 pile clusters, respectively. They ran the No.1 and 4 mooring cables to the No.1 and 4 pile clusters, respectively. Because of the positioning of the No.1 and 4 pile clusters, they led the bow polypropylene line slightly aft and the stern polypropylene line slightly forward to the same pile clusters as the No.1 and 4 wire cables. Further, because the facility had only four pile clusters, they could not secure the polypropylene lines to separate mooring devices which, in this case, would have reduced the stress on each pile cluster, provided some redundancy, and if properly located, possibly limited the JUPITER's surging at the berth. While there was nothing wrong with the size of the pile clusters at the Total Petroleum pier, they were too few in number to adequately berth the JUPITER. Placing both bow lines and both stern lines to single mooring points does not provide enough security for the vessel if one of the mooring devices fails. . Moreover, because the JUPITER's bow extended beyond the No.1 pile cluster and its stern extended beyond the No.4 pile cluster, it appears that the berth was designed for smaller vessels and barges. Figure 2, the diagram of the JUPITER's mooring arrangement, shows that crewmembers could not run the bow and stern polypropylene lines in a manner that took full advantage of each line's potential. Because the after polypropylene was placed on the same pile cluster as the NO.4 steel wire cable, giving a forward lead to the line, the line was ineffective after the piling broke and its direction offered no protection to counter a forward surge by the vessel. As the size of vessels berthing at the terminal increased, the mooring array also should have been modified to accommodate the larger vessels. An additional pile cluster at each end of the berth positioned beyond the JUPITER's bow and stern would not only afford better leads for the polypropylene lines, but would also provide the added security of additional mooring devices. The Safety Board concludes that the mooring arrangement at Total Petroleum's Bay City terminal should be upgraded so that vessels similar to the JUPITER can be moored using multiple mooring devices for bow and stern lines with proper leads fore and aft. Because the JUPITER's forward polypropylene line led slightly aft and the No.1 wire cable led slightly forward, both could be considered only partial breast lines. Given the limitations under which crewmembers had to run them, the lines were unable to pJevent the vessel from surging aft. As figure 2 indicates, the lines were more suited to keep. the vessel's bow alongside the berth. The figure also shows that the leads on both forward lines were not very effective in preventing the vessel from surging aft. If the forward polypropylene line had been led forward of the JUPITER's bow, itwould have reduced the tankship's astern motion as the BUFFALO passed. Over the years, many vessels had docked successfully at Total Petroleum's terminal, and its pier and mooring devices had received and passed visual examinations by the Coast Guard. However, the continued use of the wood mooring piles without a proper internal inspection of the piles ultimately resulted in a failure of one of the piles at a critical time. Although the USDA laboratory could not quantify the strength of the broken wood mooring pile, the test sample did show evidence of rot, indicating the strength of the wood piling had declined. The annual inspection of the pier and the mooring devices by the marine construction company should include probing of the wood pilings to determine whether the wood has

49 deteriorated to the extent that the strength of the pile may be affected. The Coast Guard should also include an examination of the mooring devices during its periodic inspections of the terminal. Responsiveness of the JUPITER's Crew Line Handling.--The AB assigned to the after winch control console, from which the Nos. 3 and 4 mooring wires were controlled, testified that when he started the winch motors, he was unable to take any action before the NO.4 mooring pile cluster broke. As spring lines, the Nos. 2 and 3 mooring wires were the only lines that could hold the vessel in position fore and aft to ensure that the JUPITER's valve manifold remained adjacent to the valves on the pier. The No.3 mooring wire was critical to preventing any movement aft by the vessel. When the crew started the winches, however, the brakes automatically released. This allowed the wire cables to be pulled off the winch drum as the tension on the cable increased, constrained somewhat by the gear friction in the winch. The AB testified that he had no time to manipulate the controls, but his testimony eliminates the only plausible explanation for the fact that the NO.3 wire cable had enough slack to make a splash that the third mate heard. If the NO.3 cable made a splash, either the No.3 mooring pile broke or the wire payed out very rapid Iy as the vessel started to surge forward. As figure 5 shows, the NO.3 mooring pile did not break; therefore, the NO.3 cable must have payed out rapidly and continued to do so as the vessel's motion reversed. Since the AB testified that he had started the winch motor, it is reasonable to assume that because he was standing close to the taut wire, he instinctively placed the control lever in the payout position as the wire became increasingly stressed to relieve the line tension as the vessel surged aft. The AB's post at the winch controls placed him between the Nos. 3 and 4 wire cables as they led away from the side of the vessel so that if the No.3 wire cable broke, he would have been in the path of the wire as it sprang back. As a seaman, he knew that if the wire broke or released from the mooring pile, it would spring back to where he was standing and possibly strike him. When the vessel reached the limit of the surge aft and started forward, the wire cable, still paying out, then fell into the water, causing the "splash." Therefore, the ;Safety Board concludes that since the NO.3 wire cable failed to prevent the JUPITER from surging aft, it is most likely that the AB operating the constant-tension winch payed out the wire cable both to relieve the strain on it and as a precaution against breaking instead of using the winch to slow the aft motion of the vessel. The third mate testified that when he heard the No.3 wire cable splash in the water, he believed something was wrong with either the winch or its operation. Since the No.3 winch successfully secured the vessel before the arrival of the BUFFALO, it is unlikely to have malfunctioned. The splash must have been the result of the AB's operation of the winch. The first mate testified that when he took over the winch controls from the AB, he hove in some of the slack in the NO.3 wire cable, but stopped when he realized that the vessel was rapidly moving forward. The amount of slack in the wire, some of which was due to the vessel's forward movement, must have been great enough to cause the first mate to start heaving the slack with the winch. Despite the AB's allegation that he did not move the control lever on the NO.3 constant-tension winch after starting the winch motor, the wire must have been paying out for a considerable amount of time to acquire enough slack to get the first mate's attention.

50 When the vessel's motion reversed and the JUPITER surged. ahead with increased momentum, the NO.4 mooring wire quickly became taut and broke the center pile of the NO.4 pile cluster. The AB who manned .the after winch controls testified that he had no time to respond to the forward surging of the vessel before the mooring pile broke. Had the AB had time to payout the NO.3 wire cable, he could also have tended the NO.4 wire cable since the controls are in the same console. Had he controlled the NO.4 wire cable tension by removing the slack when the JUPITER surged aft, the buildup of speed forward would have been minimized and the sudden force or shock-loading on NO.4 mooring pile would have been greatly reduced. The NO.4 mooring pile may have held despite the pile's questionable strength. The manner in which the AB operated the JUPITER's constant-tension winches did not take full advantage of the features of the machines. Even though the brake had released, the constant-tension winch probably did not release the NO.4 wire cable fast enough to prevent the wire from shock-loading the mooring pile. Consequently, because the NO.4 pile cluster no longer secured the NO.4 wire, the NO.2 mooring wire took the entire force of the vessel's forward motion, constrained only by the brake or the gear friction in the winch. Because the AB who manned the NO.2 winch died, the Safety Board could not determine what action, if any, he had taken to regain control of the vessel. Although investigators found the NO.1 winch control in the payout position and the NO.2 winch control in the heave position, the Safety Board cannot be certain that the deceased AB left the controls in those positions. Because the NO.2 mooring wire served as a spring line and was secured to the same pile cluster against which the vessel rested forward, the cluster acted as a pivot point around which the vessel swung due to the component of force of the line in tension and the motion of the vessel as it surged forward, swinging the stern out into the river. When the third mate assigned the ABs to the winch controls, he expected that they would operate the winches in a manner necessary to control any vessel motion caused by the passing of the BUFFALO. The purpose of starting the winch motors is to adjust the wire cables if necessary. If no adjustment is required, releasing the brakes on the constant-tension winch~s, particularly on the Nos. 2 and 3 winches, defeats their purpose, which is to hold the vessel in place. The Safety Board believes that the ABs who manned the JUPITER's constant-tension winch controls, especially the Nos. 3 and 4 winch controls, did not make the most effective use of the machines to prevent the JUPITER from surging at its berth when the BUFFALO passed. Several observations can be made based on the photograph in figure 5. Contrary to the third mate's testimony, the motion of the vessel as it surged forward did not break the NO.2 mooring pile. (The NO.2 pile cluster subsequently burned down close to the water.) Moreover, the stress on the NO.1 wire cable as seen in the photograph, further indicates that the brake held, which prevented the vessel from drifting out into the river. The fact that the NO.1 winch brake held when the wire cable was subjected to its greatest stress further indicates that either the AB stopped the winch motors before he ran forward or the explosions caused a loss of power. This further supports the Board's conclusion that the AB manning the after winch controls did not operate the Nos. 3 and 4 winches properly. Pr"ecautionary Measures Taken Aboard the JUPITER.--As the BUFFALO approached, the JUPITER's crewmembers expected their vessel to react to the hydrodynamic forces generated by a another passing vessel. Before manning the controls for the constant-tension winches, they stopped the cargo pumps and

51 started the hydraulic pump for the hose winch. The third mate, who was the watch officer at the time of the accident, explained that they took these precautions whenever the vessel was alongside a pier in a narrow waterway and another vessel was approaching. Although the JUPITER's operating manual did not include these precautions, the crew understood that they should follow them. The crewmembers' precautions, however, should have included closing the manifold valve and the ullage pipe covers on the vessel and closing the motor-operated valve on the pier. If they had used the remote switch to close the pier valve and the ship's manifold valve, spillage would have been limited to what was in the cargo hose when it ruptured. Given the short period of time that they had to respond, it is doubtful whether they could have completed these additional precautionary measures during the time available. Moreover, any opportunity to close the valves and the ullage covers quickly vanished when the fire started. The Safety Board believes that because of the potential danger to vessel and crew and the possibility of polluting the environment, Cleveland Tankers, Inc., should include procedures in its fleet operating manuals for stopping the transfer operation when other vessels pass in the waterway. These procedures should also include a requirement that the appropriate valves be closed to limit spillage and that ullage covers be closed to redirect venting of the tanks through the PN valves. Arrival of the BUFFALO When the BUFFALO arrived off the entrance to the Saginaw River, the first mate, as watch officer, broadcast a security call over VHF-FM channel 16 to advise marine traffic in the area of the vessel's position and destination. Following the security call, he established radio contact with Station Saginaw River and requested the height of the river. Later, as the BUFFALO entered the river, Station Saginaw River called the vessel and asked whether it was inbound or outbound. After responding to the question, the master broadcast a second security call, giving his vessel's position and destination. Since the JUPITER's crew did not customarily man the navigating bridge or monitor the VHF-FM radio while the vessel was moored, the watch officer on the tankship was unaware of the BUFFALO's approach. The crew on deck was expected to watch for approaching vessels. The third mate first became aware of the BUFFALO's presence when he heard its whistle signal requesting the opening of the Independence Bridge and when he sighted the vessel passing the D&M railroad bridge. Because the JUPITER's crewmembers were busy tending to the cargo transfer, they could easily have failed to notice the BUFFALO, particularly if the BUFFALO's master had opted to call the Independence Bridge by VHF-FM radio rather than sounding a whistle signal. The Safety Board believes that current practices fail to ensure that personnel aboard a vessel moored at the terminal or terminal personnel have sufficient time to suspend transfer operations and take precautionary measures. The radio watchstander at Station Saginaw River was aware of the BUFFALO's presence in the river and could have telephoned the Total Petroleum terminal to alert terminal personnel that large vessels were moving in the waterway; those personnel in turn could have notified the JUPITER. The Safety Board believes that the infrequency of large vessel transit in the Saginaw River does not warrant a formal, structured vessel traffic system; it does believe, however, that the Coast Guard could enhance area waterway safety and security by requiring vessels to call Station Saginaw River and advise them of their expected movement so that the Coast Guard could alert area terminals if necessary. Because the Safety Board advocates that tank vessels berthed at the Total Petroleum take additional

52 precautionary measures when discharging cargo, it is essential that both the berthed vessel and terminal personnel be notified by the Coast Guard of impending traffic so that they can undertake shutdown procedures in a timely manner. Speed of the BUFFALO . The record of the BUFFALO's transit in the Saginaw River from the time it entered the waterway until it arrived off the Midland Contracting Company's pier did not include the speed of the vessel at various points during the voyage or the times that the vessel passed bridges, landmarks, and navigational. aids. The BUFFALO's logbook shows that the vessel passed the front range marker of the entrance channel range at 0800 and that it arrived off the Midland Contracting pier at 0920. Station Saginaw River's records indicate that the vessel passed the station at

1. Safety Board investigators calculated the BUFFALO's average speed between

the river entrance and the Midland pier, a distance of 6.5 miles, to be about4.8 knots or 5.5 mph. The vessel's speed between the river entrance and the D&M railroad bridge, a distance of 2.8 miles, was 5.4 knots, or 6.2 mph. Based on the estimated transit time (10 minutes) between the D&M Railroad Bridge and the Independence Bridge, a distance of 0.7 miles (1,417 yards), when the BUFFALO passed the JUPITER, the BUFFALO's speed was approximately 4.2 knots, or 4.8 mph. Board investigators took the times from the automatic time records of the 911 central dispatch when the bridge tender called in to report the opening and closing of the Independence Bridge. To calculate speed using the time 'record of the 911 central dispatch, it was assumed that the bridge tender placed the call to 911 at the same interval following the passage of the BUFFALO through each bridge. The BUFFALO's master became aware that the JUPITER was moored to the Total Petroleum pier when he visually sighted the vessel on his approach to the railroad bridge. He testified that when he saw the JUPITER at the Total Petroleum facility, he immediately adjusted his vessel's propeller pitch setting to 4 feet and maintained that setting until he passed the JUPITER. The master stated that it was the minimum pitch he could use and still maintain control of the vessel, although he testified that he could not relate pitch to speed and did not know what speed was equivalent to the 4-foot pitch setting in the Saginaw River. Investigators could not verify the BUFFALO's speed as it passed the JUPITER because, like most Great Lakes vessels, the BUFFALO did not maintain a pitch/speed record during the river passage. However, both the master and the chief engineer testified that 4 feet of pitch was the minimum setting before the propeller went to zero pitch. The master stated that at zero pitch, he would lose control of the vessel. Although the Safety Board believes that the BUFFALO had a 4-foot pitch setting on its engine controls when it passed the JUPITER, the Board cannot determine whether the vessel had slowed to the corresponding speed by the time it reached the JUPITER. The BUFFALO's master testified that because of the effect of the wind on his vessel's starboard side, he steered closer to the JUPITER than he ordinarily would have to avoid setting over to the opposite bank. He was aware that he passed abeam of the tankship with about 60-65 feet of clearance. Members of the JUPITER's crew corroborated the clearance between the vessels. The port side of the JUPITER was outside, but close to the western edge, of the 200-foot-wide channel. The BUFFALO's beam was 68 feet. Thus, the centerline of the BUFFALO was within a few feet of the center of the dredged channel, placing its port side about 70 feet from the channel's eastern edge. According to the master's testimony, he believed that if he had steered any closer to the eastern side of the channel, the BUFFALO would have grounded. His statement that he passed "closer than normal" to the

53 JUPITER because of the wind on his starboard side implies that in the past he had passed vessels at the Total Petroleum terminal with greater clearance by navigating closer to the opposite bank. As an experienced shiphandler"the BUFFALO's master should have been aware that by passing closer to the JUPITER, the hydrodynamic forces generated by the BUFFALO would have a greater effect on the moored vessel. In short, if he had to pass closer to the JUPITER, the master should have used less speed. Ifa reduction in speed was not a viable option, he should have passed the JUPITER at a greater distance. The Safety Board believes that when the BUFFALO passed closer than normal to the JUPITER without a further reduction in speed, the combination of speed and proximity resulted in hydrodynamic forces that caused the tankship to surge heavily at the berth and subsequently to break away. ' Because the mate on watch on the bridge of the BUFFALO had limited duties (watching the wake), he could have readily logged the times that the vessel passed buoys and bridges. The Coast Guard regulations in 33 CFR Part 164 for vessels over 1,600 gross tons require that the vessel's position be placed on the navigation chart of the area and that the person directing the movements of the vessel set the speed with consideration for underkeel clearance and damage that might be caused by the vessel's wake and for any local vessel speed limit. (See appendix I.) Large vessels, such as the BUFFALO, should maintain an accurate record of the engine maneuvers and courses steered, either manually or automatically; so that if the speed of the vessel becomes a safety issue, the appropriate records are available. Moreover, such records would allow investigators to recreate a vessel's trackline, further aiding the investigation of marine accidents. By maintaining accurate r'ecords of the vessel's maneuvering, including necessary speed reductions to safely pass vessels berthed in narrow waterways, masters and pilots will become more aware of the hazards of navigating large vessels in narrow waterways. Continuous attention to the vessel's speeds and courses is necessary because of the possible damage from wake or other hydrodynamic phenomena when vessels move. The Safety Board believes that the bridge watch of vessels over 1,600 gross tons that transit the Great Lakes and its tributaries should record the vessel's position'at regular intervals and have a means of recording the times of engine maneuvers, as well as a means of continuously recording the vessel's compass headings (course recorder). Total Petroleum's Inspection of Its Pier Total Petroleum's periodic inspections of its Bay City pier apparently did not include an adequate examination of the mooring piles. A visual inspection by the marine construction company failed to detect the defects in the wood. From its appearance, the wood section that the USDA laboratory analyzed did not seem to be strong enough to properly secure a vessel the size of the JUPITER, especially a vessel large enough to be affected by the momentum caused by hydrodynamic forces created by a passing vessel. Further, the marine contractor had not sounded or probed the center pile in the NO.4 pile cluster during his last examination. The strength of the center pile was critical to the safe mooring of vessels because it functioned as a mooring device. If Total Petroleum had properly inspected and maintained the center pile, the evidence of rot would have been discovered and the necessary repairs could have been made in a timely fashion. Because vessels berth infrequently at the Bay City terminal, Total Petroleum had ample time to schedule any repairs without affecting vessel use of the pier. The Safety Board concludes that Total Petroleum was remiss in its examination of the mooring facilities at its pier; the company should have arranged for a condition survey of the mooring pile clusters at regular intervals, particularly of the strength of the center pile to which vessels' mooring lines are secured.

54 Spread of the Fire When gasoline spilled onto the pier from the broken nitrogen purge line connection on the 12-inch pipeline, sparks from the damaged electrical conduit ignited the gasoline. The fire quickly spread to the deck of the tankship and ignited the gasoline that spilled from the ruptured cargo hose. Contained by the 6-inch spill rail, the burning gasoline spread throughout the midships area and around the open ullage pipes. Because the inside periphery of the ullage pipes had no continuous shoulder or ledge to properly support the flame screens and completely seal the space around the periphery of the flame screens (the clearance between the pipe and the edge of the flame screen was wide enough to allow a measuring tape to be kept in the ullage pipe without removing the screen), the fire on deck probably propagated into the tanks through the open ullage pipes. The design of the flame screens conformed to the applicable Coast Guard regulations (46 CFR 30.10-25-- "Flame Screens"); however, the installation of the screens in the ullage pipes rendered them ineffective because the clearance around the edge of the screen was greater than the mesh of the screen itself. The Coast Guard regulations do not address this problem. Instead, a Coast Guard spokesman characterized it as a "common sense" item that inspectors should check during Coast Guard vessel examinations. Therefore, the Safety Board urges the Coast Guard to tell their inspectors to pay particular attention to flame screen installations to ensure that the flame screen completely seals the opening around its periphery. Moreover, if crewmembers had closed the ullage pipe covers when the JUPITER stopped discharging and allowed the tanks to vent throu~h the PN valves, the explosions most likely would not have occurred. The vessel s crew probably could have extinguished the gasoline fire on deck using the fixed foam extinguishing system before the heat caused ignition in the tanks. The Safety Board concludes that the most likely cause of the explosions was the propagation of fire around the improperly designed flame screens in the open ullage pipes and into the cargo tanks. Total Petroleum's Operating Manual Total Petroleum prepared the operating manual used by the Bay City facility in accordance with 33 CFR Part 154. Approved by the Coast Guard, the manual includes descriptions of the types and grades of liquid petroleum products handled at the terminal, the hazards involved, and instructions for the safe handling of the products. It also includes procedures that terminal employees should follow in the event of spills, instructions on how to care for persons exposed to the material, what equipment is available at the terminal for containment and recovery, and the names of persons and agencies, Federal, State, and local, to notify in the event of a spill. However, the manual does not outline the procedures that terminal employees should follow when a vessel berthed at the terminal during transfer operations is approached by another large vessel. Total Petroleum leaves such procedures to the discretion of the vessel personnel in charge of the transfer operation. Although the Declaration of Inspection Prior to Bulk Cargo Transfer (see appendix C) lists requirements personnel must comply with before transfer may begin, the terminal's operating manual does not state that transfer operations should cease during passage of river traffic or in the event of other hazards developing that could affect the operation's safety. The Safety Board believes that the terminal should be more involved with vessel transfer operations that may seriously affect the outcome of a spill or casualty. The Board also believes that the operating manual of the Total

55 Petroleum facility should include a provision for notifying a vessel berthed at the terminal when other vessels of significant size are expected to pass in the waterway so that the crew can halt transfer operations in a timely manner. During April 1990, Coast Guard examiners inspected the Total Petroleum facility at Bay City and reviewed the company's Terminal O~erations Manual for compliance with Federal regulations; they made another spot" inspection in August 1990. Inclusion of shutdown procedures in the Coast Guard regulations would ensure that the operators of the terminal and the vessel both have responsibility for the vessel's safety and for safeguarding the waterway from pollution. Although the Coast Guard approved the Bay City facility's operating manual, acknowledging that it was in compliance with existing regulations for liquid bulk transfer operations, the manual does not address a shutdown requirement by vessels transferring liquid cargo when large vessels are expected to pass. The Safety Board· believes the Coast Guard should amend the regulations so that Coast Guard-approved Marine Oil Transfer Facility operating manuals include procedures for stopping the transfer of product between the terminal and tankships moored at the terminal when the danger of surging exists from passing vessels. Terminal Responsibility for Tankships Moored at the Facility The terminal's manager was in the terminal office when the BUFFALO sounded its whistle to open the Independence Bridge. Although he had a VHF-FM radio in the office, he had it tuned to the frequency of the handheld radios carried by the terminal operator and the watch officer aboard the JUPITER. Because a shoreside facility is not required to monitor VHF-FM channel 16, the terminal manager was not aware of the approaching vessel until he heard its whistle. When a vessel is moored and transferring liquid cargo, early knowledge of an approaching vessel would enhance the safety of both the terminal and the vessel. Terminal personnel could be alerted by Coast Guard Station Saginaw River that a vessel is expected to pass in the river. The terminal personnel could then notify the vessel berthed at the terminal. If the terminal manager had known earlier of the BUFFALO's presence in the river, he could have alerted the watch officer on the JUPITER sooner. Critical functions, such as suspending cargo transfer operations and manning the mooring winches, should not be left to chance. Terminal personnel should share responsibility for notifying vessels at their facility of ships moving in the river when transfer operations are under way. Because the terminal operator and the JUPITER's deck officer each had a handheld radio that was tuned to the radio at the terminal manager's office, the information could have been passed quickly. As a backup, the terminal operator, who was positioned near the JUPITER with his handheld radio, could also have notified the vessel. The Safety Board believes that as an added back up, operations at the Total Petroleum terminal should include receiving information from Station Saginaw River so that terminal employees can give timely notice to vessels loading or discharging at the Total Petroleum pier. Survival Factors/Search and Rescue Coast Guard Response.--When Coast Guard personnel at Station Sagil1aw River received word that the JUPITER had suffered explosions and was on fire, they immediately dispatched a boat and were on scene 13 minutes after receiving notification from the RCC. If the fire and explosions had forced the tankship's crew into the water before the Coast Guard rescue units arrived, the chance of injuries would have increased. The Coast Guard station's location close to the accident site

56 enabled the boats to reach the scene quickly. When the Coast Guard units attempted to fight the fire, they soon realized it was beyond their capability and concentrated their efforts on recovering persons from the water. The Safety Board believes that the Coast Guard units involved should be commended for their promptness and their decision to attend to the JUPITER's crew first. The Safety Board concludes that the timely and effective on-scene response from the Coast Guard units limited the fatalities and injuries. Abandon Shi~ Procedures.--Within minutes of the explosion, the JUPITER's master had notifie the Coast Guard of the accident and started to assemble the crewmembers on the stern of the vessel for a personnel check. Both first mates made certain that all crewmembers on the stern had donned either lifejackets or exposure suits before the master gave the order to abandon ship. Unfortunately, the third mate and an AB were trapped on the bow and did not have the time to get lifejackets before jumping into the water. The Safety Board believes that the AB who drowned could have survived had he been able to locate and don one of the lifejackets that were stowed forward before he jumped overboard. Since the crew did not have the capability to extinguish the fire, the most expedient thing that the master could do was to quickly get the crew off the vessel in a safe manner. At the time, it was uncertain whether more explosions would follow. Considering the loss of pressure in the fixed foam extinguishing system, the master was prudent in ordering his crew off the vessel instead of having it stay aboard to fight the fire. Response by Local Authorities.--Despite the timely response of local fire and other emergency units, fire fighting efforts were not immediately effective because of the magnitude of the fire. Through their combined efforts, local firefighters, the Coast Guard, and a commercial fire fighting company extinguished the fire after it had burned for 2 1/2 days. During a December 6 critique of the initial response held at the Bay City City Hall, participants agreed that they allowed the fire to burn because "there was no equipment or trained personnel to extinguish it." Although shipboard fires, in particular tankship fires, occur infrequently in the Bay City/Saginaw River area, the JUPITER accident highlights the fact that local fire departments need specific training in fighting shipboard fires. Units from Station Saginaw River assisted in deploying the oil booms, and the Coast Guard district commander provided the buoy tender BRAMBLE as a platform from which commercial fire fighters could work. The Bay City area does have a contingency plan, but the plan does not provide for training in shipboard fires or other marine catastrophes. The Safety Board has previously recommended that the Coast Guard integrate Coast Guard planning and training efforts with those of local authorities in developing port contingency plans that involve participation by the local waterfront facilities, the local fire and police departments, existing port authority agencies, and other disaster preparedness agencies. In 1985, as a result of a cruise ship fire in Port Canaveral, Florida, the Safety Board issued the following recommendation to the Coast Guard: M-85-29 Direct the Captain-of-the-Port, Jacksonville, Florida, to participate in establishing a port contingency plan for Port Canaveral with the Canaveral Port Authority and local jurisdictions in the port community. A similar recommendation (M-85-36) was made to the .Canaveral Port Authority.

57 The recommendation to the Coast Guard has been incorporated in the Marine Safety Manual;21 it directs the captain-of-the-port (COTP) to develop a fire fighting contingency plan that addresses fire fighting in each port in the COTP zone. The recommendation to the Canaveral Port Authority resulted in acquisition of and training in the use of emergency equipment in the port. Both recommendations have been classified "Closed--Acceptable Action." The Safety Board recommends that the Detroit Coast Guard COTP, who has responsibility for the Bay City/Saginaw River area, in cooperation with local authorities, develop a port contingency plan that includes shipboard fire fighting training and drills. . Toxicological Testing Because the results of chemical tests for drugs and alcohol are dependent on how soon the samples are taken after an incident, the Coast Guard regulations require that the marine employer ensure that the necessary specimens are collected as soon as practicable after an incident occurs. The Safety Board recognizes that the JUPITER operator and master were concerned about the rescue of the crew and were engaged in other emergency measures immediately after the accident. Nonetheless, the operator and master were responsible for having crewmembers provide samples for toxicological testing, and they should have fulfilled that responsibility by notifying the hospital to collect specimens from the injured crewmembers who were taken there. The uninjured crewmembers should have been taken for testing as soon as emergency conditions had abated. Because specimens were not obtained until the following day, meaningful tests for alcohol were not possible. The accident occurred about 0835, but the crew of the BUFFALO did not recognize for some time their role in the accident. That afternoon a Coast Guard offi'cer· informed the BUFFALO master of his ship's involvement and the need for collecting specimens. Some of the crew had already gone ashore. About 1900, the marine employer took urine specimens from nine crewmembers, and the specimens were tested for drugs. Again, it was not feasible to perform meaningful tests for alcohol. However, the Safety Board believes that as soon as Coast Guard officials arrived on the BUFFALO, they should have notified the master to collect urine specimens that may have made it feasible to test for alcohol. The Safety Board received only the MRO's assessment of the toxicological testing results on the crewmembers of both vessels; it did not receive the laboratory results. The information received did not include the time the specimens were collected or the drugs that were included in the testing protocols. Investigators determined, based on phone conversations with consultants involved in the evaluation of testing results, that those results did not include results of alcohol testing and that the MROs did not know whether tests had been done for alcohol. The MRO's report states that the individuals on the BUFFALO "met the drug-free requirements specified under U.S. Coast Guard regulations (46 CFR Parts 4, 5, and 16)." The MRO's report regarding the JUPITER crewmembers states that the individuals "underwent a substance abuse test in accordance with applicable DOT regulations." However, because alcohol was not included in either of the MRO's 21 U.S. Coast Guard Marine Safety Manual, volume VI, chapter 8, paragraph B.

58 reviews, the Safety Board does not agree that the crewmembers underwent abuse testing in accordance with 46 CFR Parts 4, 5, and 16, which require testing for alcohol. The Safety Board is concerned that sampling for drug tests was not carried out in a timely manner, and because of the lack of timely response, that testing for alcohol was not carried out. The Board is also concerned that MRO reports on each of the vessel appear to be misleading. CONCLUSIONS Findings 1. 2. 3. 4 5. 6. 7. 8. 9. The BUFFALO was proceeding at 4 feet of pitch when it passed the JUPITER; however, based on the lack of substantiating evidence, such as engine maneuvering records, investigators could not determine the BUFFALO'speed. The BUFFALO'S speed and close proximity to the JUPITER resulted in large hydrodynamic forces that caused the JUPITER to surge at the pier, .break the NO.4 mooring pile, and swing out into the river, rupturing the flexible discharge hose. Total Petroleum's four mooring devices at its Bay City terminal were inadequate to safely berth the JUPITER. By the time they sighted the BUFFALO as it passed through the Detroit and Mackinaw railroad bridge, The JUPITER's crewmembers had sufficient time only to stop the cargo pumps and man the constant-tension winches to protect the tankship from the effects of hydrodynamic forces generated by a vessel passing in the river. It is doubtful that they had sufficient time to take additional precautions, such as closing the ullage covers and the discharge valve at the cargo manifold. The JUPITER's crewmembers did not have an alert system that would give them reliable and timely notification of the BUFFALO s impending passage in the Saginaw River. The NO.3 wire cable failed to prevent the JUPITER from surging aft because when the AS started the winch motor, the brake released, and allowed some cable to payout. Moreover, the AS probably paid out additional cable to relieve the stress. The JUPITER crew's failure to take up the slack in the NO.4 wire mooring cable when the tankship first moved astern resulted in shock-loading on the NO.4 mooring pile when the vessel surged ahead. Sparks from the damaged electrical conduit ignited the spilled gasoline on the pier, and fire spread to the deck of the JUPITER. Explosions resulted when the flame front passed around the improperly installed flame screens in the open ullage pipes and entered the cargo tanks.

59 10. The operating manual for the JUPITER was inadequate because it failed to include specific instructions that vessel personnel were to follow when danger of surging from a passing vessel existed. 11. The JUPITER burned for 2 1/2 days until a commercial firefighting company extinguished it because local firefighters were not trained or equipped to fight shipboard fires. 12. The disaster contingency plan for the Saginaw River/Bay City area was inadequate because it did not include training in fighting shipboard fires for local fire departments. 13. Postaccident drug and alcohol testing procedures were not followed. Probable Cause The National Transportation Safety Board determines that the probable cause of the fire and explosions aboard the tankship JUPITER was the failure of Total Petroleum, Inc., to provide adequate mooring facilities for tankships such as the JUPITER, which allowed the vessel to break away from the pier because of surging caused by a passing vessel. Contributing to the accident were the inadequate procedures used aboard the JUPITER for managing the mooring lines and winches while other ships passed nearby and the fact that the BUFFALO was navigated to pass closer to the JUPITER than normal. Contributing to the severity of the accident were the lack of a reliable and timely alerting system that would have given the JUPITER's crew adequate time to take additional precautions to safeguard the vessel and the failure of the owners of the JUPITER and the U.S. Coast Guard to ensure that flame screens were properly fitted. RECOMMENDATIONS As a result of its investigation of this accident, the National Transportation Safety Board made the following safety recommendations: --to the U.S. Coast Guard: Amend 33 CFR Part 154, "Oil Pollution Prevention Regulations for Marine Oil Transfer Facilities," to require that the Facility Operatinr Manual include procedures for stopping the transfer 0 product between a vessel and the terminal when a danger of surging exists from passing vessels. (Class II, Priority Action) (M-91-31) Direct the captain-of-the-port of Detroit to instruct the officer-in-charge of Coast Guard Station Saginaw River to notify in a timely manner area marine bulk oil/hazardous material terminals in the Bay City/Saginaw port area within Coast Guard jurisdiction of impending river traffic so that personnel at the terminals and aboard moored vessels can take appropriate measures to suspend the transfer operations, thereby enhancing safety. (Class II, Priority Action) (M-91-32)

60 Direct the captain-of-the-port of Detroit to work with State and local jurisdictions to establish a port contingency plan for the Saginaw River/Bay City port area that includes training and drills for shipboard fire fighting. (Class II, Priority Action) (M-91-33) Include in the Coast Guard inspection instructions for marine oil transfer facilities a requirement that inspectors check the condition of the mooring facilities. The inspection should include a determination of the overall adequacy of the mooring facilities to safely berth vessels of varying lengths. (Class II, Priority Action) (M-91-34) Instruct Coast Guard inspectors to determine that the flame screens installed aboard tankships provide· a complete seal around the periphery of the screen. (Class II, Priority Action) (M-91-35) Disseminate the information contained in this accident report to the marine industry by means of Coast Guard publications and notices, emphasizing the requirements of 33 CFR Part 164. (Class II, Priority Action) (M-91-36) --to Cleveland Tankers, Inc.: Amend your fleet operating manuals to include written procedures for suspending the bulk transfer of hazardous liquids when a danger of surging exists from passing vessels. These written procedures should include, but not be limited to, stopping pumps, closing valves at the loading/discharge manifold, closing ullage pipes or other tank openings, notifying terminal personnel, and manning and operating mooring winches. (Class II, Priority Action) (M-91-37) Modify, as necessary, the flame screen installations aboard the vessels in your fleet so that they provide a complete seal around the periphery of the screen. (Class II, Priority Action) (M-91-38) --to Total Petroleum, Inc.: Include probing of the wood pilings during your annual inspection of the pier and the mooring devices to determine whether the wood has deteriorated to the extent that the strength of the pile may be affected. (Class II, Priority Action) (M-91-39) Require that all vessels using your facility have a forward and aft lead for their bow and stern lines. (Class II, Priority Action) (M-91-40) Amend the Bay City Terminal Operations Manual to include procedures for shutting down loading/discharging operations in a timely manner aboard vessels moored at the terminal

61 when a danger of surging exists from vessels transiting the waterway adjacent to the terminal. (Class II, Priority Action) (M-91-41) . Establish a procedure for receiving river traffic information from Coast Guard Station Saginaw River when transfer operations are in progress so that terminal personnel can notify vessels at your Bay City facility of such traffic in a timely manner. (Class II, Priority Action) (M-91-42) --to the Lake Carriers' Association: Recommend that your members establish a procedure aboard their vessels to record engine maneuvers, either manually or automatically, when entering or leaving port and at other times during a voyage when maneuvering by engines is required, and have a means of continuously recording the vessels' headings (course recorder). (Class II, Priority Action) (M-91-43) --to the State of Michigan: Direct the Michigan Department of State Police, Emergency Management Division, to amend the County Emergency Planning Workbook, dated November 1986, to include provisions for shipboard firefighting training and to include procedures for fighting shipboard fires in the State Contingency Plan. (Class II, Priority Action) (M-91-44) --to Bay County Emergency Services: Amend the Bay County emergency contingency plan to include guidelines for fighting shipboard fires. (Class II, Priority Action) (M-91-45) BY THE NATIONAL TRANSPORTATION SAFETY BOARD /s/ James L. Kolstad Chairman lsI Susan M. Coughlin Vice Chairman 1st John K. Lauber Member /sl Christopher A. Hart . Member /s/ John A. Hammerschmidt Member October 29, 1991

63 APPENDIXES APPENDIXA INVESTIGATION The National Transportation Safety Board was notified of the accident on September 16, 1990, through its North Central Regional Office. The Safety Board conducted its on-scene investigation jointly with the u.S. Coast Guard from September 17, 1990, through September 28, 1990, and on November 27, 1990, in Bay City, Michigan. Total Petroleum Corporation, American Steamship Company, and Cleveland Tankers, Incorporated, participated in the investigation as parties. The estate of John Sexton, deceased, participated in the joint NTSB/USCG public hearing as a party. ----- ----------" (----------- Preceding page blank .. ; / "'-------------.- ----- --------

65 APPENDIX B PERSONNEL INFORMATION David L. Beckwith Captain David L. Beckwith, 44, master of the JUPITER, had been employed continuously by Cleveland Tankers since 1976. He had sailed on four company tankers and was master of the JUPITER for 2 1/2 months during the 1990 shipping season. He alternated between the company vessels on a regular basis. He started his sailing career in 1964 aboard U.S. Steel vessels in an unlicensed capacity. He had been a licensed deck officer since 1973 and held a master's license, unlimited tonnage, for the Great Lakes with a first class pilot's endorsement and an unlimited radar observer's endorsement. Since 1976, he had visited the Total Petroleum terminal at Bay City about three to five times a year. Peter Walton Peter Walton, 34, was first mate aboard the JUPITER until 0800 on the day of the accident. His replacement had assumed the duties as first mate, and both were on the vessel when the fire and explosion occurred. Peter Walton had served aboard the JUPITER for about 2 1/2 months during the current shipping season. He had been employed by Cleveland Tankers since his graduation from the Great Lakes Maritime Academy in 1979. He served aboard the JUPITER for a period of time each season and on two other company tankships. He held a Coast Guard license as master near coastal and Great Lakes, including first class pilot, unlimited tonnage, and an endorsement as unlimited radar observer. George A. Defrain George A. Defrain, 39, had assumed the duties as first mate at 0800 on the day of the accident. He had been employed by Cleveland Tankers since 1983 and had served aboard other company vessels each shipping season. He had served aboard the JUPITER earlier during the current shipping season. He held a Coast Guard license as mate, Great Lakes and inland waters, and as first class pilot, Great Lakes, unlimited tonnage. He had a radar endorsement. Before 1980, he served in unlicensed capacities aboard Great Lakes and inland vessels. James M. Stengel, Jr. James M. Stengel, Jr., 24, second mate of the JUPITER, had graduated from the Great Lakes Maritime Academy in 1987. He first worked aboard vessels of the U.S. Steel Corporation's Great Lakes fleet. He was employed by Cleveland Tankers about 1 1/2 years before the accident. He had about 7 to 8 months experience aboard the JUPITER. He held a Coast Guard license as mate and first class pilot, unlimited tonnage, for the Great Lakes and a radar endorsement. Daniel A. Rentschler Daniel A. Rentschler, 28, third mate of the JUPITER, joined the vessel soon after his graduation from the Great Lakes Maritime Academy in June 1990. The day of the accident marked his second visit to Total Petroleum's Bay City terminal. He held a Coast Guard license as mate and first class pilot, unlimited tonnage, for the Great Lakes and an unlimited radar observer's endorsement. Preceding page blank '

APPENDIX·B James Warren 66 James Warren, 52, the JUPITER's pumpman had been employed by Cleveland Tankers since 1981. He started sailing in 1955 and had served in all unlicensed capacities in the engineroom. He held a merchant mariner's document with endorsements as engineman, fireman, oiler, tankerman, pumpman, and ordinary seaman. Randall J. Skinner Randall J. Skinner, 61, an 8-12 AB/watchman, had been employed by Cleveland Tankers since August 1979, during which time most of his experience had been aboard the JUPITER. He started his seagoing career on deep-sea tankships and cargo vessels in 1957 and has held a merchant mariner's document as AB since 1970. He started sailing on Great Lakes vessels in August 1979. John Macfalda John Macfalda, 42, master of the BUFFALO, held a Coast Guard license as master and first class pilot, unlimited tonnage, for the Great Lakes with an unlimited radar endorsement. He had been employed by American Steamship Company since

1. With the exception of a few years following a company/ union change in the

seniority system, he had sailed as master since 1982. His experience included service aboard the larger 1,000-foot-long Great Lakes vessels. His training included a shiphandling course in Port Revell, France, and observing other shipmasters handle Great Lakes vessels of various sizes. Richard P. Hollingsworth Richard P. Hollingsworth, 35, the BUFFALO's third mate, had been employed aboard the vessel since its fitting out for the 1990 shipping season in March. He sailed mostly as second mate, occasionally as third mate. He held a Coast Guard license as mate and first class pilot, unlimited tonnage, for the Great Lakes with a radar endorsement. He started sailing when he was 17 and had been licensed since 1979. He estimated that he had been into the Saginaw River about 20-30 times during the current season. Daniel L. Meyers Daniel L. Meyers, the AB/wheelsman at the BUFFALO's helm when it passed the JUPITER on the day of the accident, had been sailing since 1966. He had held a merchant mariner's document as AB since 1969. He had 13 years experience as a wheelsman on Great Lakes vessels. He joined the BUFFALO in 1982 and, except for the seasonal layup during the winter, had sailed aboard the bulk carrier continuously. Alan P. Garner Alan P. Garner was the terminal manager at Total Petroleum's Bay City terminal. He had been employed by the company for 5 years. He held no Coast Guard documents or licenses. His duties as terminal manager included scheduling of pipeline deliveries, working with the product supply department when vessels were

67 APPENDIX B due, managing truck traffic through the terminal, and ensuring that the terminal had sufficient products for sale. Elmer Seltz Elmer Seltz was the terminal operator on the day of the accident. He had been employed by Total Petroleum for 23 years. He held no Coast Guard documents or licenses. His responsibilities included general maintenance around the terminal and the truck loading racks. He helped tie up vessels calling at the terminal and connected the hoses. He also lined up the terminal's valves and operated the pumps to transfer product as necessary.

69 APPENDIX C DECLARATION OF INSPECTION PRIOR TO BULK CARGO TRANSFER VESSEL =:s u eIT E. g, TRANSFER FACILITY _/C_O;;....:.'-:A...;..:.,I ---:" _ LOCATION Be '( C ,-r I( (Y1 " TIME & DATE TRANSFER STARTED _ PRODUCTS ~I The following lisl refers to requirements I8t fanh in detail in 33 CFR 156.20. 156.15O.nd 46 CFR 35.35·30. The IPlcealldjecentto hem& on the lisl are provided to indicate thetthe detailed requirements heve been met.

1. Vessels Moorings 156.120 (AI
2. Hoses; Iength.nd IUppon 156.120IBIICI
3. Hoses or LoICIing Arms condition 156.120 III IJI 156.170
4. Trensfer System Alignment 156.120 101
5. Transfer System; unuaed componenll 156.120 eEl IF)
6. Trensfer Sv-tem; filUld piping 156.120 IGI
7. Transfer Syst8lTl8; moniloring devices 156.120 ILl 164.525
8. Overboard Discharges/Sea Suction Velves 156.120 IHI
9. Connections 156.130; 156.120 eKI (PI
10. Discharge Containment System 166.120 eM!IN)
11. Scuppers or DllIins 156.120 101
12. Emergency Shutdown 156.120 IRI
13. Spill & Emergency Shutdown Procedures 166.120 (RI 156.125
14. Person in charge; on vessel/on facility 156.120 lSI (n
15. Sufficlenl Personnel 156.120 lUI
16. Communications/t..ngueg8 Fluency 166.120 lailVI
17. Trensfer Conference 156.120 (WI
18. Agreement to begin transfer 156.120 (XI
19. Lighling (sunselto IUnrisei 156.120 (YI III
20. Werning Signs & red Warning Signals 135.35·30)
21. Repair Work Authorizalion 135.35·301
22. Boiler and Galley Fires Safety 135.35·301
23. Fires or Open Flames 135.35·30)
24. Sefe Smoking Spaces 135.35·301

I do certify thaI I have personally inspeCted this fecility or vessel with reference to the requirements let forth in Section 35.35·30 end thet opposite each of ltoem I have indicaled thelthe regUlations hive been complied with. TITLE TIME AND DATE Perton in Chlrge Delivering Unit ~~ TIME AND DATE TRANSFER COMPLETED DISTRIBUTION: ORIGINAL· Reuined by Mester PINK COpy· Terminel Superintendent YELLOW COpy· Cleveland Office Preceding page blank ." -----._----------

r

71 APPENDIX D U.S. COAST GUARD CERTIFICATE OF INSPECTION, JUPITER .,J CERTIFICATION c,,-e '211'1AR90 I~ 4tl2:JJ1."t",tU I Uti T\ I MUt. ~Ur-.l ~ ~-:j!:. r:-..AJO '" .",tAf '1 ~ ~ SIGNAtVRi RANiI'':~:'::'''C!ifit..::.. ""m'o."" 2INA.'2 • Q:£rtiftcgtt'Of~ip~£~i ~fl:K 7367287 UPITER 0511820 c....... IIGN II"vICI ZC1603 '~NK SHIP PHILADELPHIA, PA IEN~INGS. LOUISIANA LEVELAND TANKERS INC 00 WEST TENTH AVE ~ILMINTON, DE 19899 ~TEEL 4200 CIESEL REDUCTION CLEVELAND TANKERS. INC 55 PUBLIC SQ. PO BOX 6419 CLEVELAND. OH 44101 Ti04IS 'vESSEL. MUS":" BE MA .... NE~ WITt-t THE FO.LOWINCi L.ICENSED AND UNLICENSEO II'ERSONNEL, I""'CL.UOEO IN "",~" T"E~E ... "'ST BE --L-~EP,T'FI~ATEO L'FEBOATMEN AND~C:ERTIF'C:ATEOTANKERMAN __ "'A.S-EFI & 1ST CL.ASS PILOT ..L- ABLE SEAPltter. ---L. C"41Et: ENGI~EE~ _ C,",ASS PILOT ~ OROI".AF!Y SE ...MEN __ 1ST _SST EI'I,IG' .... EER 1 -1- ~'E" _C EI:~L-E __ OeCK'o-lA'.IOS ____OPEPATORISI _ __ 2"'0 ASST ENCi'I'IIEER -2.. ASS! ST E"C'RS __ FIFle"'E!'oI·WATER""e ... :o:=.s __ Ol ... eRS , I i."'" A:l~I~IJ,... TI"I,5 '·.ess:. .. MA Y :A.R.A'" __.......O'--PASSE.... GERS. _ ....4iL-_OTHER PERSOI'.IS IN CAE\II. 3 PE~SONS lilt ADDITION '!'C :I=IE" A... : NO OTbeRS TOTAPEPSO,"S ALLO"E~~ GREAT LAKES 'THE ELIMINATION OF WATCHSTANDING QMEDS AND LICENSED ENGINEERS IN THE IMACHINERY SPACES IS CONTINGENT UPON THE PROPER OPERATION OF THE AUTOMATED ICONTROL/MONITORING SYSTEMS. ALTERATIONS TO OR FAILURE OF THESE SYSTEMS :~~ST BE REPORTED IMMEDIATELY TO THE OCMI WHO ISSUED THE VESSEL'S CERTIFICATE OF INSPECTION. ... SEE NEXT PAGE FOR ADDITIONAL CERTIFICATE INFORMATION ••• "","" T... lS "B"ECTIO"o ..All''''':; BEE'" ~o~WAUKEE, WI SCONSI N ON2 IMAR90 . T> IIES6E IS CERT'F'ED BY T>< T> Al'l'LIC4BLE VESSlEL INSPECTION UWliS AND 'n III.JI.ES 0 AEOULA 6Ns ORE9CfIl'IIE.DTl4EIlIEUNOE'" PER'O:J,C RE'''SFECTIONS THISt:ERTI??,/ ~~;~G OATE I ZOIoE I SICNATU'-E . R~ I I OFFICI" ltrll C..... .-.G. "'''''1..,1 I""S'"CT I0"" i "''' WI , I' I '"'''fCTIO''' ZO""'. Ot1"T. 0" TRAN$P.. lJ'SCG, CG... : IRe", a... , 510 P~E'IIOUS EOITIONS ARE OSS.)l.ETE

Preceding page blank I

73 APPENDIX E U.S. COAST GUARD CERTIFICATE OF INSPECTION, BUFFALO OMBNo 21150 I ~ CERTIFICATION DATE .~(IMAF!8q I UNITED STATES OF AMERICA ,I (i) Di....IIIT111flfT Of " ....,....,'...TIOIIiI fllPIRATION DATE: 2(lMAI~91 UNITED STATES COAST GUARD ([crtificotc or if ,. 1110 NUI1BEP.: i62~)·~:'3 LASTnH~~~!~02QMARee [IRYDOCI: "'ESSE l I\ojAlro'e OFIllICIAL Nu"IEIll CAL.L. SIC:;"" S~ 1Il .... ICiE BUFfALO D~·9b352 WSXb134 REIGHT SHi~ HOIIrIIIIE coo"''' '"'UI..'- ......TE"IAL "OIllU"OW( • ·.0"UL.510"'" PHll..A[lELF'Hl A, F'A STEEl.. 7200 'IE5El.. REDUCT 1OI'J Si"lmCEor~ CATE I'-,PL.T r~llloss TOfll$ I~ETTO""S iO~T I." C" BAY, WISCONSIN 01JAN78 11619 8036 tJl -:.1)(1 I O..... ""f R o·A'AF.:R 1CAN I FH~ST NAT BAN}: OF CON~I[CT 1CUT STEAMSHIF' COMPAN't' I BENEFIT CONNELL RICE ~, StJ 3200 MARINE MIDLAND CNTR. OtJE CONST I TUTI ON PLA2A EtUFFAl..O, NV 14203 HARTFORD, CT 06115 THIS VESSEL MUST BE MAtrlNEO WITH THE FOL.LOWING L.ICENSED AND UNLICENSED HRSONNEL., INCLUDED IN WHiCH TI"tERE. MuST 8E __ ·~·_CERTIFICATEDL,IFEIIOATMEN ....,..o__··'_CEATIFICATED TANKEAMA..... ...:......STER __ MASTER '& 1ST CLASS PILOT ~: AILE SEAMEN ~ CHIEF ENGINEER ~ FIAEMEN.wATE~TENO:'FlS I _CttIEFMATE _ C~ASS 'l~OT __ ORDIN..RY se....EN ~ 1ST ASST. ENGINEER __ OI~ERS , 2NO MATE -- RADIO OFFICER'S}

(';""""Bt'tp:NB~ILl TY----r ~SS,;S"rGINEER

I -:r ___....TE5 O'ER ..TORIS) __ __ ENG'RS -- : / OTHER 'ERSONS IN CREW, -=:-'ERSONS IN ADDITION TO CREW, AND IN ADDITION, THIS VESSEL MAY CARRY 'ASSENGERS, ::'1 . TOT AL PERSONS ALLOWE 0 ROUTE PEIOtMITTED AND CONDITIONS OF OPERATION CF,;:_I~T LAI~E.S AIJU THE Wf.,'l'EHS OF THE ST. LA"'RENCE AS FAF: EAST AS AN'/'] COST! ISLAND. 2P~CIAL suns Ht,'.'£ BEEI~ UTILIZED IJUR IlliG CONSTRUCTION. THE CONSTRUCT rLJi'I I"OI':TFOLI 0 SH~LL BE. CO"ISULTE[I F'F:l or~ TO AN'y 1~Ei"Al F:S OF: ALTEFo:,~.T1 DN~,. *THR£E OF THE DECI~ UTILIT'r' PERSONS NUST HOLD THE Et-IDORSMENT fOR AEiL':: SEf;tli'_tJ. I *,~.." sn: NEXT P.(,(,E FOR ADDITIONAL CERTlFlCATE HIFORI'1AT ImJ +,.... WITH THIS INSPECTION HAVING BEEN c:oo.PLETED AT TOl~EDO I OH1O ON 2(lM~,R89 . THIS VESSE~ IS CERTIFIED BY T1-IE OFFIC£R IN O'4ARGE, ~INE INSPECTION, TOLI:DO, OHIO TO BE IN AU. RESP£CTS IN CONFO....'TY WIT>< THE APP~ICABL.E VESSEL INSPECTlON LAWS AND T1-IE RUL.ES AND REGULATlONS PRESCRIBED T1-IEREUNDER. PERIODIC REINSPECTIONS THIS CERTIFICATE ISSUED BY: DATE Z - ..... e SIG",ATURE J. L. CONVERSE, LCDr1/USCC OF'.CElJIItPol CHAlJIICjE ...... flIIIllIE I~SPEC:TIO"" " ST. lGt-JACE, Ml , IHS~ECTION lC .... !: 11 DEPT. OF TRANSP,. USCG, CG~'. (Re., J,HI PREVIOUS EDITIONS ARE OBSOL.ETE r--. I . '-------- --- ~ lUD-4D·FOI-4J1D Preceding page blank ,,------ )

75 APPENDIX F ~ EMERGENCY STATION BILL, JUPITER &.:u ... In~, 11)--'4'\ Il.l.C"••l·OU."" UNITED STATES COAST GUARD SPECIMEN OF A STANDARD STATION DILL PREPARED FOR FREIGHT AND TANK SUIPS CARRYING PERSO~S IN ADDITION TO CREW STATION BILL SIGNALS ..:.!'!...:...Y....lli.I!.~!'!.!") ..:.~..!.~!.____ Cle ve lan.~.:;'~_~.~!i.L..!~..£.:- _.... 01_.. ...,,) 01 _ I FIRE AND EMERGENCY-:-Rapid rinlrinlt 01 tha ship's bEolI and eODLinuo~ rin:;ing o/generoJ oJ&no beth lor I period or"' 1euL 101lilU. ADAP\'DON FlIIIP-Morl thlD e aborL blusts snd I Inng bl""l 00 Lbe wbillie and Lbe lUll. a':;na! on L40 g8DCl'll1 alarm bello. MJ\N OVERnllARD-Hail. ud p." Ihe "'ord ":\I.\N OVEIWOARU" '" LbIl bridge. DISM~Fnun FIRE ~D.!M.:n~EN?~~l.Lio~.~a.la011 Lb. whilOe &lid 3 ahorl riDca OD t.be lellUoJ oJarm beIlf. SPECIAL S I G N A L S "I~E l'ORWARD••••••••••••• ON! LONG & ONE SHORT BLA.:>T ON SHIP'S WHISTLE. SAME 01 GENEJlAL ALARJ P1RE APT.. , , ONi: LONG & TWO SHORT BLAST ON SHIP'S WHISTLB. SAl1E ON GCNJ::RAL~! RESC\re BOAT REQUI~D " THREE: LONO 81 THREE: SHORT BLAST ON SHIP'S WllISTLE fOAl~ ftECUIRED~••••••••••• AU 'l'OIIA'l'E:D !'CAM SYSTEM WILL BE ACTIVATED PROM BRIDGE !1l:i:RGENC'l SQUAD ~RQ::NC'iS"U.D "'~lL CONSIST OP THE 'lA'l'lI AJI1) CRIN Oll WATCH PLUS THRll:E O'1'HB:B AB!.! QiAHER 8&RTH 110. "UUll) P'IftB .. BHIl:RG::NClC pUTIES~H SHIP STAT: /777(1/1/J(IIIJJII?(IZJI/I17/JI7I/IJJZJJJI/I/777I/71/771/111I7IJJI/11!!/7,'/11111/11/1117117, A I-lASTi:R M41i SlUDGE - ASSUMB .COHHAIID 0' LIJlERAP'l' NO. 1 OR ALL OPE;:RATIOtIS IN kOHHJ.ND 2 1 tiO. 1 NO. 1 NO. 2 NO.2 110. 2 1'(1. 2 !lO. 1 110. 1 III C01·!)o'J.MD LplERAPI' t.'O. 2 seCOND HATS 2 i) ~'lbtTIl ttA':! !. nl"l-.,.nV,lcl 1I~C(j-11l0 ~leJo. OhIo ~.1~-77 ~hd 11 16 15 1 PIRST lUTE IUN DRUlOE - ASSIST MASTER AS Iii COt1loUND DIRF.CT:;;D - SZCONp IN COMMAND LIPlRJ.!"r tlo. 1

77 APPENDIXG USDA FORESTRY LABORATORY'S REPORT ON WOOD PILE SAMPLE Forest service Forest Products Labaratcny CD! Gilfam Pincbot Dr. Midiscn. WI 53705-2398 Reply to: 4710 (I) Date: Nrvenber 9, 1990 Mr. ~er Phillips Physical SCience Technician National Transportatioo safety Board Washingtoo, DC 20594 Dear Mr'. Phillips: This letter SlJIIIl'Brizes cur Noveuber 6 prone cc:nversation regarding· the wocrl sanple sent with yw.r OCtd:>er 24 letter. The semple is a species of the oak Ouercus) belonging to the white oak graJP. It C of a lighter-colorEl.d sapwocrl area. ani a slightly darker-colorai heart\o.ocd area.. Terry Highley, project leader of the Biaieterioration of Woai groop, exarninerl. the piece ani corx:luderl. that decay was present. The characteristics of the \tiCXrl cells at the fracture zone in:Ucate that the wcx:rl was subject to brashness. The enclosed page describes this corrlition ani its ccnsequen::es. Ycur semple is being retumerl. uroer separate cover. The streak on the flat surface is the resul t of a chemical solution I applierl. as part of the analysis. Sia::erely, ~~'-:"V..A'J.. DONNA J. C , Botanist Center for Wood Anatany Research Enclosure r-----~------------__ " I ~1'E. ~08) ·231-9200 Preceding page blank ',,----- ------ - ------ TELEK: 7400032 I / FACSIMILE: (608) 231-9592 FS-6200·~8a (5.'64,

APPENDIXG 78 ~i\l't ER 6i Strength or Wood 133 Compression failures Illl ri Ilg ~L'\ en: \1 iIIlI ~ lu :'lllS or umk r h,'~ \"\ sno\ IU~1d lhe 1,..Ie' 01 a tl'l'L' 1li:1\ he' bL'lll L'\CL",.;jIL,h" Thi~ :ll"u ~Ol:ll'­ :Illle" Ue'l'lIl ," dlll'i;~ g bIu\ dl ,\ nUl iI~ Il'; Illlg :1 LIl'l', Wh"1l t1k' hulc: 01 ~\ tl'eL' is bL'nl I'Kl' onL' giant bl'~\Ill, Lhl' \ucid in Ihe' l'Onea\ e ,ide l'an Ll iI iIl CUl11rreioll \1 ilhoul ien~ iOIl '~\illIll' d,,\,,'lupi'l!;! ill th,' COI1\"t'\ silk, ThL' cumpl-L'ssion c!~IIII~\gL' tu tilL' t'L'L' gUL'S Ullilulicl'ci. In lhl' woud, the Il"lIll is illq;U!:t:' pldIIL" ul bucKkd 10llgitudin~tI cL'II" ,.tllnl compression failures, The"l' I(x~di/l'd pLllll'," ul d.'IlI~\gl' gel:e'r:dh rUIl lTO,S\1 iSe' to tilL' gr:lin, III ruugh :UIII:)eT th,' ~rl' \ i I'lll~tlh il11;XJssihk lo lk:L'l't, but Of] !)Idlied ur salldl'l! longitudill~\1 ,url"'" Lhl'\ arc USll~\1I. \ i,ih:l', appL'dl illg ~\S \1 1'lnK!c, ~lcru"s th,' gr~1if] ill, Cum- I): e'ssiun l~\i!ures ;\re L'\lreilleh (ktril11l'lltallu InL'mh<-'rs 'In:''L'd in b<-'nding, I"or the' hucklc'd cl,ll s[:'lIC1Ure' f"il, rl'dd,l\ in tl'lbion, resulting: ir~ sudden be~1ll failul'c ~l IO\ler-than-nul;11;11 slre~s leI cis, Critic,,1 structul~d l11l'llllxr,,,, sud1 a" ladder r, ,c;l!"[olding, aill'r;"l p;:I-b or bU:\l ,p~\rs. r~llht be carelull,\ inspl,ctc:d tu e,- clude IC:lteri;\1 \1 iih cUl11pr'L',siun f"ilurL's, \-uud cur!- l;lining l'ulllprt'ssiun I"Zlilu:-e" i~ alsu u:l,uit,lhk 11.)[' ,LL'dm-bending \IOrK_ Brashness-:\oI"lTlal \Iuud i, ch'Hacteristically lough, When it breaks in bending. lhe ct'll strul'ture progrl's- si\ely st'parates as splinlering rracLures, Auuibk crack- ing and creaking accomp,lny the grauu~1 failure of the \uod, There is eonsiuerable udormZltion, lI'ell beyond Iht' clastic limit. bdorl' tutal failurL' finall) lakes place, I-Compression failures appear on longitudinal faces of sur· faced lumber as wrinkles across the grain. Under cerlain condi:iuns, \uod lail~ ahrupLI.', \Iith llIinilllal dclleCliun and at IU\I'l'r tlwn l'\pect,'d IU~lds_ llte,,-' L\illlIL'~ ;\Il' char.I,-'lni/cd b) lTu"s bre.1K" 1~.Il laCK thL' usu;t!,'\'ioencL' or fibrou~ 01 splint''l"ing scpara- tiOll, Such brittle ;\fld \L'aK bdl,\'ior in \Ioud is called brashness 12;, Thl' fioluus breaKillg or normal \OOU might bt' cumpared lu thl' brL'aKing uf a string'- stalk ur cL'kn', \hik Lh" brdsh fai~ure or \Ioud \oule! be an;t1ugous to thl' ahrupt sn;lpping of a carrol. A, llescribl'd ;,hOl!:', \1000 d,IJnageo oy c()lllpres~ion r;,ilure" II ill e!~ihit h:',.';hIlL'~S whl'n ~:r"ssed in b,'nd- ing_ Rl',lctiun \Iuud in cOllikr" (Coillpressioll \I'ood) ,t1so shu\I' br;"hfll'SS, l'\ L'1l Lhough ils UenSil) l~ greater Ihan nUllll~11 \oml. E,:remc grO\I th rale~ ma) also pru- d~I".:"",· b:·~<..:nL'~"", In I'i~"';.:;·puru~~~ hard\{Jud..,. C\1It.'1l1("Iy ,lu\1 gl"UII th rl',ull~ in IU\'-dl'nsil) ~UOU b"C:lu~c of thL' I:II-g" pe'rcl'nlage 01 e:\ rl \"\1 oml n'sseh, This \UOU is clul ;\l"lL'risticall~ brash and is l'spl'Li,dh' truublesumc ill slL'alll-bendillg, Among C<.H1ircr~. muo<-'rall'ly slo\ but h,'althy gJo\"th pruduct's dcnse, strong \IOOU, E:l.trl'TIlt'ly s!o\ gro\I,th, a" in stuntt,d ur Olermalun: Irt't's (\Iood \1 ith 35 or Illort' rings pL'r- inch) may also product' brash \oud, E,\lremt'ly fast gl"O\,.h in conif!:'rs, reflecting the 10\1 d,'nsity or thL' dominant early\oou, also tend~ to be brash_ The widt'-ringeu growlh of pronounced ju\'enile \vood is especially pro"ne 10 brashnL'ss_ Prolonged ex- posure 10 high tcmperatur<-' and fungal decay are other causes of brashness in \Ioud, 2-Normal gradual splintering failure in catalpa beam. top. contrasts with abruptly cracked (brash) white pine beam that contains reaction wood, above. Reproduced from 0 best available copy· ------_--.-/ ,----------

79 APPENDIX H EXCERPTS FROM CFR PART 164-NAVIGATION SAFETY REGULATIONS Coa.t Guard, DOT 30, 1964. Redesignated by CGD 81-017, 46 FR 28154, May 26. 1981) PART 164-NAVIGAnON SAFETY REGULATIONS Sec. 164.01 Applicability. 164.02 AppllcabUity exception for foreign vessels. 164.03 Incorporation by reference. 164.11 Navigation underway: General. 164.19 Requirements for vessels at anchor. 164.25 Tests before entering or getting un- derway. 164.30 Charts, publications, and equip- ment: General. 164.33 Charts and publications. 164.35 Equipment: All vessels. 164.37 Equipment: Vessels of 10.000 gross tons or more. 164.38 Automatic radar plotting aids ). 164.39 Steeling gear: Tankers. 164.40 Devices to Indicate speed and dis- tance. 164.41 Electronic position fixing devices. 164.42 Rate of tum Indicator. 164.51 Deviations from rules: Emergency. 164.53 Deviations from rules and reporting: Non-operating equipment. 164.55 Deviations from rules: Continuing operation or period of time. 164.61 Marine casualty reporting and record retention. AUTHORITY: 33 U.S.C. 1223, 46 U.S.C. 3703. Sec. 164.61 also Issued under 46 U.S.C. 6101: 49 CFR 1.46 ). /l164.01 Applicability. (a) This part (except as specifically llniited herein) applies to each' self- propelled vessel of 1600 or more gross tons (except foreign vessels described in § 164.02) when it is operating in the navigable waters of the United States except the St. Lawrence Seaway. [CGD 83-004, 49 FR 43466, Oct. 29. 1984] /l164.02 Applicability exception for for· eign vessels. (a) This part (including §§ 164.38 and 164.39) does not apply to vessels that: (1) Are not destined for. or departing from. a port or place subject to the Ju· risdiction of the United States: and (2) Are in: (i) Innocent passage through the ter· ritorial sea of the United States; or § 164.11 (Ii) Transit through navigable waters of the United States which form a part of an international strait. [CGD 77-063, 44 FR 66530. Nov. 19, 1979, as amended by CGD 79-148, 45 FR 54039, Aug. 14, 1980] /l164.03 Incorporation by reference. (a) Certain materials are incorporat- ed by reference into this part with the approval of the Director of the Feder- al Register. The Office of the Federal Register publishes a table, "Material Approved for Incorporation by Refer· ence," which appears In the Finding Aids section of this volume. In that table is found the date of the edition approved. citations to the particular sections of this part where the materi· al is incorporated, addresses where the material is available. and the date of the approval by the Director of the Federal Register. To enforce any edi· tion other than the one listed in the table. notice of the change must be published in the FEDERAL REGISTER and the material made available. All approved material is on file at the Office of the Federal Register. Wash· ington. DC 20408 and at Room 4402, U.S. Coast Guard Headquarters, 2100 Second St. S.W., Washington, D.C. (b) The materials approved for in- corporation by reference in this part are: Radio Technical Commission For Marine Services (RTCM) Paper 12-78/ DO-100 dated 12/20/77. [CGD 81-081, 47 FR 58244, Dec. 30, 1982] /l164.11 Navigation underway: General. The owner, master, or person in charge of each vessel underway shall ensure that: (a) The wheelhouse is constantly manned by persons who: (1) Direct and control the movement of the vessel: and (2) Fix the vessel's position; (b) Each person performing a duty described in paragraph (a) of this sec· tion is competent to perform that duty; (c) The position of the vessel at each fix Is plotted on a chart of the area and the person directing the move- ment of the vessel is informed of the vessel's position; 433

APPENDIX, (i 80 11164.]9 Requirement. for' vessels .at anchor. The rriaster or person in charge of each vessel that is anchored 'shall ensure that: ' (a) A proper anchor watch is main· tained; (b) Procedures are followed to detect a dragging anchor; and (c) Whenever weather, tide; or cur· rent conditions are likely to cause the vessel's anchor to drag, action is taken 'See also 46 U.S.C. 672, which requires an able seaman at the wheel on U.S. vessels of 100 gross tons or more In narrow or crowded waters ~r during' low visibility. 33 CFR Ch. I (7~1-90 Edltlo,n) (d) Electronic and other navigational (p) The person directing the move· equipment, external flxed aids to na.v~·--Jw.t:n.IL of the vessel sets the vessel's gation. geographic reference po , speed with consideration for: ' and hy~ographic contours are used (1) The prevailing, visibility ,and when fixing the vesSel's position; weather conditions; , (e) Buoys alone are not used to fix (2) The proximity of the vessel to the vessel's position; " fixed shore and marine structures; . NOTE:' BuoyS are aids'to navigation-plaeed The tendency of the vessel un- In approximate positions to alert the marl; derway to squat and suffer impair· ner to hazards to navigation or to indicate mentof maneuverability when there is the orientation of a channel. Buoys may not small underkeel clearance; maintain an exact position because strong (4) The comparative proportions of or varying currents, heavy seas, ice, and col· the vessel and the channel; lislons with vessels can move or sink them or set them adrift. Although ,buoys may cor- (5) The density of marine trafflc; roborate a position 'flxed by other means, ·(6l The damage that might be buoys cannot be used to fix a position: how- caused by the vessel's wake; . ever, Wno other aids are available, buoys (7) The strength and direction of the alone may be used to establish an estimated current; and position.' ' . " (8) Any local vessel speed limit: :e within the preceding 2 hours, mined is competent to steer the vessel except when operating on the Great is in the wheelhouse at all times: I Lake:; and their connecting and'tribu. (k) If a pilot other than a member of tary waters. the vessel's crew is employed, the pilot (tl At least two of the'steering gear is informed of the draft, maneuvering power units on the vessel are in oper. characteristics, and peculiarities of the ation when such units are capable of vessel and ',of any 'abnormal c.ircum- simultaneous operation, except when stances, on the vessel that may alfect operating on the Great Lakes arid its safe navigation. " ()) Current velocity and direction for their connecting and tributary waters. the area to be transited are known by [COO 74-77, 42 FR 5956, Jan. 31, 1977, as the person directing the movement of amended by COD 83-004. 49 FR 43466, Oct. the vessel; 29, 1984]' ' (m) Predicted set arid drift are known by the person directing move· ment of the vessel; (nl Tidal state for the area to be transited is known by the persondi· recting movement of the vessel; , (0) The vessel's anchors are ready for,letting go; , § 164.19 434

81 Coalt Guard, DOT to ensure the safety of the vessel, structures; and other vessels, such as being ready to veer chain, let go a second anchor, or"get underway using the vessel's own propulsion or tug as- sistance. " [CGD 74-77, 42 FR 5956, Jan. 31, 1977] 11164.25 Tests before entering or getting underway. (a) Except as provided in paragraphs (b) and (c) of this section no person may cause a vessel to enter into or get underway on the navigable waters of the United States unless no more than 12" hours before entering or getting un- derway, the following equipment has been tested: " . (1) Primary and secondary steering gear. The test procedure includes a visual inspection of the steering gear and its connecting linkage, and, where appll.cable, the operation of the follow- ing: " (i) Each remote steering gear control system. " (ii) Each steering position located on the navigating bridge. (iii) The main steering gear from the alternative power supply, if installed. (iv) Each rudder angle indicator" In relation to the actual position of the rudder. . "(v) Each remote steering gear con- trol system power failure alarm. (vi) Each remote steering gear power unit failure alarm. (vii) "The full movement of the rudder to the required capabilities of the steering gear. (2) All internal vessel control com- munications and vessel control alarms. (3) Standby or emergency generator, for as long as necessary to show proper functioning, including steady state temperature and pressure read- Ings. (4) Storage batteries for emergency lighting and power systems 'In vessel control and propulsion ma.chinery spaces. (5) Main propulsion machinery, ahead and astern. (b) Vessels navigating on the Great Lakes and their connecting and tribu- tary waters, having once completed the test requirements of this subpart, are considered to remain in compli- APPENDIXG ance until arriving at the next port of call on the Great Lakes. (c) Vessels" entering the Great L8.k.es from the St. Lawrence Seaway are considered to be In compliance with this sub-part If the required tests are conducted preparatory to or during the passage of the St. Lawrence Seaway or within one hour of passing Wolle Island. " " (d) No vessel may enter, or be oper· ated on the navigable waters" of the United States unless the emergency steering drill described below has been conducted within 48 hours prior to entry and logged In the vessel logbook, unless the drill is conducted and logged on a regular basis at least once every three months. This drill must in- clude at a minimum the following: (1) Operation of the main steering gear from within the steering gear compartment. (2) Operation of the means of com· munications between the navigating bridge and the steering compartment. (3) Operation of the alternative power supply for the steering gear If the vessel is so equipped. (92 Stat. 1471 (33 U.S.C. "1221 et seq.); 49 CFR 1.46(n)(4» [CGD 77-183. 45 FR 18925, "Mar. 24, 1980. as amended by CGD 83-004", 49 FR 43466, Oct. 29, 1984] 11164.30 Charts; publications, and equip- ment: General. No person may operate or cause the operation of a vessel unless the vessel has the marine charts, publications, and equipment as required by II 164.33 through 164.41 of this part. [CGD 82-055. 48 FR 44535. Sept. 29, 19831 11164.33 Charts and publications. (a) Each vessel must have the fol- lowing: (1) Marine charts of the area to be transited, published by the National Ocean Service, U.S. Army Corps of En- gineers, or a river authority that- (i) Are of a large enough scale and have enough detail to make safe navi- gation of the area possible; and ) Are currently corrected. (2) For the area to be transited, a currently corrected copy of, or appllca· 435

APPENDIX G § 164.35 82 33 CFR Ch. I (7.1.90 Edition) ble currently corrected extract from, each of the following publications: (i) U.S. Coast Pilot. (ii> Coast Guard Light List. (3) For the area to be transited, the current edition of, or applicable cur· rent extract from: (i) Tide tables published by the Na- tional Ocean Service. (ii> Tidal current tables published by the National- Ocean Service, or river current publication issued by the U.S. Army Corps of Engineers, or a river authority. (b> As an alternative to the require· ments for paragraph (a) of this sec- tion, -a marine chart or publication, or applicable extract, published by a for- eign government may be substituted for a U.S. chart and publication reo quired by this section. The chart must be of large enough scale and have enough detail to make safe navigation of the area possible, and must be cur· rently corrected. The publication, or applicable extract, must singly or in combination contain similar informa· tlon to the U.S. Government publica· tion to make safe navigation of the area possible. The publication, or ap· plicable extract must be currently cor· rected, with the exceptions of tide and tidal current tables, which must be the current editions. (c) As used in this section, "current· ly corrected" means corrected with changes contained in all Notices to Mariners published by Defense Map· ping Agency Hydrographic/Topo- graphic Center, or an equivalent for- eign government publication, reason· ably available to the vessel, and that is applicable to the vessel's transit. [COD 82-055. 48 FR 44535. Sept. 29, 19831 !l164.35 Equipment: All vessels. Each vessel must have the following: (a) A marine radar system for sur· face navigation. (b> An 1lluminated magnetic steering compass, mounted in a binnacle, that can be read at the vessel's main steer· ing stand. A current magnetic compass devi· ation table or graph or compass com· parison record for the steering com· pass, in the wheelhouse. A gyrocompass. (e) An illuminated repeater for the gyrocompass required by paragraph ) of this section that is at the main steering stand, unless that gyrocom· pass is illuminated and is at the main steering stand. (f) An illuminated rudder angle indi· cator in the wheelhouse. (g) The following maneuvering in· formation prominently displayed on a fact sheet in the wheelhouse: (1) A turning circle diagram to port and starboard that shows the time and distance and advance and transfer reo quired to alter course 90 degrees with maximum rudder angle and constant power settings, for either full and half speeds, or for fUll and slow speeds, For vessels whose turning circles are essen· tially the same for both directions, a diagram showing a turning circle in one direction, with a note on the dia· gram stating that turns to port and starboard are essentially the same, may be substituted. (2) The time and distance to stop the vessel from either full and half speeds, or from full and slow speeds, -While maintaining approximately the initial heading with minimum application of the rudder. (3) For each vessel with a fixed pro· peller, a table of shaft revolutions per minute for a representative range of

speeds,

(4) For each vessel with a controlla· ble pitch propeller, a table of control settings for a representative range of speeds. . (5) For each vessel that is fitted with an auxiliary-device to assist in maneu· vering, such as a bow thruster, a table of vessel speeds at whIch the auxiliary device is effective in maneuvering the vessel. (6) The maneuvering information for the normal load and normal ballast condition for: (i) Calm weather-wind 10 knots or less, calm sea; No current; (iii> Deep water conditions-water depth twice the vessel's draft or great- er; and (Iv) Clean hull. (7) At the bottom of the fact sheet, the following statement: 436

83 Coast Guard, DOT WARNING The response of the (name of the vessell may be different from that listed above If any of the following conditions. upon which the maneuvering information Is based. are varied: (1) Calm weather-wind 10 knots or less. calm sea; (2) No current; (3) Water depth twice the vessel's draft or greater; (4) Clean hull; and (5) Intermediate drafts or unusual trim. (h) An echo depth sounding device. (1) A device that can continuously record the depth readings of the ves- sel's echo depth sounding device. except when operating on the Great Lakes and their connecting and tribu· tary waters. (j) Equipment 'on the bridge for plot· ting relative motion. (k) Simple operating instructions with a block diagram. showing the change-over procedures for remote steering gear control systems and steering gear power units, permanent· ly displayed on the navigating bridge and in the steering gear compartment. An indicator readable from the centerline conning position showing the rate of revolution of each propel· ler, except when operating on the Great Lakes and their connecting and tributary waters. (m) If fitted with controllable pitch propellers. an indicator readable from the centerline conning position show· ing the pitch and operational mode of such propellers, except when operat- ing on the Great Lakes and their con- necting and tributary waters. (n) If fitted with lateral thrust pro- pellers, an indicator readable from the centerline conning position showing the direction and amount of thrust of such propellers, except when operat- ing on the Great Lakes and their con· necting and tributary waters. (92 Stat. 1471 (33 U.s.C. 1221 et seq.); 49 CFR 1.46(n)(4» [CGO 74-77, 42 F'R 5956, Jan. 31. 1977, as amended by CGO 77-183, 45 FR 18925. Mar. 24.1980; CGO 83~, 49 F'R 43466, Oct. 29. 1984] APPENDIXG § 164.38 11164.37 Equipment: Vetl8els of 10,000 gross tons or more. (a) Each vessel of 10,000 gross tons or more must have, in addition to the radar system under § 164.35(a), a second marine radar system that oper· ates Independently of the first. NOTE: Independent operation means two completely separate systems. from separate branch power supply circuits or distribution panels to antennas. so that failure of any component of one system will not render the other system Inoperative. (b) On each tanker of 10,000 gross tons or more that is subject to Section 5 of the Port and Tanker Safety Act of 1978 (46 U.S.C. 391a), the dual radar system required by this part must have a short range capability and a long range capability; and each radar must have true north features consist· ing of a display that is stabilized in azimuth. (Titles I and II. 86 Stat. 426. 427 (33 U.S.C. 1224; 46 U.S.C. 391); 49 CFR 1.46(n)(4» [CGO 77-016. 43 FR 32112. July 24. 1978. as amended by COO 79-033. 44 FR 26741. May

1. 1979; CGO 79-033. 47 FR 34389. Aug. 9.

1982] 11164.38 Automatic radar plotting aids (ARPA). (a) The following definitions are used in this section- "Bulk" means material in any quan· tlty that is shipped, stored, or handled without benefit of package, label. mark or count and carried in integral or fixed independent tanks. "Constructed" means a stage of con· struction where- (1) The keel is laid: (2) Construction identifiable with a specific ship begins; or (3) Assembly of that ship has com· menced comprising at least 50 tons or 1 percent of the estimated mass of all structural material, whichever is less. "Hazardous material" means- (1) A flammable liquid as defined in 46 CFR 30.10-22 or a combustible liquid as defined in 46 CFR 30.10-15; (2) A material listed in table 15L05 of 46 CFR 151.05, table 1 of 46 CFR 153, or table 4 of 46 CFR Part 154; or (3) A liquid. liquefied gas, or com· pressed gas listed in 49 CFR 172.101. 437

FD07159 ｜ 1994_美国_AAR9401.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1994 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

NATIONAL TRANSPORTATION SAFE1Y BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT RUNWAY DEPARTURE FOLLOWING LANDING AMERICAN AIRLINES FLIGHT 102 McDONNELL DOUGLAS DC-10-30, N139AA PB94-910402 NTSB/AAR-94/01 DALLAS/FORT WORTH INTERNATIONAL AIRPORT, TEXAS APRIL 14, 1993 -·-

61098

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NTSB/AAR-94/01 PB94-910402 NATIONAL TRANSPORTATION _ SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT RUNWAY DEPARTURE FOLLOWING LANDING AMERICAN AIRLINES FLIGHT 102 McDONNELL DOUGLAS DC-10-30, N139AA DALLAS/FORT WORTH INTERNATIONAL AIRPORT, TEXAS APRIL 14, 1993 Adopted: February 14, 1994 Notation 61098 Abstract: This report explains the runway departure of American Airlines flight 102, a DC-10-30, after landing at Dallas/Fort Worth International Airport, Texas, on April 14,

1. The safety issues discussed in the report include weather conditions affecting the

flight, flightcrew and air traffic control training and procedures, airplane emergency evacuation lighting, and runway maintenance. Recommendations concerning these issues were made to the Federal Aviation Administration, Dallas/Fort Worth International Airport, and American Airlines, Inc.

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2. 2
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6. 5.1
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12. 7.3
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15. 7.6
16. 7.6.1

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3. 7.9
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5. 7.11
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10. 11.1
11. 11.2
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15. 12.2.1
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CONTENTS EXECUTIVE SUMMARY............................................................. Vll FACTUAL INFORMATION History of the Flight .......................................................................... . Injuries to Persons ............................................................................ . Damage to Aircraft ........................................................................... . Other Damage .................................................................................. . Personnel Information ....................................................................... . Flightcrew General Background ........................................................ . Flightcrew Activities Prior to the Accident Flight.. ............................ . Aircraft Information .......................................................................... . Meteorological Information .............................................................. . General Weather Conditions ............................................................. . Surface Weather ............................................................................... . Recorded Weather-Measuring Equipment at DFW ........................... . Radar Mosaics .................................................................................. . Additional Weather Radar Information ............................................. . National Weather Service Forecasts .................................................. . Fort Worth Forecast Office ............................................................... . Fort Worth Center Weather Service Unit (CWSU) ........................... . National Severe Storms Forecast Center, Kansas City, Missouri ....... . American Airlines Weather Forecasts ............................................... . Airline-Provided Weather Information .............................................. . Changeover Information ................................................................... . Low Level Windshear Alert System (LLW AS) ................................. . Predeparture Weather Briefmg .......................................................... . Aids to Navigation ............................................................................ . Commun1cat1ons ............................................................................... . Aerodrome Information .................................................................... . Flight Recorders ............................................................................... . Cockpit Voice Recorder ................................................................... . Flight Data Recorder ........................................................................ . Wreckage and unpact Information .................................................... . Wreckage Path Information .............................................................. . Airplane Structure ............................................................................. . Landing Gear .................................................................................... . Fuselage ........................................................................................... . Ill 1 14 14 14 14 14 15 15 18 18 19 20 21 21 22 22 23 23 24 26 27 27 30 31 31 31 34 35 35 36 36 37 37 39 1.12.2.3 1.12.2.4 1.12.2.5 1.12.2.6 1.12.2.7 1.12.3 1.12.3.1 1.12.3.2 1.12.3.3 1.12.3.4 1.12.4 1.12.5 1.12.5.1 1.12.5.2 1.12.5.3 1.12.5.4 1.13 1.13.1 1.13.2 1.14 1.15 1.15.1 1.15.2 1.15.3 1.15.4 1.16 1.16.1 1.16.1.1 1.16.1.2 1.16.1.3 1.16.1.4 1.16.1.5 1.16.1.6 1.16.1.7 1.17 1.17.1 1.17 .2 1.17.2.2 Wings................................................................................................ 40 Empennage....... .. .. . . . . ... .............. .. . . . ..... ............. .. .................. ......... .. . . 40 Lightning Strike/Static Dischargers.................................................... 40 Fire Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Cabin................................................................................................. 41 Airplane Flight Control Systems ........................................................ 42 Flaps.................................................................................................. 42 Spoilers . . ........................................................................................... 43 Rudder.............................................................................................. 43 Nosewheel Steering Controls............................................................. 44 Wheels, Tires, and Brakes................................................................. 44 Other Systems . . . . .. . . . .. . . . ... . .. ........ .. ... . . . . . ...... ..... ............. ......... .. ....... ... 4 7 Powerplants ....................................................................................... 47 No. 1 Engine ..................................................................................... 47 No. 2 Engine . .. ................... ............................................................... 49 No. 3 Engine ..................................................................................... 49 Medical and Pathological Information................................................ 50 Medical Certification and History...................................................... 51 Toxicological Testing........................................................................ 51 Fire.................................................................................................... 51 Survival Aspects................................................................................ 52 Evacuation......................................................................................... 52 Flight Attendant Training................................................................... 53 Emergency Response......................................................................... 53 Cabin Emergency Lighting System ...... .................... ... . ........ .. ..... ....... 54 Tests and Research............................................................................ 55 Airplane Performance Study.............................................................. 55 General Information........................................................................... 55 Airplane Radar Data.......................................................................... 59 Wind Calculations ............................................................................. 60 Position and Time Calculations.......................................................... 61 FDR and CVR Data.......................................................................... 62 Airplane Response to Flight Control Inputs........................................ 63 Effect of Misconfigured Thrust Reverser Cascades on No. 2 Engine ................................................................................... 64 Additional Information....................................................................... 65 Flightcrew Interviews .............. ............. .. . . .... ......... ... ....... ... ............... 65 Douglas OC-10 Approach and Landing Procedures ......... .......... .. ... . . . 67 Handwheel Steering/Forward Pressure on the Yoke........................... 69 IV

1. 17.2.3
2. 17.2.4
3. 17 .3
4. 17.3.1
5. 17.3.2
6. 17.3.3
7. 17.3.4
8. 17.4
9. 17.5

Reverse Thrust . . . . . . . . . . . . .. .. . . . . . . . . . . . . . . . . .. ....... ...... ... ........ ... . . . .. .. . . .. . . . . . .. . . . 70 Braking.............................................................................................. 70 American Airlines Procedures and Techniques ..... ... .. .. . .. .. .. ..... .... .. .. .. 71 Airborne Weather Radar.................................................................... 72 Windshear Guidance.......................................................................... 74 Cockpit Resource Management (CRM) Training Program................. 75 Approach Procedures......................................................................... 75 American Airlines Flightcrew Training Recordkeeping System.......... 76 FAA Oversight . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 6 2. ANALYSIS 2.1 General.............................................................................................. 77 2.2 Weather Aspects............................................................................... 79 2.2. l Weather Planning and Forecasts........................................................ 79 2.2.2 Movement of Thunderstorms Across DFW ........................................ 82 2.2.3 Centerfield Anemometer Wind Reports From 0656 to 0701............... 84 2.2.4 Winds Affecting AAL102.................................................................. 85 2.2.5 LLWAS System Testing.................................................................... 86 2.2.6 Windshear Algorithm......................................................................... 86 2.3 Air Traffic Control............................................................................. 87 2.4 Flightcrew Actions During Approach and Landing............................. 89 2.4.l General.............................................................................................. 89 2.4.2 Pilot Actions and Company Procedures............................................. 90 2.4.3 Landing Briefing................................................................................ 94 2.5 Flightcrew Decision-Making.............................................................. 95 2.6 AAL Pilot Training Program and Recordkeeping ............................... 96 2.7 Survival Factors and Airport Fire and Rescue.................................... 98 2.8 Landing Runway Surface Conditions................................................. 100 2.9 Evaluation of Tire Marks and Tire Traction....................................... 103 3. CONCLUSIONS 3 .1 Findings............................................................................................. 105 3.2 Probable Cause.................................................................................. 107 4. RECOMMENDATIONS................................................................ 108 5. APPENDIXES Appendix A--lnvestigation and Hearing............................................. 111 Appendix B--Personnel Information................................................... 112 V

Appendix C--Cockpit Voice Recorder Transcript .............................. 116 Appendix D--DFW Tower/fRACON Transcript............................... 149 Appendix E--Antiskid System............................................................ 163 Appendix F--Selected Weather Radar Data....................................... 165 VI

EXECUTIVE SUMMARY On April 14, 1993, about 0659:43 central daylight time, American Airlines flight 102, a McDonnell Douglas DC-10-30, departed runway 17 left, following landing at Dallas/Fort Worth International Airport, Texas, after a nonstop, overnight flight from Honolulu International Airport, Hawaii. It was raining at the time of the landing, and there were numerous thunderstorms in the area. There were 189 passengers, 3 flightcrew members and 10 cabincrew members aboard the airplane. Two passengers received serious injuries, and 35 passengers, 1 flightcrew member, and 2 cabincrew members received minor injuries during the evacuation of the airplane. The airplane sustained substantial damage. The National Transportation Safety Board determines that the probable cause of the accident was the failure of the captain to use proper directional control techniques to maintain the airplane on the runway. The safety issues in this report focused on weather conditions affecting the flight, flightcrew and air traffic control training and procedures, airplane emergency evacuation lighting, and runway maintenance. Safety recommendations concerning these issues were addressed to the Federal Aviation Administration, Dallas/Fort Worth International Airport, and American Airlines, Inc. Vll

NATIONAL TRANSPORTATION SAFETY BOARD WASHING TON, D.C. 20594 AIRCRAFT ACCIDENT REPORT RUNWAY DEPARTURE FOLLOWING LANDING AMERICAN AIRLINES FLIGHT 102 McDONNELL DOUGLAS DC-10-30, Nl39AA DALLAS/FORT WORTH INTERNATIONAL AIRPORT, TEXAS APRIL 14, 1993

1. FACTUAL INFORMATION
2. 1

History of the Flight On April 14, 1993, about 0659:43 central daylight time, 1 American Airlines flight 102 (AAL102).2 a McDonnell Douglas DC-10-30, departed the right side of runway 17 left, following landing at Dallas/Fort Worth International Airport, Texas (DFW), after a nonstop, overnight flight from Honolulu International Airport, Hawaii (HNL). With a 1753 Hawaii-Aleutian Standard Time departure, (2353 cdt), on April 13, I 993, the flight from HNL to touchdown at DFW took about 7 hours and 7 minutes. The first officer was at the controls prior to landing, and the captain made the radio transmissions. It was raining at DFW at the time of the landing, and there were numerous thunderstorms in the area. Of the 202 persons aboard the airplane, there were 189 passengers, 3 flightcrew members, and IO cabincrew members. The flightcrew consisted of a captain, first officer, and flight engineer. The 10 cabincrew members were positioned throughout the first class and coach cabins, seated in jumpseats near the eight cabin emergency exits, during the approach and landing. Prior to departure from HNL, the flightcrew received a weather briefing that indicated possible thunderstorms and turbulence at the time of arrival at DFW. During their predeparture briefing, the captain told the flight attendants that possible turbulence was expected upon arrival. ;unless otherwise indicated, all times are central daylight time (cdt). Flight 102 was operating as a scheduled passenger flight under 14 Code of Federal Regulations (CFR), Part 121.

2 While inbound to DFW, the flightcrew received approach and destination weather information from an American Airlines flight dispatcher, Fort Worth Center Air Route Traffic Control (ARTCC) and DFW approach control, as well as recorded Automatic Terminal Information Service (ATIS) arrival information and in-cockpit radar data. See Section 1.17 .1, Flightcrew Interviews, for additional information about the flightcrew's statements about the accident circumstances. About 30 minutes prior to the landing, at 0629:57, the captain announced on the public address system:3 our flight attendants to go ahead and round everything up ... and take your seats, and just as a precaution, our radar is showing numerous areas of rain showers around the Dallas/Fort Worth area ... we'll be doing a little bit of deviating, radar is working very well, so we can kinda pick our path through these cells that are up ahead ... shouldn't be any particular problem other than some bumpy air. .. nothin' dangerous ... more of a nuisance than anything else. During the final approximately 1/2 hour of flight, the flightcrew received frequent updates of destination and inbound weather information from the combination of sources, including a description of numerous thunderstorms, extending north and south of DFW. The weather reports changed while the airplane was on approach. After the flight was cleared for the Bridgeport Boyds Two arrival, the captain asked the Fort Worth Center controller, at 0634:13, about the possibility that the flight "might be able to come in from the south and land to the north." The controller replied that he could "check with them." The captain stated, " .. .let's wait 'til we get a little closer and look at it. The radar at this range is not really as accurate as it is when we get in oh forty fifty miles away." 3see appendix C for a complete transcript of the cockpit voice recorder (CVR). Where the identificatior.is of words or the times of radio transmissions disagree (up to about 4 seconds) between the recordings on the accident flight CVR and by air traffic control (ATC), the CVR identification words and recorded times are used. Where words or phrases in radio transmissions are "unintelligible" in the CVR, the ATC transcribed recording is used.

3 From about 0636:39 to 0645:51, there were conversations between the pilots about the radar. At 0637:05, the captain indicated that they were 80 miles out, that he saw "yellow scud" on the scope, and they were "not looking at anything that even approaches red." About 0639:53, the captain and first officer agreed that they were picking up red radar returns. At 0640:18, one of the flightcrew members, who was not identified, stated that "red should be a really bad cell." Around the Bridgeport VOR, at 0642:23, the flightcrew saw a brilliant flash of light and the cockpit area microphone picked up a rumble that sounded like thunder. This coincided with the report of a possible lightning strike observed by several passengers and flight attendants. The flight engineer found no system malfunctions and observed that the cockpit instrumentation appeared to be functioning properly. (See figure 1 photographs of lightning damage). When the captain described the lightning to air traffic control (A TC) at 0642:54, he stated that he did not believe the lightning had come into contact with the airplane. He again requested a landing to the north. The controller expressed his doubts that a north landing would be approved but assured him that he would forward the request. As communications with AAL102 were transferred from Fort Worth Center to DFW approach control, their request for a north landing was made. On initial radio contact with approach control, the captain verified the status of his request but was told that DFW's southbound departures would preclude landing to the north. In a postaccident interview, the captain stated that he accepted the landing to the south because his airborne weather radar showed that the opening in the weather to the south that he had planned to use had filled in with weather. DFW arrival information Echo was received by the flight engineer at 0644:35, about 15 minutes before landing. It stated, in part: The one one three five Zulu special, measured ceiling one thousand four hundred overcast, visibility two and one half, thunderstorms, rain showers and fog. Temperature, six seven, dew point six five. Wind two two zero at six. Altimeter two niner four eight. Thunderstorms in all quadrants, moving northeast. lightning in clouds, cloud to cloud, cloud to ground. Frequent Pressure's

4 tI l Figures la and lb.--Lightning damage to right wing tip.

5 falling rapidly. Attention all aircraft, convective SIGMET [significant meteorological information] four one central, four two central, four four central and four five central affects the DFW area. ILS [instrument landing system] runway one seven left, one eight right approaches in progress .... At 0645:31 the captain stated on the cockpit microphone, "I don't know what the [expletive] happened with this radar." At 0645 :51, the first officer asked, " .. .is it not working or is it working?" At 0646:24, the flight engineer provided the captain and first officer with the information that he had received from the A TIS transmission, with the exception of "thunderstorms all quadrants" and the information after "attention all aircraft, convective SIGMET .... " At 0647:58, while descending to 3,000 feet, AAL102 received the following radio transmission from the Feeder West controller (FW): For everyone landing at DFW, the weather now is measured ceiling one thousand four hundred overcast, visibility two and one half, thunderstorms, rain showers, fog, wind one four zero at one one, altimeter two niner four niner, and uh, expect south landing. At 0649: 15, after being instructed by approach control to switch radio frequencies and contact another approach controller, the captain radioed, "Approach, American one oh two heavy we're uh, out of four for three." The controller stated, "American one zero two heavy, expect ILS runway one seven left, localizer frequency one uh, one zero point three." At 0649:34, the captain stated, "One one zero three OK uh, how's it look on your scope for gettin' in there?" After the controller stated instructions to "Fly heading one three zero," the captain again asked, "OK, one three zero. How's it look coming down final on your radar?" The controller replied that:

6 Well uh, I show an area of weather at, at fifteen miles either side of DFW airport proceeding uh, straight north uh fifteen miles on uh, each side uh, for about thirty miles. At 0650:09, the captain asked, "OK, can you uh, give us a good heading then to come in on?" The controller replied: Uh, well I can give you a good heading to intercept the localizer but there's weather all down the final is what I'm saying there's I don't see any openings on the final of I see a weather area all the way down the final. The captain then stated, at 0650: 18, "OK uh, and is this stuff moving?" The controller replied, "Uh, does not appear to be moving uh, much if any American one zero two heavy if able, tum right heading one five zero and join the runway one seven left localizer." At 0650:33, the captain radioed, "Uh, I don't think we're goin' to be able to do that that's uh, that's a pretty big red area on our scope uh, about ninety degrees and that's about what we're looking at. Uh, we're gonna have to, just go out I guess and wait around to see what's goin' on here." The controller replied, at 0650:46, "American one zero two heavy, eight miles south of you's a heavy DC-8 at three thousand joining uh, the final's uh, reporting a smooth ride at three. The captain replied, "Oh, OK, eight miles south of us?" At 0650:59, the captain radioed, "OK uh, we'll head down that way then and uh, worse comes to worse we'll go out from there." The controller replied, "OK, one zero two heavy, tum right heading two zero zero and intercept the runway one seven left localizer." The airplane was in approach configuration with the flaps set to 15 degrees. At 0652, the captain questioned the first officer as to the veracity of the localizer frequen~y despite the fact that the captain had read it back to approach control at 0649:34. Subsequently, at 0652, the captain questioned the first officer as to whether they were landing on runway 17L or l 7R. The first officer reminded the captain that they were landing on runway l 7L. At 0652:40, they were cleared for the approach.

7 The first officer requested that the captain and flight engineer be alert for any indication of windshear. The captain encouraged him to carry 10 to 15 knots of extra airspeed, and the first officer assured him that he would do so.4 When asked to describe their flight conditions by approach control at 0653:20, the captain stated that they were in the clouds with "just ah little ripple and pretty good . . '' size ram. At 0653:32, about a minute before intercepting the localizer, the cockpit area microphone recorded a click. The first officer asked if the captain and engineer thought that it was a lightning strike. The captain said that he had been hit twice before and that "that's what it looks like" but went on to say "I don't think this is going to be a problem." The captain reported a 10- to 15-knot gain in airspeed at 0655:36. Approach control informed them that the DC-8 had reported fluctuations of 10 to 15 knots on their approach to runway 18R. They extended the landing gear at 0655:53. After their ride was reported as "light and occasionally moderate chop," approach control transferred AALl 02 to DFW tower control. On initial contact with DFW tower, at 0656:39, AAL102 was cleared to land. The flightcrew completed the landing checklist and activated the windshield wipers at 0657:54. The flightcrew later stated that the airplane was in a crab due to a crosswind from the right on fmal approach. Flight data recorder (FDR) data after the accident verified that the airplane was in about a 10-degree right crab on short final approach. The flightcrew later stated that they could see the runway during fmal approach and that they could see down the runway during the approach and after touchdown. On short final, at 0659: 17, less than 1 second after the automated voice called out "fifty" [feet], the first officer stated, ''I'm gonna go around." The captain stated, "No, no, no, I got it." The first officer responded, "You got the airplane." As the first officer said the word "airplane," the automated voice said "thirty." The captain took control and landed the airplane. 4v ref was 146 knots indicated airspeed (KIAS). V bug was 160 KIAS.

8 A sound of a thump, similar to aircraft touchdown was recorded at 0659:29 on the CVR. The sound of a second thump was recorded about 2 seconds later. At 0659:36, the first officer said, "OK, hundred and twenty knots." At 0659:38, the captain said, "Oh [expletive]." At 0659:41, the first officer said, "hundred knots," then, "OK, we're off the grass," and, at 0659:45, "eighty knots." One of the flightcrew members then said, "Gosh dam," and a sound similar to a horn sounded in the cockpit. At 0659:53, the captain stated, "Emergency evacuation." When he was interviewed, the flight engineer stated that as the airplane proceeded down the runway, he believed that the spoiler handle "was not coming back fast enough." He reached over the pedestal to manually move the handle to help deploy the spoilers.5 At 0700:15, one of the flightcrew members made an announcement on the public address system to evacuate the airplane. However, only one flight attendant reported hearing the announcement. The flight attendant, seated in the forward left portion of the first class cabin, stated that he initiated the cabin emergency evacuation by activating the evacuation signaling system. Two other flight attendants also reported initiating the evacuation without hearing any call from the cockpit. The CVR recording ended about the time of estimated generator power shutdown, following the captain's statement, at 0700:34, "spoiler handle won't stay closed." A special weather report, at 0701, about 1 minute after the accident, described the weather at DFW as: Ceiling measured 900 feet overcast; visibility 1 1/2 miles, thunderstorm, heavy rain shower, fog; surface wind 300 degrees at 22 knots gusting to 33 knots; altimeter setting 29.51 inches of mercury (Hg); Remarks--Wind shift 0700, thunderstorms all quadrants moving northeast, occasional lightning in cloud, cloud to ground, pressure rising rapidly. 5Toe postaccident systems examination found that the spoiler handle was driven by an actuator, which, once activated, resulted in handle movement of one speed during deployment. Therefore, once the spoiler system was activated, the handle movement would be constant.

9 Witnesses at the fire station and elsewhere stated that it had been raining during and following the landing of the airplane. The rain appeared to become heavier following the accident, and one witness later described it as "coming down in sheets." The captain of a Simmons SA-340, flying the ILS to 17L behind AALI 02, later stated that on the approach he encountered light to occasional, moderate turbulence. He needed a 20-degree heading correction to hold the localizer course inbound, but the correction became less severe as his airplane approached the airport. He also reported that he used a +20-knot speed correction. He was in instrument meteorological conditions (IMC) throughout the approach, but he saw the ground after descending below about 700 feet above ground level (agl). After the crash of AAL102, which was ahead of him, when his airplane was about 600 feet agl, he was advised by air traffic control to go around. The captain stated that he overflew DFW on the missed approach, on the way to an approach and landing at Love Field in Dallas. He did not observe any indication of windshear in the vicinity of DFW during the overflight. The flightcrew of a Delta Air Lines B-737 was awaiting departure from 17L, with the airplane positioned on the perpendicular taxiway at the north end of the runway. After AALl 02 touched down, the B-737 was taxied into position for takeoff. About that time, the B-737's captain noticed the windsock, which was about 200 feet southwest of the approach end of l 7R, indicating the wind out of the west at 10 to 12 knots. He saw a glow emanating from the crashed airplane off the runway and observed the fire and rescue response. About 15 to 20 minutes later, he noticed that the windsock was indicating a wind out of the north. He described the rain as intermittent but not heavy. An American Airlines MD-80 captain was waiting for takeoff in the ramp area next to l 7R. He looked southeast and observed the windsock as straight out, with the wind from the west. He saw the accident airplane fly by and touch down. He then noticed the windsock fully inflated, with the wind out of 340 degrees to 350 degrees as the Delta Air Lines B-737 took position and held on 17-R for departure. Two Delta Air Lines mechanics were outside their maintenance hangar when AAL102 touched down. The hangar was east of the accident runway, and the mechanics were standing on the ramp on the north side of the hangar. They reported that they remained dry, sheltered by the hangar, as the wind was blowing

10 the rain away from them. They obsetved the fire where the airplane came to rest, and they watched the fire and rescue response. Several witnesses, including pilots of other airplanes on taxiways, noted that a large fire developed aft of the left wing of the accident airplane about the time it came to rest. The fire was extinguished soon after emergency vehicles arrived at the crash site (they began to arrive about one minute after the airplane came to rest). But the fire affected the urgency of passenger egress because it could be seen glowing through the left windows of a darkened aft cabin (see Swvival Aspects section 1.15). Investigators examined the landing runway after the accident and found three long sets of lightly shaded tire traces that paralleled the centerline but then angled to the right and departed the runway. The tracks from the right main landing gear continued as furrows in the soil. Then the airplane traveled across high speed taxiway 3S before returning to the soft soil. The airplane came to rest, upright, about 2,607 feet from the departure end of 17L and about 250 feet from the right edge of the runway, with the nose on perpendicular taxiway 31. (See figures 2, 3 and 4 ). The first tire marks found on the runway were traced to the left and right main landing gear, and started at 4,303 feet from the beginning of the runway. The tracks approximately paralleled the runway centerline for about 1,700 feet, then turned gradually to the right until they departed the runway. The accident occurred in darkness (0700 was official sunrise) just after the airplane landed on runway l 7L at DFW about 0659:43 cdt, during a thunderstorm, at 32 degrees 53.18 minutes north latitude and 97 degrees 01.62 minutes west longitude.

NGrrl:11 ,3SSFT '· ~ ·J \l.. · · · · -· ~ · · · · · · · · · · · · · '. · · · · · · · · · · · · · 1.4 WIDTH:150FT ~ ,I .. _ , . J 6.59.20, 161, CAM-4, thirty. 6;59:19, 162, CAM-2, you got th• •irpf•,,.. 11 11 • I 6:59:18, 161, CAM-1, :no no no~ I got It. l 6;59:17, 164, CAM-2, J'm gon_rv~g_o_•r_o_u_nd.. __ ;__ ____ _ TRUE t:.:Jl163• CAM-4, :tlfty. x MEASURED POSITION . NORTH ~ ~ ( ' o RADAR RETURN. ~ ~

'.

CALCULATEDPOSfTION -· · · · · · · · · · · 6:59{";65, ·ci.ii4,· ~,;. i,~~~ · · · · · · · : · · · · · · · · · · · · · 1 ·8 6:59:11, (/Ht ,-dar ,.)um untfl &le comn to rn:t) 4.7 4.3 3.9 3.5 Figure 2.--Approach and landing. History of airplane motion and events.

12 Figure 3a.--Tire marks on landing runway l 7L (looking north). Figure 3b.--Tire marks on high speed taxiway 3S, and trenches in the soil leading to the final resting position of the airplane. ) r I l l I I l.__, I

13 { Figures 4a and 4b.--Airplane resting attitude and location.

14 1.2 Injuries to Persons Injuries Flightcrew Cabincrew Passengers Other Total Fatal 0 0 0 0 0 Serious 0 0 2 0 2 Minor 1 2 35 0 38 None 2 .a ill 162 Total 3 10 189 0 202 1.3 Damage to Aircraft The airplane sustained substantial damage, estimated at $35 million. Based on the damage and repair costs, the hull was written off as destroyed. 1.4 Other Damage Damage to the airport facility consisted of trenches in the soil, dug by the airplane and landing gear, a damaged culvert, broken taxiway sign, and four fractured taxiway lights. 1.5 Personnel Information 1.5.1 Flightcrew General Background The captain, first officer, and flight engineer comprised a three-person flightcrew on the ,accident airplane. The captain, age 59, had a total of 12,562 flight hours, 555 of which were in the DC-10. He was employed by American Airlines on August 1, 1966, and was designated a captain in the DC-10 in November 1991. He held an Airline Transport Pilot Certificate and was type rated in the DC-10, B-727, and DC-9, with a commercial type rating in the B-377. The first officer, age 40, held a commercial pilot certificate, and multi- and single-engine, land ratings. He was employed by American Airlines in September 1986. He had accrued a total of 4,454 flight hours, 376 of which were as a first officer in the DC-10. The flight engineer, age 60, held a current Flight Engineer certificate. He was employed by American Airlines in October 1955. He had a total of 20,000

15 flight hours, all of which were as a flight engineer, and 4,800 hours of which were in the DC-10.6 1.5.2 Flightcrew Activities Prior to the Accident Flight The flightcrew had been in an off-duty status for a minimum of 6 days prior to beginning the 3-day accident trip. The crew reported for duty at DFW about 0900 on April 12, 1993, and completed the flight from DFW to HNL, arriving around 1900 Dallas time. Each crewmember slept for varying periods that night between 2200 and 0700 Dallas time, and napped for varying periods between 1700 and 2100 Dallas time the next evening prior to reporting for duty on the accident flight. The captain and flight engineer reported that they did not feel tired during the overnight flight from HNL to DFW. The first officer reported that he felt tired on two occasions during the flight and said that at those times he briefly used oxygen to "perk-up." The captain stated that he had not previously been paired on a flight with the first officer, but that some years earlier he had been paired with the flight engineer on a B-727 flight. ~ ~ 1.6 Aircraft Information The airplane, registration N l 39AA, Serial No. 46711, was owned and operated by American Airlines. The airplane was built by the Douglas Aircraft Company and was sold new to National Airlines on June 11, 1973. It was operated by National Airlines as registration N80NA, and, following the transfer of National Airlines to Pan American World Airways, it was operated by Pan American with the same registration. The airplane was sold by Pan American to American Airlines on November 4, 1983. American Airlines sold the airplane to First Security Bank of Utah on December 31, 1984, and then leased the airplane back. The airplane accumulated 35,348 airframe flight hours and 9,163 cycles when operated by National and Pan American, and 39,483 flight hours and 8,757 cycles when operated by American Airlines, resulting in a total, at the time of the accident, of 74,831 hours and 17,920 cycles. 6 A more detailed summary of the flightcrew's background is contained in appendix B.

16 The weight and balance infonnation was prepared by American Airlines Dispatch at HNL. It was presented for use by the flightcrew on a computer printout containing "Airport Analysis Data." The calculated weight and balance for the accident flight were within limits for takeoff from HNL, the en route flight, and the landing at DFW. Upon landing, about 3 flying hours of fuel remained in the airplane's fuel tanks. With 173,000 pounds of fuel for takeoff, the calculated gross weight for the accident flight, departing HNL on April 13, 1993, was 503,000 pounds. Considering forecast winds and the route of flight, dispatch estimated that 133,000 pounds of fuel would be consumed en route, and that the landing weight at DFW would be 370,338 pounds. The airframe was last inspected as follows: Inspection Date Hours Cycles Periodic Service 4/13/93 74,824 17,919 A Check 4/08/93 74,753 17,910 B Check 3/20/93 74,546 17,870 Phase Check 3/14/92 70,224 16,947 The engines were last inspected as follows: Total Time Since Time Total EHM Cycles Serial No. (Hours) Cycles (Hours) Since EHM Engine No. 1 455414 60,602 12,916 12,228 1,661 Engine No. 2 455292 46,838 9,873 285 50 Engine No. 3 455302 50,530 10,767 2,480 536 The maintenance logbooks for the 4 months prior to the April 14, 1993, accident revealed no outstanding discrepancies. There were five writeups that had been deferred, as follows: Date Entered Discrepancy 4/01/93 RH logo light inop

4/09/93 4/09/93 4/10/93 4/11/93 17 Lwr "B" yaw channel inop Downgrade LMP to #2 single land Zone B "Lav Occupied" signs burned out #2 engine B ignition inop The discrepancy recorded on April 1, 1993, was classified as a "Technical Control Item," which permitted the airline to track the item and schedule its repair within an appropriate time period. Each of the other discrepancies was classified as a Category C Minimum Equipment List (MEL) item, which allowed 10 days for re~olution. All five logbook discrepancies were deferred in accordance with the provisions of the MEL. A logbook entry on April 4, 1993, mentioned to "check hyd. leak in left main gear wheel well." Maintenance action taken after arrival was a field repair of the left main gear antiskid line with a flex line; the leak check was good. An entry on March 31, 1993, noted that the left and right outboard antiskid did not test when the gear was extended, and would not test at the gate. American Airlines maintenance removed and replaced the antiskid control box, and the system checked okay. The Safety Board investigator's review of the accident airplane logbooks revealed several writeups regarding the engine thrust reversers. A writeup on March 27, 1993, noted that none of the engines could obtain more than 86 percent NI, during reverse operation during the landing that day. An entry on February 18, 1993, stated that the No. 3 engine thrust reverser unlocked, but it was difficult getting a green light. An entry on February 17, 1993, noted that the No. 3 engine thrust reverser lever was stiff on landing ground roll. All of the above engine thrust reverser discrepancies were recorded as corrected, and there were no pilot reports regarding the engine thrust reversers following the March 27, 1993, writeup. Because of the finding during the investigation of an improper thrust reverser cascade configuration on the No. 2 engine of the accident airplane, (see section 1.12) the records were examined for this system. American Airlines' records indicated that the fan reverser for the No. 2 engine was installed in May 1991. The procedures required a visual verification for the proper cascade configuration after installation of the fan reverser. There was no criterion for a subsequent periodic inspection of the reverser cascades, and the time of misrigging of No. 2 engine

18 reverser cascades, evidenced by lack of subsequent maintenance on this area, was determined to have occurred at the time of the May 1991 installation. No discrepancies regarding the emergency lighting system of NI 39AA were found during the records review, although there were statements that the cabin was only partially lighted during the egress period (see section 1.15). The last operational check of the system, which was called for on the Special Items maintenance card, PS/0912, occurred on April 8, 1993, and the last check of the emergency lighting batteries, which was required on every B Check, occurred on March 20, 1993. A lightning strike was reported to maintenance personnel by the crew of American Airlines Flight 73, on April 11, 1993. An inspection of the airplane, in accordance with maintenance manual procedures, found no damage from the lightning strike. There was, however, a lightning strike noted by the flightcrew, cabincrew, and passengers, occurring as the accident flight was inbound to DFW, about 17 minutes prior to landing. Examination, as part of the Safety Board's investigation following the accident, found evidence of a lightning strike at the top of the right wing tip.

1. 7

Meteorological Information 1.7.1 General Weather Conditions According to the National Weather Service (NWS), the 0700 smface weather analysis, for April 14, 1993, showed a low pressure center over northeastern Missouri. A moderate cold front trailed southwestward across northwestern Arkansas and southern Oklahoma, through a low pressure center over west-central Texas. A second area of low pressure was centered near Junction, Texas, with a weak cold front extending southeast of Del Rio, Texas. A third low pressure center was located west of College Station, Texas, with a trough of low pressure extending to the south. At 0101, the National Severe Storms Forecast Center (NSSFC), in Kansas City, Missouri, issued Tornado Watch No. 115. The watch area included parts of western and central Texas and was valid until 0700. The NSSFC issued Tornado Watch No. 116, at 0347, for a large part of central Texas. It included the DFW metroplex area. Tornado Watch No. 116 was valid until 1100, April 14, 1993.

19 1.7.2 Surface Weather The weather obseivations at DFW were taken by Weather Experts, Inc., a private company under contract to the NWS. The company's only role at DFW is to take and disseminate weather obseivations. This information is used by FAA air traffic controllers, NWS, and other appropriate agencies. The obseivation facility is on the second floor of the Delta Air Lines maintenance hangar, on the east side of the airport complex. The following surface weather obseivations were made for DFW: Time--0639; Type--Special; 1,500 feet scattered, estimated ceiling 3,500 feet broken, 5,000 feet overcast; visibility 5 miles, thunderstorm, moderate rain shower; surface wind 220 degrees at 3 knots; altimeter setting 29.47 inches of Hg; Remarks--thunder all quadrants moving northeast, frequent lightning in cloud, cloud to cloud, cloud to ground, pressure falling rapidly, wind shifted gradually.7 Time--0650; Type--Record; 1,500 feet scattered, measured ceiling 4,000 feet broken, 7,500 feet overcast; visibility 6 miles, thunderstorm, light rain shower; temperature 67 degrees F.; dew point 65 degrees F.; surface wind 220 degrees at 4 knots; altimeter setting 29.49 inches of Hg; Remarks--thunder northeast- southeast moving northeast, frequent lightning in cloud, cloud to ground. Time--0701; Type--Special [Special weather obseivation, completed about one minute after the accident]; measured ceiling 900 feet overcast; visibility 1 1/2 miles, thunderstorm, heavy rain shower, fog; surface wind 300 degrees at 22 knots gusting to 33 knots; altimeter setting 29 .51 inches of Hg; Remarks--wind shift 0700, thunder all quadrants moving northeast, occasional lightning in cloud, and cloud to ground, pressure rising rapidly. 7The NWS reports the wind direction with reference to true north. The wind direction and speed are a I-minute average. For air traffic control purposes, the FAA reports wind direction with reference to magnetic north. In accordance with International Civil Aviation Organization (ICAO) rules, the FAA provides wind direction and speed information as a 2-minute average.

20 Part B of the DFW Surface Weather Observations forms for April 14, 1993, indicated moderate rain showers from 0627 to 0645, light rain showers from 0645 to 0700, and heavy rain showers from 0700 to 0710. Fog was reported from 0633 to 0638 and from 0700 to 0845. Sunrise was at 0700. In a written statement to Safety Board investigators, the contract weather observer, who was on duty at the time of the accident, stated that at 0659 he was in the process of taking a special observation because of diminished visibility. He then observed the airplane coming to a halt, and he noted that the intensity of the rain shower had increased. He completed the special observation [Type--Special, at 0701, above] and then called the tower with the report. He and the incoming contract weather observer then time checked and annotated all of the recording charts. 1.7.3 Recorded Weather-Measuring Equipment at DFW Wind Gust Recorder.--The NWS anemometer was about 50 feet south and 10 feet east of the FAA center field anemometer, and approximately 5,000 feet north-northeast of the point where the airplane came to rest. The height of the anemometer was 22 feet agl. Subsequent to the accident, the NWS anemometer was checked, calibrated, and found to be within tolerance. The gust recorder did not record wind directions, but it did record speeds. According to the gust recorder trace, the wind speed at 0655 for DFW was about 3 knots. Approximately 1 knot was indicated on the chart at 0656. The wind speed was estimated at 4 knots at 0657. The wind speed at 0658 was estimated from the trace at 14 knots. By 0659, the chart showed the wind speed at around 20 knots. At 0700, the wind speed was indicated at around 33 knots (it was later determined to be the peak wind recorded during that period in the vicinity of DFW). Record of Precipitation.--The rain gauge was approximately 150 feet southwest of the Delta Air Lines maintenance hangar, or about 1/4 mile east from the point where the airplane came to rest. The recorder chart showed that about 0.32 inch of rain fell between 0615 and 0700. The chart also indicated that approximately 0.23 inch of rain fell between 0700 and 0707. Runway Visual Range (R VR).--The RVR transmittance readings for runway l 7L were recorded from a position approximately 1,000 feet south of a point between the thresholds of 17L and 17R. The minimum transmittance value of

21 0.66 was recorded between 0700 and 0701. The light setting at the time of the accident is unknown. However, according to the Federal Meteorological Handbook Number 1, Surface Observations, Table A3-6C, the transmittance value of 0.66, at light setting 3, corresponded to an RVR of 3,500 feet; at light setting 4, the corresponding RVR was 4,500 feet; and at light setting 5, the corresponding RVR was 5,000 feet. 1.7.4 Radar Mosaics Radar mosaics for 0650 and 0700, April 14, 1993, were obtained from the Fort Worth Center Weather Service Unit (CWSU). The radar information was accessed directly from the Stephenville radar and processed at the CWSU. The mosaics displayed radar returns in standard VIP format. In addition, the DFW VOR [ very high frequency omnidirectional radio range] and DFW comer posts and airways were plotted on the mosaics. The mosaic for 0650 showed light green (VIP level 1) and dark green (VIP level 2) colors in the vicinity of the DFW VOR. At 0700, the mosaic indicated the colors light green, dark green, yellow (VIP level 3), and brown (VIP level 4) within the same general area. Radar mosaics for the DFW area at 0630, 0645, 0700, and 0715 were also obtained from the American Airlines Weather Services section. The mosaics were generated by a private meteorological company that used radar data from NWS radar facilities and disseminated the information to the airline within 10 to 15 minutes of the generation time. Radar returns were processed into 16 levels. Shades of green were equivalent to VIP levels 1 and 2, shades of yellow equated to VIP levels 3 and 4, and shades of red corresponded to VIP levels 5 and 6. The mosaics showed shades of green and yellow in the area surrounding DFW during these times. (See appendix F, Selected Weather Radar Data). 1.7.5 Additional Weather Radar Information In conjunction with the FAA, the Massachusetts Institute of Technology's Lincoln Laboratory was preparing to conduct a test of the Integrated Terminal Weather System (ITWS) at DFW. As part of the test, the University of North Dakota (UND) installed a C-band Doppler radar at Lewisville, Texas, approximately 12 1/2 miles (20 km) north northeast of the approach end of runway l 7L. The radar installation was completed on April 13, 1993, and the radar was

22 operable at the time of the accident. Air traffic controllers were using the ASR-7 and ASR-8 for daily operations at DFW. In addition, there was an FAA airport surveillance radar (ASR-9) at Azle, Texas. The ASR-9, located approximately 33 1/2 miles (54 km) west of DFW runway 17L-35R, depicted weather echoes in the standard six NWS VIP intensity levels. The FAA was not using the ASR-9 operationally. The Lincoln Laboratory provided reflectivity plots from the UND Doppler radar and the ASR-9 for the time around the accident. In addition, the laboratory provided Doppler radial velocity plots and prepared 3-dimensional weather radar plots of the DFW area for 0656 to 0702. Examination of the reflectivity plots indicated widespread radar echoes throughout the DFW area. Plots from 0650 to 0702 showed a north-northwest, south-southeast line of equivalent VIP levels 2 to 4 echoes progressing toward the east across the airport. Using ASR-9 data, the laboratory calculated individual storm cell movement to be toward the northeast at around 43 miles per hour. Lincoln Laboratory constructed minute-by-minute, 3-dimensional radar plots using data from 0.5, 3.4, 6.3, 10.0, 16.7, and 27.5 degree antenna tilts. The plots depict the 39 dBZ isosurfaces (VIP level 2 incorporates 30-40 dBZ) along with runway l 7R and l 7L and the aircraft track. Plots for 0657, 0658, 0659, 0700, and 0701 are advected echo depictions using calculated storm cell motion. The advected plots potentially become less reliable during the later minutes. The 3-dimensional plot for 0656 shows 39 dBZ isosmface north and west of DFW runway 17L. The advected plots for 0659 and 0700 depict the isosurface traversing runway 17L. 1.7.6 1.7.6.1 National Weather Service Forecasts Fort Worth Forecast Office Terminal Forecast (FT) - The DFW FT in effect at the time of the accident was prepared by the Fort Worth Forecast Office and was valid beginning at 0300 cdt. It called for the following:

23 Ceiling 2,500 feet broken, wind 150 degrees at 14 knots; occasional ceiling 1,200 feet overcast, visibility 3 miles with thunderstorm and moderate rain shower; chance ceiling 800 feet obscured, visibility 1 mile with severe thunderstorms, heavy rain showers, hail and wind gusts to 50 knots. Public Weather Warning - No Tornado or Severe Thunderstorm Warnings were issued by the Fort Worth Forecast Office around the time of the accident. Local Airport Weather Advisory - No weather advisories for DFW were issued by the Fort Worth Forecast Office on April 14, 1993. 1.7.6.2 Fort Worth Center Weather Service Unit (CWSU) TRACON [terminal radar approach control] weather briefing prepared by the CWSU at 0635--DFW Terminal Area Forecast valid until 1600: Ceiling 2,500 broken, wind 180 degrees at 15 knots; chance ceiling 800 obscured, visibility 1 mile, severe thunderstorm, heavy rain shower, hail, wind gust 50 knots. 0900: Cold front passage, wind 030 degrees at 10 knots, chance visibility 1 mile, chance thunderstorm, heavy rain shower, hail, wind gust 50 knots. No Center Weather Advisories were valid for the DFW area for around 0700. 1.7.6.3 National Severe Storms Forecast Center, Kansas City, Missouri Weather Watch Number 116 - Tornado. Valid 0415-1100. Axis 55 nautical miles east and west of line 28 nautical miles south- southeast San Antonio to 28 nautical miles south-southwest of Ardmore. Hail surface and aloft 2 1/2 inches. Wind gusts 70 knots. Max tops to 53,000 feet. Mean wind vector 230 degrees at 40 knots.

24 Convective Significant Meteorological Information (SIGMET) MKCC WST 0555 Convective SIGMET 44C Valid until 0755 Texas From 20 nautical miles west-southwest of DFW to 30 nautical miles northwest of Austin to 50 nautical miles east-southeast of Del Rio. Line severe thunderstorms 20 nautical miles wide moving from 270 degrees at 30 knots. Tops above 45,000. Tomadoes ... hail to 3 inches ... wind gusts to 70 knots possible. Convective SIGMET 45C Valid until 0755 Oklahoma/f exas From Fort Smith to 30 nautical miles north-northeast of DFW to 50 nautical miles west-southwest of Wichita Falls to 40 nautical miles northwest Ardmore to Fort Smith. Area thunderstorms moving from 250 degrees at 15 knots. Tops to 40,000 feet. MKCC WST 0655 Convective SIGMET 48C Valid until 0855 Texas From 40 nautical miles east of McAlester to 40 nautical miles south-southwest of McAlester to 20 nautical miles south of Waco to 30 nautical miles west-northwest of San Antonio. Line severe thunderstorms 20 nautical miles wide moving from 270 degrees at 25 knots. Tops above 45,09() feet. Tomadoes ... hail to 3 inches ... wind gusts to 70 knots possible Texas portion.

1. 7. 7

American Airlines Weather Forecasts American Airlines produced several aviation forecasts and advisories under the FAA's Enhanced Weather Information System (EWINS) program. The weather services section, staffed by professional meteorologists, was in the Systems Operations Control Center. Among the products generated by the weather staff were terminal forecasts for specific airports, map features that were entered into computer flight plans, Terminal Significant Meteorological Conditions (SIGMECs), and Thunderstorm SIGMECs.

25 The weather seivices section also prepared oral weather briefings for incoming shifts of flight dispatchers. The morning weather briefing on April 14, 1993, was broadcast to dispatchers about 0615, and it lasted approximately 15 minutes. Normally, weather briefings were taped so that dispatchers could review them later in their shifts. The tapes were reusable, and any written notes, prepared to aid in the weather briefings, were not saved. The taped weather briefing for 0615 cdt, April 14, 1993, was not available for evaluation after the accident. Forecasts valid for the time of the accident, issued by American Airlines' weather seivices section and passed to the flightcrew of AALl 02, are as follows: The amended terminal forecast for DFW issued at 0600, stated, in part: DFW April 14, 0610 0600/1,500 feet broken occasional 600 feet overcast visibility l mile thunderstorm moderate rain shower. 0800/ 800 overcast 3 miles light rain showers briefly thunderstorm with light rain shower. Wind 0600/ variable 15 knots gusting 20 knots. 0900/south 10-15 knots gusting 25 knots. · The Thunderstorm SIGMEC, valid April 14, 1993, from 0400 to 1100, is as follows: At 0500, broken area thunderstorms extended from 100 miles south of San Angelo to 20 miles east of Abilene to 60 miles north- northwest of Abilene to 60 miles east to 100 miles south of San Angelo. Line was moving to the northeast at 35 knots. Maximum tops over flight level 50,000 feet At 0500, a scattered to broken area of thunderstorms extended from Wichita Falls to 60 miles north of Oklahoma City to 40 miles north of Shreveport to Wichita Falls. Movement to the northeast at 20 knots in the north and to the northeast at 40 knots in the south and east. Tops to flight level 40,000 feet. Little change expected in north and slow decrease expected in north. DP/FTW Weather Watch 115 valid until 0700 ... Severe thunderstorms/tornadoes possible central/southwest Texas along

26 and 60 miles east and west of a line from 21 miles east-southeast of Del Rio to 32 miles north-northeast of Abilene. Weather Watch 116 valid until 1100 ... Severe thunderstorms/tornadoes possible centraVnorth central Texas along and 55 miles east and west of a line from 28 miles south-southeast of San Antonio to 28 miles south-southwest of Ardmore. The Terminal SIGMEC for DFW/Dallas/Austin/San Antonio follows: Valid April 14, 0358 to 1000 Line thunderstorms approaching north central Texas along centerline 30 miles southwest Wichita Falls to 60 miles southwest DFW to 80 miles west San Antonio is moving northeast at 30 knots/ Expect occasional thunderstorms with heavy rain/ low level windshear/ surface wind gusts to 40 knots/ frequent lightning possible in vicinity of DFW /Dallas/ Austin by 0700 and San Antonio by 0800. Expect occasional thunderstorms throughout the remainder of the period. SR/FTW

1. 7.8

Airline-Provided Weather Information The accident airplane's flight log indicated that the following information was provided to the airplane via Aeronautical Radio Inc. (ARINC) between 0400 and 0700, April 14, 1993: 0418 0423 0428 0437 0505 Product DFW observation, American Ff, NWS Ff Terminal SIGMEC 1)mnderstorm SIGMEC, Tornado Watches 115 and 116 Route weather update DFW observation, American Ff, NWS Ff

27 0532 Pilot Report 0619 DFW obsezvation, American Ff, NWS Ff 0624 Changeover information 0646 Changeover information 1.7.9 Changeover Information Changeover information disseminated to American Airlines flightcrews include meteorological landing data, arrival gate information, and other pertinent remarks. The information had been transmitted automatically via ARINC to airplanes a few minutes prior to the landing of AALI 02. According to American Airlines, Terminal SIGMECs issued within 1 hour of arrival time were normally appended to the changeover information message. The Terminal SIGMEC for DFW issued at 0358 , April 14, 1993, and valid until 1000, was not attached to changeover information messages sent to the accident flightcrew at 0624 and 0646. 1.7.10 Low Level Windshear Alert System (LL WAS) A windshear alert was transmitted by the westfield LL WAS anemometer from 0653:25 to 0655:35. The Local West controller (LCW) issued a windshear alert at 0653:30, 0653:50, and 0654:29 to the flightcrew of a heavy DC-8 which landed about 0655:25 on 18R. The windshear alert was not passed to the accident flight because the alert had terminated before the flightcrew of AAL102 made initial radio contact with the local controller. The ATIS, which advised that windshear advisories were in effect, was initially broadcast at 0704:07, after the accident. Ten-second and two-minute DFW centerfield LLW AS winds are plotted on the graph from 0656:05 to 0703:05, April 14, 1993 (see figure 5). In addition, calculated cross track winds based on the 10-second data and estimated NWS wind gusts are shown on the graph. The LLWAS at DFW at the time of the April 14, 1993, accident used five anemometers, located around the periphery of the airport complex, plus a center . field anemometer. Subsequent to the accident, FAA maintenance personnel tested

CJ) 1----- C) z ,,L I 0 w w 0.... CJ) 0 z t---< 3 28 Or-W CENTERFIELD LLWAS ANO NWS DATA 35 _ ~ 10 sec avg wind spd ~ -a- 2 m i n avg w i r1 d s pd 30 ~ ---o-psbl peak gust

• • reported pe0k gust

25

-b-cr- oss track

y approx n.w. s. gust 20 1 S - 10 - ( t-0--0-0-0-0-0-0 s - touchdpwn . l final stop + 11 5[,: 03 1 lS"/: 05 1150:05 1159:05 1200:05 1201:05 1202:05 1203:05 TIME (UTC)-HHMM:SS Figure 5.--LL WAS data.

29 all six sensors. The northwest, west, and center field sensors were found to be out of tolerance. The three anemometers were shipped to the manufacturer and under direction of the Safety Board's Investigation Weather Group Chairman, the "out of tolerance" anemometers were further evaluated. The sensor from the center field was found to be within manufacturer's tolerances. The generator output from the sensor from the northwest DFW field position was found stable, and tested root mean square errors were found only slightly out of tolerance. The sensor from the west field station at DFW failed potentiometer tests in nearly every direction, with high root mean square errors. Following the April 14, 1993, accident the FAA, the manufacturer of the system, and Massachusetts Institute of Technology's (MIT) Lincoln Laboratory examined the raw LLWAS data and calibrations to gain additional information regarding the performance of the sensors on the day of the accident. The FAA representative specialists compared wind directions and speeds from the individual anemometers with center field reading during the period from 0000 utc, March 20 to 2359 utc, April 18, 1993. Regarding the west sensor, the FAA concluded that wind speeds varied from minus 2 knots to minus 7 .5 knots, from 260 to 350 degrees, when compared to the center field sensor. Belfort Instrument, the manufacturer of the sensors, concluded that the northwest and center field sensors were unlikely to have contributed to significant LLW AS errors. Considering the large magnitude of error in the west sensor's potentiometer, the manufacturer surmised that the potentiometer may have been damaged by an electrical transient. MIT/Lincoln Laboratory compared wind speeds from each anemometer with the network mean wind speed for a period of eight days, around the time of the accident. According to laboratory personnel, speed variations within 20 percent of the mean are considered acceptable. The appraisal revealed that the southwest sensor's wind speeds were marginally low when compared to the network mean. Speed values from the other anemometers were within the acceptable standard.

30 1.7.11 Predeparture Weather Briefing The following are selected portions of the weather briefing, issued by the American Airlines weather services section to the crew of AALl 02, at 0302 utc, April 14, 1993, (2202 cdt, April 13, 1993):8 Forecast weather at DFW for 1100 Zulu (1100 utc), about 1 hour before AAL102's landing at DFW: 700 foot broken, 1,500 foot overcast, visibility 3 miles, light rain and fog, occasionally 600 foot overcast, 1 1/2 miles thundershowers or rain showers and fog. In addition, the following weather advisory was issued by the AAL weather services section at 0302 utc on April 14, 1993, in abbreviated format: TSTM SIGMEC Valid 14 [April] 0215 Zulu to 14 [April] 0800 Zulu, 1993, At 0200 Zulu, a scattered to broken line of moderate to heavy thunderstorms, approximately 15 miles wide, was located over Oklahoma along a centerline 20 miles south of Tulsa, to 30 miles west of McAlester, to 30 miles west of Ardmore, moving east- northeast at 15 to 20 knots, with maximum tops at or above 45,000 feet. A scattered area of heavy thunderstorms was located over northeastern Texas, 70 miles south of McAlester, to 40 miles southwest of Texarkana, to 120 miles west of Shreveport to 40 miles east-northeast of DFW, to 70 miles south of McAlester, moving east-northeast at 35 knots, with maximum tops at or above 45,000 feet. A scattered line of heavy thunderstorms was located over west-central Texas, from 50 miles northwest of Abilene to 30 miles east-northeast of Abilene, moving northeast at 15 knots, with tops above 45,000 feet. Some increase in activity over north- central Texas and eastern Oklahoma is expected during the period. Also, 8Utc is universal coordinated time, also referred to as "Zulu" time. DFW local time was utc (Zulu) minus 5 hours.

31 Weather Watch 114. Valid until 0800 Zulu [about 4 hours before AAL102 was to land at DFW] Tornado and severe thunderstonns possible over Texas and Oklahoma, along and 55 miles north and south of a line 41 miles west-northwest of Abilene to 25 miles southwest of Fayetteville, Arkansas. 1.8 Aids to Navigation The ILS approach to runway 17L transmits on 110.3 megahertz (MHz). The localizer course is 173-degrees magnetic. The touchdown zone (TDZ) elevation is 562 feet msl, and the approach minimums are 200 feet agl and 1/2 mile visibility. The final approach fix (FAF), "Jiffy," has a low-frequency radio compass locator (LOM) and an outer marker radio transmitter and is 4.6 nautical miles from the runway threshold. The minimum altitude at Jiffy and the decision height (DH) for the approach are 2,300 feet and 200 feet (762 feet msl), respectively. On April 13, 1993, there was construction activity at the approach end of runway l 7L. At 1310 cdt, the glides lope portion of the ILS was taken out of service. It was returned to service at 1450 cdt. Around 1600 cdt, the captain of an American Airlines flight stated that there was a glidepath anomaly on the ILS to 17L, and he also noted that there were vehicles in the ILS "critical area." The glideslope was taken out of service at 1410 and returned to service at 1550. The accident flightcrew reported no difficulties with the ILS glidepath on April 14, 1993. On April 19, 1993, the ILS for 17L was checked by an FAA flight inspection flight. The approach and, specifically, the localizer and glidepath were found to be satisfactory, but the 75 MHz marker beacon was out of tolerance. 1.9 Communications There were no known difficulties with communications. 1.10 Aerodrome Information DFW is owned by the cities of Dallas and Fort Worth, Texas, and is operated by the DFW Airport Board. The airport is about 17 miles west of Dallas and 17 miles east of Fort Worth. DFW is 603 feet above mean sea level (msl), and operates with six concrete runways, all of which are grooved. They are runways l 3L/31 R, l 3R/3 l L, 17L/35R, 17R/35L, 18L/36R, and l 8R/36L. There is also one

32 short takeoff and landing (STOL) runway that is superimposed on a taxiway. (See figure 6). The runways are served by eight ILS and nondirectional beacon (NDB) instrument approaches. Runway 17L-35R is 11,388 feet long and 150 feet wide and has a grooved concrete surface. Runway 17L is served by a Category II instrument landing system (ILS), high intensity runway lighting (HIRL), runway edge and centerline lighting (RCLS), touchdown zone lighting (TDZL), with sequence flashers, and runway threshold/end lighting. Runway 17L is equipped with an ALSF-2 approach lighting system. Runway 17L-35R was originally constructed as runway 18L-36R, in accordance with plans and specifications entitled "Runways, l 8R/36L and 18L/36R Phase II, Paving, Drainage and Lighting," under the issue date of March 1982, Contract C-279-82. The runway designation was changed to 17L-35R prior to its opening. Runway 17L-35R was designed and constructed in accordance with FAA advisory circulars (ACs) and specifications. The runway is constructed of reinforced Portland cement concrete pavement with 35-foot-wide asphalt concrete shoulders. The pavement has a crowned section of 1.0-percent cross slope on the runway, a 2.0-percent cross slope on the paved shoulders, with a 1.5-inch vertical drop at the outside edge of the shoulder pavement. 17L has a negative 0.18-percent gradient constant throughout its length, and the concrete pavement is grooved transversely 130 feet wide, across the runway's entire length. The grooves are 1/4 inch deep and 1/4 inch wide, and are spaced approximately 1 1/2 inches apart. Following the accident involving AALl 02, investigators worked with the FAA friction program manager in conducting coefficient of friction tests on runway 17L-35R, using the airport's Saab friction test vehicle. Initial erroneous data results were followed by minor repairs to the equipment. Subsequent data, taken on April 16, 1993, found that the friction levels on runway 17L-35R were in the .60 to .65 range with the test vehicle traveling on the runway at 40 miles per hour. Friction tests, taken with the vehicle at 60 miles per hour, revealed friction levels in the range

~ ·-· "' ". "" , " S 120, T200, TTbOO, 0018.50 RWY l 7R-35L, l 7l-35R S 120, T200, TTbOO, OOT850 RWY 18L-30R, 18R J0L S 120. T200, TTbOO, OOT850 I RWY 18S-30S RESTRICTED TO PROP ACF1 12500 lb, Oil LESS ANO STOL ACF1 r ELE.,._ 553 J I FIRE ST A TION

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~ 1 ;,, -1---,---,---,----,---;....---,---,---+l -,-----,--r--.--.----,--.-,-f AIRPORT DIAGRAM :'A ~, .:i. :'.J.fOC WOUN , TEXAS DALLAS-FORT WORTH !NTL (OFW) Figure 6.--Airport diagram.

34 of .52 to .57. 9 Friction values in these ranges fell within the area of "maintenance planning."10 Microtexture tests on runway l 7L-35R were also accomplished under the direction of the Safety Board. 11 Data from the microtexture tests showed texture depths of .012 inch at 4,000 feet from the threshold of 17L, .010 inch at 6,000 feet, and .014 inch at 7,000 feet. Slope was measured at 1.25 degrees at all three locations. FAA AC 150/5320-12B states: Average texture depth in good skid-resistant pavement will average 0.0625 inch or more. Less than that indicates a deficiency in macrotexture that will need correction as the surface deteriorates.12 When Safety Board investigators inquired of the FAA Airports Certification Inspector, who was involved in the investigation, whether FAA annual certification inspections include runway coefficients of friction measurements, he replied that it was not within the authority of the inspector(s) to evaluate runway friction coefficients or airport friction measurement programs. 1.11 Flight Recorders An operable CVR and a 28-parameter flight data recorder (FDR) were recovered from the airplane and transported to the Safety Board's laboratories in Washington, D.C., for readout. Both recorders arrived at Safety Board headquarters on the day of the accident. Neither of them showed any damage, and they provided clear information. i[oefficient of friction values are a ratio and have no unit of measure. Reference FAA AC 150/5320-12B, dated 11/12/91 , "Measurement, Construction, and Maintenance of Skid-Resistant Airport Pavement Surfaces," Chapter 3, Section IV, paragraph 45 - 46, and Table 3-3. 11Ibid., page 22, Pavement Texture Measurement, for provisions followed in runway microteMure test. . FAA AC 150/5320-12B, dated November 12, 1991, states "0.0625 mm" it should read "0.0625 inch." (reference report, "Friction Survey for Runway 17L-35R, DFW, dated May 26, 1993, by Thomas H. Morrow, C.E., P.E.)

35 1.11.1 Cockpit Voice Recorder The CVR was a Fairchild model A-lOOA. It was examined at the Safety Board's Audio Laboratory, beginning on the afternoon following the accident. The recording consisted of four channels of good quality audio information. A transcript was prepared of the entire 31 minutes of recording. (See appendix C for CVR transcript). 1.11.2 Flight Data Recorder The FDR was a digital Sundstrand Model UFDR-DXUS (Serial No. 9582). The data indicate that at 0658:29, the airplane's main landing gear touched down with the airplane at an attitude of 4.21-degrees nose up and 1.76-degrees left wing down, on a heading of 174.02 degrees. The airplane touched down at an airspeed of 142.75 knots, but the speed fluctuated between 145.0 knots and 139.5 knots over the next 3 seconds. The data also indicated that nose gear touchdown occurred at 0658:31. During the period between main gear and nose gear touchdown, the elevator position values changed from 10.3-degrees nose up to 12.03-degrees nose down. In the 6 seconds following the indication of main gear touchdown, the heading of the airplane remained at between 174 degrees and 175.4 degrees, as the airspeed decreased to 125 knots. The elevator position values remained nose down, decreasing from a peak value of about 14 degrees to 3 degrees, while the rudder position values fluctuated between 2.8 degrees right rudder to 23 degrees left rudder. The thrust reverser values recorded during this period were consistent with a symmetrical deployment of all three engines' reversers. The NI, or engine gas generator speed values, were also consistent with a symmetrical application of reverse thrust starting at 0659:33. Within the next second, the elevator position changed from 9.8-degrees nose down to 1.84-degrees nose down, where it remained nearly constant, changing less than 0.3 degrees. The rudder position decreased from approximately 6 degrees left rudder to nearly 2 to 3 degrees left of neutral. During the next 6 seconds, the data are consistent with the airplane departing the runway heading to the right of centerline. The heading of the airplane changed 7 degrees to the right as the airspeed decreased to 106.5 knots. Maximum reverse thrust values were recorded during this 6 seconds with NI between 85.2 and 83.26 percent.

1. 12
2. 12.1

36 Wreckage and Impact Information Wreckage Path Information Investigators examined the landing runway after the accident and found traces lighter than the surrounding runway surface, or white tire traces from the left, center, and right main landing gears, starting at 4,303 feet from the beginning of the runway, or with 7,085 feet remaining. The center gear tire marks were 4 feet to the right side of the runway centerline. There were no marks of any kind before this point on the runway that could be linked to the accident airplane. The terms "erasure mark," or "white tire trace," pertain to the phenomenon whereby an airplane tire, subjected to braking and/or cornering on the wet surface, will scrub or erase contaminants from the runway surface resulting in a temporary white appearance of the surface in the tire track. There were a large number of these marks on runway l 7L. White tire erasure marks (or traces) found on the surface of the runway were identified as the ground track of AAL102 by tracing the marks to the airplane and checking the spacing with the known dimensions of the DC-I O's landing gear and tires. The distance between the white traces was consistent with the DC-I O's landing gear measurements. The set of white traces from the right main gear tires were the most visible, and paralleled the runway centerline for about 1,700 feet, until the airplane was abeam taxiway 27, about 5,988 feet from the beginning of the runway. White tire traces from all three main landing gear became clearly visible as the airplane cornered to the right before it departed the runway. The marks from the left main landing gear tires crossed to the right of the runway centerline about 6,443 feet from the beginning of the runway. Several scuff marks were found parallel to the center main landing gear track, about 6,773 feet from the beginning of the runway. These marks continued intermittently until they were nearly abeam the entrance to high speed taxiway 3S. One of these marks, about 6,773 feet from the beginning of the runway, was 175 feet long and 7 inches wide, and was located 22 inches right of the mark from the right tire of the center main gear. The airplane crossed the right shoulder of the runway with the left and center landing gear, while the right gear exited the shoulder and left furrows in the wet soil, about 7,453 feet from the beginning of the runway. Black rubber tire

37 marks became visible as the airplane crossed the runway l 7L shoulder and high speed taxiway 3S. On the taxiway, the marks from all three main landing gear were evident as black marks. Measurements of the center main and nose gear tracks showed that the airplane was yawed approximately 9 degrees to the right as it crossed the high speed taxiway. After crossing the taxiway, the airplane returned to the soft soil and left deep trenches from all landing gears. The airplane came to rest, upright, about 8,781 feet from the approach end of 17L and about 250 feet from the right edge of the runway, with the nose on perpendicular taxiway 31. The heading at final stop was about 203 degrees magnetic. Separated airplane debris was found in the area between where trenches associated with tire paths ended and the final resting point of the airplane. This debris was primarily from the left main landing gear and associated hardware where the left main landing gear mounted into the wing structure. Shallow trenches or furrows were found consistent with the location of the left wing tip and left outboard flap track fairings. They were found between the grooves in the soil from the left main landing gear and the final resting point of the airplane. The airplane came to rest supported by the forward fuselage, the center and right main landing gear, and the left wing and No. 1 engine. The left main gear strut was fractured and the nose gear strut was folded aft. The airplane came to rest slightly nose low and about 10 degrees left wing low. In its final resting position, the left wing and forward fuselage, as well as the right main and center gear, provided support and areas of ground contact. 1.12.2 1.12.2.1 Airplane Structure Landing Gear The nose gear was found folded aft. The wheel and tire assembly penetrated the floor of the lower lobe galley, and the wheels were turned about 90 degrees to the right. (See figure 7, which is a photograph of the lower lobe galley, showing the final position of the nose gear tires). The center main gear was found attached to the airplane in the down and locked position with the wheel well structure aft of the gear undamaged. The

Figure 7.--Lower lobe galley.

-

39 center main gear had sunk into the mud up to the lower fuselage of the airplane, requiring separation from the structure for recovery of the airplane. The right main landing gear remained attached to the airplane, in the down and locked position, and supported the right side of the airplane. The tires were buried in mud to a depth of approximately 2 feet. The left main landing gear was found separated from the wing structure at the forward "zero margin" trunnion pin and at the aft trunnion pin lug. It came to rest against the trailing edge of the left wing's oytboard flap. A portion of the forward trunnion pin was found about 200 feet aft of the left wing. Examination showed that the pin had fractured at the groove. The aft lug of the forward and aft clevises that hold the "zero margin" trunnion pins were also found fractured. The aft trunnion pin was intact. The truck beam of the left main landing gear was found fractured, and the upper side brace was separated at the wing hinge. No indications of fatigue or corrosion were observed along the fractures of the trunnion pin and lugs, truck beam, upper side brace, or any fracture in the landing gear area. No flat spots or reverted rubber material were found on any of the tires. All tire pressures were documented and found within normal pressure levels, except the left rear tire from the left main landing gear. The pressure gauge for this tire indicated approximately 195 pounds per square inch (psi). 13 1.12.2.2 Fuselage The forward fuselage underside sustained crushing damage in the area of the nose gear wheel well and aft to the area where the nosewheels penetrated the lower lobe galley. A circumferential crack-like fracture in the lower fuselage extended just aft of the L-1 and R-1 cabin exit doors across the underside of the fuselage. Other areas of the forward skin along the belly were wrinkled and tom. All of the examined fractures and cracks showed evidence of overload, resulting from the crash. The fairing aft of the left wing was damaged, and the underlying metal fuselage skin was split open. Rubber transfer marks were found on the fairing, and, 13Toe normal inflation pressures for a DC-10-30, as specified in American Airlines' General Procedures Manual, are as follows: main landing gear, 180 - 190 psi; nose landing gear, 180 - 190 psi; center landing gear, 155 - 160 psi.

40 in the split, a distinctive circular pattern was found that matched the bottom of the landing gear assembly. lmbedded in the side wall of one of the left main landing gear tires was a piece of metal that matched in color, thickness, and shape a portion of fuselage skin from the breached area. There was also a 3-foot by 6-foot area of damage to the wing-to-body fairing under the left wing, near the front spar. 1.12.2.3 Wings All slats on the left wing were found extended, except for the No. 2, or second-most inboard slat, which had been driven aft and up by displacement of the No. 1 engine. All spoilers were found retracted, although the outboard edge of the No. 1 spoiler was bent up slightly. The left outboard aileron was found in the up position, and the inboard aileron was down slightly from the up position. The left outboard flap was found partially extended and exhibited damage along the trailing edge, consistent with a secondary impact from the left main landing gear. The left inboard flap was found extended and exhibited up-and-aft impact damage to the middle of the lower surface and the trailing edge. The outboard comer of the flap (36 inches by 44 inches) was found to have burned away. The forward edge of the No. 3 flap track fairing was found tom and buckled and embedded with dirt. The No. 1 engine pylon was still connected to the left wing, but the engine had been rotated counterclockwise (aft looking forward) and turned inward and nose up. The underside of the left wing aft and outboard of the engine sustained fire damage. No right wing damage was observed. All slats and flaps on the right wing were found extended. All spoilers were retracted, except for the No. 5 or outboard-most spoiler, which was partially deployed. The outboard aileron was up, and the inboard aileron was down. 1.12.2.4 1.12.2.5 Empennage No empennage damage was found. Lightning Strike/Static Dischargers Two areas of the airplane's fuselage skin were identified as possible entry points for a lightning strike. They were two small black pits that were located

41 below the window line aft of the L-2 door (left cabin exit door, second from the front of the cabin). No additional damage was observed around these pits. The top of the light lens on the right wing tip trailing edge exhibited melting and discoloration characteristic of a lightning strike. Melting and discoloration were also observed along the boundary of the lens and on the static discharger located outboard and adjacent to the lens. Only the retainer portion of the static discharger was found. No similar damage was observed on the remaining static dischargers on the airplane. However, three other dischargers were found broken--one each on the right wing trailing edge, left wing trailing edge, and left wing tip. 1.12.2.6 Fire Damage The most severe fire damage was on the underside of the left wing, aft and outboard of the No. 1 engine rear pylon. The left lower wing skin, between the front and rear spars and outboard of the rear pylon to the No. 3 flap track fairing, was heavily sooted. Less sooting was found farther inboard on the wing and outboard of the No. 2 flap track fairing. The lower surface of the inboard aileron and portions of the flaps and wing panels between the No. 1 and No. 2 flap track fairings were burned through. Melted metal hung from the lower surfaces of the inboard aileron and the outboard portion of the inboard flap on the left wing. The outboard side of the No. 1 flap track fairing was significantly more burned than the inboard side. Both sides of the No. 2 flap track fairing were burned through. Only minor fire damage forward of the front spar was observed. All fuel tanks were found intact. In the No. 1 engine pylon area, fuel and hydraulic lines, electrical cables, wire bundles, and fire extinguisher lines were severed at a point near the wing-to-pylon interface. Fire damage was present in this area. The outboard side of the pylon was significantly more burned than the inboard side, and a small area immediately below the leading edge of the wing was burned through. No fore-to-aft streaking of soot or metal was seen along the pylon or the underside of the wing. 1.12.2.7 Cabin During the landing, after the airplane departed the right side of the runway, a few ceiling panels and some articles stored in overhead bins were reported to have fallen, striking two passengers. In rows 11 to 16, two ceiling

42 panels by the right aisle and two by the left aisle were separated from the ceiling. Overhead panels were opened for inspection, revealing no evidence of fire, smoke or lightning strike. The oxygen masks were found deployed above seats A and B in row 22. 1.12.3 Airplane Flight Control Systems No preexisting failures or conditions that could have adversely affected the flight controls were found. The rudder was hydraulically operated through its entire range of left and right travel. Two steering cables and a pulley bracket from the collapsed nose landing gear steering system were examined at the Safety Board's Materials Laboratory. The laboratory reported that although the cables contained corrosion, their failure was due to overstress. The cables and brackets were in an area with extensive soil impact damage, including broken and bent brackets and tom insulation blankets. Out of 20 antiskid valves tested for response to electrical signals, 5 were found to be out of the prescribed limits established for new parts. The manufacturer of the airplane's brake/antiskid system, Aircraft Braking Systems, Inc., noted that the mode in which the valves exceeded tolerances would have made it less likely for the affected wheels to skid. 1.12.3.1 Flaps The flap/slat handle in the cockpit was found in the 35-degree position. Postaccident interviews of the flightcrew and the FDR record show that the landing was made at the 35-degree flap setting. The leading edge slats and trailing edge flaps were found in the extended positions--appropriate for the landing configuration. They were examined where the airplane came to rest and were found evenly flecked with mud. Data from the FDR showed the positions of the left Nos. 2 and 4 slats, right No. 4 slat, and right No. 3 flap panel. A readout of the FDR data showed that the slats were fully extended and that the flap position indicated 37.97 degrees while the airplane was in final approach and landing. Below 70 knots, the No. 2 left inboard slat sensor changed to indicate slat retraction. This slat had separated from the airplane and was found near the final resting point of the airplane.

43 1.12.3.2 Spoilers After the airplane came to a stop, the flight engineer reported that he completed his checklists, which included stowing the spoilers. However, he could not stow the spoiler handle beyond 1/3 deployment. After the accident, the flight engineer stated that the autospoilers had functioned during the landing, but he "thought the speed brake handle was not coming back fast enough, [and he] reached up and pulled [the] speed brake handle." The spoiler control handle was found in the 1/3-deployed position. On the exterior of the airplane, the spoiler panels were in the stowed position. Mud was packed into the spoiler mixer assemblies in the centerline landing gear wheel well, preventing movement from the 1/3 position until the mud was removed. The spoiler mixers and the cable assemblies attached to each actuator were in positions corresponding to approximately 1/3 of their full rotational travel. Damage occurred to the electrical and hydraulic portions of the spoiler system, and a spoiler fault indication was displayed on the fault isolation panel under the flight engineer's desk. All spoiler position indication wiring in the left wing was burned in the area where witnesses had reported the postcrash fire. Lower surfaces of the left wing were melted near the No. 1 engine pylon, and damage was visible in the spoiler hydraulic and electrical pathways. Hydraulic lines were also fractured at the top of the separated left main landing gear. 1.12.3.3 Rudder During the postaccident systems check, each of the four rudder pedals were depressed through their entire range of travel to determine control continuity to the actuators. The rudder control cables were examined for tension at several locations. Once the mechanical integrity was established, the upper and lower actuators were operated to full left and right travel under hydraulic power. The manufacturer of the airplane, Douglas Aircraft Company, noted that the designed range of rudder travel was +/-23 degrees. Investigators arriving on site found the resting position of the rudder at full left deflection.

44 1.12.3.4 Nosewheel Steering Controls In the forward electronics compartment, the nosewheel steering cables, routed to the rudder pedals and tiller, were found without tension and slack. A bracket that mounted four pulleys in the nose landing gear well was found separated from the compartment ceiling. The four nosewheel steering cables were routed around the pulleys. Each of the pulleys had a cable impression on one side of the groove. Where the impressions were deepest in two of the pulleys, the pulley side walls were fractured. The forward rudder steering cable that passed through the compartment ceiling was fractured, as was the tiller steering cable that was the most forward cable attached to the steering linkage and followup sector assembly. Examination of the broken nosewheel tiller and pedal rudder cables at the Safety Board's Materials Laboratory found that while corrosion was present on the strands, the fractures found were due to overstress. 1.12.4. Wheels, Tires, and Brakes The left nosewheel assembly came to rest in the lower lobe galley. The nose landing gear had pivoted 90 degrees right, so that the left wheel was on the bottom when the assembly was viewed from inside the galley. The left tire was properly inflated and showed no flat spots or rubber reversions. Also, scratches were found perpendicular to the tread and parallel to the axle. The right nosewheel on the nose gear assembly was found inflated properly and had tread remaining. There was no evidence of flat spots or rubber reversion. Scratches perpendicular to the tread and parallel to the axle were also observed on the right nosewheel tire. There were no indications of flat spots in the tread or rubber in any of the main landing gear tires on the airplane. The investigation revealed the following information relative to the main landing gear brakes: 1. All brakes were manufactured by Goodyear, and were marked with part number 5000758-l0R, except for wheels 5 and 7, which were missing the dash number. 2. The DC-10 Maintenance Check Manual showed that the main landing gear brake wear pins must be longer than 1.50 inches.

45 3. Although the unpressurized wear pin lengths were measured at the crash site, and met extension requirements, the DC- I 0 Maintenance Check Manual states that the wear pins must be checked with the brake system pressurized. New measurements were made during the detailed inspections of brake assemblies. 4. All brakes were tested to 3,000 psi and functioned normally. When pressure was reduced to I 00 psi, the top disc in each assembly could be turned, which was a normal indication. The antiskid components found in the wreckage path were examined under the Safety Board's direction at the facility of the brake and antiskid system's manufacturer, Aircraft Braking Systems, Inc. (ABSC). No faults were found with the wheel speed transducers, used for antiskid and spoilers, or with the antiskid control box. As described in the operator's DC-10 Maintenance Manual, the accident airplane was equipped with 20 antiskid pressure control valves, mounted in six manifolds. Two valves led to the brake assembly at each wheel. Testing revealed that 16 of the valves responded to electrical signal applications, signal step changes, and signal releases. One valve was found to be inoperative, and three had damaged or missing valve motor caps that prevented testing. Five of the 16 valves that responded were found out of tolerance. (Reference diagram of brake manifold system, figure 8). When the right main landing gear antiskid manifold, Serial No. 71-104, was dissembled, the connector and wiring at the connector was found corroded. Erroneous BITE information had not been identified by the electronic control unit on the accident airplane. 14 The aircraft wiring diagram shows that the antiskid wiring in the airframe uses an air-ground sensing circuit. The circuit was inspected after the 14The manufacturer of the brakes, ABSC, issued a March 15, 1979, Service Letter (DC-10-10-SL-9 and DC-10-30/40-SL-8) stating that antiskid built-in test equipment (BITE) could be used to identify an inappropriate valve circuit malfunction. The manufacturer noted that loss of a wire could diminish pressure release to the associated half of a wheel brake 0,11 the affected main landing gear (left, centerline, or right).

46 DC-10 ANTI-SKID SYSTEM FINDINGS Legend: D - Unknown Pre-impact Condition LJ - Pass«i TBSting

lltJ • RtJSponss of Va/vs Was Out al TolMIJIIOII

• Failure to Fully or Panially Pressurize Brakes

-T.-W -T-.p -r-.i -r-.i Centerline Left Ano-Skid Centerli~ Right Anti-Skid --..i1uo1-n1 --2.000p., .L Manifold S/N 73-101 Manifold SIN 72-<,4 I l. .. """'"' I .,, l i 5 l I !_ !} J I ~n~. Figure 8.--Brake manifold system. Ollo/T..,._ ,..,,,,,,.. -T.-W ~-913 --2.!160p.,.I. Vwe Rlgtit lower Anti-Sl Bodies Monilold S/N 71-104 I ,Ii ii Ii 47 accident, and actuation of the mechanical portions of the system was confirmed. Electrical integrity was verified by a continuity check. 1.12.5 Other Systems The airline reported that in February 1993, a Sundstrand MK VII Ground Proximity Warning System (GPWS) was placed into service on the accident airplane. The GPWS system included a mode for aural windshear warning alerts to within 30 feet of the runway surface. The airplane had also been equipped with two Litton LTN-72 inertial navigation units and a Litton LTN-311 Omega navigation system. Safety Board investigators determined that data from these systems could not be used to obtain wind data for the time of the accident landing. Postcrash examination found that the air-driven generator (ADG) deployed. Cable continuity was established to the ADG from the cockpit activation handle. The ADG uplock bracket was bent, and the cable had been pulled by deformed structure. 1.12.5.1 Powerplants Examination of the three engines (left or No. 1, center or No. 2, and right or No. 3), engine nacelles, and pylons revealed that all three thrust reversers were fully deployed. Large quantities of mud and grass were ingested by the left and right engines. Only trace amounts of mud were found in the center engine. An anomaly in the center engine reverser cascade configuration was found. The installation of two thrust reverser cascades on the center engine did not correlate to the operator's DC-10-30 Maintenance Manual provisions. No preexisting failures or conditions were found on the three engines that would have prevented normal operations. All three engines were General Electric CF6-50C2, each rated at 51,800 pounds of thrust. Engines Nos. 1 through 3 had the following manufacturer's serial numbers, respectively: 455414, 455292, and 455302. 1.12.5.2 the wmg. attachment. No. 1 Engine The No. I engine was found resting on the ground, partially attached to The engine mount was fractured in the area of the pylon-to-wing The engine and wing were both lying on the ground providing support

48 to the left side of the airplane fuselage. A Safety Board metallurgist, who examined the fractured left engine mount, as well as the fractured nose and left main landing gear struts, found the damage consistent with overload. The No. 1 engine pylon exhibited internal and external heat damage, scorching and small areas of localized melting, beginning vertically down from the wing leading edge and continuing aft. The outboard wing-to-pylon faring burned through the metal skin near the engine fuel line. The pylon structure was folded at around a 45-degree angle, inboard, midway between the wing and engine, severing all fuel lines, hydraulic lines, fire extinguishing agent lines, bleed air lines, and all electrical connections. The pylon attachment points at the wing and engine remained intact. The No. 1 engine was found rotated approximately 45-degrees counterclockwise 15 about its horizontal axis, and articulated about 30-degrees up and inboard toward the fuselage. The wing leading edge slat was extended and pressing against the inboard core cow I. Mud was splattered on the exterior of the engine, nacelle, and pylon. Large amounts of mud had entered the engine and coated the inside wall of the inlet duct. Mud was also found downstream of the fan and throughout the engine reverser. Parts of a runway sign were found in the engine and imbedded in the inlet acoustical material. The leading edge of the inlet duct was damaged at the 5:00 and 7:00 positions, and the dents matched the dimensions of the runway sign. The outboard translating cowl was found separated from the No. 1 engine, whereas the inboard translating cowl remained attached to the engine at the upper "tee" track. All six jackscrew actuators were found extended approximately 22.25 inches. According to the operator's DC-10-30 Maintenance Manual, a 22.25-inch extension of the jackscrews corresponded to a fully deployed reverser translating cowl. One jackscrew shaft was found imbedded in the wing inboard leading edge slat, and a second one was about 50 yards behind the final resting position of the engine. The reverser cascades were in the normal configuration. The inboard and outboard fan and core cowlings were sprung, ajar, partially crushed, and split at the seams. Black soot covered the upper portion of the exhaust nozzle and core cowl but was limited to the exterior of the engine 15 All descriptions using clock positions are referenced looking aft.

49 nacelle. There was also black and blue discoloration on the lower half of the inboard core cow 1. 1.12.5.3 No. 2 Engine There was some damage to the No. 2 engine fan, but the core engine inlet did not reveal any evidence of mud ingestion. Mud spots and brown water stains were found along the inside of the inlet duct and engine compressor inlet. There was no evidence of fire on the nacelle or pylon. The rest of the No. 2 engine was undamaged, and the jackscrews were extended 22.25 inches. The hydraulic mechanism that served to open the fan reverser and translating cowls operated nonnally, with the reversers in the extended position. The low pressure rotor could easily be rotated by hand without contacting associated hardware. No openings, penetrations, or bulges were found in the exterior of the engine cases. All of the cascades on the No. 2 engine were undamaged. However, two of the 32 cascades, located at the 5 o'clock position, were the incorrect part numbers and styles for the installation, according to the operator's DC-10-30 Illustrated Parts Catalogue. 1.12.5.4 No. 3 Engine There was no evidence that the No. 3 engine contacted the ground; however, large amounts of mud were ingested by the engine. Mud covered the exterior of the engine, nacelle, and pylon, and the inside wall of the inlet duct. Mud also coated the bleed doors, between the booster and high pressure compressor. There was heavy damage to the fan and fan rub strip. There was no damage to the engine cases, or evidence of fire or damage to engine ducting, tubing, or wiring at any point on the No. 3 engine. There was also no evidence of fire on the interior or exterior of the engine nacelle. The engine reverser and translating cowls, fan cowls, and core cowls were latched, unsprung, and undamaged. The translating cowls were extended, the cascades were visible, and the blocker doors were in their deployed position; and mud coated each door. The jackscrews were extended 22.25 inches. The hydraulic mechanism to open the fan reverser and translating cowls operated nonnally with the reverser in the extended position.

50 All of the engine reverser cascades remained in place and were undamaged. Mud was found in the turning vanes, throughout the inner diameter of the cascades. The cascades were in the normal configuration. The low pressure rotor could be easily rotated by hand with friction noted at the fan tips. All fan blades were intact from root to tip. However, all of the leading edges and some of the trailing edges were bent, chipped or fractured, and mud deposits, loose dirt and debris were in the plane of rotation. The fan rub strip exhibited heavy circumferential scraping. 1.13 Medical and Pathological Information Out of a total of 202 persons aboard the airplane (189 passengers, 3 flightcrew and 10 cabin crewmembers), two injuries were described as serious, involving fractured bones or spinal injuries to passengers that occurred during the evacuation of the airplane. There were 38 reported minor injuries (35 to passengers, 2 to the cabincrew and 1 to the flightcrew). Two passengers received minor injuries that could be attributed to ceiling panels as the airplane slowed to a stop in the soft soil. However, most of the minor injuries and all of the serious injuries were reported to have occurred during the emergency evacuation, especially as passengers attempted to slide down steep- angled slides from the right side of the cabin, landing in sticky mud that made it difficult or impossible for some of them to move away from the bottom of the slides (see section 1.15.1). The flight attendant stationed at 3-R said that the problem was exacerbated by the high number of elderly persons attempting to evacuate at that exit. The steep angle of the slides at 3-R and 4-R resulted from the final resting attitude of the airplane. In addition to deep mud at the bottom of the slides, winds, driving rain, and slippery slides heightened the difficulties. Due to the resting attitude of the airplane, slides at 3-R and 4-R were described by some witnesses as not touching the ground, a situation that contributed significantly to the steepness of the slides.

51 1.13.1 Medical Certification and History The captain held an FAA First Class Medical Certificate issued on March 9, 1993. The certificate contained the limitation "Must have available glasses for near vision." The captain reported that at the time of the accident, he was wearing trifocal corrective lenses, which included lenses for near vision. The first officer held an FAA First Class Medical Certificate issued on October 23, 1992, without limitations. The flight engineer held FAA Second Class Medical Certificate issued on March 23, 1993. The certificate contained the limitation "Must have glasses available for near vision." The flight engineer reported that he was in possession of glasses as required at the time of the accident. The crewmembers reported that they were in good health in the days prior to the accident, that they were not suffering from any chronic or acute ailments or illnesses, and that they were not under the influence of medications, drugs, or alcohol. 1.13.2 Toxicological Testing In response to the requirements of 14 CFR, Part 40, for postaccident toxicological testing, all three flight crewmembers submitted urine samples, taken approximately 5 hours after the accident. The specimens were collected by medical personnel at the American Airlines medical facility at DFW. The samples were tested for amphetamines, phencyclidine, cocaine, cannabinoids, and opiates in accordance with Federal requirements. The results of the examinations were negative for the flight crewmembers. 1.14 Fire About the time the airplane came to rest in the grass to the right of landing runway 17L, witnesses reported seeing a fire erupt near the. left wing. The bum pattern showed that the fire was most intense near the area in the rear of the No. 1 engine and along the retreating edge/inboard flap area of the left wing. There

52 was also substantial fire damage to the grass, soil, and underside of the left wing. The main fuel supply line to the No. 2 engine was found fractured. 1.15 1.15.1 Survival Aspects Evacuation The flight attendants attempted to evacuate the passengers from exits on both sides of the cabin. The left roll and nose-down pitch attitude of the airplane caused the angle of the right rear slides to steepen to what appeared to some witnesses as a near vertical angle. Initially, flight attendants directed passengers out of the four right cabin emergency exits and the two forward-left exits. Because fire was seen aft of the left wing, the flight attendants did not open the two aft left emergency exits (3-L and 4-L). After some of the passengers had exited from right side exits, cabin crewmembers moved the passengers forward to other exits. At one point during the evacuation from 3-R, passengers bunched up on the right wing because of the steepness of the slide from the wing to the ground. A flight attendant saw a holdup at the top of the slide and came out on the wing. Noting the steepness of the slide, the high number of older passengers attempting to evacuate, and the passenger pileup at the bottom of the slide, the flight attendant told the passengers on the wing that they would have to return to the cabin and use another exit. At the same time, some passengers said that a flight attendant inside the cabin, behind the group of people trying to exit onto the right wing, told them that they would have to move quickly from the airplane because of a fire out the left side cabin windows. There was a high number of elderly passengers lined up at 3-R and 4-R, and some of them were unwilling to jump onto the slides until they were urged to do so or were pushed onto the slides. Some female passengers wanted to take personal items with them, especially purses. Flight attendants warned against taking these items and physically removed them from several passengers as they jammed forward attempting to enter the slides. The urgency of the situation was described by several passengers and flight attendants as becoming apparent when the glow from the left side fire was obseived clearly in the dark cabin through the aft-left cabin windows. Many of them said later that the flight attendants and nearly

53 all the passengers evacuated expeditiously and as calmly as possible from the dark cabin. 1.15.2 Flight Attendant Training All of the flight attendants were qualified by American Airlines on the DC-10, as well as on B-727, B-757, B-767, MD-11, and A-300 airplanes. Initial flight attendant training is conducted by the American Airlines training facility in Arlington, Texas. During the 7-week program, trainees receive 79 .5 hours of instruction in first aid, fire fighting, cabin management, and emergency evacuation procedures and techniques, one of which is flow control (the expeditious and efficient command of passengers from within the aircraft cabin, through usable emergency exits). Instruction is provided during classroom lectures, computer- based instruction, proficiency workshops, and competency checks. Subsequent recurrent training is conducted in two phases annually. Recurrent classroom training is conducted at the flight attendants' base station, and, within the same month, they attend practical evacuation drills at DFW. Practical demonstrations incorporate exit operation, blocked exits, exit malfunctions, flow control, cabin management, primary and secondary exits, and proficiency drills, intended to build critical thinking skills. 1.15.3 Emergency Response The DFW fire and rescue department's crash alarm sounded about 0701 , within about 1 minute from the time the airplane came to rest. About I minute later, the first trucks were arriving at the airplane. They extinguished a fire at the left wing in about 50 seconds, while the passengers were still exiting the airplane. DFW Emergency Medical Services (EMS) responded with three DFW ambulances and eight mutual aid ambulances. Four triage areas were used due to the dispersion of passengers. One triage area was initiated near the airplane at the intersection of taxiway 31 and l 7L, two triage areas were at Terminal 4E, and a fourth was at the DPS Headquarters Building (Station 1). Thirty-one persons were transported to four area hospitals by ambulance. Two people were treated and transported with possible critical injuries, and several people were treated for possible serious injuries. All other injuries

54 appeared to be minor. All of them were transported within I hour. Later during the day, some passengers complained of pain and were routinely transported to hospitals, or they proceeded to hospitals on their own initiative. 1.15.4 Cabin Emergency Lighting System The airplane's emergency cabin lighting system consisted of two subsystems: one to illuminate overhead and door exit lights, and one to illuminate the floor path and side wall exit sign lights. The overhead and door light subsystem was manufactured by Gulton Industries, Inc., of Hawthorn, California, and was installed when the airplane was manufactured. The components of this subsystem consisted of four battery-charging units and nickel cadmium batteries (NICAD). The floor path and side wall exit sign lighting subsystem was manufactured by the DME corporation, Fort Lauderdale, Florida, and was installed in the accident airplane in 1993 by DME. These components were located along the right ceiling and adjacent to the 1-R through 4-R exit doors. Two complete units of logic modules and battery packs for the system were located at each right side cabin exit door. During the on-scene investigation, a functional test of both emergency lighting systems revealed that only the floor path lighting on the left aft side of the cabin illuminated. Subsequently, both systems were disassembled on the scene, under Safety Board supervision, and no mechanical or structural anomalies were found. However, in this accident, such functional tests would not have been sufficient to detect the problem because of the short period of time that the emergency lights were illuminated. Both emergency lighting systems were removed from the accident airplane and shipped to their respective manufacturers where each subsystem was subjected to additional testing under Safety Board supervision. Seven of the eight DME Control Modules located in four electrically independent (output) and redundant zones were found to be functional during the evaluation. The one nonfunctional module was located on the right aft portion of the airplane. Evaluation of the lamp load indicated that the right aft zone lighting would have adequately powered and illuminated that zone of the cabin. The Gulton cabin overhead and door emergency lighting system was disassembled and reexamined. All logic units and system charging capabilities

55 tested satisfactorily; however, examination of the system battery packs, which contained 24 individual power cells, revealed that the tap wire or primary lead was incorrectly soldered onto all four battery packs. In addition, individual battery cells were out of the original factory-assembled sequence. This factor affected the amount of charge each battery cell would accept during charging and thereby diminished the overall level of power for the battery packs. American Airlines' maintenance records showed that the battery packs had been serviced by the airline's maintenance department. It was established that neither the manufacturer of the battery packs nor the system's manufacturer had provided written guidance to the airline's maintenance department on the importance of ensuring, during maintenance, the replacement of individual power cells in the same sequence from which they were removed, as well as ensuring the correct procedure for soldering the tap wire to the battery packs. Due to the decreased power and charge level, there was sufficient power to indicate an operational system at the flight engineers instrument console but not enough to actually operate the system. The tests concluded that as a result of the improper soldering of the tap wires and the improper configuration of the individual cells, which constituted the battery packs used by American Airlines maintenance, the power and charge level was not sufficient to illuminate the overhead and door emergency lighting system. 1.16 1.16.1 1.16.1.1 Tests and Research Airplane Performance Study General Information Data from ATC radar, weather, CVR, FDR, and information from the examination of the aircraft wreckage and the accident runway were used to develop a time history of the accident flight's motion during the approach and landing. (See figure 10 for airspeeds and altitudes during the landing sequence). Calculations were made of the crosswind component during the final 21/2 minutes before landing. A composite plot was developed that shows, in a graphical format, the flight control positions and airplane headings when key events occurred during the landing sequence. (See figures lla and llb).

grass. Figure 10.--Airplane airspeeds and altitudes versus time.

• . . : 162,~AM2/·0WIRt\ .. ·:· .. '.· .. · · -:- 161,CAM-1° NONONOl,IGOT'rT. • -:- • • -:- • • -:- • • RUNWA.Y HEADING • • • (174 DEG) ·

• ... ·'· ..... . ..

. . . ........ ...... . . ' . . '. \ . .

• - . ,· 164, CAM-2

fMGONNAGOAROUND .. ,• ---------,, ••• · , . -~· ...• ~ 163, CAM-4 FIFTY._ .

-- RUDDER

OWN El.EVA TOR FLJGHTCOHTROLDEFLEcnONS(DEGREES) MAGNETIC HEADING (DEGREES) Figure 11 a.--Flight control positions and airplane headings during landing sequence.

58 FLJGHT CONTROL MOVEMENTS AND SEQUENCE OF EVENTS RUNWAY DEPARTURE AFTER LANDING, AMERICAN FUGHT 102 44---rn YlfCTfP fYENT. . . . ....... . .. . . , 95, CAM-2 OK. WE'RE OFF THE GRASS. , , 0659 : 43 ...... _ -_ -_ :-_ . 9:·.T-r~?~tr r~7~~:~ .. 42 . . . >11. . . . :: : : : t·t:2:J~L: : : :: : : L: I I f f I I t I I t f I I I I I . . .. -. .. - . .. . . :: : : ::~:;1 :~j);~scqJ! !~T.~5.r.R.Urr I I I I • I I I I I I I I I I I I I 37 · · · - - - -· · - - .. -

• ·

· - • • • • .. • - .. - · · - - - • . • • • · , - • • r ... . • 116, CAM·2 OK. HUNDRED AND TWENTY KNOTS. • I t I I I I I I I 36 · · · : - · ·.· · · · . '

• . . .. - - .. - - .. -

. . 35 - · -:- · - -:- · - · 34 . . - ~ 133, ~AM-3 ~ ~REEN: - • • I I ~ I I I I I I I 33 .. . ,. 135, DFDR· REVERSERS DEPt.OYED, ENGINE THRUST INCREASING.,. 32 3 1 30 25 24 23 I I I I I I I

• . . .. .. .

.. . ' ... 25 20 15 10 5 0 -5 -10 -15 -20 170 180 190 L£FT RUDDER, LEFT .AILERON •• 1--+-t---1 .. • RIGHT .AIL.ERON, RIGHT RI/ODER HOSE-UP ELEVA TOR NOSE-DOWN ELEVA TOR FLIGHT CONTROL DEFLECT70NS (DEGREES) MAGNEnC HEAD/HG (DEGREES) Figure 11 b.--Flight control positions and airplane headings during landing sequence.

59 Prior to touchdown, the airplane transitioned from a 10-degree right crab to a 2-degree right-wing-down (RWD) roll and a IO-degree airplane-nose-left (ANL) rudder deflection. The data show that the airplane touched down at 0659:29 and tracked near the centerline of l 7L for about 8 seconds, averaging an 8-degree ANL rudder deflection. During the 8 seconds after touchdown, the airplane decelerated to 116 knots indicated airspeed (IGAS), while the rudder was deflected on average about 8 degrees ANL, the aileron position averaged 5 degree RWD, and the elevator averaged 7 degrees airplane nose down (AND). About 6 seconds after touchdown, the airplane heading began to move to the right of runway heading. At 7 seconds after touchdown, FDR data show that the airplane's rudder, elevator, and ailerons moved in the direction of the neutral position (zero deflection). The airplane then began to track to the right of the runway centerline. The heading change continued to the right, except for one point when the rudder was deflected 15 degrees ANL for 1 second, upon which the heading stabilized for about 2 seconds. Also, there was basically no movement of the elevator or ailerons from the neutral position prior to the airplane departing the right shoulder of the runway. The right main landing gear departed the runway shoulder with the airplane's speed slowing to about 95 KIAS about 14 seconds after airplane touchdown. The effects of the misconfigured reverser cascades on the No. 2 engine were examined. Calculations, using information from the airplane and engine manufacturers, showed that input into the flight controls could readily offset the effect of the two misconfigured thrust reverser cascades, at the speeds of the accident airplane, prior to its departure from the landing runway. 1.16.1.2 Airplane Radar Data At the time of the accident, DFW had an operable Automated Radar Terminal System (ARTS) under FAA supervision. A magnetic tape containing recorded data from the facility's computer was read out at the Safety Board's laboratory. Data were found from antenna sites at Colleyville and the U.S. Naval Air Station at Dallas (NAS Dallas). The Colleyville antenna site is about 4.6 miles from the accident site at DFW, and the .NAS Dallas antenna is about 9.7 miles from the accident site. The DFW antenna was apparently not operating at the time of the accident. It did not record any primary returns for AALI 02.

60 Radar data from the Colleyville antenna were used in the calculations. Comparisons of radar altitudes with FDR altitudes revealed that the clock times for the radar system were offset approximately 6 seconds from the FDR clock times. Colleyville radar data were smoothed for use in approximating the winds experienced by the accident flight on final approach. These data were then interpolated to I -second intervals for use in wind calculations that are described in the section below. 1.16.1.3 Wind Calculations To better estimate the winds to which the airplane was subjected during the final 3 minutes of flight, FDR and radar data were examined, starting with the flight on approach at approximately 2,600 feet msl. A computer program was written to approximate the winds experienced by the accident flight during the approach. Wind velocity was calculated each second, by comparing the radar- defined flightpath to the FDR-defined flightpath, beginning at 0657:00 cdt. These calculations are a function of the accuracy of both FDR and radar data, and are not valid if the airplane is in a sideslip. FDR data were integrated to produce a no-wind flightpath. The no-wind flightpath was then compared to the actual flightpath as recorded by the radar antenna, and it was assumed that the difference between the two paths was attributable to atmospheric wind. The program compared the two flightpaths and calculated wind speed and direction. The data show that the airplane was in a right crab during the majority of the approach. Approximately 7 seconds before touchdown, the airplane heading moved left toward runway heading, and the airplane transitioned to a sideslip attitude prior to touchdown. There is a gap in radar coverage after AALI 02 crossed the runway threshold. Therefore, it was assumed that the airplane flew a straight line between the radar return at 0659: 11 and the touchdown point. The time of 0659:29 and location at 4,303 feet from the approach end of l 7L for the touchdown point were calculated from FDR and data verified by ground measurements. The calculated wind directions varied between approximately 225 and 310 degrees during the final 2 1/2 minutes before touchdown (except for the final 7 seconds of data, which are assumed to be inaccurate since the airplane was in a sideslip ). The calculated wind speeds varied from 30 to 50 knots early in the approach to 15 to 30 knots as the airplane neared the touchdown point.

61 The calculated wind direction varied randomly between a quartering headwind and a quartering tailwind between 0657 and 0659. At 0659:00 cdt, AAL102 was approximately 270 feet agl, and the wind was from about 270 degrees at 25 knots. Wind speed then decreased to about 15 knots, and changed to a direct crosswind at approximately 0659:08 when the airplane was at 150 feet agl. Calculated wind directions remained constant, but the speeds increased to 25 to 30 knots over the next few seconds. These data would indicate that AAL102 was subjected to a direct right crosswind of 25 to 30 knots, when the first officer stated, 'Tm gonna go around," at 0659: 17, about I -second after the automated voice called out "fifty" (feet agl). Wind conditions could not be continued in the program after touchdown, because the crosswind component cannot be calculated by this method when the airplane is on the ground. After touchdown, the closest LL WAS anemometer to the airplane (centerfield) was used to provide winds calculated during the airplane's ground roll. 1.16.1.4 Position and Time Calculations The winds that the airplane was subjected to during final approach were also entered into a second computer program to calculate the airplane's flightpath and ground roll every second from 0657 :00 until the airplane came to rest at 0659:54. The program integrated FDR data using the calculated winds in flight and the LLW AS-recorded winds after touchdown to produce a time history of positions for the airplane. Indicated airspeeds (IAS) are not accurate at low speeds, and an estimated airspeed decrease during the period near the end of the landing ground roll was used in the program. The airplane was on the glideslope during the approach; however, radar data ceased as the airplane crossed the runway threshold. The first tire marks found on the runway from the airplane were 4,303 feet from the beginning of 17L, with 7,085 feet of runway remaining. The FDR-derived flightpath and CVR information are consistent with touchdown occurring 4,303 feet from the beginning of the runway. The airplane's radar altimeter recorded "ten" (feet) 1.8 seconds before this point, and the sound of a thump similar to an airplane touchdown was recorded 0.7 second after this point. The calculated ground track closely approximates the measured tire erasure marks for AAL102.

62 AALl 02 had just descended below 50 feet agl, when the first officer stated, ''I'm gonna go around" at 0659: 17. The captain took control of the airplane, and the sound of touchdown was heard at 0659:29.7 at 143 KIAS. 1.16.1.5 FDR and CVR Data Microphone keying infonnation was used to establish a time correlation between the CVR and FDR infonnation for the accident flight. The CVR transcript provides the time of each radio transmission in central daylight time. The FDR examines whether the microphone is "on" or "off' for 1n68th of a second, once each second. Allowing for realistic variance between CVR microphone "on" segments and FDR binary data, no detectable offset (other than the normal 5-hour difference in the clocks between cdt on the CVR and utc on the FDR) was found between CVR and FDR recorded times. After the accident, the flightcrew stated that the captain took control when he said, "No, no, no I, I got it," at 0659: 17.93. At 0659: 18 the airplane was IO degrees right of runway heading. At 0659:22, when the airplane was approximately 20 feet agl, the airplane heading moved to the left, reaching the runway heading of 174 degrees in about 3 seconds. During the left heading change, the FDR recorded left rudder and right aileron inputs, and a right roll attitude, all of which are consistent with a nonnal sideslip maneuver in preparation for landing. The accident flight touched down at approximately 4 degrees nose-up pitch attitude, with 2-degrees left-wing-down at 143 KI.AS. Nose gear touchdown occurred approximately 2 seconds later at 0659:31. Pitch attitude remained slightly above zero after nose gear touchdown until after the airplane departed the right side of the runway. Pitch attitudes during the ground roll, with the nose gear on the runway, varied between approximately 0.3 and 1 .4 degrees. The same range of pitch attitudes were found in FDR data from the previous landing of the accident airplane. The downforce on the nose gear was not recorded by the FDR, but the accident airplane's pitch attitudes during the rollout were consistent with those recorded on the previous landing. According to FDR data, NI speed for all three engines increased to normal reverse thrust levels shortly after touchdown. The airplane came to rest approximately 25 seconds after touchdown. The average rate of deceleration of the airplane, while it was approximately on centerline, was about 3 1/2 knots per second.

63 The flight tracked close to runway centerline for approximately 8 seconds after touchdown, crossing right of centerline at 0659:37, when the airplane was at 116 KIAS. Rudder and elevator positions averaged about 7 .9-degrees nose left and 7 .?-degrees nose down, respectively, during the first 8 seconds after touchdown. However, elevator deflection had decreased to about 1.5-degrees nose down and 2.5-degrees nose-left rudder deflection by 0659:37. The rudder was also steady at 2.5 degrees prior to the correction of the crab angle at the start of the transition. The captain stated, "Oh [expletive]," at 0659:38, as the airplane was moving right of runway centerline. The airplane continued moving to the right until the right main landing gear exited the runway shoulder at 0659:43, at a speed of 95 KIAS. Between 0659:37 and 0659:43, rudder and elevator positions averaged about 4.6-degrees nose left and 1.8-degrees nose down. The rudder was generally at 2.5-degree ANL except for a momentary spike in rudder position during this period, described below. 1.16.1.6 Airplane Response to Flight Control Inputs The airplane pitch attitude changes were consistent with the airplane on the runway and with changes in elevator position. Roll attitude changes of the airplane were consistent with changes in aileron position. Airplane heading values respond to changes in roll attitude and rudder position on final approach and to rudder position after touchdown. The airplane touched down at 143 KIAS and maintained a runway heading. Approximately 7 seconds and 1,800 feet after touchdown, at 118 KIAS, the rudder and elevator positions approached neutral, and the airplane heading and ground track changed to the right. When enough friction exists between the tires and runway to allow cornering, the ground track will be fairly consistent with airplane heading. The airplane heading will lead the tum. In the case of the accident flight, FDR heading data and tire erasure marks indicate that the airplane turned right and also moved to the right of runway centerline. At 0659:40, a spike of 12 to 15 degrees of nose-left rudder input was recorded by the FDR. The airplane heading momentarily stopped moving to the right, consistent with a normal response to left rudder input. The input was not maintained. At this time, the airplane's heading and ground track were

64 approximately 8 degrees right of runway centerline. This track continued until the right main landing gear departed the right shoulder of the runway. The previous landing performed by the airplane was compared with the accident landing. Rudder positions varied approximately +/-4 degrees about the neutral position during the previous landing rollout. Approximately 5 degrees of nose-down elevator was used until about 45 KIAS in the previous landing rollout. 1.16.1.7 Effect of Misconfigured Thrust Reverser Cascades on No. 2 Engine During the application of reverse thrust, the wing engines create a nose-down pitching moment and the center engine creates a nose-up pitching moment. In the horizontal plane, the reverse thrust forces are normally symmetric, while in the vertical plane there is a slight net nose-down pitching moment. According to the engine manufacturer, a general effect of the misconfiguration of the No. 2 engine cascades would have been to reduce the weight on the nose landing gear and push the nose of the airplane to the right during the period of reverse thrust. The FDR data show that the airplane touched down on 17L at approximately 0659:29, reached full reverse thrust by approximately 0659:36, and maintained full reverse on all engines for the remainder of the ground roll. When the airplane was developing full reverse thrust on all engines, the effect of misdirected thrust due to the two misconfigured cascades on the No. 2 engine was a change in pitching moment on the airplane of 65,000 to 72,000 foot pounds (65 to 72 kft-lbs) nose up. The change in yawing moment on the airplane was 61 to 68 kft- lbs nose right. The effect of the two misconfigured No. 2 engine thrust reverser cascades on the controllability of the airplane in the pitch and yaw axes was determined. The available hingewise rudder deflection on the DC-10-30 is +/-23 degrees. The available elevator deflection is 16.5 degrees trailing edge down and 27 degrees trailing edge up. The rudder pedals also provide +/-10 degrees of nosewheel steering. The change in pitching and yawing moments due to the tail engine were compared with the moments provided by a fixed amount (5 percent) of elevator and rudder at various airspeeds. It was determined that the change in moments available through the use of flight controls was more than sufficient to

65 offset the change due to the misconfigured tail engine thrust reverser at the speeds recorded by the FDR. 1.17 1.17.1 Additional Information Flightcrew Interviews After the accident, the members of the flightcrew were interviewed individually as part of the Safety Board's investigation. From these interviews, the approach and subsequent events are summarized as follows: When they joined the Boyds standard terminal arrival route (STAR), 16 they used the aircraft's radar to track thunderstorm activity. They saw an opening in the weather to the south of the airport that caused the captain to request a landing to the north. A TC advised that thls would be disruptive to departures and that they would have to land to the south. A TC also told him that another aircraft was landing to the south ahead of rum and that this aircraft had not reported any difficulties. The captain noticed that the opening in the weather to the south was filling in and agreed to land to the south on runway 17L. Around the Bridgeport VOR at about 14 miles from the airport, they saw a brilliant flash of light and heard thunder in the cockpit which could have been associated with lightning. The flight engineer found no system malfunctions, and the cockpit instrumentation appeared to be normal. Intercepting the localizer, the CVR recorded a second lightning event that may have been lightning striking the airplane. They discussed entering the event in the aircraft logbook after arrival in DFW. The first officer stated that he thought the weather in the area of DFW was just routine for springtime. He did ask the captain and flight engineer to be alert for indications of windshear. The visibility was reported as 6 miles, which was in excess of a 4,000 feet RVR requirement to allow the first officer to fly the approach and make the landing. The captain was performing the duties of the nonflying pilot. From the outer marker, he made the required callouts; 1000 feet, 500 feet, and thereafter for each 100 feet of altitude, giving airspeed and rate of descent. l 6 A preplanned instrument flight rule (IFR) air traffic control arrival procedure. ST ARs provide transition from the en route structure to an instrument approach fix in the terminal area.

66 When the first officer had the runway in sight, he disconnected the autopilot but not the autothrottles. He swung the nose of the airplane slightly to the left, and the airplane drifted left. He swung the nose of the airplane back to the right and said tnat he was "not comfortable." He felt that they were "high" and that the airplane would need too much nose down to accomplish the landing. He announced that he was going to make a missed approach. The captain said that he believed the aircraft was drifting to the left, and he felt he could make a safe landing. He did not want to make a missed approach and have to deal with the thunderstorm activity again. He said that they were at 200 feet agl and that he took control of the airplane from the first officer. He made an alignment correction, but said it was not necessary to make an altitude/glideslope adjustm~nt. He was confident that the landing would be within "the desired 3,000-foot touch down zone." He said that there was no need to go around, no windshear, no airspeed, height, or alignment problem. He aligned and landed the airplane on centerline. The touchdown was very smooth. After he lowered the nose, he activated the reverse thrust. The spoilers had extended and the normal reverse deployed, but he felt only a slight deceleration. At that time, he said that the airplane "weather vaned" about 5 degrees to the right. He acted "instinctively" to return to the centerline of the runway. He released the control column and used the nosewheel steering handwheel control. He commented that the airplane does not normally need forward pressure on the control column. He felt some "sliding," but he did not use asymmetric reverse power. He applied the brakes, although he commented that braking was normally not done until the airplane was moving slower than 100 knots. After the airplane did not respond to his actions, he said that "there was nothing we could do but hang on." The first officer said that after the captain took control of airplane, the airplane seemed to "float," and that he was not sure where the touchdown was made. The CVR data showed that the first officer made callouts expected of the nonflying pilot. After the landing, he did not hold forward pressure on the control yoke after the nosewheel touchdown. He said it was not normal procedure to do so unless he was previously briefed. When asked his opinion regarding the captain continuing the approach to landing after the first officer had judged the need to initiate a missed approach, the first officer replied, "I've got to trust him."

67 1.17.2 Douglas DC-10 Approach and Landing Procedures In its January 1977 and September 1989 issues of Flight Crew Newsletter, Douglas addressed stopping the DC-10, summarized as follows: 1. Do not be afraid to delay landing. Under zero wind conditions, most runways have adequate crossfall to provide drainage under quite high rates of precipitation. It appears that drainage can be seriously affected in crosswinds above 10 knots; however, a 15- to 20-minute waiting period after a downpour is usually sufficient to drain the water. 2. Be knowledgeable of the many variables associated with landing under wet runway conditions: Landing weather forecast Aircraft weight and approach speed Hydroplaning speed Condition of tires Brake characteristics Wind effects on the aircraft on a wet runway Runway length and slope Glidepath angle ... and lastly remember, do not overlook or underestimate the effects of a crosswind because of its low magnitude. 3. Do not exceed 1.3 Vs + wind additives at the runway threshold. 4. Establish and maintain a stabilized approach. 5. Be prepared to ·go-around from the threshold. 6. Do not perform a long flare. 7. Do not allow the aircraft to drift during the flare. 8. Touchdown firmly and do not allow the aircraft to bounce.

68 9. If a crosswind exists, apply lateral wheel control into the wind. 10. Keep the aircraft centerline aligned with the runway centerline. 11. Antiskid braking should be applied steadily to full pedal deflection when automatic ground spoilers deploy and main wheel spinup occurs. Do not modulate brake pressure. 12. Apply maximum reverse thrust as soon as possible after main gear touchdown. 13. Be prepared to deploy ground spoilers manually if automatic deployment does not occur. 14. Get the nose of the aircraft down quickly. Do not attempt to hold the nose off for aerodynamic braking. 15. Apply forward column pressure as soon as the nosewheel is on the runway to increase weight on the nosewheel for improved steering effectiveness. Do not, however, apply excessive forward column pressure because the down elevator will unload (to some extent) the main wheels and decrease braking. 16. When the aircraft is in a skid, align the aircraft centerline with the runway centerline if you can. Get off the brakes to maximize cornering capability and bring aircraft back to runway center. If you are in a crab and cannot align aircraft centerline with runway centerline and attempted cornering is not effective, get out of reverse thrust to eliminate reverse thrust component side forces tending to push the aircraft off the side of the runway.

69 1.17.2.2 Handwheel Steering/Forward Pressure on the Yoke When interviewed, the captain reported that he had tried to use the handwheel steering control to return to the runway centerline. Douglas published an All Operators Letter (AOL), dated November 6, 1986 that addresses handwheel steering control: The control input from the handwheel is much more sensitive than from rudder pedal steering at high speeds. Its use may result in overcontrol of nosewheel steering. Because it is difficult to judge and control the amount of handwheel input at high speeds, it is recommended that use of the handwheel be restricted to taxiing and never be used for control of the aircraft on the runway at ground speeds in excess of 15 knots. During the landing roll, should the aircraft begin moving toward the edge of the runway while at high speed, the pilot applies appropriate control inputs to stop the lateral movement and then to return to the runway centerline. If the nosewheel steering angle becomes excessive, such as through handwheel inputs or even by rudder pedal inputs on a slippery runway, the desired corrective force will be greatly decreased or even reduced to practically zero. In this situation, it may be necessary to reduce the nosewheel steering angle until steering force is regained, then cautiously reapply steering control inputs until the desired aircraft response is attained. 17 Douglas published this information in an AOL, two flightcrew newsletters, and the DC-10 flightcrew operating manual. The Douglas precaution on the use of nosewheel steering was not included in the American Airlines "Operating Procedures" for the DC-10. However, the Douglas guidance on excessive nosewheel angles on slippery runways was included in the "Techniques" section. In order to use the handwheel steering control, the accident captain removed his left hand from the control yoke while his right hand was occupied with engine reverse. Douglas has published information regarding the necessity for 17 Douglas Aircraft Company All Operators Letter, dated November 6, 1986.

70 forward pressure on the yoke to reduce lift and improve the steering characteristics of the nose gear in two flightcrew newsletters. Additionally, its DC-IO flightcrew operating manual contains an expanded landing roll procedures guide, which makes "nosewheel contact" a line item and emphasizes the need for forward pressure. American Airlines states the importance of forward pressure on the yoke after touchdown in the "technique" section of its DC-10 operating manual. However, American has no procedure or technique for the pilot not flying to apply forward pressure on the yoke after touchdown. The Douglas All Operators Letter states: "The pilot not flying must apply sufficient forward pressure on the control column to maintain the nosewheel firmly on the ground for maximum directional control." Other air carriers that operate the DC-IO have made this a procedure. 1.17.2.3 Reverse Thrust The captain stated that he did not take the engines out of reverse thrust or return to forward thrust to attempt to return to the runway centerline. Douglas, and other air carriers that operate the DC-I 0, have a procedure addressing the use of reverse thrust during loss of directional control on landing roll. Essentially, the procedure calls for the pilot to bring the engines out of reverse and to use forward thrust to pull the airplane back to the centerline. This procedure is considered to be a "technique" in the American Airlines DC- IO Operating Manual. 1.17.2.4 Braking When interviewed, the flightcrew was asked if they had previous experience with maximum antiskid braking. The engineer said that he was familiar with the sound and feel of the braking cycling in antiskid braking on the DC- I 0. 18 He stated that he did not hear or feel the brakes cycle on the accident landing rollout. The FDR does not record brake application. When the captain described the landing and subsequent accident, he was unable to describe his specific actions following the heading change during the landing rollout. His only reference to use of the brakes and the flight controls was that he normally did not brake until the aircraft had slowed below I 00 knots and that he acted "instinctively." 18Maximum antiskid braking requires full pedal deflection at 60 to 90 pounds of force.

71 When he was interviewed the following day, the captain made no mention of any effort to maintain the full pedal deflection. 1.17.3 American Airlines Procedures and Techniques American Airlines' guidance on flying the DC-10 is contained in its DC-10 operating manual in two chapters entitled "Operating Procedures" and "Operating Technique," respectively. The following excerpt from the preface to the Operating Technique section explains the difference: A procedure is an orderly plan for doing some particular thing, and usually involves several steps. Technique is the expert manner of performing each of these steps .... Proper technique is the hallmark of the professional, and a requirement for an airline crewmember. It is emphasized that the contents of this section are presented as recommended techniques, and not as regulatory-type procedures with which strict literal compliance is always required, either by the company or FAA regulations. It is recognized that, in some situations, the crew may find it necessary to modify or deviate from some of the recommendations. 19 American Airlines did not have procedures for: 1) Holding forward pressure on the yoke after touchdown; 2) Not using the handwheel steering control at high speeds; 3) Using the elevator, aileron, and rudder after landing until the airplane decelerates below 50 knots; and 4) Coming out of reverse into forward thrust to regam directional control. 19 American Airlines DC-10 Operating Manual, Section 3A, page 2, Preface.

infonnation: 1.17.3.1 72 American's Operating Technique section contains the following Should the airplane begin moving toward the edge of the runway while at high speed, appropriate control inputs should be applied to stop the lateral movement and return to the runway centerline. If the nosewheel steering angle becomes excessive, because of inadvertent steering wheel inputs or even from rudder pedal inputs on a slippery runway, the desired corrective force will be greatly decreased or even reduced to practically zero. In this situation, it may be necessary to reduce the nosewheel steering angle until steering force is regained, then cautiously reapply steering control inputs until the desired aircraft response is attained.2° Airborne Weather Radar There was extensive conversation between the pilots about the radar (0636:39 to 0645 :51 ). At 0637, the captain indicated that they were 80 miles out, that he saw "yellow scud" (radar returns), and that he was "not looking at anything that even approaches red." At 0639, the first officer began to pick up red returns. Then, the captain said " ... wherever the heavy stuff is, it's down low, I'm searching level right now, and uh, I wanted to see where the red is on here, and then go from there .... " An unidentified voice then said " ... red should be a really bad cell." The American Airlines DC-IO operating manual classifies the colors in the radar displays as: displays as: page I 3. green - yellow - red - light rainfall medium rainfall heavy rainfall The color radar manufacturer's manual classifies the colors in the radar green - yellow - light return medium return rainfall rate 0.7 - 4mm/hr rainfall rate 4 - 12 mm/hr 20 American Airlines DC-10 Operating Manual, Section 3A Operating Technique,

73 red - heavy return rainfall rate> than 12 mm/hr Part 1 of American's Flight Manual contains its thunderstorm and radar policy. It does not address the color display scheme but does identify VIP levels 3 and 4 precipitation intensity as heavy and very heavy, respectively. It indicates that American considers any echo that is seen on the scope beyond 50 miles to be a "strong echo." On the CVR, the flightcrew of AAL102 described seeing echoes at 80 miles. The flight manual defines airborne weather radar as "primarily an avoidance rather than a penetration tool." At 0641, the first officer said "I think fm going to go through this at what about two fifty?" "Two fifty" (250 knots) is the DC-I 0-30's turbulence penetration speed to be used below I 0,000 feet. At 0642:23, the cockpit area microphone picked up a loud rumble that sounded like thunder. The captain described it to ATC as a "big blast of lightning" at 0642:38. The following are excerpts from the CVR transcript at 0645: Captain: "I don't know what the# happened with this radar." First officer: "is it not working or is it working?" Unidentified voice: "all that line that we passed through" Further conversation concerning the mechanical status of the airborne radar was not understandable because the volume of the radio drowned out some of the conversation during this period which was picked up by the cockpit area microphone (CAM) and recorded on the CVR. At 0649:47, the captain asked approach control if its radar showed weather. Approach control advised that there was weather all down the final course, 15 miles on either side of the airport, and that it did not appear to be moving much. The captain stated that the final approach was a "big red area" on his scope and that they would "wait around." Approach then advised them of a DC-8 that was on final approach, 8 miles south of their position, that was experiencing a smooth ride at 3,000 feet. The captain then accepted the ILS approach to runway 17L. The American Airlines Flight Manual provides the following guidance regarding radar:

74 3) Radar Procedure a. The primary purpose of our airborne radar equipment is fixing the position of thunderstorm cells so that these areas of turbulence, and possibly hail, may be avoided. In avoiding thunderstorm cells the following cell clearance rules shall be observed. b. When operating below 20,000 feet, aircraft may be flown through an area where radar echoes indicate a weak rainfall gradient if such action dictates that this is the best course to follow. Above 20,000 feet weak rainfall gradient areas should be avoided by 10 miles. c. Areas where echoes indicate a steep rainfall gradient should be avoided by 20 miles at all altitudes. American Airlines uses self-directed video tape training for airborne weather radar. I.I 7.3.2 Windshear Guidance American's operating technique section of the manual has guidance on windshear. American's list of "Identifiers of Wet Thunderstorm Micro bursts" cites the following: Thunderstorms Forecast - Although no techniques currently exist to forecast wet microburst, crews should consider the thunderstorm forecasts contained in the terminal forecasts and severe weather advisories as a possible indication of wet micro bursts. Visual Clues - Heavy Rain, lightning, ... Avoidance Actions - Search for clues which may indicate the presence of severe windshear. Severe windshear has been encountered under the following conditions: Thunderstorm and convective clouds

1. 17.3.3

75 Rain When positive indications of severe windshear exist, avoid the area by: In flight, divert around areas. On approach, initiate a go-around or hold until conditions improve. Cockpit Resource Management (CRM) Training Program American administers a CRM training program based upon the principles of "Authority with Participation and Assertiveness with Respect," focusing on developing a synergistic relationship between cockpit crewmembers, enhancing pilot awareness of physiological and psychological factors that affect pilot performance, and eliminating communication and attitude problems among crewmembers. All three crewmembers on AALI 02 had received CRM training at American Airlines. Interviews with a CRM instructor and several captains and first officers established that the training focuses upon discussions of CRM issues present in recent major accidents and incidents. The company does not currently integrate a CRM "practice and feedback phase" through the use of video recording equipment and crewmember critiques in its Line Oriented Flight Training (LOFr) simulator training program, with the exception of its Fokker I 00 program. 1.17.3.4 Approach Procedures For the DC-I 0, American's normal procedures section of the manual has the following guidance: Basic Procedures And Crew Coordination Practices Applicable to All Instrument Approaches After evaluating weather, wind, runway conditions, etc., the captain will specify who will fly the approach and who will make the landing. He will brief the crew on how the approach and missed approach, if necessary, will be conducted. The captain is in

76 command and must take over control any time the situation requires; however, last minute changes in planned procedure should be avoided. This section also has the DC-IO descent and landing checklists and expanded procedures for using these checklists. An approach briefing is not a line item in either of the checklists. The accident crew did not perform an approach briefing. 1.17.4 American Airlines Flightcrew Training Recordkeeping System American Airlines used an integrated crew qualification and flight training computerized recordkeeping system. The system was approved by the FAA to meet the requirements of Federal Aviation Regulations (FAR), Part 121.683, which states, in part, "Maintain current records of each crewmember .... " The FAR does not specify which training records are to be maintained. American Airlines recordkeeping system maintains the training files of its flightcrew in a composite format. The system does not retain performance information generated during actual training, such as examination scores, and simulator instructor performance evaluations and comments. These original records were routinely disposed of for pilots who have successfully completed training, and their record of satisfactory completion is entered into the system. FAR Part 121.683 does not define "training" records and does not specify that training performance data should be maintained. No records of previous training performance for the accident flightcrew were available to Safety Board investigators, other than the record of training taken and of its satisfactory completion. 1.17.5 FAA Oversight The FAA handbook recommends an annual training record audit. The FAA Principal Operations Inspector (POI) explained that if he were to conduct an audit, he would compare American's computer data base records to American's microfiche records. The FAA handbook recommends checking training records against an independent source, such as the FAA Oklahoma City data base. The POI had not performed an inspection of American's flightcrew training records and could not tell Safety Board investigators when such an inspection had last taken place.

77

1. ANALYSIS
2. 1

General The investigation found that the air traffic controllers and meteorologists were qualified, current, and properly trained. The investigation found that the flight attendants were properly trained and qualified in accordance with applicable FARs and company requirements. The pilots were in good general health and had proper FAA medical certificates at the time of the accident. There was no evidence of adverse medical conditions that affected the flightcrew, and there was no evidence that they were under the influence of, or impaired by, drugs or alcohol. The flightcrew had been trained in accordance with an FAA-approved trammg program. The quality of the training and the procedures used by the flightcrew is discussed later is this report. The airplane had been maintained in accordance with an FAA- approved maintenance program. Examination of the airplane's fuselage and wing structure, flight control systems, and powerplants disclosed no evidence of a malfunction that would have caused or contributed to the accident, although certain discrepancies, not considered to be a factor in the accident, were noted during the investigation. All three thrust reversers were found fully deployed, as evidenced by jackscrew actuator positions. However, on the No. 2 engine, two of the reverser cascades were found to be improperly configured. The resultant differences in the angles of thrust from the vanes of the two misconfigured cascades would have partially changed the reverser air flow pattern or "efflux." With the No. 2 engine in reverse thrust, the airflow would have been altered from a vertical (thrusting downward) direction to a near-horizontal direction, and from an inboard direction (toward the fuselage centerline) to an outboard direction (away from the fuselage). The reduction in the vertical component of airflow would have reduced the nose- down pitching moment of the airplane and lessened the down force on the nosewheel, with the No. 2 engine in reverse thrust.

78 There also would have been a component of thrust vectored horizontally away from the right side of the center engine, with the engine in full reverse thrust. The evidence showed that the force in full reverse would have generated a relatively small nose-right yawing moment of approximately 1/10 the moment that could be generated by 10 degrees of rudder deflection during the tum off the runway. Therefore, there was ample rudder and elevator authority to redirect the airplane and overcome any input from the two misconfigured No. 2 engine cascades. The brakes were found to be within service limits. Although 5 of the 20 antiskid valves tested for response to electrical signals were found out of design limits for new parts, the manufacturer stated that the mode in which the valves exceeded tolerances would have made it less likely for the affected wheels to skid. A change in pressure would only come after the pilot or pilots had released main wheel brake pressure, then reapplied pressure. The Safety Board concludes that the evidence shows that the antiskid system was functioning properly and was not considered a factor in this accident. The two nosewheel steering cables and pulley bracket found broken in the nose landing gear compartment were caused by overload. The evidence showed that the failures were a result of the accident, not a cause. That is, the forces and damage that occurred during the collapse of the nose landing gear led to the broken components. The broken cables fit a pattern of damage along the aft nose landing gear (NLG) compartment wall. During the accident, the NLG collapsed aft, and the bottom of the wall acted as a plow in the soil. The bent and broken bracket was dislodged in an upward direction. Mud packed under compartment protrusions, and tom and shredded insulation blankets, provided further evidence of the upward forces in the wheel well following impact. Even if the cables had not been broken as the general pattern of damage was occurring, the fuselage separation under the L- l/R-1 doors crossed the cable routing. If the cables had failed first, the pulleys and bracket would not have been damaged, nor would the cables have damaged the compartment pressure seal. Although perpendicular scratches were seen on the NLG tires, the treads were intact and not distinctly different. If the NLG had turned to the side, one tire would have been lifted and the other would have suffered abrasion or hydroplaning. However, no reverted rubber was seen on either NLG tire.

79 The Auto Ground Spoiler indicator on the fault isolation panel was found in the "set" position. The Safety Board concludes that this was most likely due to fire damage to the spoiler position wiring in the left wing and not due to any malfunction of the autoground spoiler system. This accident occurred following an instrument approach made in the presence of strong winds and rain showers resulting from thunderstorms moving across the airport at the time of the approach and landing. The first officer had elected to abandon the landing approach about 50 feet above the runway because he believed the airplane was not in a position to make a safe landing. The captain elected to take control of the airplane and land. The airplane was landed on speed and on centerline but long (4,303 feet from the approach end of 17L). However, shortly after the airplane landed, it began to drift to the right, left the runway surface, and came to rest off the runway with substantial damage to the airframe. The Safety Board's analysis of this accident included examination of the conditions that could have caused or contributed to this event, including the decision of the flightcrew to initiate and continue the approach, and their failure to maintain the airplane on the runway after the landing. The Safety Board examined the accuracy and communication of weather information to the flightcrew by American Airlines, the NWS, and ATC, the effects of the weather conditions on the performance of the airplane, American Airlines' procedures and training for its flightcrews, and the decisions and actions by the flightcrew. The analysis also examined the postaccident events related to the emergency evacuation. 2.2 Weather Aspects 2.2.1 Weather Planning and Forecasts Prior to departure from HNL, the flightcrew of AALI 02 received weather reports indicating that about the time of their anticipated arrival at DFW, thunderstorms would be in the vicinity. The captain revealed this information when he briefed the cabincrew at HNL. There was ample opportunity before and during the approximately 8 1/2 hour flight from HNL to brief a variety of normal and abnormal procedures regarding the anticipated flight into thunderstorm conditions at the destination. There was, however, no indication either from the statements of the flightcrew or on the CVR that briefings regarding the approach and possible go- around procedures at DFW were conducted ahead of time.

80 The forecaster for American Airlines amended the DFW Ff at 0600 to reflect expected worsening conditions at the airport. The worse conditions forecast at the arrival time of AAL102 were "occasional ceiling 600 feet overcast, visibility 1 mile, with thunderstonns and moderate rain showers." The surface wind forecast was "variable 15 knots, gusting 20 knots." A Tenninal SIGMEC for DFW was valid from 0358 to 1000 on April 14, 1993. The SIGMEC, advised, in part, occasional thunderstorms, with heavy rain, low level windshear, surface wind gusts to 40 knots, and frequent lightning expected in the vicinity of DFW by 0700. According to American Airlines personnel, terminal SIGMECs were disseminated via ARINC immediately upon issuance and were also attached to changeover infonnation messages, if issued within I-hour of landing. The flight log for AAL102 indicated that receipt of the terminal SIGMEC for DFW was at 0423 on April 14, 1993. However, the SIGMEC advisory was not attached to the two changeover information messages provided to the crew at 0624 and 0646. The Safety Board believes that an extra margin of safety could be realized if pertinent Tenninal SIGMECs were appended to all changeover information messages during the valid period. American Airlines meteorologists also provided oral weather briefings to incoming shifts of company flight dispatchers. The briefings were taped so that dispatchers could review the forecasts as needed during their shifts. The 0615 weather briefing tape was not retained, and, when he was interviewed, the forecaster did not specifically recall what he said during the briefing. The Safety Board believes that American Airlines should require that pertinent briefing tapes be retained for a suitable period in the event of a future need to reconstruct the briefing. Federal Regulations 14 CFR, Part 121.599 and 121.601, require that airline dispatchers be thoroughly familiar with reported and forecast weather, and that they provide pertinent weather information to the pilot-in-command that might affect the safety of the flight. The dispatchers responsible for AAL102 provided the flightcrew with appropriate American Airlines advisories and forecasts. A company PIREP was also sent to the crew at 0532, about 1 1/2 hours before the airplane landed at DFW. In summary, American Airlines meteorology and flight dispatch sections correctly advised AAL102 of expected thunderstorms, moderate-to-heavy

81 rain showers, low-level windshear, and variable surface winds, gusting 20 to 40 knots, upon arrival at DFW. The contract weather observer at DFW accomplished two hourly and four special weather observations between 0550 and 0701 on April 14, 1993. The observations show timeliness and good quality. DFW weather observations were disseminated via a computer, located in the weather observatory, to the Wichita Falls, Texas, Weather Service Office and then through a distribution circuit to the Fort Worth Forecast Office. The FAA provided a dedicated link from the forecast office to DFW. On the day of the accident, the dissemination computer in the weather observatory was out of service between 0515 and 1315. As a backup, the weather observer telephoned_ the observations to personnel in the Fort Worth Forecast Office, who then typed them into a communications computer. Postaccident investigation found that the 0635 special observation was disseminated at 0637, the 0639 special observation was disseminated at 0643, and the 0650 hourly observation was disseminated at 0656. Delays in transmission of the surface weather observations were not a factor in the accident. However, a concern remains that critical weather observations could be unacceptably delayed when communications circuits are down. Moreover, it is possible that in some circumstances, the weather observer would not know that his observations did not ultimately reach ATC personnel. The implementation of the Automatic Surface Observing System (ASOS) should relieve these concerns. The NWS FT prepared by the Fort Worth Forecast Office, which was valid at the time of tqe accident, called for prevailing visual flight rules (VFR) conditions, with occasional thunderstorms and moderate rain showers. In addition, the Ff advised of a chance of severe thunderstorms, ceiling of 800 feet obscured, visibility 1 mile in heavy rain showers, hail and wind gusts to 50 knots. According to NWS guidelines, no amendment was required. The forecast office also issued local airport advisories for DFW, as required. No advisories were issued or required during the morning of April 14, 1993.

82 The NSSFC followed NWS guidelines in issuing convective SIGMETs 44C and 45C, at 0555, April 14, 1993, and Convective SIGMET 48C at 0655. 2.2.2 Movement of Thunderstorms Across DFW During the final approach of AALl 02, cloud bases north of DFW were, from the evidence, likely 1,000 to 2,000 feet broken to overcast. The UNO Doppler radar at 0650:23 showed an area of radar echoes up to and including VIP level 4 intensity, northwest through north of the airport. Cockpit communications and sounds similar to windshield wipers, recorded on the CVR, indicated that AALl 02 was in and out of thunderstorms and rain showers during most of its approach. The flightcrew reported runway lights in sight, at 0658: 14, and the airplane touched down on I 7L at 0659:29. The first period of moderate-to-heavy rain showers at DFW ended at the weather observatory located in the Delta Air Lines hangar, about 0645. These showers moved off to the east of the airport. The precipitation recording chart at the facility showed that only about 0.02 inch of rain fell during the next 15-minute period, ending at 0700. Interviews and statements by the duty observer and oncoming weather observers confirmed that rain shower intensity increased about 0658. At 0645, the leading edge of the second band of si~ificant precipitation was ap~roximately 7 miles west of 17L. The UNO Doppler radar 0.5-degree tilt scan 1 at 0650:23 showed that the line was slightly west of the airport complex. The LLWAS west sensor went into sector alert at 0653:25, as the line traversed that area. Radar returns from the UNO radar 0.5-degree tilt scan at 0656: 10 showed that the leading edge of mostly VIP level-2 echoes was near the terminal area, and that VIP level-3 and -4 echoes were just west of 18R. The runway visual range (RVR) sensor for 17L was located midway between 17R and 17L, approximately 1,000 feet south of the thresholds. According to the NWS recording, the RVR began a marked decrease around 0659 and stabilized between 0700 and 0701. This decrease in runway visibility is consistent 19 At 0.5-degree antenna elevation, the height of the center of the radar beam was about 1,200 feet to 1,400 feet msl over the airport.

83 with a heavy rain shower passing over the RVR location. In addition, the captain of American Airlines flight 1710, which was awaiting clearance for departure on l 7R, later stated: The aircraft [AAL102] appeared to be in the normal attitude and altitude for landing as he crossed the runway threshold.20 The rain had just picked up to a more moderate to almost heavy level as I watched him for a very short time. An airfield operations assistant officer was parked on the south taxiway J at about 0655. In a letter to the Safety Board, he stated, "Precipitation had been variable with light moderate and heavy rain. Visibility was poor .... " The NWS rain gauge was located about 1/4 mile east of 17L, approximately opposite the location where AAL102 came to rest. According to the recorder and NWS observers, the rain showers began to increase at the gauge and in the vicinity of the Delta Air Lines hangar around 0658, and heavy rain showers began at those locations about 0700. Delta Air Lines mechanics located at the hangar reported that, about 0700, the rain was "heavy and constant...blowing in sheets to the east across the ramp." The evidence suggests that the line of rain showers and thunderstorms probably started in the vicinity of the south end of 17L a little after 0657, becoming heavier 1 to 2 minutes later. While this timing is generally consistent with the reduced R YR readings at the north end of 17L, it would seem to indicate that the leading edge of the heavier precipitation was slightly farther east, in the vicinity of the southern portion of the runway. ASR-9 radar data between 0659 and 0700 confirms a slight north-northwest to south-southeast orientation to the line traversing the airport. Finally, an advected UND 3-D radar plot prepared by MIT/Lincoln Laboratories for 0659:04 indicates heavier radar echoes just to the west of the northern end of 17L. At the southern end of the runway, the plot indicates that cells at that time were slightly to the east of the runway. The UND Doppler radar accomplished a 0.5-degree tilt scan at 0701 :56. Radar returns showed predominately equivalent VIP level-3 radar returns along and east of 17L. In summary, the evidence shows that a line of moderate to heavy rain showers and thunderstorms was crossing runway 17L as AAL102 was landing. The 20 AAL102 crossed the runway threshold about 0659:11.

84 flightcrew of AALl 02 should have had sufficient information to realize that this was occurring at the time of the landing. 2.2.3 Centerfield Anemometer Wind Reports From 0656 to 0701 The FAA centerfield anemometer (CFA) was approximately 1,450 feet east of the centerline of 17L, and the NWS anemometer was approximately 50 feet south and 10 feet east of the CF A. The elevation of both instruments was about 20 feet agl. CFA-measured winds were normally collected at IO-second intervals, with the output recorded as a running weighted 7- to 10-second average. By international convention, a 2-minute average wind was computed and supplied to landing and departing aircraft. A gust meter at the CF A provided a I -second average of the highest winds in a l 0-second period. A gust was noted on the display in the tower whenever it equaled or exceeded the 2-minute average speed by 10 knots or greater. The NWS anemometer displayed instantaneous winds at the weather office and maintained a gust recording in the office. Wind directions from the NWS anemometer were not recorded or archived. An initial comparison of the NWS gust recorder and the FAA CFA data revealed an apparent discrepancy in the timing of the strong wind gusts passing over their locations. The NWS showed a peak gust of 33 knots at 0700, while the CFA indicated a gust to 32 knots between 0700:55 and 0701 :05. Since the FAA LLW AS computer clock was found to be accurate within 2 seconds of the WWV ( call letters for the U.S. Government time standard broadcast station), the LL WAS winds were used in lieu of the NWS gust recorder. A detailed correlation of wind speeds between the two sensors showed that the NWS gust recorder was probably about I-minute slow around the time of the accident. The A TC tower controller gave AALI 02 a report of "wind calm," at 0656:39. The 2-minute data showed that calm winds were displayed in the tower until 0658:25. The CFA 2-minute average wind speed then began gradually increasing, and, at 0658:55, the CFA wind speed was reported as 290 degrees magnetic at 4 knots, gusting to 14 knots. The tower CFA display at the time of touchdown was 300 degrees magnetic at 7 knots. The 10-second CF A LL WAS data showed a near-calm wind at 0656:39, and a wind speed of 5 knots at 0658:05. The wind speed then steadily increased, and, at touchdown, the I 0-second data reported the wind to be 302 degrees magnetic at 14 knots. The I 0-second average wind speed reached a

85 peak of 25 knots at 0701 :25. A gust of 25 knots was recorded between 0700:45 and 0700:55, and a maximum gust of 32 knots was recorded during the following 10 seconds. The computed average cross-track wind speed increased to about 20 knots at 0700:55 and to 24 knots during the following 10 seconds. The gust to 32 knots, recorded between 0700:55 and 0701 :05, yielded a maximum cross-track wind of 31 knots. 2.2.4 Winds Affecting AAL102 It is impossible to determine the exact magnitude and direction of the wind during the period the airplane was on the runway. However, the data do allow for a reasonable estimate of the wind conditions experienced by the airplane. Using an eastward translation of the line of showers and thunderstorms of 23 knots, winds measured at the CFA would have passed over 17L about 37 seconds earlier. Since the airplane touched down at 0659:29, the CFA IO-second average wind from 0700:05 was considered appropriate for the time of touchdown. That wind was reported to be 295 degrees magnetic, at 16 knots. Ten seconds later at 0700:15, the CFA IO-second average wind was reported to be 282 degrees magnetic, at 16 knots. No gusts were reported during the above 20-second period; however, the wind could have gusted to 21 knots without triggering the CFA gust meter. The computed CFA cross-track winds at 0700:05 and 0700:15 were approximately 14 knots and 15 knots, respectively. The I 0-second wind for 0659:35 from the northeast LLW AS sensor (located about 7,300 feet due north of the touchdown point) was 275 degrees magnetic at 14 knots. That wind was consistent with the estimated touchdown wind mentioned in the previous paragraph. The strongest wind speed reported by the northeast LLWAS sensor was 25 knots at 0700:25. Based on witness statements, radar data, and weather information, a wind surge was associated with the line of showers and thunderstorms moving across the airport. At the time of touchdown, the Safety Board believes that the leading edge of the line of heavier showers and thunderstorms was located in the vicinity of 17L. It is likely that the wind gusts of 25 to 32 knots, which occurred about 0701 at the CFA, did not affect the airplane. However, based on the meteorological data, the Safety Board could not rule out that the airplane experienced similar wind speed surges while on the runway.

86 2.2.5 LL WAS System Testing The Safety Board supervised examination and testing of the LLW AS to determine if the system functioned properly at the time of the accident. FAA maintenance technicians performed evaluations of the system on April 15 and 16, 1993, and again on May 6, 1993. The evaluations revealed that some of the potentiometer outputs of the west, northwest, and centerfield wind sensors were "out-of-tolerance." Subsequently, the three suspect out-of-tolerance anemometers were shipped to the manufacturer for further examination under Safety Board supervision. Additional factory tests on June 7, 1993, showed that the centerfield sensor outputs were within tolerance and that the northwest sensor outputs were only slightly outside the established limits. The west sensor outputs were substantially out-of- tolerance, which caused the manufacturer to surmise that the sensor might have been damaged by a transient input. The manufacturer stated that the centerfield and northwest sensors were unlikely to have contributed significant errors into the system. Although three anemometers failed to meet published calibration standards, postaccident evaluations revealed that the wind speed and direction outputs of the individual sensors were not significantly in error and did not seriously impact the windshear alert algorithm. 2.2.6 Windshear Algorithm The LLW AS Il algorithm, in place at DFW at the time of the accident, had a modest capability to detect wind field divergence. However, the algorithm relied mainly on comparing each sensor wind with the mean network wind and issuing a windshear sector alert when a predetermined threshold was reached. On April 14, 1993, the system issued a windshear alert from 0653:25 to 0655:35 for the west sensor. No other sensors alerted as the line of showers and thunderstorms traversed the airport complex. No divergent windshear was indicated.

87 2.3 Air Traffic Control Air traffic control, specifically the Fort Worth Center and the two DFW approach controllers, kept the accident flight and other flights updated regarding current weather on approach to DFW. They answered requests for weather information, and provided clearances to deviate around weather cells. The accident flightcrew requested and was granted two such clearances during the approach. Although the controllers neglected to advise the pilot of an A TIS update, the procedures used by the controllers were otherwise in accordance with the FAA

• Air Traffic Control handbook, Order 7110.65, and local orders.

Additionally, although the controllers were not able to accommodate all requests by the flight during its arrival sequence, and the flight did not receive a windshear advisory that was relevant to its situation, these events resulted from operational and procedural constraints and did not contribute to the accident. The events are discussed below. At 0643:09, the Feeder West controller at the Dallas/Fort Worth TRACON received the request to land in the opposite direction made by the flightcrew of AAL102 to the Fort Worth Center controller. The Feeder West controller denied this request because of the operational impact on the airport and surrounding airports. That is, when changes, such as requested by AAL102, occur at DFW, airport operations, arrivals, and departures, must be stopped at nearby airports, such as Dallas Love Field, NAS Dallas, Addison Field, and Meacham Field. Their proximity to DFW and the overall airspace configuration makes it operationally impractical to allow an opposite direction approach each time it is requested. Additionally, the DFW air traffic control facility has a local order that states that unless an emergency condition exists, opposite direction approaches21 will not be conducted. Furthermore, the weather conditions at the time of the request did not warrant a runway change. Therefore, because of the combination of the operational impact on the surrounding airports, and the local order, the controller appropriately denied the opposite direction arrival request from the flightcrew of AAL102. At 0650:23, the Arrival 2 controller instructed the flightcrew of AAL 102 to tum southbound toward the airport, although there was precipitation depicted in that area on the controller's radar display. The captain of AAL102 stated, "Ah I don't think we're going to be able to do that that's ah pretty big red area on our scope ah it's about ninety degrees and that's about what we're looking at ah 2 l Approaches opposite its established flow of arriving and departing flights.

88 we're going to have to just go out I guess and wait around to see what's going on here." It is noteworthy that the controller's radar display does not indicate the various intensities of precipitation, as does the pilot's display. The controller then issued a pilot report which had been received from a pilot of a preceding DC-8 which was on approach to 18R. The report indicated that the ride was "smooth." Based on this information, the flightcrew of AAL102 elected to tum inbound and subsequently complied with the controller's amended instructions. At 0656:36, the flightcrew of AAL102 made initial contact with the local controller. The controller stated, "American one oh two heavy regional tower runway one seven left cleared to land r1ind calm." Although a windshear alert had occurred at 0653:25, the controller did not issue an advisory in accordance with the A TC handbook. It states that after the last windshear alert, a windshear advisory will be issued to all pilots for 20 minutes by either an A TIS message, or, at facilities without ATIS, by a controller. In this case, the A TIS broadcast containing the windshear advisory was not broadcast until after the accident had occurred. Although the flightcrew of AAL102 did not receive the windshear advisory, the approach controller relayed a pilot report (PIREP) received from the pilot of the heavy DC-8, which was landing on runway 18R. The controller stated to AALl 02 that the DC-8 pilot reported that he had encountered an airspeed fluctuation of plus or minus 10 knots at the outer marker and plus or minus 5 knots on short final. Despite the availability of an ATIS, the information may not be immediately available because of the time required to record and review the revised A TIS broadcast. Even if a recording were broadcast in a timely fashion, pilots normally would not monitor the A TIS while they were on final approach because of high workload. Because pilots rely on controllers to issue pertinent weather information, such as windshear alerts, in a timely fashion, the Safety Board believes that the A TC handbook should be amended to require controllers to continue to verbally broadcast windshear advisories until he/she is assured that the information has been recorded and is being broadcast on the ATIS, and pilots have had time to receive the information. Although windshear was not a factor in this accident, the rapidly changing weather q:mditions occurring at the airport might have been more apparent to the flightcrew of AALl 02 if a timely windshear advisory had been made.

• 89 There is no requirement for tower controllers to continually display or relay information from LLW AS wind sensors other than the one located at the centerfield site. In the tower cab, centerfield wind information is always displayed because of the requirement for controllers to issue the wind direction and speed from this sensor. Wind information from the LLWAS wind sensors is displayed only when a windshear alert condition exists or if the controller selects a particular sensor for display of its information. This is accomplished by pressing the sensor button for that specific site. During the approach of AALI 02, when the controller issued "wind calm" in the clearance to land at 0656:39, the west wind sensor indicated 270 degrees at 16 knots. The difference in the west wind sensor and the network mean wind was not enough to trigger a windshear alert. This information, however, would have been important to the flightcrew because it indicated the highly variable nature of the wind at the airport. If the flightcrew had had this additional information, it could have assisted them in their decision to land or to execute a missed approach. Although the lack of wind information from the west sensor is not considered to be a contributing factor in this specific accident, the Safety Board believes that providing such wind sensor information to flightcrews would be a safety improvement in the A TC system. In summary, the Safety Board concludes that A TC services were provided in accordance with established procedures and were not causal to the accident. 2.4 Flightcrew Actions During Approach and Landing 2.4.1 General By the time the airplane was on final approach for landing, the flightcrew had already undergone a series of weather-related difficulties and decisions, including two possible lightning strikes, two requests by the captain to DFW approach control for vectors around weather cells, which were accepted, and requests to Fort Worth Center and DFW approach control to land to the north, which were denied. Then, about 50 feet agl, the first officer stated that he was "gonna go around." The captain said, "No, no, no I, I got it." The first officer said, "you got the airplane." The actual transfer of control probably took place about 40 feet agl. The captain's decision at that low altitude to assume control and land the airplane certainly was within his authority; however, it left him with virtually no

90 time to communicate with the first officer or flight engineer, or to assess conditions affecting the airplane, including wind direction and velocity, rain, rate of descent, speed and runway alignment. By ovenuling the first officer's decision to abort the landing, the captain committed the airplane to landing long on a rain and crosswind- swept runway. 2.4.2 Pilot Actions and Company Procedures During the Safety Board's interviews of the flightcrew, the first officer indicated that he elected to go around because he believed the airplane was "high" and that too much nose-down control input would be needed to make the landing. The captain stated that he took control of the airplane because he thought that the first officer was having difficulty aligning the airplane with the runway. The investigation determined that the airplane touched down, on the runway centerline, about 4,303 feet from the approach end of 17L.22 The Airman's Information Manual defines the first 3,000 feet of runway, beginning at the threshold, as the "touchdown zone." The recommended touchdown point is 1,000 feet from the approach end of the runway. When interviewed, the captain stated that he was confident that his landing was "within the desired first 3,000 feet." The FDR indicates that the reversers were deployed and thrust was increasing about 4 seconds after touchdown. The reverse thrust level was approximately 83 to 85 percent NI (or turbine speed) on all three engines; thrust on engine Nos. I and 3 was symmetrical. Immediately after touchdown, the captain applied forward pressure to assist in holding the nosewheel down on the runway. Analysis of the FDR data indicate a negative or down elevator, resulting in aerodynamically nose-down forces, during about the first 7 seconds after touchdown. Immediately thereafter, the elevator position went to a near neutral or in-trail position and showed virtually no movement for approximately 12 seconds, until about the time the airplane departed the south side of taxiway 3S. The Safety Board believes that when the elevator went to a neutral or in-trail position, the captain moved his left hand from the yoke to place it on the tiller (handwheel) to commence nosewheel steering. 22The runway touchdown point is derived from radar data, calculations, and tire marks.

91 The captain said that after touchdown the airplane "weathervaned" about 5 degrees to the right. It would be expected that if an airplane "weathervaned" and the tires were hydroplaning, the airplane's nose would tum into the wind and the airplane would track downwind, or left of runway centerline. The investigation found that while the airplane's nose turned to the right, most likely due to the right cross wind acting upon the vertical stabilizer, the airplane did not track downwind, or to the left. Rather, it tracked into the direction the nose was pointing, until, as the tire marks show, the airplane tracked off the right side of the runway. Therefore, the direction of the airplane track off the right side of the runway indicates that the main landing gear tires had enough friction to allow cornering and therefore were not hydroplaning. During this same time period, the FDR indicates that there was little input into the flight controls to maintain the airplane on the runway. For example, the FDR indicates that below 118 knots there was very little input into the rudder which was capable of 23 degrees of travel from center. Also, there was virtually no input into the elevator or ailerons. The captain stated that he acted "instinctively" to get back to the centerline of the runway. He stated that when the airplane did not respond, "there was nothing we could do but hang on." The FDR shows that after touchdown, below 120 knots, the rudder remained near a neutral position, except for a momentary deflection of 15 degrees, about 11 seconds after touchdown. The rudder remained near neutral until the airplane departed the runway. Both the rudder pedals and the tiller (handwheel), provide nose gear steering. The movement of the rudder pedals provides corresponding deflection of the nosewheel up to IO degrees either side of neutral. Movement of the handwheel or tiller steering control will override the rudder pedal control and provides up to 68 degrees of deflection, either side of neutral. The intended use of the hand wheel is to make turns at low speeds. DAC had published specific information regarding the use of forward pressure on the control column during the landing roll, as well as on the use of the nosewheel steering handwheel, in an AOL, two flightcrew newsletters, and in its DC-IO Flightcrew Operating Manual. However, the Safety Board could find no reference to these procedures in American Airlines DC-IO Operating Procedures or training program. The "Technique" section of the American Airlines DC-10 Operating Manual makes a short reference to the importance of forward pressure on the yoke after touchdown. However, the manual does not provide either a

92 procedure or technique for the nonflying pilot to apply forward pressure on the yoke after touchdown. When asked, the captain said that he thought forward pressure was not necessarily a DC-10 procedure but generally a good thing to do. The first officer said that he did not push forward on the yoke, after the captain released it, and would not unless it was specifically requested by the captain. The infonnation published by DAC regarding the necessity for forward pressure on the yoke, after landing, explained that it was necessary to reduce lift and improve steering characteristics of the nose gear. In addition, DA C's DC-10 Flightcrew Operating manual contains an "Expanded Landing Roll Procedures Guide," which cites nosewheel-to-runway contact as a line item and emphasizes the need for forward pressure. The recommendation states: The pilot not flying must apply sufficient forward pressure on the control column to maintain the nosewheel firmly on the ground for maximum directional control. For about 7 seconds, about I-second after touchdown, until about the time the airplane departed the runway, the FDR shows that the captain kept all three engines near maximum reverse thrust. DAC, and some other operators of the DC- I 0, provide written operations procedures that address the use of reverse engine thrust during loss of directional control on a landing roll. In general, the operating procedures instruct the pilot to bring the engines out of reverse thrust. The pilot may then use forward thrust, as necessary, to help the airplane realign. American Airlines addresses this issue not in the Operating Procedures section of its manual, but in the Operating Technique section. During the postaccident depositions, American Airlines' DC-10 fleet manager, a current DC- IO check ainnan, was asked his opinion regarding the American DC-IO Operating Manual reference to application of forward thrust to regain directional control on a landing runway. He said that he would not use it. He stated that it should be removed from the manual and that "it might be something that they picked up from DAC." The Operating Technique section of American Airlines DC- I 0 Operating Manual, Section 3A, does discuss the possibility of the airplane " ... moving toward the edge of the runway while at high speed .... " However, it

93 merely urges the use of "appropriate control inputs" to return the airplane to the runway centerline. The guidance does not specify the necessity of maintaining forward pressure on the control column to ensure nosewheel steering effectiveness. If the captain were at the controls during the landing roll, the only way he could "reduce the nosewheel steering angle," as suggested by this technique, would be to release the yoke and to use his left hand on the handwheel steering control, while making the appropriate rudder input. This technique, published without the requirement for the nonflying pilot to hold forward pressure on the yoke, is considered ineffective. Further, the technique could lead one to believe that the use of the handwheel steering control to steer back toward the runway centerline, during attempted deceleration, is appropriate. However, as the manufacturer's procedure describes, such high speed use is not the purpose of the handwheel steering control. The Safety Board understands that certain aspects of air carrier line flying involve the use of "techniques" that are not necessarily procedural in nature. However, the Safety Board is concerned that American Airlines has placed critical items in its Operating Techniques section of the manual to avoid the "regulatory" nature of procedures. It seems apparent that certain aspects of flying an airplane, such as use of flight controls during landing, should be considered procedural and should be standardized so that they can be practiced and evaluated during training and are used consistently by line pilots. The implication of citing an action as a technique, rather than as a procedure, could permit nonstandard use of critical flight control inputs by pilots during critical phases of flight, such as evident during this accident. The Safety Board believes that the FAA should reevaluate the Operating Techniques section of American Airlines' Operating Manual to ensure that critical flightcrew actions that are expected to be used are properly included in the Procedures section of the manual. In postaccident interviews, the flightcrew was asked if they had previous experience with maximum antiskid braking. The flight engineer stated that he was familiar with the sound and feel of the brakes cycling in antiskid braking on the DC-I 0. He stated that he did not hear or feel the brakes cycle during the landing rollout. The FDR does not record brake application. However, when the captain described the landing and rollout, he stated that he normally did not brake until the aircraft had slowed below 100 knots. Maximum antiskid braking requires

94 full pedal deflection at 60 to 90 pounds of force. The captain's discussion of acting "instinctively" did not mention full pedal deflection. 2.4.3 Landing Briefing Safety Board investigators were unable to find specific American Airlines operations policy on when and where a captain should brief specific procedures, emergency or otherwise. There is a requirement that the captain brief the approach and, if appropriate, possible missed approach procedures. 23 However, there is no specific policy regarding such a briefing if the captain were to take over the airplane during the approach. A reasonably opportune time to brief significant procedures with the flightcrew is prior to the beginning of the approach. Understandably, all possible procedures cannot be briefed for every approach; however, prior to the beginning of the airplane's approach into DFW, no briefings on approach, landing, or go around procedures, emergency or otherwise, were conducted. Without an approach briefing, the flightcrew must fall back upon standardized operational training. After the captain countermanded his decision to go around on short final and took control of the airplane from him, there was no specific guidance to the first officer regarding his duties to back up the captain during the landing. The American Airlines Operating Manual does not give clear direction on what the first officer should do following a captain taking control of an airplane. When American Airlines line fi~st officers were asked what they would do to assist a captain, undirected, with the flight controls on the landing runway, their statements were not consistent. Some stated that they would not make control input, with the captain at the controls, unless directed. Others stated that they would assist with nosewheel steering, by putting forward pressure on the yoke. When asked if the airplane were about to depart the runway, whether they would make undirected control inputs to assist the flying captain, some said they would not; others said that they would do whatever was necessary to help keep the airplane safely on the runway. The Safety Board concludes that American Airlines training, pilot standardization, and flight manuals need to provide clear and definitive direction to first officers regarding those unbriefed and unspoken times, 23Refer~nce American Airlines Operators Manual on the duties of a captain in briefing the flightcrew prior to approach and landing.

95 especially during emergencies, when their input into the flight controls may be needed. 2.5 Flightcrew Decision-Making The Safety Board examined the actions and decisions of the captain and the first officer upon their arrival into the DFW terminal environment to determine the effect, if any, such performance may have had on the accident. The evidence indicates that the captain and the first officer were aware of and were prepared for the possibility of encountering severe weather on the approach into DFW. The weather information that the crew received in HNL called for adverse weather upon their arrival into the DFW. Center and arrival controllers gave the crew updates on the weather, including a real time identification of storm cells lying over the final approach path that the arrival controller saw on his radar scope. Moreover, the CVR indicates that the crew had numerous discussions about the weather, and added airspeed, as appropriate, to mitigate against the likelihood of encountering windshear. Given the amount of information about the adverse weather in the DFW area that the captain was aware of, as well as the first officer's assertively articulated suggestion in favor of discontinuing the approach, the Safety Board examined the captain's decision to continue the approach and his decision to countermand the first officer's decision to go around at 50 feet. The Safety Board considered the factors involved and the context in which the decisions were made to determine whether they were appropriate. Despite the thundershowers north and south of DFW, as AALl 02 proceeded to the ILS approach to 17L, there were no weather conditions that made the decision of the captain to initiate or continue the approach unacceptable. Although the airplane was in a I 0-degree right crab on short final to l 7L, this condition was not inherently unsafe. The DC-8, which had landed on 18R about 4 minutes before AAL102, had reported a "smooth ride" that had been passed by an approach controller to AAL102. Also, on approach to 17L behind AAL102, an SA- 340 captain, who flew a missed approach beginning about 600 feet agl, reported that he experienced light to moderate turbulence during the approach and no windshear activity. The captain of AAL102 was well within his authority to take the airplane from the first officer after the first officer had announced, without prior

96 warning, that he was going to go around. The fact that the captain was able to land the airplane on centerline provides evidence that he was in control of the airplane through the touchdown. No clear evidence exists that there was any fault in the captain's decision-making throughout the initiation or continuation of the approach to l 7L, or in his decision to take control of the airplane from the first officer and land on the intended runway. The departure from the runway resulted from the captain's failure to maintain directional control of the airplane after touchdown rather than from events or decisions made prior to touchdown. Finally, in light of the captain's improper aircraft control during the landing roll, the relatively long duration of this overnight flight, and the fact that the captain's sleep periods were disrupted in the 48-hours prior to the accident, the Safety Board considered the possibility that fatigue adversely affected his performance. These factors and the captain's age of 59 years lead the Safety Board to believe that the captain might have been fatigued to some extent. Even though the circumstances surrounding the flightcrew's activities from April 12 through 14 could have led to a deterioration of his judgment and piloting skills, there is no information available regarding the captain's ability to perform under either long- term or short-term fatigue. Therefore, a finding that his performance on the accident flight was the result of fatigue could not be supported; nor could it be dismissed. 2.6 AAL Pilot Training Program and Recordkeeping The Safety Board attempted to obtain information about the quality of the past training and checking performance of the flightcrew of AAL102 from American Airlines, but was unable to do so because of the lack of detailed information in the records. The FAA-approved recordkeeping system only provided information on when pilots completed required actions such as flight checks. Their performance on the checks, or even the number of unsuccessful checks, was not included. As a result, the Safety Board was unable to determine if the quality of the performance of the flightcrew on AALI 02 was an aberration or was consistent with a performance decrement. The Safety Board was concerned to learn that American Airlines did not maintain individual pilot training files in any more detail than pass/fail records. Although this recordkeeping might have satisfied minimal training, oversight, and regulatory requirements, it restricts the airline's ability to monitor the long-term training, perf brmance, and personal history of its individual pilots and prevents it from tailoring or modifying training for its pilots. Without adequate recordkeeping,

97 not only was the Safety Board at a disadvantage in establishing the quality of the training received by the accident flightcrew, but American Airlines and the FAA were equally disadvantaged in assessing the effectiveness of the training program. The FAA DC-10 program manager for American Airlines, FAA Inspectors, and American Airlines instructor, check, and line pilots were interviewed regarding the pilot training records system. The FAA program manager said that American Airlines was conducting training and keeping records properly, doing things as "we do," and that he expressed no need for the operator to keep more detailed training records, specifically those on pilot performance in simulator training, and passed or failed check rides. The American Airlines simulator check captain stated that he looked at written performance records of pilots prior to the check. However, he did not express an extensive interest in their written training records because he wanted to give the checks with no preconceived notions regarding the pilots. He also stated that after examining the training evaluations of pilots, he tore them up. Thus, the basic training records, specifically those that would differentiate one pilot from another in performance or capability, were kept in the form of a "Pass" or "Fail" record. Nevertheless, the check captain showed interest in keeping records of reasons why a pilot had failed a check ride. However, written evaluations for pilots who had completed training and check flights were not retained. The FAA's principal operations inspector (POI) for American Airlines stated he believed that checking the operator's computer recordkeeping of pilot training records against the FAA's own American Airlines-related microfiche records was an adequate means for inspecting such records. The FAA handbook recommends the checking of an operator's training records against an independent source, such as the FAA's Oklahoma City data base. However, during the interviews, the POI stated that he had never performed a records inspection on American Airlines training records and that he could not recall when such an inspection of the operator had last been accomplished. The Safety Board believes more emphasis should be placed on the examination of pilot training procedures and records. The Safety Board's investigation included formal depositions of American Airlines line, training, and check captains, including captains who worked at training management positions. When investigators asked questions relative to corporate policies, operational practices, and performance history of the accident

98 flightcrew, the general responses were in agreement with the actions of the accident flightcrew. The investigation found no evidence that the operator had previously identified any adverse performance characteristics in training or operational difficulties for the flightcrew. In the past, the Safety Board has urged the FAA to ensure that airlines examine their maintenance and inspection programs to determine if trends exist that might suggest possible difficulties with a particular aircraft, or with particular maintenance practice. In fact, there are specific regulations governing airline maintenance quality assurance programs. The Safety Board believes that the quality of the training and checking of flightcrews operating the aircraft is equally as important as the quality of an aircraft maintenance program. At the time of the accident, American employed over 9,000 pilots based at several domiciles throughout the United States. Given the extent of supervision possible by one chief pilot over several hundred pilots, the Safety Board believes that American's recordkeeping systems for its pilots did not provide sufficient information to allow the airline, or the FAA, to determine if trends existed to suggest changes in flightcrew performance over time, or to evaluate the effectiveness of the overall training program. Such information could be easily obtained and recorded by the airline and would enable the airline to assist a flightcrew member who might be experiencing performance difficulties. Such a program would enhance safety by allowing the airline to undertake a performance enhancement before a problem developed outside of the training environment. Therefore, the Safety Board urges the FAA to review the recordkeeping systems of airlines operating under FAR Parts 121 and 135 to determine the quality of information contained therein and, if necessary, require the airlines to maintain information on the quality of pilot performance in training and checking programs.

1. 7

Survival Factors and Airport Fire and Rescue The cabin crewmembers performed in a professional manner in assisting 189 passengers, a high percentage of which were of retirement age, off the airplane. The evacuation was complicated and difficult. The cabin emergency lighting, by witness accounts, worked, at best, only temporarily in the forward coach cabin and not at all in the rear coach cabin. The result was a darkened cabin after the airplane came to rest. Furthermore, because the nose gear and left main landing gear were fractured, the airplane came to rest in an approximately IO-degree left wing down and slight nose-down pitch attitude. Consequently, as a result of this

99 fuselage attitude, the emergency evacuation slides, for the two right rear cabin exits, were deployed at nearly a vertical angle. A fire was apparent outside the aft left side of the cabin, providing a glow into the otherwise dark aft cabin. Cabin crewmembers and many passengers later stated that all of them knew of the urgency of evacuating the airplane as quickly as possible, and several persons later described a deliberate attempt by nearly everyone to remain calm. Nevertheless, some passengers were injured as they fell to the base of 3- and 4-R slides and became stuck in the mud as others fell on top of them. A flight attendant made a self-described difficult decision to exit his station at 3-R, and walk out onto the right wing to try to see why there was a holdup of passengers on the wing at the top of the 3-R slide. When he looked down and saw the steepness of the slide and some of the elderly who seemed to nearly fall down the vertical slide, he made the decision to direct the remaining passengers back into the cabin, although he knew that there were flames out the aft left cabin windows, and to move them forward to another exit. The Safety Board finds these actions exemplary. As a result of the actions of the cabin crewmembers, all persons exited the airplane, and there were only two serious fracture injuries. · DFW airport fire department personnel estimated that they arrived at the airplane around 0701, about I minute from the time the airplane came to rest, with persons still coming out of the cabin. Their performance in responding to the accident scene was well within the established guidelines and permitted rapid extinguishing of the fire on the left side of the airplane. Several flight attendants and passengers said that during the emergency evacuation they did not see cabin emergency lights illuminate. The aft coach cabin was described as extremely dark or black. Two DFW fire fighters, who conducted the postevacuation cabin search, stated that they had to use the emergency flashlights that were located in the cockpit. The Safety Board conducted a functional test of the emergency lighting system on the airplane on April 16, 1993. The floor path lighting illuminated on the left side of the aft section of the cabin, but no other cabin emergency lights illuminated.

100 Both emergency lighting subsystems were independent of each other, and they linked together at the emergency light switches in the cockpit and at the 1-L flight attendant's station. The entire cabin emergency lighting system is designed to activate automatically whenever the airplane's electrical system is shut down or when the engine fire suppression system is activated. The system- activating cockpit switch was found by investigators in the "standby" position, and the switch at the 1-L flight attendant station was found in the "off' position. No deficiencies were found in either the subsystem or in the components on the airplane. The cockpit and 1-L flight attendant activation switches were found functional. In addition, voltage and impedance tests conducted on the wiring of each subsystem indicated no deficiencies. Additional testing was done under Safety Board supervision on both subsystems at the facilities of their manufacturers. This inspection and testing determined that the Gulton systems battery pack had been reassembled improperly during maintenance. There was no evidence of improper assembly by the manufacturer. The individual battery packs (constituting 24 batteries for each of the four battery charging units) are required by maintenance scheduling to be replaced in the same sequence as they were previously installed on the airplane. Three of the four battery packs were found to have been configured improperly. With the improper configuration, enough electrical power would have been provided to indicate an "up system" in battery tests but not enough power to energize the emergency lights in the actual emergency. Upon receiving this information, American Airlines issued an Engineering Service Order and initiated an inspection of battery stores in all airplanes that might have been affected by the configuration. 2.8 Landing Runway Surface Conditions It is apparent that the surface texture of 17L-35R had deteriorated with use, or as a result of high levels of jet traffic and weather-related erosion. FAA guidance, as stated in FAA Advisory Circular (AC) 150/5320-12B, addresses runway wear. Although, by definition, "maintenance planning" for this runway was called for, the friction levels of the majority of the runway fell within acceptable levels for airplane operations. Furthermore, as described below, there is no evidence that the airplane entered hydroplaning on the runway or that traction was significantly reduced because of the condition of the runway.

101 The investigation foun·d a buildup of rubber at the approach end of 17L that showed a coefficient of friction below the FAA minimwn standard. According to airport records, for the past 3 years, rubber removal was conducted at 4- and 8-month intervals. There was an average of 261 landings on 17L each day. FAA guidance suggests a rubber removal frequency of every 2 months for runways with a frequency of turbojet landings of more than 210 per day. The Safety Board concludes that DFW should monitor the runways more frequently, and, if necessary, remove the rubber buildup on all runways, in accordance with the referenced directive. However, because the accident flight landed long, the airplane did not traverse the areas where rubber buildup was found. Although this buildup needs to be corrected, it did not contribute to the loss of directional control on the runway. The FAA provides guidance in advisory circulars for runway friction measurement and runway maintenance._ However, there is no formal requirement for FAA oversight of airports regularly performing friction measurements. In addition, there are no formal requirements for the FAA to regularly inspect certificated airports to ensure that they have adequate friction measurement or, if necessary, rubber removal programs. The Safety Board has addressed the subject of runway friction since 1973 when Safety Recommendation A-74-119 was issued to the FAA to: Amend appropriate regulations and procedures to establish an alerting service to advise pilots of hydroplaning probabilities before and during the landing approach. Such an advisory system would entail (1) A runway slipperiness rating and runway contamination monitoring program; and (2) The use of measuring devices and associated charts to correlate rainfall, wind direction, and velocity, with runway gradient and water depth on the runway surface. Safety Recommendation A-74-119 was superseded by the recommendations issued with the accident report on the January 23, 1982, World Airways accident at the Boston-Logan Airport. The applicable recommendations in the Boston-Logan World Airways report were superseded by the recommendations in the report on the October 25, 1986, accident at the Charlotte-Douglas airport-- specifically A-87-110. In all, 19 safety recommendations have been issued regarding runway friction and friction measurement.

102 As a result of the Safety Board investigation of the Piedmont Airlines Boeing 737 accident at Charlotte-Douglas International Airport, North Carolina, on October 25, 1986, the Safety Board issued Safety Recommendation A-87-110 which recommended that the FAA: During annual inspections of full certificate airports, emphasize the identification of deficient runway conditions and use approved friction measuring devices to measure the dry runway coefficients of friction. Encourage the airport operator to correct ( or provide appropriate notice to users) runway conditions that do not meet criteria recommended in advisory circular 150/5320-12A. Following previous correspondence, on December 12, 1992, the FAA replied that it agreed with the safety recommendation and has revised AC 150/5320- 12B to include guidance and procedures for the design and construction of skid- resistant pavement, pavement evaluation with or without friction equipment, and maintenance and high skid-resistant pavements. As a result of that letter, on March 26, 1993, the Safety Board classified Safety Recommendation A-87-110 as "Closed--Acceptable Action." However, as a result of the investigation of the accident involving AALI 02, the Safety Board believes that the FAA should take a more assertive role in overseeing airport runway friction measurement programs. Therefore, the Safety Board concludes that FAA airport .safety and certification inspectors should have the responsibility for ensuring that airports certificated under 14 CFR Part 139 establish and maintain programs for measuring coefficient of friction levels to an acceptable standard above that of "maintenance planning" on runways handling air carrier operations. Specifically, the Safety Board concludes that 14 CFR Part 139 should require such friction measurement programs and correction programs. FAA airport certification and safety inspectors should be required to review airport certification manuals (ACMs) to ensure that friction measurement programs are established and continued. In addition, these FAA inspectors should be provided with the training and resources necessary to conduct friction measurement checks. The Safety Board is aware that due to budgetary constraints, airport inspection resources are limited and workloads are heavy, and thus additional responsibilities, such as overseeing friction measurement programs, may be burdensome. A number of aviation safety workforce positions, such as air traffic controllers, flight standards inspectors, and flight service staff are categorized in

103 special emphasis workforce positions, which provide for minimum staffing levels and hiring priorities to ensure that safety is not compromised. The Safety Board believes that airport certification and safety inspectors are also critical to aviation safety, and that the FAA should provide special emphasis status to such positions. 2.9 Evaluation of Tire Marks and Tire Traction The touchdown point on 17L was about 4,303 feet from the approach end of the runway. Initially, the tire marks were characterized by very brief black rubber marks. The runway marks and subsequent off-runway marks in the soft soil and on high speed taxiway 3S were consistent with the spacing of the airplane's landing gear tires and led to their positions on the resting airplane. The airplane's tire marks, where it crossed high speed taxiway 3S, were black. The position of the marks, with the nose gear tire marks to the right of the center gear tire marks, indicates that the airplane was skidding as it crossed the taxiway. Traverse scuff marks found on some of the tires also indicated that they had been subjected to a skid. The offset between the tire marks and the nose gear and center gear indicates that the airplane was in nearly a I 0-degree yaw as it skidded across high speed taxiway 3S. There are three basic forms of tire hydroplaning: viscous, dynamic, and reverted-rubber. Viscous hydroplaning occurs when a tire is unable to penetrate a thin film of fluid. It is characterized by reduced friction between the tires and the runway surface. Dynamic hydroplaning occurs when standing water on a runway acts to lift the tire off the runway. The major conditions required to cause dynamic hydroplaning are a ground speed greater than the tire dynamic hydroplaning speed, standing water, and poor runway surface microtexture. Although the accident airplane's ground speed was greater than the dynamic hydroplaning speed (9 times the square root of p where "p" equals tire pressure in pounds per square inch), and the runway surface microtexture was fairly low (but acceptable), the grooves in the runway should have channeled away the standing water, as would the tire treads. Although one, and perhaps two of the tires on the left main landing gear were found to have excessive tread wear, the Safety Board does not believe that the condition of the tires contributed to the loss of airplane directional control or to a condition of dynamic tire hydroplaning.

104 In the case of reverted-rubber hydroplaning, a film of water between the tire and the runway is heated into steam. This high heat leaves a clean path on the runway and reverts the portions of the tire or tires in contact with the steam into a "gummy" rubber mixture. There was no evidence of reverted rubber or overheat on any of the tires on the airplane, nor was there reverted rubber on the runway. The Safety Board believes that the tire marks noted on the runway were not caused by hydroplaning, but were instead erasure marks on the wet runway. There were a large number of similar marks on the runway surface from other landing airplanes that were not hydroplaning. Furthermore, if hydroplaning had occurred, tire traction would have been lost and the airplane would not have tracked up wind in the direction that it was pointed, when it weathervaned to the right. Rather, it would have drifted toward the left side of the runway.

105

1. CONCLUSIONS
2. 1

Findings I. The airplane was certificated, equipped, and maintained (with the exception of the two misconfigured reverse thrust cascades on the No. 2 engine) in accordance with Federal Aviation Regulations and approved procedures. 2. The airplane was within its weight and balance limitations. 3. The flightcrew was properly certificated and had received the proper rest to perform their respective duties, in accordance with Federal Aviation Regulations. 4. The American Airlines flightcrew training recording procedures and records met FAA minimum standards and indicated that the pilots were qualified. However, the records were inadequate to use for trend analysis or evaluation of an individual's performance during training. 5. Although air traffic control was not a factor in this accident, because of procedural shortcomings, windshear advisory information was not provided to the flightcrew in a timely fashion. 6. The practice of displaying only the centerfield wind on the low level windshear alert system limited the amount of information the controller had available to him to issue to the flightcrew. 7. The LL WAS system operated within acceptable limits at the time of the accident. 8. NWS and American Airlines weather information provided to the flightcrew of AAL102 was timely and substantially accurate. 9. At touchdown, flight I 02 was subjected to cross-track winds of about 15 knots that may have been increasing, with gusts about 5 knots above the steady winds.

106 10. The wind gusts of 25 to 32 knots recorded on the centerfield anemometer were not a factor in the accident; however, wind speed surges of similar strength could not be ruled out entirely based on meteorological data. 11. No microbursts or hazardous low level windshears affected the airplane at the time of the landing. 12. A line of moderate to heavy showers and thunderstorms was crossing runway 17L as AALI 02 touched down. 13. The captain failed to compensate for moderate crosswinds from the right, allowing the airplane to weathervane and drift off the right side of the runway with minimal rudder commands, inappropriate tiller nosewheel steering commands, and lack of forward pressure on the control column. 14. The evacuation of the passengers, although made difficult by the fire and the nose-down left roll final resting attitude of the airplane, in mud, was handled in an expeditious and professional manner. 15. The emergency lighting did not operate properly because the emergency overhead lighting system battery packs were found to be out of sequence. This condition resulted in enough electrical power to indicate that the system was fully charged on the flight engineer's console but insufficient power to operate the overhead emergency lighting system for a specified 5 minutes. The manufacturer's instructions did not describe the importance of properly sequencing the batteries in each pack. 16. Runway 17L-35R was worn to a "maintenance planning" level. However, the majority of the runway's coefficient of friction was found to be within prescribed advisory circular guidelines. 17. There is inadequate FAA oversight of the runway friction measurement at U.S. airports.

107 18. The emergency response of the DFW ARFF was exceptionally good. 19. There was no evidence of hydroplaning on the runway or reverted rubber on the airplane's tires. 20. The broken nose landing gear steering cables were a result of the accident. They were not broken before the collapse of the nose landing gear. 21. Two of 32 reverser cascades on the center or No. 2 engine were found not to be in the proper configuration. The calculated misdirected force could be counteracted by about I degree of rudder deflection. 3.2 Probable Cause The National Transportation Safety Board determines that the probable cause of the accident was the failure of the captain to use proper directional control techniques to maintain the airplane on the runway.

108

1. RECOMMENDATIONS

As a result of the investigation of this accident, the National Transportation Safety Board makes the following recommendations: --to the Federal A vi at ion Administration: Review the pilot training recordkeeping systems of airlines operated under FAR Parts 121 and 135 to determine the quality of information contained therein, and require the airlines to maintain appropriate information on the quality of pilot performance in training and checking programs. (Class II, Priority Action) (A-94-24) Amend the ATC handbook, 7110.65, Chapter 3, "Airport Traffic Control - Terminal," Section 1, General: paragraph 3-8, "Low Level Windshear Advisories," to state that tower controllers should issue the LLWAS advisory, "Low Level Windshear Advisories in Effect," whether or not the facility is equipped with an ATIS. The advisory should continue to be transmitted by A TC, relative to all runways in operation at the airport, until either the information is confirmed to be on the ATIS, or the prescribed 20-minute time limit from the time of the alert has expired. (Class II, Priority Action) (A-94-25) Revise ATC handbook, 7110.65, Chapter 3, "Airport Traffic Control - Terminal," Section 1, General: paragraph 3-8, "Low Level Windshear Advisories," to require controllers to select for display all sensors on the LLWAS when adverse weather conditions, such as thunderstorms, are forecast or present in the terminal area to improve controller and pilot perception of wind conditions affecting the entire airport. (Class II, Priority Action) (A-94-26) Require the manufacturers of rechargeable batteries to provide specific maintenance instructions and recommended care practices. (Class II, Priority Action) (A-94-27)

109 Issue an Advisory Circular that provides proper maintenance instructions to aviation battery maintenance and repair facilities. (Class II, Priority Action) (A-94-28) Require all 14 CFR Part 139 airports to perform runway friction tests regularly. (Class II, Priority Action) (A-94-29) Provide FAA certification and safety inspectors with the training and resources necessary to oversee airport runway friction measurement programs. (Class II, Priority Action) (A-93-30) Place airport certification and safety inspectors on the special emphasis workforce list. (Class TI, Priority Action) (A-94-31) --to Dallas/Fort Worth International Airport: Monitor surface friction on all operational runways on a more frequent basis, including the buildup of rubber on all runways, and perform rubber removal operations as required, in accordance with FAA Advisory Circular l 50/5320-12B. (Class II, Priority Action) (A-94-32) -- to American Airlines, Inc.: Review the guidelines for developing, implementing, reinforcing, and assessing CRM training programs for flight crewmembers, as contained in FAA Advisory Circular 120-51 A, and ensure that the CRM program conforms to the guidance contained therein. (Class II, Priority Action) (A-94-33) Examine the maintenance procedures and practices that resulted in the misconfiguring of two reverse thrust cascades on the No. 2 engine of N139AA. Determine if this is a single incident, or a more common procedural or maintenance practice error and make the appropriate changes. (Class II, Priority Action) (A-94-34)

110 BY THE NATIONAL TRANSPORTATION SAFETY BOARD February 14, 1994 Carl W. Vogt Chairman Susan Coughlin Vice Chairman John K. Lauber Member John Hammerschmidt Member James E. Hall Member

111

• APPENDIXES

APPENDIX A INVESTIGATION AND HEARING Investigation The National Transportation Board was notified of the accident about 0900 eastern daylight time, April 14, 1993. An investigative team was dispatched, arriving about 1530 cdt at DFW. Investigation groups were formed for: Airport Fire and Rescue, Aircraft Performance, Aircraft Structures, Aircraft Systems, Cockpit Voice Recorder, Flight Data Recorder, Human Performance, Powerplants, Maintenance Records, Metallurgy, Operations, and Survival Factors. Parties to the investigation included: The Federal Aviation Administration, Aircraft Braking Systems Corporation, Allied Pilots Association, American Airlines, Association of Professional Flight Attendants, Dallas/Fort Worth International Airport, Flight Dispatchers, Meteorologists, and Operations Specialists Union, General Electric, McDonnell Douglas, and the National Air Traffic Controllers Association.

Public Hearing A public hearing was not held in conjunction with this investigation. 112 APPENDIXB PERSONNEL INFORMATION Flightcrew Background The Captain The captain, age 59, was born on April 27, 1934. He was hired by American Airlines on August 1, 1966, as a first officer on the BAC-111. He was transferred from that position to fly as a navigator on the Boeing B-707, where he flew on Pacific Ocean routes for American Airlines for about 2 years during the Vietnam War. He then progressed from the position of Boeing B-727 flight engineer, to first officer, to captain. He then flew for a short time as a captain on the McDonnell Douglas MD-80, and then became a captain on the DC-10. Records indicate that at the time of the accident, he had flown about 12,562 total hours for American Airlines, 555 of which were in the DC-10. The captain holds Airline Transport Pilot certificate No. 1478746, with the rating of airplane multi-engine land, and type ratings in the DC-9, DC-10, B-727, and commercial privileges for airplane single engine land, and B-337. Additionally the captain holds Flight Navigator certificate No. 1746479. His FAA First Class Medical approval was issued on March 9, 1993, and bore the limitation: "Must have available glasses for near vision." He had no record of an accident, incident, or violation. The captain began training on the DC-10 in November 1991. His instructor gave him an additional simulator training period, beyond the programmed number of periods prior to the simulator check flight. He was type rated in the DC-10 on December 10, 1991, by an American Airlines FAA Aircrew Program Designee. He was trained and qualified for international flights in April 1992. This training also served as his last line-required check. The captain's last recurrent training and proficiency check were in December 1992. All of the American Airlines training records were kept in a computer data base. The data base contained the dates that the training was completed, and indicated whether the pilot passed or failed the check. There is no

113 qualitative information regarding performance m these records, or whether a maneuver had to be repeated. The First Officer The first officer, age 40, was born on September 5, 1952. He was hired by American Airlines in September 1986, as a Boeing B-727 Flight Engineer. He progressed to the position of B-727 first officer, and then to DC-IO first officer. Records indicate that at the time of the accident, he had accrued about 4,454 total flying hours for American Airlines, about 376 of which were as a first officer in the DC-10. The first officer holds Commercial Pilot certificate No. 585406734, with the ratings of airplane single and multi-engine land. In addition, he holds Flight Engineer certificate No. 585406734, with a turbojet rating. His First Class Medical approval was issued on October 23, 1992, and bore no limitation. He had no record of an accident, incident, or violation. The first officer began training in the DC-IO in June 1992. He pointed out in an interview, as part of the Safety Board's investigation, that an additional simulator period, prior to the check, was necessary to train the pilot that he was paired with during training to proficiency, and that he did not require the extra period. The next required recurrent training period for the first officer was July 1993. The Flight Engineer The flight engineer, age 60, was born on September 29, 1932. He was hired by American Airlines in October 1955 as an aircraft mechanic. He progressed to become a professional flight engineer in the Douglas DC-6n, Lockheed L-188, Boeing B-707 and -727, and DC-10. American Airlines records indicate that he was qualified in the DC-10 in November 1985, and, at the time of the accident, accrued about 4,800 flight hours in the DC-10. He holds Flight Engineer certificate No. 1209924, with ratings in reciprocating engine, turbopropeller, and turbojet airplanes. In addition, he holds Airframe and Powerplant Mechanic certificate No. 1209924. His Second Class Medical approval was issued on March 23, 1993, and bore the limitation, "Must

114 have available glasses for near vision." He is not a licensed pilot. He has no record of an accident, incident, or violation. Flightcrew 72-Hour History The captain had been off duty for an 11-day period prior to being notified of the April 12 to 14, 1993, DFW-HNL-DFW trip. He was at home, on a reserve status, when he was called, about 1730 cdt, on Sunday, April 11, 1993, to notify him of the flight. He slept for about 8 hours and reported for duty at DFW at 0920 cdt, April 12, 1993. He flew as captain on flight 123 from DFW to HNL. The first officer and flight engineer were the same for both the DFW to HNL leg of the trip and the return (accident) leg from HNL to DFW. The flight arrived at HNL at 1416 Hawaiian Standard Time (hast) or 1916 est. The captain later stated that prior to this trip he had not been paired with the first officer. However, several years earlier, he had been paired with the flight engineer while flying the B-727. The captain checked into his hotel room and subsequently ate a meal. He walked in the vicinity of the hotel, and watched television in his room before retiring for the night at 1700 hast (2200 est). He stated that he slept well. He awoke at 0630 hast (1130 cdt) on April 13, 1993, had coffee and ate breakfast, walked, and spent time at the hotel swimming pool. He took a nap between 1300 and 1515 (1800 cdt to 2015 cdt), and then met his crew and proceeded to the airport, reporting for duty at 1750 (2250 cdt). The captain stated that he was not tired during the return flight to DFW. The first officer stated that he had been off duty for 6 days prior to being notified on April 11, 1993, while at home on reserve status, of the trip from DFW to HNL to DFW. He had a normal night's sleep, at home, and reported for duty at DFW at 0810 cdt, April 12, 1993. He stated that he had not previously flown with either the accident captain or flight engineer. Upon completion of the flight from DFW to HNL, the first officer checked into his hotel room, then went shopping, ate dinner, and spent time in the room, making a telephone call and watching television. He stated that he retired for the night at 2200 hast, April 12, 1993 (0300 cdt, April 13), and arose at 0600 hast (1100 cdt) April 13, 1993. He took a morning walk and spent time reading in his room until 1100 hasJ (1600 cdt). He ate lunch, and then took a nap between 1200 and 1600 hast (1700 to 2100 cdt). He met the other members of the crew and reported for duty at HNL at 1750 hast (2250 cdt), April 13, 1993. He stated that he

115 had felt tired during the accident flight and had taken naps briefly twice to "perk up." (The captain, when interviewed, also noted that the first officer had twice taken oxygen to refresh on the flight from HNL to DFW.) The flight engineer had previously bid the April 12 to 14, 1993, DFW to HNL to DFW trip, and was scheduled for it. On April 11, 1993, he slept at his home between 2030 and 0645 cdt, and reported for duty at DFW at 0840 cdt, April 12, 1993. He arrived at the hotel in HNL with the other members of the crew, checked into his room, ate a meal, and retired at 2000 hast, April 12, 1993 (0100 cdt, April 13). He slept until 0300 hast (0800 cdt), April 13, 1993. He took a walk in a park near the hotel during the morning hours and then napped between 1300 and 1600 hast (1800 to 2100 cdt), prior to meeting with the crew and reporting for duty at HNL at 1750 hast (2250 cdt).

116 APPENDIXC COCKPIT VOICE RECORDER TRANSCRIPT CAM RDO INT PA -1 -2 -3 -4 -? CTR-1 ATIS-1 APR-1 APR-2 217HL AAMT TWR-1 GND-1 * @

% ( ) (( )) LEGEND Cockpit area microphone voice or sound source Radio transmission from accident aircraft Transmissions over aircraft interphone system Transmissions over aircraft plblic address system Voice identified as Captain (PIC) Voice identified as First Officer. Voice identified as Flight Engineer Voice identified as cockpit mechanical voice Voice unidentified Radio transmission from Ft. Worth air traffic center Radio transmission from DFW ATIS Radio transmission from 1st DFW approach controller Radio transmission from 2nd DFW approach controller Radio transmission from aircraft 217 HL Transmissions from DFW 3E maintenance Radio transmission from DFW Control Tower Radio transmission from DFW Ground Control Unintelligible word Non pertinent word Expletive Break in continuity Questionable insertion Editorial insertion Pause Note: Times are expressed in central daylight time (CDT).

TIME & SOURCE INTRA-COCKPIT COMMUNICATION CONTENT START OF RECORDING START OF TRANSCRIPT 0629:46 CAM-3 0629:50 CAM-2 0629:53 CAM-? 0629:57 PA-1 uh, a whole bunch of sigmets are out. OK, I'll••. I'll be••••. uh, good morning folks, Captain Kruslyak again, uh, we've begun our descent now into the Dallas Ft. Worth area. we're presently uh, a hundred and uh, thirty five miles to the west of the airport. uh, we've been in and out of a little bit of bumpy air for the last uh, fifty miles or so. uh, aircraft up ahead of us tells us that as we get into the clouds and down below 'em into the lower altitudes, it's going to be bumpy. so uh, I'm gonna ask . out flight attendants to go ahead and round everything up at this time and uh, take your seats, and, just as a precaution. our uh, radar is showing numerous • uh, areas of rain showers around the Dallas Ft. Worth area so from uh, here on in we'll be doing uh, a little bit of deviating uh, radar is working very well, so we can kinda pick our path through these cells that are up ahead of us here, shouldn't be any particular problem other than some bumpy air every once in a while. nothin' dangerous just uh, more of a nuisance than anything else. right now it looks like we oughta be landing ina uh, just about twenty five to thirty minutes from now. the weather at the airport is good uh, there are, several layers of clouds starting at about three thousand feet above the ground, and uh, visibility is seven miles with uh, just some light rain in progress at, at the present time. temperature is sixty seven degrees. TIME & SOURCE AIR-GROUND COMMUNICATION

CONTENT

....J

I TIME & SOURCE 0631 :36 CAM-2 0631 :39 CAM-? 0631 :46 CAM-2 0631 :47 CAM-1 0631 :54 CAM-? 0632 :06 CAM-1 0632:12 CAM-2 0632 :23 CAM-3 0632:27 CAM-2 0632 :28 CAM-3 INTRA-COCKPIT COMMUNICATION CONTENT couple of bulbs burned out here, so I'm gonna to test this real quick. ya, I think that's co-pilot's red side • I saw green. did ya? looks like we're gonna be taking about a, 'bout three left course correction here ••• another sixty miles or so. (are you lookin' at that one about a hundred miles) ••• yes sir.

• twelve miles **

what was the winds? one eighty at what? one eighty at seven. - - you all ready for some numbers? TIME & SOURCE AIR-GROUND COMMUNICATION

CONTENT

00

TIME & SOURCE 0632 :35 CAM-1 0632:37 CAM-3 0632 :56 CAM-? 0632 :57 CAM-? INTRA-COCKPIT COMMUNICATION CONTENT uh, yeah. OK. the top. -- two thirty one, one ninety nine, one sixty four, thirty five flaps, one forty six. and Charlie. ••• •• TIME & SOURCE 0633:08 AIR-GROUND COMMUNICATION CONTENT CT R-1 • one zero two, contact Ft. Worth center, one two seven point niner five. 0633:13 RD 0-1 twenty seven ninety five, thanks for your help. 0633:30 Ft. Worth center, American one oh two heavy out of two eight two four zero. CTR-2 American one oh two heavy, roger. --American one oh two heavy, cleared uh, Dallas/Ft. Worth cleared direct Bridgeport Boyds Two arrival. 0633:34 RD 0-1 OK uh, direct Bridgeport Boyds two arrival and uh, we're gonna wait 'til we get a little bit closer and see what it looks like on our radar, do, uh, maybe do some deviation there.

TIME & SOURCE INTRA-COCKPIT COMMUNICATION CONTENT TIME & SOURCE 0633:46 AIR-GROUND COMMUNICATION CONTENT CTR-2 they have a uh, twin engine prop penetrating the weather uh, about twenty two north of uh, Bridgeport. I'll try to get a report out of him. he's at seventeen and I'll get right back with you. 0633:57 RD 0-2 uh OK, is there a lot of traffic coming into DFW at this hour? 0634 :01 CTR-2 say again please. I was uh, on another radio. 0634 :03 RD 0-1 yeah, is there a lot of uh, traffic coming into DFW at this hour? 0634:07 CTR-2 0634:13 RD0-1 0634:28 CTR-2 0634:41 RD0-1 uh, no sir, there is not, uh. matter of fact, I'm not indicating anybody on final right now. OK, I was just wondering uh, just looking at it, it looks like there is at least a remote possibillty that you might be able to come in from the south and land to the north but uh, we'll keep an eye on it, huh? OK, I don't know if they're gonna uh, I can check with them uh, was that a request or uh, have a quick wind uh, approach uh, north landing you mean? well yea, but uh, let's wait 'til we get a little closer and look at It. the radar at this range is uh, is not really as accurate as It is when we get in uh, oh forty fifty

miles away (er).

N . o

TIME & SOURCE 0635:58 CAM-? INTRA-COCKPIT COMMUNICATION CONTENT • TIME & SOURCE 0634:59 CTR-2 0635:07 RD0-1 0635:24 CTR-2 0635:26 217HL 0635:32 CTR-2 0635:44 RD0-1 0635:54 RD0-3 0635:56 AAMT AIR-GROUND COMMUNICATION CONTENT American one oh two, roger. American one oh two, descend and maintain one zero thousand, ten thousand, Dallas/Ft. Worth altimeter two niner five one. on down to one zero thousand, American one oh two heavy. two one seven Hotel Lima, what are your uh, flight conditions? oh we've got light uh, moderate rain here and some

uh, light chop.

N - American one oh two uh, moderate chop uh, seventeen thousand the aircraft at your ten o'clock about uh, seventy miles uh, penetrating weather moderate light to moderate rain. OK, thank you. three E maintenance. American one zero two. this is huh, this is maintenance, go ahead.

TIME & SOURCE 0636:39 CAM-2 0636:46 CAM-1 0636:57 CAM-2 0637:00 CAM-1 0637:04 CAM-2 0637:05 CAM-1 INTRA-COCKPIT COMMUNICATION CONTENT •• it's raining that stuff doesn't look that bad •• eighty three miles from the airport, on our nose -- looks like if we jog around to the left,••• an opening. which opening *****? •• twenty degrees? well yea, I'm looking, look on your eighty mile scope, -- uh, we're eighty miles out right now. you see that space that that 'bout seventy eight miles from here? TIME & SOURCE 0635 :59 AIR-GROUND COMMUNICATION CONTENT RDO - 3 uh, American one zero, two, aircraft uh one thirty nine uh, we've got just a couple of minor cabin items and uh, our right uh, gear uh, indicating uh, light capsule, the lower half of it's burned out 'n, that's it. 0636:15 AAMT OK, sir, you're cutting out, I didn't get your aircraft number or your gate assignment. 0636:20 RDO - 3 OH, uh, it's aircraft one three nine, gate twenty nine. 0636:28 AAMT one thirty nine, gate twenty nine, you have a g --- 0636:32 RDO-3

OK thank you, American one oh two.

N N

TIME & SOURCE 0637:19 CAM-2 0637:21 CAM-1 0637:39 CAM-2 0637:40 CAM-1 0637:55 CAM-3 0637:58 CAM-1 0637:59 CAM-3 0638:00 CAM 0638:03 CAM-? 0638:08 CAM-? INTRA-COCKPIT COMMUNICATION CONTENT • you're looking at yellow scud, you're not looking at anything that even approaches red, so and it's kinda centrally located. then you've got that area there, and then you've got another area, at the eighty mile point there. we'll look at it when we get a little bit closer and see what the best ••• is that***? I think right now 'bout that eighty five mile or seventy five mile point, you can just about go right in there with nothing more than some bumpy air. ••• uh, you want to carry some engine heat uh, Ken down through there? yea, whenever we need it. • ((sound of three clicks)) ••• (we've got about seventy two miles) ••• TIME & SOURCE AIR-GROUND COMMUNICATION CONTENT

TIME & SOURCE 0638:17 CAM-? 0638:21 CAM 0638:26 CAM-1 0638:36 CAM-? 0638:38 CA_M-3 0638:46 CAM-2 0639:53 CAM-1 0639:54 CAM-2 0639:54 CAM-1 0640:18 CAM-? 0640:22 CAM-1 INTRA-COCKPIT COMMUNICATION CONTENT •• twenty nine sixty ••• •• uh, call • and make sure they're all sitting down back there, would ya? alright. ** are you all down •• I can't tell now ... • you're picking up the red aren't you? yep. OK, that's what I'm doing I'm trying to, whatever the stuff is, wherever the heavy stuff is, it's down low, I'm searching level right now, and uh, I wanted to see where t_tie red is on here, and then go from there. right now, we're sixty miles from the airport on our uh, ten degrees to the right. •••• ** red should be a really bad cell. well, I'm searching low right now. gettin' up to where we're looking at ••• TIME & SOURCE AIR-GROUND COMMUNICATION CONTENT

TIME & SOURCE 0640:46 CAM-1 0641 :01 CAM-2 0641 :03 CAM-1 0641 :20 CAM-2 0641 :22 CAM-1 0641 :23 CAM-2 0641 :27 CAM-.? 0641 :39 CAM-2 0641 :40 CAM INTRA-COCKPIT COMMUNICATION CONTENT that's really what we're looking at right there.

• I think I'm goin' to go through this at what about, two

fifty? yea, I'd, I'd go ahead. one oh eight outbound. se.y what? one oh eight's the outbound course ** Bridgeport. ** ((concurrent with previous statement)) out of eleven for ten and it's armed. ((sound of alert horn similar to altitude alert)) AIR-GROUND COMMUNICATION TIME & SOURCE 0640:48 CONTENT CTR-2 American one oh two, radio check. 0640:51 RD 0-1 you're loud and clear. 0640:52 CTR-2 'kay.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 0641 :43 CAM-? ••• 0642 :08 R00-1 are you gettin' any movement on this stuff uh, American one oh two? 0642 :12 CTR-2 American one oh two uh, no sir, let me check uh, with people were here all night. not of any significance, American one oh two. 0642:23 CAM ((sound of loud rumble)) 0642:24 CAM-? #, that was a good one.((concurrent with following

transmission))

N °' 0642:28 RD0-1 say It again? 0642:29 CTR-2 not of any significance uh, It's pretty much uh, static. 0642:33 RD0-1 OK. 0642 :37 CTR-2 how's the ride so far? 0642:38 RD0-1 well, It's been good so far, we just had a big blast of lightning and. 0642:47 CAM-3 everything appears to be functioning ••••

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 0642 :51 CTR-2 uh, you say you took a big blast or you say uh, see a lot of lightning. 0642 :54 RD0-1 ah, just one one big shot of lightning, we didn't take it though uh, I don't suppose there is any chance of uh, landing to the north, huh? 0643:03 CTR-2 uh, I doubt it but I will forward that request. 0643:05 RD0-2 yeah, we're going to have to make a decision here in just a few miles. 0643:26 CTR-2

OK. ---- American one oh two contact Regional

N approach, American one oh two, descend and -..J maintain niner thousand, contact Regional approach one two five point eight, they do have your request. 0643:33 RD0-1 twenty five eight, down to nine thousand, American uh, one oh two. 0643:37 CAM-2 nine thousand set and armed. 0643:38 CAM-1 what's your, what's your? 0643:39 CAM-3 Charlie. --- altimeters baro?

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 0643:41 RDO-1 uh, approach, American, one oh two heavy, Charlie uh, descending through ten to nine. 0643:47 CAM-1 I'm going to go to over override and air start. 0643:52 CAM-? (*** check right ignition loop) 0643:52 APR-1 (was there) American one zero two heavy calling approach? 0643:54 RDO-1 yes uh, we're descending from ten to nine, did you get our request for Ian uh, possibility of landing to - the north? N 00 0643:58 APR-1 American one zero two heavy, I have your request, right now we're uh, checking upstairs. they've got quite a few departures lined up to takeoff southbound so I wouldn't uh, count on three six. now you can plan on a uh, south landing and if we do get a north landing I'll let you know. you can descend and maintain five thousand. did you have information Echo? 0644:05 CAM ((sound of alert horn similar to altitude alert, concurrent with previous transmission.)) 0644:14 RDO-1 yeah, we've got Echo, uh standby, we'll get, never, disregard, we're getting, uh we're gonna have to go ,i around to the left then uh, to deviate around this 't stuff, we're gonna have to go about uh, oh, fifty ,· degrees or so to the left. l ..

TIME & SOURCE INTRA-COCKPIT COMMUNICATION CONTENT TIME & SOURCE 0644 :26 APR-1 0644:29 RD0-1 0644 :33 APR-1 0644 :35 RD0-3 AIR-GROUND COMMUNICATION CONTENT one five, fifteen degrees or five zero, fifty? five zero. American one zero two heavy, roger, yeah you can deviate as necessary. you want to turn to a heading of zero five zero, is that it? ((starts concurrent with previous transmission and next five statements or transmissions)) DFW airport arrival information ECHO. the one one three five Zulu special. measured ceiling one thousand four hundred overcast. visibility two and one half, thunderstorms rain showers and fog. temperature, six seven, dew point six five. wind two two zero at six, altimeter two niner four eight. thunderstorms in all quadrants, moving northeast. frequent lightning in clouds, cloud to cloud, cloud to ground. pressure's falling rapidly. attention all aircraft, convective sigmet four one central, four two central , four four central and four five central affects the DFW area. ILS runway one seven left, one eight right approaches in progress. aircraft arriving over Bridgeport or Acton can expect one eight right. aircraft arriving over Blue Ridge • can expect runway one seven left. notice to airmen. runway one seven right threshold displaced four hundred and twenty feet. runway one seven right glideslope is out of service. read back all runway hold short instructions. advise approach control you have Echo.

TIME & SOURCE 0645:10 CAM-? 0645:10 CAM-? 0645:31 CAM-1 0645:51 CAM-2 0645:54 CAM-? 0646:02 CAM-? 0646:24 CAM-3 0646:49 CAM-1 INTRA-COCKPIT COMMUNICATION CONTENT ** yeah that's heavy •• everything's high now. I don't know what the# happened with this radar. ... (is it not working or is it working?) all that line that we passed through ** •• right straight down ** .. --- OK -- Echo, fourteen hundred overcast, two and a half miles visibility, uh, winds, two two zero at six, uh, twenty nine forty eight, lightning cloud to cloud, cloud to ground, uh, thunderstorms moving northeast and pressure falling rapidly. OK. -- • twenty frve to the right, twenty eight miles, twenty twenty eight ** TIME & SOURCE 0644:39 AIR-GROUND COMMUNICATION CONTENT RDO-1 negative, it'll be a heading of about uh, zero seven five or so. 0644:44 A PR -1 American one zero two heavy roger, you can deviate as necessary. 0644:47 RDO-1

thank you.

v,) 0

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 0647:06 CAM-2 verification 0647:07 CAM-3 uh, they're giving (now) an altimeter now of twenty nine forty eight. 0647:11 CAM-? •• 0647:13 CAM-1 forty eight OK, 0647:14 CAM-? I don't dis***

0647:17

v,) CAM-1

OK, how we doing on our altitude?

0647:18 CAM-2 we're cleared to five thousand. 0647:21 CAM-?

0647:23 APR-1 American one zero two heavy, descend and maintain three thousand. 0647:26 RD0-1 down to three, American one oh two heavy. 0647:41 CAM-1 why don't we go ahead and get'er on down and we'll have a better choice at getting down below this stuff. 0647:45 CAM-2 I'm going to slow down and, and ••

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 0647:58 APR-1

• everyone landing at DFW, the weather now is

measured ceiling one thousand four hundred overcast, visibility two and one half, thunderstorms rain showers, fog, wind one four zero at one one, altimeter two niner four niner, and uh, expect south landing. 0648:25 CAM-3 thrust computer? 0648:29 CAM-2 set go-around. 0648:30 CAM-3

OK, altimeters?

v.) 0648:33 N CAM-1 uuuh, let's see, whats we got, twenty eight? 0648:37 CAM-3 the conversion is twenty eight, eighty four. 0648:41 CAM-1 eighty four, OK. 0648:42 CAM-2 eighty four set. 0648:45 APR-1 American one zero two heavy, contact approach now on one three two point one. 0648:49 RDO-1 thirty .two one, goodday. 0648:50 CAM-2 ** one fifty heading. that was one fifty heading.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 0648:54 CAM-1 one fifty heading or one oh two? 0648:57 CAM- 2 he said one fifty heading. 0648:59 RDO-1 who was that last transmission for? 0649:02 APR-1 go ahead? 0649:04 RDO-1 uh who was the last transmission for? 0649:05 APR-1

American one zero two heavy.

w w 0649:07 RD0-1 say it again, the frequency? 0649:09 APR-1 one three two point one. 0649:10 RD0-1 thirty two one. 0649:12 CAM-2 she said one fifty. 0649:15 RD0-1 approach, American one oh two heavy we're uh, out of four for three. 0649:23 CAM ((sound of horn similar to altitude alert.))

TIME & SOURCE INTRA-COCKPIT COMMUNICATION CONTENT TIME & SOURCE 0649 :27 AIR-GROUND COMMUNICATION CONTENT APR -2 American one zero two heavy, expect ILS runway one seven left, localizer frequency one uh, one zero point three. 0649:34 RD 0-1 one one zero three OK uh, how's it look on your scope for gettin' in there? 0649 :41 AP R- 2 American one zero two heavy, when able, fly heading one three zero. 0649 :47 RD 0-1 OK, one three zero. how's it look coming down final on your radar? 0649:51 APR -2 0650:09 well uh, I show an area of weather at, at fifteen miles either side of DFW airport proceeding uh, straight north uh fifteen miles on uh, each side uh, for about thirty miles. RD O -1 OK, can you uh, give us a good heading then to come in on? 0650:10 AP R-2 uh, well I can give you a good heading to intercept the localizer but there's weather all down the final is what I'm saying there's I don't see any openings on the final of I see a weather area all the way down the final. 0650:18 RD 0-1 OK uh, and is this stuff moving?

TIME & SOURCE 0650:31 CAM INTRA-COCKPIT COMMUNICATION CONTENT ((sound of three clicks)) TIME & SOURCE 0650:21 APR-2 0650:33 RD0-1 0650:46 APR-2 0650:54 AIR-GROUND COMMUNICATION CONTENT uh, does does not appear to be moving uh, much if any American one zero two heavy if able, turn right heading one five zero and join the runway one seven left localizer. uuh. I don't think we're goin' to be able to do that that's uh, that's a pretty big red area on our scope uh, about ninety degrees and that's about what we're looking at. uh, we're gonna have to, just go out I guess and wait around to see what's goin' on here. American one zero two heavy, eight miles south of you's a heavy DC-8 at three thousand joining uh, the final's uh, reporting a smooth ride at three. RD 0-1 oh, OK, eight miles south of us? 0650:56 APR-2 uh, about eight nine miles south, straight south of you. 0650:59 RD 0-1 OK uh, we'll head down that way then and uh, worse comes to worse we'll go out from there. 0651 :04 APR-2 OK, one zero two heavy, turn right heading two zero zero and intercept the runway one seven left localizer.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 0651 :10 RD0-1 right to two hundred and intercept the localizer. 0651 :13 CAM-2 right to two hundred. OK, (checks) 0651 :17 CAM-? yeah** 0651 :18 CAM-2 uh, slats extend please. 0651 :19 CAM ((sound of two clicks)) 0651 :28 CAM-2

slowin' to two ten.

l.,J 0651 :31 °' CAM-? yeah. 0651 :31 APR-2 *an one zero two heavy, would you like to slow down? 0651 :32 RD0-1 yeah, we're gonna bring 'er way back. 0651 :33 APR-2 OK. 0651 :34 CAM-? ** 0651 :36 CAM-1 go ahead and and slow the thing on down uh 0651 :40 CAM-2 flaps ten degrees.

TIME & SOURCE 0651;43 CAM 0651 :46 CAM 0651 :48 CAM-3 0651 :54 PA-1 0651 :58 CAM-2 0652:02 CAM 0652:09 CAM-3 0652:10 CAM-1 0652:20 CAM-2 0652:22 CAM 0652:26 CAM-1 INTRA-COCKPIT COMMUNICATION CONTENT ((sound of three clicks)) ((sound of horn similar to landing gear warning horn)) flight instruments and bugs? uh, flight attendants uh, prepare for landing. we're gonna be on the ground uh, in just about uh, about five six minutes from now and it uh, could be bumpy from here on in so just if you would, stay in your seats please. · flaps fifteen, please. ((concurrent with previous PA-1)) ((sound of horn similar to landing gear warning horn concurrent with PA-1)) flight instruments and bugs? uuuh, they're set and cross checked, let's see ten three? one ten three. -- don't have •• ((sound of horn similar to landing gear warning horn)) this is for the left runway, right? TIME & SOURCE AIR-GROUND COMMUNICATION

CONTENT

vJ --..J

TIME & SOURCE 0652:28 CAM-2 0652:29 CAM-1 0652:32 . CAM-? 0652:58 CAM-2 0653:01 CAM-1 0653:08 CAM-2 0653:12 CAM-1 0653:20 CAM-? INTRA-COCKPIT COMMUNICATION CONTENT one seven left. ••• I mean one*, one, seven (identified) if anybody sees anything that looks like windshear, let me know. yeah, don't be afraid to carry an extra ten to fifteen knots on final, and then slow down when we get close. that's what I'll do. *** we oughta be getting out of this stuff, most of this stuff (looks) high here. •••• TIME & SOURCE 0652:40 APR-2 0652:49 R00-1 AIR-GROUND COMMUNICATION CONTENT American one zero two heavy, you're uh, one two miles from the outer marker, maintain three thousand 'til established on localizer, cleared ILS runway one seven left approach. we're cleared for the one seven left uh, ILS

approach, American uh, one oh two heavy.

vJ 00

TIME & SOURCE 0653:31 CAM-2 0653:32 CAM 0653:42 CAM-2 0653:46 CAM-1 0653:50 CAM-3 0653:51 CAM-1 0653:53 CAM-? 0653:54 CAM-? 0653:55 CAM-? INTRA-COCKPIT COMMUNICATION CONTENT flaps twenty two please. ((sound of click)) • do you think that was a lightning strike, or was that just uh -- uh, it's hard to tell, we probably oughta go ahead and tell 'em that -- it's a possibility. yeah. -- I've been hit twice and that's what it looks like. yeah. •• I've never been hit. I've seen things like that before but it's • hard to tell. TIME & SOURCE 0653:20 AIR-GROUND COMMUNICATION CONTENT AP R-2 American one zero two heavy, uuh, say your flight conditions. 0653:24 RD 0-1 uh, we're in the clouds it's uh, just uh, little ripple, in

uh, pretty good size rain out here.

w ""

TIME & SOURCE 0654:35 CAM-1 0655:08 CAM-1 0655:17 CAM-2 0655:31 CAM-1 0655:43 CAM 0655:53 CAM-2 INTRA-COCKPIT COMMUNICATION CONTENT ** identified. -- yeah, localizer's comin' alive. I don't think this is going to be any problem ** about a * fifteen knot variation. -- it's all hooked up right now. uh, gettin' a pretty good spike on the airspeed. ((sound of horn similar to landing gear horn concurrent with pervious transmission)) landing gear down. --- add fifteen knots to one forty six. AIR-GROUND COMMUNICATION TIME & SOURCE 0655:36.95 CONTENT RD O -1 anda, American one oh two heavy, in our position here, we're gettin' about a ten to fifteen knots uh, fluctuation on our airspeed. 0655:45 AP R-2 was that gain or a loss? 0655:47 RD 0-1 uh, that's mostly a gain. 0655:50 APR-2

American one zero two heavy, roger.

~ 0

TIME & SOURCE 0656:17 CAM 0656:18 CAM-? 0656:33 CAM-2 INTRA-COCKPIT COMMUNICATION CONTENT ((sound of clank)) four green no red. ((concurrent with previous transmission)) gear's down four green. TIME & SOURCE 0656:01 APR-2 0656:18 RD0-1 0656:20 AIR-GROUND COMMUNICATION CONTENT ((concurrent with previous statement and two following statements)) American one zero two heavy, • I just got a report from the heavy DC-8 that landed on_ runway one eight right, reported a plus or, minus uh, one zero knots at the outer marker and a plus or minus uh, five or a minus five, excuse me, at a, or at the, uh, on short final for one eight right. OK, thank you. AP R-2 American one zero two heavy, how's your ride now? 0656:22 RD0-1 well we're gettin' uh, light an occasionally moderate chop. 0656:26 APR-2 American one zero two heavy, contact tower now, one two six point five five. 0656:28 RD 0-1

twenty six fifty five, good night, thanks for your help.

~ ....

TIME & SOURCE 0656:38 CAM-3 0656:48 CAM-3 0656:49 CAM-1 0656:50 CAM-2 0656:59 CAM-1 0657:03 CAM-2 0657:11 CAM-3 0657:13 CAM-1 INTRA-COCKPIT COMMUNICATION CONTENT anti-skid, checked and on. spoiler handle? armed. ((sound of click and thud)) flaps thirty ftve, please. (( sound of click)) -- I'm goin' to maintain one sixty for my final speed. that'll be good. -- if you need the wipers, just holler for the wipers, if you need Dave *** never mind. ((concurrent with previous statement)) flight guidance system and radios. uh, they're, they're set. TIME & SOURCE 0656:35 AIR-GROUND COMMUNICATION CONTENT R D 0-1 tower, American one oh two heavy, nine and a half out for one seven left. 0656:39 T W R-1 American one zero two heavy Regional tower, * one seven left, cleared to land, wind calm. 0656:42 RD 0-1 cleared to land, one seven left, American one oh two heavy.

TIME & SOURCE 0657:21 .50 INTRA-COCKPIT COMMUNICATION CONTENT CAM ((sound of intermittent audio tone similar to outer mari beacon)) 0657:23 CAM-2 mari seventeen* ((concurrent with following statement)) 0657:27 CAM-1 mari seventeen hundred. 0657:49 CAM-2 need the wipers for a few seconds** 0657:50 CAM-1 alright definitely. 0657:52 CAM-2 0657:54 CAM-1 0657:57 CAM 0658:06 CAM-1 0658:11 · CAM-3 0658:12 CAM-? 0658:14 CAM-1 go ahead. we're goin' to clean those windshields off. ((sound similar to windshield wipers)) thousand, feet, thirty five, thirty five and land. before landing checklist complete. * (there's) runway lights are in sight, we're goin' to lose them in a second here. TIME & SOURCE AIR-GROUND COMMUNICATION CONTENT

TIME & SOURCE 0658:38 CAM-3 0658:39 CAM-1 0658:45 CAM-1,, 0658:53 CAM-4 0658:55 CAM-1 0658:59.15 INTRA-COCKPIT COMMUNICATION CONTENT OK, there's five hundred. runway lights in sight. ---- pretty good right crab. there's uh, five hundred now, and plus about ten. -- there's four hundred. traffic. three hundred. CAM-1 there's two hundred. 0659:03.19 CAM-1 I've got a plus ten sinking a thousand. 0659:05.92 CAM-1 there's one hundred. 0659:12.21 CAM-4 one hundred. 0659:16.16 CAM-4 fifty. 0659:17.03 CAM-2 I'm gonna go around. 0659:17.93 CAM-1 no no no I, I goU. 0659:19.45 CAM-2 you got the airplane. TIME & SOURCE AIR-GROUND COMMUNICATION CONTENT -t

INTRA-COCKPIT COMMUNICATION TIME & SOURCE 0659:19.76 CONTENT CAM-4 thirty. ((concurrent with last word in previous statement)) 0659:22.68 CAM-4 twenty. 0659:27.88 CAM-4 ten. 0659:29.73 CAM ((sound of thump similar to aircraft touchdown)) 0659:31 .63 CAM ((sound of another thump)) 0659:33.69 CAM-? 0659:34.05 CAM-3 all green. 0659:36.64 CAM-2 OK, hundred and twenty knots. 0659:38.15 CAM-1 oh#. 0659:41 .40 CAM-2 hundred knots. 0659:43.44 CA M-2 OK, we're off the grass. 0659:45.54 CAM-2 eighty knots. TIME & SOURCE AIR-GROUND COMMUNICATION CONTENT

TIME & SOURCE 0659:48.01 INTRA-COCKPIT COMMUNICATION CONTENT CAM-? gosh darn. 0659:50.20 CAM ((sound of horn)) 0659:53.09 CAM-?

0659:53.09 CAM-1 emergency evacuation. 0659:54.45 CAM ((sound of continuous horn)) 0700:04.23 CAM ((sound of warbling horn similar to evacuation horn)) 0700:09 CAM-1 0700:13 CAM-3 0700:15 CAM-? 0700:15 CAM-? OK, check list. evacuation check list.

easy victor, easy victor, easy victor. TIME & SOURCE 0659:56.91 AIR-GROUND COMMUNICATION CONTENT RD 0-2 evacuate? -- alright tower uh, American one zero two, we entered a slide uh -- 0700:07 RD 0-2

• and we're evacuating.

' f-1 ~ • TIME & SOURCE 0700:15 CAM-3 0700:18 CAM-3 0700:19 CAM-2 0700:21 CAM-3 0700:22 CAM-? 0700:23 CAM-? 0700:24 CAM-3 0700:25 CAM-1 0700:27 CAM-3 0700:28 CAM-1 0700:29 CAM-3 0700:30 CAM-? 0700:32 CAM-? INTRA-COCKPIT COMMUNICATION CONTENT sound evacuation, call the tower? outflow valve? tower's already been called. ((concurrent with previous statement)) outflow valve check spoiler handle full forward. closed. ((concurrent wtth the word "check" above)) it's open. spoiler handle? full forward. brakes parked? checked. fuel levers? fuel levers off. ••• TIME & SOURCE AIR-GROUND COMMUNICATION CONTENT

TIME & SOURCE 0700:32 CAM-3 0700:34 CAM-1 INTRA-COCKPIT COMMUNICATION CONTENT power switch on? spoiler handle won't stay closed. END of RECORDING END of TRANSCRIPT TIME & SOURCE AIR-GROUND COMMUNICATION

CONTENT

~ 00

149 APPENDIXD DFW TOWER/TRACON TRANSCRIPT U.S Deportn e 11 ~ TrCJ"ISPOl'10IIOl'l federalAvlatk>n Admlnlstratton Sub~c• INFORMATION: Transcription concerning Memorandum Dallas-Fort Worth Tower/TRACON P.O. Box 610368 DFW Airport, TX 75261 Date April 28, 1993 the accident involving AAL102 Heavy DClO on April 14, 1993 at 1200 UTC From Dallas-Fort Worth Tower /TRACON Aepty to Attn OI To This transcription covers the time period from April 14, 1993, 1138 UTC to April 14, 1993, 1208 L'TC . Agencies caking transltlssions American Airlines Flight 102 Delta Airlines Flight 1438 Si=ons Aviation Simmons Aviation Mai tinai:re Executive Flight DlO Feeder ~est Position TRACON DlO Arrival Radar Two Position TRACON DlO Dallas North Position TRACON DlO ~:eachatt North Position TRACON DlO Departure Radar One TRACON DF,,; Local Control East TOWER DF~ Local Control West TOWER Fort Worth Center ARTCC Airport Operations Vehicle t:nkno1o,n Abbreviations AAL102 DAL1438 SYM730 SYM874 MRA657 EXElOl FW AR2 DN MN DRl LCE LCT ZFW Port 110 Ul-'KN I hereby certify that the following is a true transcription of the recorded conversations pertaining to the subject Aircraft Accident : Robert T, Allen Quality Assurance Specialist April 28, 1993

(1 138 ) (1139) (1140) (1141) (114 2) (11 43) 1143: 05 1143 :08 1143: 09 11 43 :1 8 1143:37 1143 : 46 1143:48 1143 : 55 (1144) 1144:12 1144 : 14 ZFW ZFW AALl 02 AAL1 02 n.· AAL102 M.Ll02 150 Feeder West on the ten Feeder West American one o two would ah has ah requested a north landing three five or three six your control Thank you PM Approach American one o two heavy charlie descending from ten to nine Was that American one zero two heavy calling approach Yes were descending from ten nine did you get our request for land possible to the landing to the north Am~rican one zero two heavy I have your request right now we are ah checking upstairs they've got quite a few departures lined up to take off south bound so I wouldn't count on three six for now you can plan on ah a south landing and if we do get a north landing I'll let you know you can descend and maintain five thousand did you have information echo Yeah we got echo Stand by disregard we're going we're soing to have to go around to the left and ah to deviate around this stuff we're going to have to go around fifty degrees or so to the left

1144:20 1144:21 1144:31 1144:37 1144:4 2 114 4:44 (11 45) 1145 :44 114 5 :L.7 11 45 :49 11 45 :5 5 11 45:5 7 1145:58 1145:59 (1146) (1147) 1147:12 AAL102 AAL102 AAL1 02 Zf",; n: ZFW n: 151 One five fifteen degrees or five zero fifty Five zero American one zero two heavy roger you can deviate if necessary you want to turn to a heading of zero five zero is that it Negative it would be a heading of about zero seven five or so American one zero two heavy roger you can deviate as necessary Thank you Feeder west Acton ten Feeder West Simmons seven thirty says he needs that heading for about another eight miles on a zero eight zero heading to join your approval That's fine with me but that's Meacham's airspace Yeah I'll point him out to Meacham Ok thank you MY ?-1eacham's

1147:14 1147:16 1147: 22 1147: 24 1147:39 1147: 4~ 11 47 : 45 11 47 : 46 11 47:47 11 4i :55 (11 48 ) 11 46 :1 4 1148 :17 1148 :4 3 1148 : 46 FW U?-l"KN AAL102 ZFW n: Ztt' SD !7 30 SYl17 30 AAL102 152 This is feeder west point out ten miles west of Denton American on~ zero two heavy descending to three (unintelligible) American one zero two heavy descend and maintain three thousand Down to three American one o two heavy Feeder West ten Feeder West Meacham South is watchin Simmons seven thirty and I gave him a hundred heading to join when he can Thats fine Good morning Regional approach Simmons Seven three zero is with you five thousand the last ATIS we got was Delta For everyone landing st DFW the weather now is measured ceiling one thousand four hundred overcast visibility two and one half thunderstorms rain showers fog wind one four zero at one one altimeter two niner four niner and ah expect south landing Simmons seven thirties with yeah at five grand Simmons seven thirty regional approach roger American one zero two heavy contact approach now on one three two point one Thirty two one good day

1148: 55 1148:59 (1149) 1149 :03 1149:05 11 49 :06 1149 :07 1149 :09 114 9: 32 1149 :40 li!..9:4 6 1149:48 (11 50) 11 50 :05 AAL10 2 AAL102 AALl 02 n ,; AAL102 AR2 AA:..l 02 AALl 02 AR2 AAL102 153 Who ·was that last transmission for Go ahead Who was the last transmission for American one zero two heavy Say it again the frequency One three two point one Thirty two one American one zero two heavy expect ILS runway one seven left localizer frequency one one zero point three One one zero three American one zero two heavy when able fly headin& one three zero OK one three zero hows it look comin down final on your radar ~ell I I show an area of weather at about fifteen miles either side of DFW airport proceedin& ah straight north ah fifteen miles on ah each side ah for about thirty miles OK can you ah ' give us a good heading then to come in on -· ·-·-----

1150:07 AR2 1150:16 AAL102 1150 : 23 AR2 11 50 : 30 AAL102 1150 :45 AR2 1150 :54 AAL102 1150 : 56 AR2 11 51 : 00 AAL1 02 1151 : 05 AR2 115 1: 08 AAL1 02 1151 :1 4 D~ 154 Well I can give you a good heading to intercept the localizer but there's weather all down the final is what I'm saying there's I don't see any openings on the final I see a weather area all the way down the final OK and ah is this stuff movin Ah does does not appear to be moving ah much if any American one zero two heavy if able turn right heading one five zero and join the runway one seven left localizer Ah I don't think we're going to be able to do that that's ah pretty big red area on our scope ah it's about ninety degrees and that's about what we're looking at ah we're goin to have to just go out I guess and wait around to see what's goin on here American one zero two heavy eight miles south of you the heavy DC ei6ht at three thousand join ah the finals ah reporting a smooth ride at three 0 OK ei ght miles south of us Yes sir about eight nine miles south straight south of you OK we'll head down that way then and ah we're just going to (unintelligible) out from there OK American one zero two heavy turn right heading two zero zero and intercept the runway one seven left localizer Right to two hundred intercept the localizer Dallas North

1151:19 1151 : 24 1151: 25 1151 : 27 11 51:30 11 51 : 31 (1 152) 11 52 : 39 115 2 : 47 (1 15:) 1152 : 55 11 52 :5 9 (1 153) 11 53:01 1153:0 3 115 3 : 04 AR2 DN AR2 AR2 AALl 02 AR2 AR2 AALl 02 LC\,; AR 2 LC\·.' AR2 AR2 155 Ah this is ARl point out American one o two heavy finally decided he would turn south he's at three thousand feet join he gonna try the localizer for one seven OK point out observed MJ American one zero two heavy would you like to slow down Yeah we're gonna bring it way back OK American one zero two heavy your ah one two miles from the outer marker maintain three thousand until established on the localizer cleared ILS runway one seven l~ft approach We 're cleared for the one seven left ILS approach AI;ierican ah one o two heavy Local West This is AR2 any complaints with Emery zero two two he~vy on the final Not yet and I'm tryin to get a report (unir.telligible) OK thanks MJ

1153: 21 1153: 24 (1154) (1155) 1155 : 26 1155:31 1155:34 1155:38 1155 :45 1155 :47 11 55 :50 11 55 : 51 115 5:5 3 1155:57 1155:58 (1 15 6) AR2 AA110 2 snn3o AR2 SYM730 AAl..102 AAL102 AR2 AR2 LC..' AR2 LC.: 156 American one zero two heavy ah say your flight conditions Ah we're in the clouds it's ah just a little ah ripple and ah pretty good size rain out here Hello regional approach Simmons seven thirty is with you descending four for three Simmons seven thirty regional approach good morning expect ILS runway one eight right One eight right for seven thirty thank you And ah American one o two he~vy in our positions here we're getting about ah ten to fifteen knot ah fluctuation on our airspeed Gain or a loss Ah it's it's mostly a gain American one zero two heavy roger Go ahead override Plus or minus ter. at by the outer marker and ah plus or minus five right short final Thank you a DC eight GY

1156 :02 1156: 18 1156:21 1156: 24 1156:25 1156:28 1156:30 1156 : 36 1156:39 1156:44 (1157) 1157:22 115i: 27 AR2 AAL102 AR2 AAL1 02 AR2 AAL102 AR 2 AAL102 LCE AALl 02 SY}:874 LCE 157 American one zero two heavy I just I just got a report from the heavy DC eight that landed on runway one eight right reported a plus or minus one zero knots at the outer marker and a plus or minus ah five minus five excuse me at ah at the ah short final for one eight right OK thank you American one zero two heavy how's your ride now 0 we're getting ah light and occasionally moderate chop Air.erican one zero two heavy contact tower now one two six point point five five Twenty six fifty five good night thanks for your help Your welcoc;e Tower American ah one o two heavy nine and a half out for one seven left American one zero two heavy regional tower runway one seven left cleared to land wind calm Cleared to land one seven left American one o two heavy Regional tower Simmons eight seventy four is with you lLS one seven leit Si1I1I.1ons eight seventy four regional tower number two cleared to land runway one seven left wind calm caution wake turbulence following a heavy DC ten

1157 : 34 (1158) 1158: 31 11 58: 33 1158:38 1158:45 11 56:46 1158 : 53 1158 :57 (1159) 1159 :05 1159:07 1159:25 1159 :30 11 59:36 1159 :40 SY11874 DAL1438 LCE DAL1438 DAL1438 DAl..14 36 LCE EXE 101 LCE DAL1438 DAL1438 LCE 158 OK cleared to land ah one seven left Simmons eight seventy four And Delta fourteen thirty eights ready Delta fourteen thirty eight runway one seven right taxi into position and hold Ah position and hold Delta fourteen thirty eight And Delta fourteen thirty eight which way are you heading Goin north Can you give a PIREP ah to departure some way we'd appreciate it .:e will Exec one zero one runway one three left taxi into position and hold Position and hold Exec one o one Delta fourteen thirty eight change your departure frequency that will be one one eight point five five Eighte~n ah fifty five It looked clear out ah to the west now I'm sorry say again

1159:43 1159 :45 1159: 58 (1 200) 1200 :07 120 0 :09 1200 : 11 1200 :15 1200 :1 8 12 00 :20 1200 :28 1200: 34 DAL1 438 LCE DAL1 438 LCE: DAL1438 LCE D;..U 4 38 LCE LCE LCE LCE 159 Ah does it look ah clear out to the west for fourteen thirty eight I'm not painting anything on radar they got ah weather reduction ah kicked in on our radar so I'm not showing anything and up here in the tower it looks ah heavy rain everywhere OK on our radar it looked pretty heavy out to the east and up to the north but ah turning south on the runway here it ah it doesn't look too bad out to the west OK what are you saying you'd like to do Like to go west Give me a heading 0 about two forty initially and then we'll wo rk our way around Al right standby American oue zero two heavy cross runway one seven right ~ erican one zero two heavy Aoerican one zero two heavy

1200 :41 1200:45 1200:50 1200:53 (1201 ) 1201:15 1201 :33 1201 : 36 1201 : 38 120 1 :4 0 1201 : 48 120 1:50 1201:50 120 1: 50 LCE SYM874 LCE LCE DR l DR l DF.. l LCE Port 11 0 DRl LCE DRl SYM87 4 160 Simmons eight seventy four go around climb and maintain two .thousand Eight seventy four American one zero two heavy can you hear OK we're calling the equipment we can see a fire in the vicinity of your aircraft we can't tell where it's coming from but we do see flames from the tower cab From fort y east of McAlester to forty south south west of McAlester Possible in the Texas portion DR one Local east handoff over the airport Simmons eight seventy four ah go around we got a aircraft on fire on runway one seven left an the runway is unusable at this time he's ah heading ah runway heading two thousand Regional tower Port one ten Alright this is DRl your calling OK Yeah OK (unintelligible) Tower eight seventy four you want us over to ah departure

1201:53 1201:58 (1202) 1202:05 1202:08 1202:20 1202 :23 (1 203) (12 04) 1204 : 23 1204 :38 1204:40 1204 :43 (1205) (1206) (1207) LCE SYI-1874 Port 110 LCE Port 110 LCE LCE DAL1438 EXE101 161 Simmons eight seventy four fly heading one seven zero and contact departure one one eight point five five Seven one eighteen five T five Regional tower port one ten Port one ten we're showing everythinb closed down on the east side of the airport aircraft is on fire on runway one seven left DC ten American one zero two heavy is the call sign Roger the airport is closed clear the bridges Roger Exec one zero one and Delta fourteen thirty eight I'm not gonna be able to let you go and it's gonna be a little while if you want go ahead and shut down in position that's fine with me I don't have any estimate as to when we'll get you goin again Ah iourteen thirty eight roger Exec one O one seven ninety eight

1207:24 LCE 162 Attention all aircraft convective SIGMET forty eight central valid until thirteen fifty five ZULU from forty miles east of McAlester to forty miles south· southwest of McAlester to twer1ty miles south of Waco to thirty miles west northwest of San Antonio line of severe thunderstorms twenty miles wide movin6 from two seven zero at two five tops above flight level four five zero tornadoes hail to three inches wind gust to seventy knot& possible End of Transcript

163 APPENDIXE ANTISKID SYSTEM The accident airplane's antiskid system components, including components found between the airplane and high speed taxiway 3S, were removed from the accident site and tested at the manufacturer, Aircraft Braking Systems, under Safety Board supervision. There were no faults found with the wheel speed transducers used for antiskid and the deployment of the spoilers, or with the antiskid system control box. The operator's DC-10-30 Maintenance Manual shows that the airplane was equipped with 20 antiskid pressure control valves, mounted in 6 manifolds. Each valve controlled half of the brake assembly for each main landing gear wheel. Testing found that 16 of the valves responded to electrical signal applications, signal step changes, and signal releases. One valve was found inoperative, and three were found with damaged or missing motor caps, which prevented their testing. Five of the 16 valves were found to be out of tolerance in electro-hydraulic tests. Test personnel from the system manufacturer noted that each of the five out-of-tolerance valves would "make it less likely for the affected wheel to skid." Three of the remaining valves were not able to be tested, and one valve, when tested, resulted in no response. The valve, which did not respond to test stimulus, had been removed from the center gear manifold and was found in the "pressure released" condition. System manufacturer engineers stated that failure in the "pressure released" condition should prevent pressurization of the brake half controlled by that valve. The hydraulic fuses in each manifold passed acceptance test criteria. The antiskid control system manufacturer had previously recognized a possibility of corrosion of the control wiring within the hydraulic manifolds. Aircraft Braking System issued a Service Letter (DC-10-10-SL-9 and DC-10-30/40- SL-8), dated March 15, 1979, which stated that corrosion, uncorrected, could result in the antiskid built-in test equipment (BITE) identifying an inappropriate valve circuit malfunction. They noted that loss of a wire could diminish pressure release to the associated half of a wheel brake on the affected main landing gear (left, centerline, or right). When antiskid manifold, SIN 71-104, was disassembled, the connector and connector wiring were found corroded. However, the electronic control unit had not identified and stored fault infonnation from the system BITE.

164 The airplane wmng diagram showed use of an air-ground sensing circuit in the airframe antiskid wiring. The mechanical and electrical portions of the circuit functioned according to design when inspected after the accident.

• ) 165 APPENDIXF SELECTED WEATHER RADAR DATA Advected 3-D Doppler Radar 39 dBZ Isosu1face for 0659

Doppler Radar Data for 0656:10 and 0701:56 VIP Levels 1 & 2 = Shades of Green; VIP Levels 3 & 4 = Shades of Yellow;

VIP Levels 5 & 6 = Shades of Red; Arrows Indicate LL WAS Wind Vectors

O"I O"I

,-- ~ f: U)

;

ASR-9 Weather Radar Images for 0659:40 and 0700:07 Depicting Weather Echoes of 1 - 6 Intensity Levels; VIP Levels 1 & 2 = Shades of Green; VIP Levels 3 & 4 = Shades of Yellow; VIP Levels 5 & 6 == Shades of Red; Arrows Indicate LL WAS Wind Vectors at 10-Second Intervals

FD07163 ｜ 1994_美国_NTSB_PAB9802_Fire_and_Explosion_Midwest_Gas_Company.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1994 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Pipeline Accident Number: DCA-95-MP-001 Type of System: Gas distribution Accident Type: Explosion and Fire Location: Waterloo, Iowa Date and Time: October 17, 1994; 10:07 a.m. local Owner/Operator: Midwest Gas Company1 Fatalities/Injuries: Six fatalities and seven non-fatal injuries Damage: $250,000 Material Released: Natural Gas Pipeline Pressure: 25 pounds per square inch, gauge (psig) Component Affected: 1/2-inch plastic pipe at steel tapping tee mechanical compression connection to steel main

1Because of a series of organizational changes and mergers, the name of the owner/operator of the gas system at Waterloo, Iowa, has changed over the years. In 1971, Iowa Public Service Company installed the gas service that ultimately failed. At the time of the accident, the gas system operator was known as Midwest Gas Company, while the current operator’s name is MidAmerican Energy Corporation. The Accident At 10:07 a.m. central daylight savings time on Monday, October 17, 1994, a natural gas explosion and fire destroyed a one-story, wood frame building in Waterloo, Iowa. The force of the explosion scattered debris over a 200-foot radius. Six persons inside the building died, and one person sustained serious injuries. Three persons working in an adjacent building sustained minor injuries when a wall of the building collapsed inward from the force of the explosion. The explosion also damaged nine parked cars. A person in a vehicle who had just exited the adjacent building suffered minor injuries. Additionally, two firefighters sustained minor injuries during the emergency response. Two other nearby buildings also sustained structural damage and broken windows. Site Information The destroyed building was a neighborhood tavern known as Buzz’s Bar. Adjacent to and east of the bar was Woodland Pattern Company, which was provided gas service by a 1/2-inch- diameter plastic polyethylene service pipeline. The service pipeline was installed by Iowa Public Service Company on September 3, 1971, and was operated at a maximum pressure of 25 psig.

2 The underground pipeline connected with the steel gas main and entered the Woodland Pattern Company building between Buzz’s Bar and the Woodland Pattern Company. The area between Buzz’s Bar and Woodland Pattern Company was unpaved and, according to those familiar with the location, was regularly used by beer trucks making deliveries to Buzz’s Bar and by semitrailers delivering materials to Woodland Pattern Company. These trucks had been seen to drive over the area of the piping assembly that cracked. At various times, beer trucks servicing Buzz’s Bar had been observed to park directly over the location of the pipe break. One witness stated that a beer delivery truck had been parked over the area of the pipe break at approximately 7:00 a.m. on the day of the accident. Excavations following the accident uncovered a 4-inch-diameter steel main at a depth of about 3 feet. Welded to the top of the main was a steel tapping tee with markings indicating that the tee had been manufactured by Continental Industries, Inc. (Continental). Connected to the steel tee was a 1/2-inch-diameter plastic service pipe leading to Woodland Pattern Company. Markings on the plastic pipe indicated that it was a medium-density polyethylene material manufactured on June 11, 1970, in accordance with American Society for Testing and Materials (ASTM) standard D2513, and marketed by Century Utility Products, Inc. (Century). A circumferential crack through the plastic pipe was found at the tip of the tee’s internal stiffener that protruded beyond the tee’s coupling nut. A 1- to 2-foot-diameter “hard ball” surrounded the cracked pipe.2 Because Safety Board investigators did not arrive at the accident site until after excavation of the failed pipe, investigators had to consult several sources to determine the condition of the piping at the time of excavation. Photographs of the excavation, a Waterloo Fire Department video tape, and several witnesses all indicated that the downstream portion of the plastic pipe was found broken off and vertically displaced below the plastic pipe portion still attached to the steel tee. However, an Iowa State Fire Marshall’s Office investigator, who directed and participated in the excavation, reported that the pipe was displaced by the excavation activities. That investigator also reported no observed voids in the soil under the failed assembly. Service-to-main connection at site of Waterloo accident. MidAmerican Energy estimated that the steel tee on the steel main was installed so that the polyethylene pipe exited the tee at an approximate 30° angle to the steel main. (See figure.)

2A “hard ball” is a term used in the gas industry for a soil condition where leaking natural gas over a period of time dries and hardens the soil adjacent to the leak. 4“ Dia m e te r Ste e l Ma in Ste e l Ta p p ing Te e 1/2“ Pla stic Se rvic e Pip e 32 Inc h Be nd Ra d ius ~ 30 o Service-to-main connection at site of Waterloo accident.

3 The plastic service pipe leaving the tee immediately curved horizontally. After a portion of the pipe was taken to the laboratory for testing, the bend radius was measured at about 34 inches. Based on field conditions and photos, MidAmerican Energy has estimated the original installed horizontal bend radius to be approximately 32 inches.3 This bend is sharper than currently recommended by industry guidelines for modern piping adjacent to fittings. However, a former Iowa Public Service Company employee stated that Iowa Public Service Company, in an effort to reduce the stress at the connection point, often attempted to install polyethylene services at an angle to the main to match the residual bend left after uncoiling the pipe.4 This former employee stated that no set time was prescribed to allow for complete relaxing of the pipe, but that the pipe would be placed in the ditch, and the crews would weld the tee at what they judged to be the appropriate angle, in consideration of the natural bend of the pipe. Also immediately from the tee outlet, the polyethylene bent downward. The tee outlet did not have a protective sleeve to reduce shear and bending forces at the connection. Tests and Examination Samples recovered from the plastic service line underwent several laboratory tests under the supervision of the Safety Board. Two of these tests were meant to roughly gauge the pipe’s susceptibility to brittle-like cracking. These tests were a compressed ring environmental stress crack resistance (ESCR) test in accordance with ASTM F1248 and a notch tensile test known as a PENT test that is now ASTM F1473. Lower failure times in these tests indicate greater susceptibility to brittle-like cracking under test conditions. The ESCR testing of 10 samples from the pipe yielded a mean failure time of 1.5 hours, and the PENT testing of 2 samples yielded failure times of 0.6 and 0.7 hours. Test values this low have been associated with materials having poor performance histories5 characterized by high leakage rates at points of stress intensification due to crack initiation and slow crack growth typical of brittle-like cracking. To facilitate identification, the fracture surfaces were divided into two regions, A and B, around the circumference of the failed pipe. If a cross section of the pipe, looking toward the tee, were superimposed on a clock face, region A would extend from approximately the 9:00 position up across the top and down to about 1:30, with the center of the region at about 11:15. Region B took up the remainder of the pipe surface, extending from about the 1:30 position down across the bottom and up to 9:00.

3Polyethylene pipe installed with a bend often, over time, permanently deforms in the direction of the bend. This permanent deformation partially reduces the stresses generated by the bending forces. When the pipe is released from its installation configuration, the pipe can straighten to some extent. 4MidAmerican Energy has indicated that Iowa Public Service’s plastic service pipe was received in coils from Century. After uncoiling the pipe, some residual bending remains. The amount of residual bending depends on the factory coiling conditions. 5Uralil, F. S., et al., The Development of Improved Plastic Piping Materials and Systems for Fuel Gas Distribution—Effects of Loads on the Structural and Fracture Behavior of Polyolefin Gas Piping, Gas Research Institute Topical Report, 1/75 - 6/80, NTIS No. PB82-180654, GRI Report No. 80/0045, 1981, and Hulbert, L. E., Cassady, M. J., Leis, B. N., Skidmore, A., Field Failure Reference Catalog for Polyethylene Gas Piping, Addendum No. 1, Gas Research Institute Report No. 84/0235.2, 1989, and Brown, N. and Lu, X., “Controlling the Quality of PE Gas Piping Systems by Controlling the Quality of the Resin,” Proceedings Thirteenth International Plastic Fuel Gas Pipe Symposium, pp 327-338, American Gas Association, Gas Research Institute, Battelle Columbus Laboratories, 1993.

4 The fracture in region A was located immediately outside the tee’s internal stiffener. The crack was perpendicular to the pipe wall and directly in line with the end of the tee’s internal stiffener. The inside surface of the pipe throughout region A was characterized by a circumferential impression from the tip of the tee’s stiffener. A similar impression was not found in region B. This impression was only found on the pipe segment that was still attached to the steel tee, and was not evident on any part of the pipe segment that was detached from the steel tee. Region A was characterized by several brittle-like slow crack growth fractures, each of which initiated on or near the pipe inner wall just outside the depression associated with the tip of the tapping tee’s stiffener. These slow crack fractures propagated on almost parallel planes slightly offset from each other through the wall of the pipe. As the cracks from different planes continued to grow and began to overlap one another, ductile tearing occurred between the planes, which produced a jagged appearance in parts of the overall circumferential crack in region A Thus, even though substantial deformation was observed in part of the fracture, the initiating cracks were still classified as brittle-like. Region B contained two brittle-like crack growth sections that initiated from each end of region A. Cracks from each end of region A propagated through region B on approximate 45° planes towards the tee (partially exposing the tee’s stiffener) and met at the bottom (the 6:00 position). The remaining ligament tore with visible deformation at the bottom. Laboratory comparisons showed that the fractures that initiated and grew in region A were consistent with fractures generated by long-term shear and bending forces at the end of the stiffener. The fractures in region B were consistent with a continuation of the same loading system described for region A but occurred subsequent to those in region A. The last ligament that fractured at the 6:00 position in region B was consistent with ductile tearing. Examination could not determine whether the last remaining ligament tore because of concentrated stresses prior to the excavation or because of excavation activities after the accident. Other Information Flooding was reported in the area during the summer of 1993. Midwest Gas’s most recent leak surveys, performed in March 1994, did not detect a leak in this area. Records of odorant tests performed in September 1994 and on October 17, 1994 (two and a half hours after the accident), show odorant levels that met the level required by Federal standards.6 Probable Cause The National Transportation Safety Board determines that the probable cause of the natural gas explosion and fire in Waterloo, Iowa, was stress intensification, primarily generated by soil settlement at a connection to a steel main, on a 1/2-inch polyethylene pipe that had poor resistance to brittle-like cracking.

6Federal standards require the odorant in natural gas systems to be detectable at one-fifth of the lower explosive limit, which is typically at gas/air concentrations of 0.9 to 1.0 percent and above. Adopted April 23, 1998 For additional information regarding this accident, see NTSB special investigation report Brittle-Like Cracking in Plastic Pipe for Gas Service, NTSB/SIR-98/01.

FD07164 ｜ 1994_美国_NTSB_PAR9501_Texas_Eastern_Transmission_Corporation_Natural_Gas_Pipeline.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1994 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

National Transportation Safety Board Washington, D.C. 20594

Addendum (Reconsideration Request) to:

Texas Eastern Transmission Corporation Natural Gas Pipeline Explosion and Fire, Edison, New Jersey March 23, 1994

PAR-95-01, adopted on 1/18/1995 PB95-916501

FD07165 ｜ 1994_美国_NTSB_PAR9601_UGI_Utilities_Inc_Natural_Gas_Distribution_Pipeline_Explosio.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1994 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

NATIONAL PB96-916501 NTSB/PAR-96/01 TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 PIPELINE ACCIDENT REPORT UGI UTILITIES, INC., NATURAL GAS DISTRIBUTION PIPELINE EXPLOSION AND FIRE ALLENTOWN, PENNSYLVANIA JUNE 9, 1994 / B (-) ,, ,—, ‘

6652

Abstract: On June 9, 1994, a 2-inch-diameter steel gas service line that had been exposed during excavation separated at a compression coupling about 5 feet from the wall of a retirement home in Allentown, Pennsylvania. The escaping gas flowed underground, passed through openings in the building foundation, migrated to other floors, and exploded. The accident resulted in 1 fatality, 66 injuries, and more than $5 million in property damage. In its investigation of this accident, the Safety Board identified safety issues relating to pipeline excavation damage prevention and rapid shut down of failed gas service lines. As a result of its accident investigation, the National Transportation Safety Board issued safety recommendations to the Research and Special Programs Administration, the Sates and the District of Columbia, UGI Utilities, Inc., Environmental Preservation Associates, Inc., the Governor of the Commonwealth of Pennsylvania, the city of Allentown, the International Association of Fire Chiefs, the Department of Housing and Urban Development, the Allentown Housing Authority, the Associated General Contractors, and the National Utility Contractors Association. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Information about available publications may be obtained by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 L'Enfant Plaza, S.W. Washington, D.C. 20594 (202) 382-6735 Safety Board publications may be purchased, by individual copy or by subscription, from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (703) 487-4600

UGI UTILITIES, INC., NATURAL GAS DISTRIBUTION PIPELINE EXPLOSION AND FIRE ALLENTOWN, PENNSYLVANIA JUNE 9, 1994 PIPELINE ACCIDENT REPORT Adopted: February 26, 1996 Notation 6652 NATIONAL TRANSPORTATION SAFETY BOARD Washington, DC 20594

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CONTENTS

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iv Metallurgy ............................................................................................................. 29 Phone Records....................................................................................................... 30 ANALYSIS ................................................................................................................... 31 Exclusions ................................................................................................................... 31 The Accident ................................................................................................................... 31 Emergency Response......................................................................................................... 32 Human Performance and EPAI Workcrew ....................................................................... 32 General .................................................................................................................. 32 Training................................................................................................................. 34 Preaccident Events ................................................................................................ 35 UGI Operations and Procedures........................................................................................ 35 General .................................................................................................................. 35 Excavation-Damage Prevention............................................................................ 35 Damage Notification ............................................................................................. 36 Rapid Shutdown of Failed Service Lines.............................................................. 36 Pennsylvania’s Pipeline Safety Operations....................................................................... 37 Premarking Proposed Excavations........................................................................ 37 Excavation-Damage Prevention Program ............................................................. 38 Housing Authority Standards............................................................................................ 38 Detection of Released Gas .................................................................................... 38 Rapid Shutoff of Failed Service Lines .................................................................. 39 Rapid Shutdown of Failed Service Lines.......................................................................... 40 Excavation-Damage Prevention........................................................................................ 44 CONCLUSIONS ................................................................................................................... 47 PROBABLE CAUSE ................................................................................................................... 48 RECOMMENDATIONS .............................................................................................................. 49 APPENDIX A: Investigation and Hearing.................................................................................... 53 APPENDIX B: Rapid Shutdown of Failed Service Lines............................................................. 55 APPENDIX C: Time Line of Events ............................................................................................ 79 APPENDIX D: September 28, 1995, Letter to RSPA from Safety Board.................................... 83 APPENDIX E: Gas Piping Technical Committee Excavation Damage Prevention Guidelines

v EXECUTIVE SUMMARY About 6:45 p.m. on June 9, 1994, a 2-inch-diameter steel gas service line that had been exposed during excavation separated at a compression coupling about 5 feet from the north wall of John T. Gross Towers, an eight-story retirement home operated by the Allentown Housing Authority at Allentown, Pennsylvania. The failed UGI Utilities, Inc., service line released natural gas at 55 psig pressure, and the escaping gas flowed underground to Gross Towers. The gas passed through openings in the building foundation, entered the mechanical room through floor vents, and migrated to other building floors. An Environmental Preservation Associates, Inc., employee, who had been using a backhoe to excavate fuel-contaminated soil from the area, detected the odor of gas and heard a third-floor resident shout that she smelled a strong gas odor. The employee went to a building entrance and encountered a very strong odor of natural gas. He told his foreman, who, after having the backhoe shut down, telephoned the gas company and the housing authority, telling them of the gas odor. The foreman then instructed other employees to locate and shut off the gas line valve. About 6:58 p.m., the natural gas that had accumulated within the building was ignited, causing an explosion. A second explosion occurred about 5 minutes later. At the time of the explosion, many of the Gross Towers and Towers East residents were out of the building. The accident resulted in 1 fatality, 66 injuries, and more than $5 million in property damage. The National Transportation Safety Board determines that the probable cause of the natural gas explosion and fire at Gross Towers in Allentown, Pennsylvania, was the failure of the management of Environmental Preservation Associates, Inc., to ensure compliance with OSHA's and its own excavation requirements through project oversight. Contributing to the accident was the failure of the workmen from Environmental Preservation Associates, Inc., to notify UGI Utilities, Inc., that the line had been damaged and was unsupported. Contributing to the severity of the accident was the absence of an excess flow valve or a similar device, which could have rapidly stopped the flow of gas once the service line was ruptured. Also contributing to the severity of the accident was the absence of a gas detector, which could have alerted the fire department and residents promptly when escaping gas entered the building.

vi In its investigation of this accident, the Safety Board identified safety issues relating to pipeline excavation damage prevention and rapid shut down of failed gas service lines. As a result of its accident investigation, the Safety Board issued safety recommendations to the Research and Special Programs Administration, the Sates and the District of Columbia, UGI Utilities, Inc., Environmental Preservation Associates, Inc., the Governor of the Commonwealth of Pennsylvania, the city of Allentown, the International Association of Fire Chiefs, the Department of Housing and Urban Development, the Allentown Housing Authority, the Associated General Contractors, and the National Utility Contractors Association.

INVESTIGATION The Accident About 6:45 p.m. on June 9, 1994, a 2-inch- diameter steel gas service line that had been exposed during excavation separated at a compression coupling1 about 5 feet north of the north wall of the John T. Gross Towers (Gross Towers), an eight-story retirement home. Gross Towers, located at 14th and Allen Streets (1339 Allen Street), is one of several subsidized-rent residence buildings operated by the Allentown Housing Authority (housing authority) in Allentown, Pennsylvania. Towers East, a 13-story building that is connected to Gross Towers, is also a rent-subsidy building for senior citizens that is operated by the housing authority. (See figure 1.) The separated service line, which was owned by UGI Utilities, Inc., (UGI) released natural gas at 55 psig pressure. The escaping gas flowed underground to Gross Towers, where it passed through openings in the building’s foundation and filled the space beneath the mechanical room, which served as a combustion air intake reservoir for boilers. (See figure 2.) Gas then entered the mechanical room through openings in the floor. The gas then migrated to the building’s other floors through an adjacent tower that housed the boiler exhaust stacks, through a trash chute, and through floor openings for electrical and other building services. At the same time, a backhoe operator, an employee of the Environmental Preservation Associates, Inc., (EPAI), was removing fuel-contaminated soil from the excavation site and detected the odor of gas coming from the building. He heard a woman in a third-floor apartment shout to him about a heavy gas odor. The loader, another EPAI employee, opened a

1A compression coupling joins lengths of pipe by applying mechanical pressure through a gasket to the end surfaces

of pipe lengths sufficient to retain the pipe lengths against movement for a specific internal gas pressure and to seal the joint against gas leakage. If the forces on the pipe are expected to be greater than the retaining capability of the coupling, the pipes are to be anchored or otherwise prevented from moving out of the coupling. Figure 1. Accident Location

— B NORTH WALL OF ~ GROSS TOWERS GAS METERm GAS SERVICE RISER xzr 1ST FLOOR z x PARKING LOT L SPACE UNDER x MECHANICAL ROOM x COMPRESSION x COUPLINGS GAS SERVICE LINE x ~n a-r 80UlH N~ 4FT. 11 IN. L O C A T I O N F O R E F V v - HAD IT BEEN INSTALLED GAS MAIN Figure 2. Schematic of Gas Service Line

3 side door to the building that led to the boiler room and encountered a very heavy gas odor that "took my breath away." He told his foreman of his observation, and the foreman told the backhoe operator to shut off the machine. The foreman said that he then went to his pickup truck and, using his cellular phone,2 called the gas company and the housing authority, telling them that he was excavating near the gas line and smelled gas. He stated that he next made three attempts to phone "911." He said that each time he called, there was no answer. He said he then moved his truck to another spot in the parking lot in case the phone signal to his cellular phone was being blocked. He said that at the new location he again tried unsuccessfully to call "911." According to the UGI’s records, the foreman's call was answered at 6:48 p.m. by UGI's Central Gas Control at Reading, Pennsylvania. According to the UGI’s records, the foreman said that there was a gas leak at 1337 (Allen Street) Gross Towers in Allentown and that the gas line had been hit during digging. (The foreman acknowledged telling the UGI that he was digging near the gas line and had detected the odor of gas, but said that he did not tell the UGI that he had "hit" the gas line.) At 6:52, the UGI received a second call, which was apparently from the foreman. The call was recorded as "Cust [customer] just called back, said they definitely hit gas line and broke it." The UGI's procedures did not require Gas Control to notify the Allentown fire department or any other emergency-response agency of either report about the release of gas because the caller did not indicate there was an imminent threat; consequently the fire department was not called. According to the housing authority’s records, the foreman called the housing authority at 6:55 and was connected to the after-hours answering service. The answering service’s records show that the foreman advised that "they [the EPAI] were digging and they think they got the gas line." At 7:06, according to the answering service, the foreman's message was relayed to one of the housing authority's maintenance employees, who promptly went to Gross Towers. The records of both the UGI and the housing authority of the foreman’s calls do not show that he said anything about detecting a strong odor of gas within the building. While he was making the calls, the foreman said, he instructed the operator and the loader to trace the gas line back toward Utica Street until they found the shutoff valve. They found the valve near the north edge of the parking lot, but were unable to close it. They lacked the necessary tools to operate the below-ground valve. (Later, when the fire department representatives arrived, the EPAI workmen did not tell them they had been unable to close the valve.)

2Details of the calls to and from the foreman's telephone appear later in the report.

5 later, the UGI on-duty serviceman arrived. The two men met with the fire department's emergency onscene coordinator and received his approval to shut off the gas line. The UGI employees made their way through the debris to the rear of Gross Towers, where a natural gas-fed fire burned from the back of the mechanical room. They located the shutoff valve, near Utica Street, and, about 7:15, closed it. As a precaution, they also closed the service-line valves at two gas meters just north of Gross Towers and then helped the emergency- response personnel. The fire in the mechanical room, which had spread through building utility chutes up to the fourth floor, died out from lack of fuel. Postaccident surveys of 115 residents show that three Towers East occupants, in units 108, 408, and 902, had smelled gas immediately before the explosion and that two other occupants had smelled gas shortly before the explosion while they were in the mail room on the first floor. The occupant of unit 108 stated that he had reported the gas odor to "911," but after the explosion. Community Response Police--At 6:58,3 a policeman working an extra job at a store at 14th and Allen Streets heard a loud explosion and radioed that information to the city’s Communication Center. He then ran to Gross Towers and, to avoid the flames, entered the building through the windows to the right of the front entrance. As he entered, several bystanders apparently followed him in and helped escort survivors out. Within minutes, a second, smaller explosion occurred within the building. The officer told the people who were helping him to put any injured residents on the front lawn as close as possible to the corner of 14th and Allen Streets and to take uninjured residents to the corner of Madison and Allen Streets, an empty parking lot. Other police officers arrived from areas within a mile of Gross Towers. They helped transport handicapped and elderly people from the stairways and, after putting on self-contained breathing apparatus, did a room-by-room search for victims and survivors. When the officer who had been the first to arrive decided that enough people were working to efficiently evacuate the building, he began to triage the injured. As more officers arrived to help remove victims from the building, he stayed outside to direct arriving emergency medical-service units. A total of 50 police officers, 8 members of the police reserves, and 12 fire police officers responded to the incident. Fire--When the Communication Center alerted the fire department, at 6:59, it dispatched three engine companies, one aerial unit, and one command car. When they arrived, the emergency onscene coordinator (coordinator), an assistant fire chief, learned that occupants were trapped by heavy smoke on the seventh floor and that several residents were trapped in an

3His call was the first to reach the Communication Center. The Center received its second call 45 seconds later. It

came from a customer at a nearby restaurant.

6 elevator. After UGI personnel shut off the valve, emergency-response personnel searched each floor to ensure that all residents had been evacuated. The fire department used the city's mass casualty incident plan, and the coordinator used the fire department's incident command system. The command post was established on the front lawn of Gross Towers at 7:03; and at 7:04, the emergency-response staging area and emergency shelter were established at the Allentown Fairgrounds, about 1/2 mile southwest of Gross Towers, where approximately 200 residents and 150 family members were helped. At 7:21, a MedEvac helicopter was requested to transport burn victims. Buses were requested at 7:40 to transport victims to the shelter at the fairgrounds, and by 7:49, the preliminary search of Gross Towers for victims was complete. The last injured resident was transported to a local hospital at 8:45. Throughout the emergency, local agencies worked with each other to provide food and shelter for the displaced residents. The agencies included the housing authority; the Allentown police, emergency medical-services, and public-works departments; the Lehigh Valley County Emergency Management Administration; the American Red Cross; the Pennsylvania Power and Light Company; and the UGI. Medical--The Communication Center notified Allentown's emergency medical services at 6:59, and it dispatched two Allentown and three Cetronia emergency medical-services units. The first medical unit arrived at Gross Towers at 7:03. The total time for triage was 1 1/2 hours.

A total of 15 emergency medical-services agencies dispatched 35 vehicles, including one MedEvac helicopter. The injured people were transported to seven area acute-care hospitals. Housing Authority--The housing authority's answering service called the EPAI foreman at 7:03, telling him that the housing authority had been notified of his 6:55 report. The housing authority’s executive director arrived at Gross Towers about 7:25. He directed the identification and relocation of the more than 300 residents and the site security operations. Additionally, 30 to 40 other housing authority employees were notified and went to Gross Towers to help. Preaccident Events The housing authority decided to eliminate potential future fuel-leak problems by removing a buried tank at Gross Towers and two more that were no longer needed at other locations. The authority receives approximately $3 million in grant funds for stock modernization each year from the U.S. Department of Housing and Urban Development (HUD), and the authority used a portion of the money to pay for removing the tanks.

7 The housing authority solicited contract proposals from three engineers who it believed capable of the work. The authority selected the least-cost proposal. The owner and principal of the selected engineering firm (consultant) was a mechanical engineer registered as a professional engineer in Pennsylvania. He had had some experience in removing buried tanks and was aware of, but not thoroughly knowledgeable about, the excavation safety requirements of the Occupational Safety and Health Administration (OSHA), a part of the U.S. Department of Labor that establishes safety standards to protect workers. The consultant did not seek advice or support from an engineer qualified in structures and soils engineering. The consultant prepared plans, dated November 17, 1993, for removing the tanks. The plans consisted of a drawing showing the layout of the three sites and a work specification document applicable to all three. The drawing showed the approximate location of the buried fuel tanks but did not show the locations of other buried facilities even though it was known that Gross Towers had a buried natural gas line. The plan and specifications included among other provisions, the following ones: • The pavement in areas to be excavated was to be saw cut before the tanks were removed.

• All work was to be performed in accordance with the latest requirements of the Pennsylvania Department of Environmental Resources and the U.S. Environmental Protection Agency.

• Bidders were to examine the specifications, drawings, and the construction sites. In signing the contract, the successful bidder was to be considered as having made a reasonable attempt to ascertain the nature and location of the work and to learn of the general and local conditions that could affect the work and its costs. In signing the contract he was also to be considered as having acknowledged that he was as knowledgeable of the character, quality, and quantity of surface and subsurface materials or obstacles to be encountered as was reasonable after inspecting the site. He was to notify the housing authority promptly, before conditions were disturbed, of subsurface or latent physical conditions at the site that differed materially from those indicated.

• The consultant was to be allowed to visit the work site, inspect it, and issue written reports to the housing authority on observed deficiencies.

• The contractor was to ensure that no laborer or mechanic was required to work in surroundings or under conditions that were hazardous or dangerous to his/her safety as determined under OSHA safety and health standards. The contractor was to protect the lives, health, and safety of other people, to prevent damage to property, materials, supplies, and equipment, and to comply with regulations and standards of 29 CFR 1926.

8 • The contractor was to protect from damage all existing improvements and utilities at or near the work site.

• The contractor was to employ a competent supervisor who would be responsible for all the construction practices and workmanship of all people employed by the contractor or subcontractor so that the contractor, rather than the consultant, would be obligated to exercise responsible control over the construction practices and workmanship.

• Side slopes of excavations were to comply with local codes, ordinances, and requirements of agencies having jurisdiction. Shoring and bracing, which was to be supplied by the successful bidder, would be required where sloping was not possible. Excavation sides were to be maintained in safe condition until completion of backfilling. The consultant stated in the specifications that he would review the on-site work in process to identify deficient conditions or instances of noncompliance with the contract’s requirements. His contract with the housing authority called for him to attend the preconstruction meeting with the successful bidder and to conduct periodic job conferences to ensure that the work was performed in accordance with the contract. In February 1994, using the consultant's plan and specifications, the housing authority advertised for bids to remove each of the buried fuel tanks and to replace one tank. The fuel tank at Gross Towers was an 8,000-gallon one buried beneath the north parking lot and used to store heating fuel. The housing authority’s executive director served as the contracting officer on construction procurement, and its construction coordinator had project oversight responsibility to ensure that the work was completed. The executive director had worked for the housing authority for 33 years, of which he had spent 4 in his present position. He had had no construction experience. The construction coordinator had worked for the housing authority for 15 years and had been involved with construction before being employed by the housing authority. The EPAI won the contract to remove the tank at Gross Towers. According to the minutes of the meeting that was held when the contract was signed, such matters as compliance with the U.S. Department of Labor standards regarding payrolls were discussed. OSHA job safety requirements were not discussed, and the consultant did not attend. On May 18, the EPAI obtained a permit from Allentown to remove the tank at Gross Towers. The permit issued by the building department, which is staffed to perform building- construction inspections, did not require on-site inspection by a building inspector because no building construction was involved. Also, the Building Officials and Code Administrator’s (BOCA’s) building code adopted by the city did not require or recommend on-site inspections of excavation work. However, the permit was forwarded to the fire department for action

9 because the city requires on-site safety inspections of work that includes the handling of flammable liquids. At 1:26 p.m., on May 19, an EPAI employee told the Pennsylvania one-call notification center4 that it planned to begin excavating at Gross Towers at 8:00 a.m. on May 23. He said the purpose was to remove an underground storage tank in the rear parking lot of the housing authority, and he noted that the proposed excavation would be 12 feet deep. The notice center disseminated the information to its member facility operators. The EPAI did not identify the approximate location of the proposed excavation with white paint, as is now done in some States, nor was it required to do so. On May 23, the housing authority issued the EPAI a Notice to Proceed. The notice stated that the EPAI was to "carefully [note] and fulfill the requirements of the general conditions relative to the submittal and approval of Workmen's Compensation and Manufacturers' and Contractors' Public Liability Insurance." No mention was made of OSHA safety standards. The housing director and the consulting engineer recognized that the site drawings did not include information on the locations of buried facilities and that they were depending on the contractor identifying the locations by notifying the excavation-damage notification system so that the facility owners would mark the locations before excavation was begun. Even though there were provisions for the consultant to oversee the work project, he did not. When they received the EPAI’s excavation notice, the UGI's Lehigh Division5 employees checked the UGI’s records for the address the EPAI had given for Gross Towers and concluded that the address should have been given as 1339 Allen Street. At 2:25 p.m. on May 19, a UGI employee telephoned the EPAI, using the telephone number the EPAI had given the one-call center, and left a recorded message that the UGI had a gas service line to Gross Towers. At 8:21 a.m. on May 20, a UGI employee marked the location of the service line on the asphalt paving with yellow spray paint. He did not talk with any EPAI employees about the gas line’s location as none were at Gross Towers while he was there. On May 23, the EPAI moved its equipment to the Gross Towers north parking lot. It removed the asphalt paving in the area to be excavated and began removing the soil above the tank. The foreman evaluated the soil being excavated as OSHA Type A, which is cohesive soil with an unconfined compressive strength of 1.5 tons per square foot. (OSHA’s postaccident evaluation indicated that a visual evaluation of the soil should have shown that it was OSHA Type C, which is a cohesive soil with an unconfined compressive strength of 0.5 ton or less per square foot.)

4A one-call notification center is one part of an overall excavation-damage prevention program that is used by

excavators for communicating with buried-facility operators about planned excavations to allow the facility operators to mark the locations of their facilities in the area of planned excavation. 5UGI's Lehigh Division is responsible for the gas system and its operations in Allentown, Bethlehem, Easton, and adjacent areas.

11 the pipe be supported or braced and that the EPAI foreman and another EPAI employee went into the excavation and attempted to brace the sagging pipe by putting three or four saw horses under it. The inspector said that he did not consider the support effective because the soil beneath the saw horses was not firm. However, he did not take any further action. Neither the EPAI employees nor the fire inspectors notified the UGI that the service line was unsupported and damaged. Later on May 23, the EPAI crew placed a cable sling around the tank and attached it to a chain that was attached to the backhoe. When the crew tried to lift the tank, the chain broke. Those who witnessed the event, including the second fire inspector, stated that they did not believe the tank struck the gas line. The tank was successfully removed from the excavation, and samples of soil were taken adjacent to the tank's concrete support, which remained in the excavation. The soil was to be tested to determine whether fuel had leaked from the tank and contaminated the surrounding soil. The EPAI foreman stated that before he and the other crewmembers left the site, they tried to support the pipe with saw horses, surrounded the excavation with orange plastic barrier fencing, put plastic sheeting over the excavation slopes, including the soil that lay beneath the pipe, and removed the equipment from the site. They left the excavation open to await the result of the tests. Housing authority employees who frequently passed the excavation between May 23 and June 9 stated they observed that the exposed pipe was not supported. Fifteen days later, on June 9, after the EPAI received the test results, which showed that the soil around and beneath the concrete tank support had been contaminated, EPAI employees returned to remove the concrete support and contaminated soil. At 8:00 a.m., the EPAI foreman arrived. He stated that the area looked unchanged from the way it had been left and that nothing appeared unusual. According to a housing authority employee, the foreman mentioned to him that the pipe needed to be shored up. The backhoe (a track-mounted excavator) arrived about 12:30 p.m., and a hydraulic hammer was installed on the backhoe bucket to break up and remove the tank's concrete support. The foreman stated that he and his crewmembers removed the saw horses from beneath the pipe as the first step in removing the concrete support. He said they did not notice any movement of the pipe and did not smell any gas. The equipment operator, not the same person who had excavated the tank in May, used the backhoe to break up and remove the concrete and to excavate the fuel-contaminated soil. It took about 6 hours for the hydraulic hammer to break the concrete up. According to the EPAI employees, the impact of the hammer caused the ground to vibrate significantly. The backhoe bucket was used to remove the broken concrete and to load the pieces into a dump truck. The path of the backhoe bucket crossed over the pipe. The backhoe operator said that about 6:40 p.m. he moved the backhoe from a spot south of the excavation to one on the west. In moving it, he crossed a buried section of pipeline that was between the excavation and the north wall of Gross Towers. The odor of gas was first detected about 6:45 p.m.

12 Injuries The following table summarizes the injuries.7 Injuries Pipeline Contractor Residents Responders Bystanders Total FATAL 0 0 1 0 0 1 SERIOUS 0 0 2 0 3 5 MINOR 0 0 54 5 1 60 TOTAL 0 0 57 5 4 66 Medical and Pathological The Allentown emergency medical services transported 88 survivors to seven local hospitals, where they were examined and, if necessary, treated. The last patient was transported at 10:45 p.m. The fatality was a 73-year-old occupant of the third floor. He died from the cranial cerebral injuries he received when he was struck by a door propelled by the force of the explosion. Pipeline Damage The plastic coating of the suspended pipe segment, predominately on the top half, had numerous gouges and cuts. The damage appeared to be recent, as corrosion was not evident on the exposed metal. The configuration and orientation of the damage were typical of the kind made by such mechanized excavation equipment as a backhoe. (See Postaccident Tests and Inspections.) The service pipe segment to the meter in the equipment room was separated below ground from the south end of the south coupling (electrically insulated-type) that was near the wall of the building. (See figure 5.)

749 CFR 830.2 defines fatal injury as: "Any injury which results in death within 30 days of the accident" and serious

injury as: An injury which: (1) Requires hospitalization for more than 48 hours, commencing within 7 days from the date the injury was received; (2) Results in a fracture of any bone (except simple fractures of fingers, toes, or nose); (3) causes severe hemorrhages, nerve, muscle, or tendon damage; (4) involves any internal organ; or (5) involves second or third degree burns, or any burn affecting more than 5 percent of the body surface."

14 upward. The majority of the damage was in the north portion of the building, with the worst damage occurring on the first and seventh floors. The apartments next to the tower that housed the trash chute and boiler stacks were heavily damaged by overpressure, and the cinder block wall enclosing the tower was blown outward, fragmenting the adjacent exterior walls. The exhaust ducting on at least two boilers was pushed outward. Towers East sustained minor damage, primarily broken windows. According to the insurance carrier for the housing authority, the damage was $4.3 million. The explosion also caused moderate damage to other area buildings, including a sports bar, automobile dealership, and tire dealership. Total damages exceeded $5 million. Personnel The EPAI employees involved with the work at Gross Towers had each had a physical examination earlier in the year, and none had been found to have any physical problems. According to their statements, none were taking any prescribed medications. A review of their activities for the 48 hours before the accident revealed nothing that should have affected their work on the day of the accident. The employees working on the day of the accident had worked together on excavation projects for the past 3 to 4 years. The EPAI’s records showed that none of them had received training in the applicable EPAI health and safety requirements. The foreman had had about 7 years of construction-work experience and had been with the EPAI full time since April 1990. He had begun work with the EPAI as a laborer and had progressed to his present position. Since being employed by the EPAI, his training had included 40 hours about hazardous materials, for which he was granted a certificate in 1989, and 8 hours hazardous-materials refresher training in 1993, as required by OSHA (29 CFR 1910.120). He held a State certificate authorizing him to remove buried fuel tanks and a certificate from the University of Maryland for a 16-hour hazardous-materials and on-scene incident commander course, and he was a volunteer firefighter specializing in hazardous materials. The training records showed no training in OSHA’s requirements. He said that he did not recall receiving instructions from the EPAI on how to support gas lines in an excavation, but he did remember receiving instructions on how to support other utilities, such as sanitary sewers. He said that as a result of his work experience, he was familiar with the stability of soils. The loader/driver had worked for the EPAI for 5 years. He held a valid Pennsylvania State commercial driver’s license, issued in 1993, a State inspection license, and a State emissions inspection license. During his time with the EPAI, his training had included 40 hours about hazardous materials, for which he was granted a certificate, and 8 hours hazardous- materials refresher training, as required by OSHA.

15 The heavy-equipment, or backhoe, operator working June 9 had worked for the EPAI during the past 5 years, of which 2 had been full time. He had a total of 32 years experience in construction, and he had worked as a backhoe operator for the 2 years before the accident. He had no formal training in excavation or working in trenches. He had learned to operate heavy construction equipment, including backhoes, through on-the-job training. He had about 200 to 300 hours of experience in operating the type of backhoe used on the day of the accident and stated that he was "very comfortable" operating such equipment. He had been trained in mine safety about 10 years before the accident. Pipeline System Information System Ownership--The UGI, a wholly-owned subsidiary of UGI Corporation, provides natural gas through its gas distribution systems to about 258,000 customers in 14 eastern and southeastern Pennsylvania counties, including the cities of Allentown, Bethlehem, Easton, Harrisburg, Hazleton, Lancaster, Lebanon, and Reading. It operates both high- and low-pressure distribution systems, offering gas service to residential, commercial, and industrial customers. Since 1975, the UGI has installed excess flow valves (EFVs)8 on more than 61,000 gas services. The UGI Corporation also provides electric power service near Wilkes-Barre, Pennsylvania, and is one of the nation's largest retail suppliers of liquefied petroleum gas. Gas Service Line History--Gas service was provided to Gross Towers on July 7, 1966. The gas service line began at its connection to a 4-inch-diameter steel gas main beneath Utica Street and ran about 135 feet south, to the north wall of Gross Towers. (See figure 2.) There it left the ground and ran through the building wall into the mechanical room. For the most part, the line was under an asphalt parking lot. The line was laid about 3 feet beneath the surface on fine soil and was sloped upward from Utica Street about 6 percent. It was covered first with fine soil and then with fill dirt. The surface above the pipe trench was crushed stone overlaid with asphalt pavement. The line was designed to provide 15,000 to 20,000 cubic feet of natural gas an hour for boiler fuel. A note on the UGI's original service record stated that the line was "Tied in Solid," meaning that the pipe lengths were welded. However, to comply with 1971 Federal requirements on protecting steel pipelines against corrosion, the UGI began installing corrosion-protection systems on segments of its pipeline systems that had been installed before the requirements were adopted. The UGI's records show that on September 27, 1973, an

8An EFV automatically stops the flow of gas into the customer's service line when his maximum gas use rate is

exceeded by a predetermined percentage. Length: 133 feet Diameter: 2 inches Thickness: 0.154 inch Material: Steel Coating: Plastic (X-Tru-Coat) Impressed Cathodic Protection Tie-in: welded to 4 inch coated steel main in Utica St. Meter in Boiler Room Max. Op. Pres: 60 psig Gas Service Line Specifications

16 electrically insulating compression coupling9 was installed in the service line. Although there is no documentation of the instructions given the crewmembers about the work, records and physical evidence show that they installed an insulating compression coupling in the service line north of the wall next to the boiler room. That coupling was installed just inches south of a noninsulating compression coupling for which there are no records and which was apparently installed at the same time as the insulating coupling to obtain adequate space to install the insulating coupling. Neither compression coupling was anchored or otherwise protected against movement relative to the service pipe, nor were there any requirements for doing so. An EFV was not installed in the gas service line, nor were any other modifications made after 1973. Applicable UGI Operations EFVs--The UGI's Manual of Standard Procedures requires the installation of EFVs on new and renewed services that operate at a pressure of more than 20 psig at all times and have a maximum gas flow through the customer meter of 425 cubic feet per hour or less. To ensure a minimum of 10 psig pressure at each gas service line equipped with an EFV when the system is operating at maximum flows, the UGI established its 20-psig pressure minimum to provide system capacity so it could add customers and meet their service requirements without affecting the activation of the EFVs. Of the approximate 152,000 gas services the UGI considers suitable, about 61,000 have EFVs. The UGI added the EFVs when the services lines were being installed or renewed. Eighty- two percent of its EFVs are installed on residential service lines and 18 percent on service lines to stores and other commercial buildings. During 1993, the UGI reported that 28 of its EFVs activated. The company attributed 23 activations to the proper operation of the valves (9 activated when service lines were ruptured, and 14 activated when company activities caused conditions similar to a line rupture). The company attributed five to unintended activation (the UGI believes three were activated because distillates in gas swelled an O-ring and could not determine the reason for the other two activations). For several years, the UGI has been proactive about using EFVs to enhance customer safety. Since 1993, it has used EFVs on services with more than one meter and on farm taps, if approved by the area distribution engineer. It has also extended the use of EFVs to other types of residential services and to some commercial services. The UGI stated that while it does not have a specific program for using EFVs on services to high-occupancy or public-assembly buildings, during the past 2 years it has begun allowing the use of EFVs on commercial services without limitations as to the type of user. It stated that if current and/or future load

9An electrically insulating compression coupling prevents the flow of electrical current between the pipe lengths that

are joined. These types of couplings are installed to separate corrosion-protection systems and to isolate protected pipe lengths from unprotected lengths.

17 conditions are not an issue, it considers installing an EFV, subject to the above listed operating parameters. Its policy on EFVs does not include informing customers about the safety benefits of using EFVs, nor does it include giving customers the chance to have EFVs installed at their own expense. As is the case with all pipeline operators, it is the UGI’s decision whether to use EFVs since using them is not required. Also, to achieve maximum effectiveness, an EFV must be installed in the pipe owned by the gas operator. The UGI stated that the housing authority had not asked the UGI about using or installing EFVs or about using gas detector equipment for alerting building residents. Excavation-Damage Prevention Plan--The UGI uses customer-bill inserts, media ads, and discussions at meetings with contractors to make the public aware of the danger of damaging pipelines during excavation. The information the UGI provides informs the public and excavators about the importance of notifying the Pennsylvania One Call System (a one-call center) before excavating. Also it informs excavators of the precautionary measures they should take both before and during excavations to maintain the integrity of the pipelines. Because the UGI is a member of the Pennsylvania One Call System, a contractor can notify it by making a single toll-free call to tell all member facility operators of his intent to excavate anywhere in Pennsylvania. When the UGI receives an excavation notification, its employees check its maps and other records to determine whether any of its pipelines are in the area of planned excavation and whether they could be damaged by the excavation. The UGI tells the excavator either that it has no facilities in the area of the planned excavation or of the action the UGI will take in response to the notice. UGI procedures call for marking the locations of its lines and area shutoff valves in the area of the planned excavation. The UGI uses high-visibility yellow paint in paved areas and yellow stakes or flags that have GAS printed on them in unpaved areas. The UGI encourages its employees who mark the locations to warn the excavator, whenever possible, that the marks show only the approximate location of the lines and that the excavator must verify the actual location by hand digging. Type of customer load (boiler or process, surging or level) Potential for additional gas demand Customer's fuel line pressure requirements Length and size of required service lateral Current system pressure at customer's location Impact of planned and projected load growth on system pressure in the customer's vicinity Variance between network analysis balance run pressure versus actual pressure in the customer's vicinity Potential for liquids or dirt in the gas system at the customer's location. What UGI Considers in Deciding Whether to Install an EFV

18 If the UGI determines that an excavation project is likely to damage a UGI gas main, or if damage could cause a major unplanned shutdown of 50 or more customers, UGI's procedures call for the area engineers or the area construction and/or maintenance superintendents to consider developing an emergency plan for shutting down the potentially affected main in an orderly way. Although not included in its procedures, the UGI expects its personnel to consider several factors in determining whether to develop a written emergency plan for an excavation project, including: Scope and nature of the project; Contractor's proposed mode of operation; Type of distribution system in the project area; Location and material of facilities within the project area; Number of potential conflicts between UGI facilities and contractor activities; Type of area (city, suburban, rural); and Density of customers located within the project area. The UGI also expects the on-site representatives of the excavator and the UGI area personnel to decide together how often UGI employees need to inspect the site. In making the decision, UGI employees are supposed to consider the following factors: how long it will take to do the excavation, how close the excavation is to UGI facilities, the size and extent of the excavation, the type of excavation activities that will be necessary, and the UGI’s previous experience with the excavator. When UGI employees see contractors operating in ways that are inconsistent with UGI requirements about supporting gas facilities, that violate Department of Environmental Resources blasting requirements (15 CFR 211), or that are negligent regarding due care of gas facilities, the UGI's locator or inspector is to notify the contractor's job superintendent. If the situation is not corrected, the UGI's area human- resources specialist meets with the contractor's job superintendent or project engineer to discuss the seriousness of the situation and to remind the contractor of his responsibility for protecting the UGI’s facilities. The meeting and its results are to be confirmed by letter, with copies being sent to the operating head of the contracting company, the contractor's insurance carrier, the person or municipality authorizing the excavation, the UGI's area human-resources superintendent, and, if appropriate, to the UGI's local attorney. If the situation is still not corrected, the UGI declares that the situation constitutes an emergency and applies to the courts for a temporary restraining order that will force the excavator to suspend the project. Provides for locating all gas mains, service lines, main-line valves, and service-line valves in the area of excavation. Requires inspections to ensure that all valves can be operated. Identifies the number of customers in each main section that may be shut down due to an emergency. Identifies how the UGI will monitor the excavation project on a scheduled basis until all work in the area of its pipelines is finished. Components of UGI's Excavation Emergency Plan

19 In 1994, the UGI was asked more than 55,000 times (about 15,000 times in the Lehigh Division) to locate its facilities in areas of planned excavations. This was a 20 percent increase over the requests for 1993. Of that total, the UGI physically marked facilities at 47,786 locations (14,043 in the Lehigh Division) and assessed the other requests as not involving gas lines. In 1994, the UGI’s facilities were damaged 199 times (93 in the Lehigh Division). Of the 199 times, 87 of them (32 in the Lehigh Division), or 44 percent (35 percent in the Lehigh Division), were caused by excavators who had not notified the UGI that they were planing an excavation. Emergency Plan--The UGI's emergency plan establishes, as required by 49 CFR 192.615, operating guidelines applicable to various emergency situations. The types of emergencies addressed by the procedures include gas leaks, fires, gas explosions, overpressure of distribution systems, loss of distribution system pressure, natural disasters, civil disorders, and national emergencies. The area superintendent of construction and maintenance and/or the area superintendent of customer service is in charge of directing all emergency field operations. The manager of distribution operations takes charge of operations upon his arrival, if he deems it necessary. Other UGI areas help should the magnitude of a situation exceed an area's resources. According to the UGI’s procedures, the first UGI employee on scene is to act immediately to protect property, the public, and the welfare of the people involved in the emergency. If the report is one of escaping gas, as it was on June 9, when the UGI first learned of the emergency, the on- scene employees are to take precautionary measures: ventilate enclosed areas that contain gas, shut off automatic furnaces and appliances, warn occupants to avoid using open flames and electrical switches, urge occupants to evacuate the building, shut down gas lines, and find the source of the gas. If the report is one of fire or explosion, as it was on June 9 just before the first UGI employee arrived on the scene, the first on-scene employee is to assess the situation, radio his assessment to the UGI dispatcher, check for the presence of gas in all buildings in the immediate area, take appropriate action to protect people and property, and monitor all buildings in the immediate area for gas until the source of the released gas is located and blocked. The procedures also describe the preparedness and response assignments for each position held by a UGI employee who might be involved in the emergency response. Employee Training for Emergencies--The UGI's emergency plan requires each employee who is responsible for responding to emergencies to participate in annual simulation board exercises. Each exercise is prepared by the UGI's distribution engineering personnel and Provisions for responding to various emergencies; Emergency operations; Education of employees, customers, the public, and officials; Provisions for maintaining personal contact with public officials of local government and their fire and police departments; and Training of employees in emergency procedures. Subjects Addressed in UGI's Emergency Plan

20 includes scenarios about a system shutdown or loss of a major gas supply line, a shutdown or loss of a district regulator station, or a major line break within the distribution network. The scenario may be based on previous incidents or on incidents described in Safety Board reports. Each exercise must include a step-by-step analysis of the procedures for investigating, pinpointing, and repairing leaks and of the procedures for taking emergency actions and protecting people and property. Each employee who is responsible for responding to emergencies is also required to attend at least two presentations a year of preprogrammed emergency training selected by his superintendent. Every 5 years, the UGI's employees in its customer-service, engineering, and corrosion- control divisions are trained in fighting fires. The UGI’s employees in its construction-and- maintenance, gas-supply, plant, and liquefied-natural-gas divisions are trained every 2 years. Emergency Preparedness According to the Allentown Emergency Operations Plan, its purpose is to train emergency-response personnel, minimize fatalities and injuries, enhance coordination between all responding units, and ensure that everyone involved knows enough about preparedness to avoid any confusion at an emergency site. The mayor, the emergency management director, and the emergency management coordinator approved the plan in August 1992. The fire department employees had trained with the UGI a month before the accident. The UGI briefed them on numerous types of responses to natural-gas emergencies and on using gas shutoff keys to close service-line valves. Also, all fire and police department personnel had had first-responder training, and all Allentown Emergency Medical Services personnel had had mass casualty incident management training. During the year before the accident, Allentown had conducted four emergency exercises, and the UGI had given wrenches to the fire department employees that allowed them to operate the smaller buried service-line valves, which are typically used on residential service lines. The UGI had also trained the fire department employees in using the valves correctly. When the fire department responds to a report of a gas odor or leak, its first priority is to notify the UGI through its communication center. The department also has procedures for preventing accidental ignition, evacuating buildings, locating the source of escaping gas using combustible-gas indicators, ventilating buildings of accumulated gas, shutting off service lines at the meter or at the curb valve if possible, and communicating with the UGI representative as soon as one is on scene.

21 Housing Authority Operations--The housing authority houses about 800 residents in the Allentown area. Gross Towers was constructed during 1965 and 1966 as rental housing for seniors and as headquarters for the housing authority. Gross Towers and Towers East were connected by a lobby. Gross Towers had 8 stories, 147 apartments, and 163 residents. Towers East had 13 stories, 129 apartments, and 147 residents. Both buildings were constructed to comply with the then current BOCA codes adopted by Allentown. Since 1992, the housing authority has been working to modernize all of its buildings so that the buildings’ fire water sprinklers and fire communication systems comply with the 1993 BOCA code. The energy for heat and hot water used in Gross Towers came from equipment in the mechanical room on the first floor. The equipment included two conventional gas-fed boilers, which were not operating at the time of the explosion, and a fast recovery boiler, which supplied hot water during periods of low use. It was operating at the time of the accident. Several openings between floors were not protected against the upward flow of gases. A separate tower, which was next to the gas-fired boilers and housed a trash chute and the boiler exhaust stacks, connected every floor. The floors were also connected to each other and the mechanical room by chase openings for electrical cables and other facilities. The openings were uninterrupted, or nonfire-stopped. Gases could also enter the mechanical room from the outside air and from the soil through a combustion-air system that consisted of a 3-foot-high airspace beneath the mechanical room that was connected to subsurface trenches that ran to outside ground-level vents located along the building’s north wall. Emergency Preparedness--The explosion happened during nonworking hours, when no housing-authority personnel were on duty. An answering service received the emergency calls. The service could page on-call maintenance personnel or other housing-authority employees. The executive director stated that the housing authority had procedures for evacuating the occupants and that the residents practiced the routines. For example, every 6 months the fire department conducted fire inspections and drills that also tested the evacuation procedures and emphasized how important it was for the residents to respond promptly. The drills included special precautions for the elderly and handicapped; and after a drill was held, all residents participated in a critique. Placards were posted on the windows and doors of apartments that had handicapped occupants and of rooms in which occupants were using pressurized oxygen. Gross Towers, like all other housing complexes operated by the housing authority, had an internal fire alarm system that had alarm bells on each floor. When the system was activated, the company that monitored it promptly called the Allentown Communications Center.

22 Gross Towers had a gas-powered emergency generator that started automatically whenever the flow of electricity to the building was interrupted. As long as the building’s gas supply was uninterrupted, the generator provided emergency lighting in the stairwells and exit lights. During this emergency, however, the generator did not operate because the gas supply had been interrupted when the service line separated. EPAI Procedures Drug and Alcohol Policy--The EPAI employees who worked at the accident site were not tested after the accident for drugs or alcohol; Federal regulations did not require such testing. The EPAI’s policy was to test potential employees for drugs and alcohol and to test employees at random intervals and after an event suggesting reasonable cause. (Reasonable cause is a visual observation that an employee might be under the influence of drugs or alcohol.) The EPAI now forbids an employee to possess, use, sell, or trade illegal drugs or alcohol during working hours. Also, he cannot report to work while he is under the influence of illegal drugs or alcohol. The EPAI states that this policy is in accordance with the Drug-Free Workplace Act of 1988 and the U.S. Department of Transportation's (DOT’s) regulations at 49 CFR Part 40. After discussions with Safety Board investigators, the EPAI now has a better understanding of the merits of postaccident toxicological testing and is developing a policy to test its workers postaccident/mishap to determine drug or alcohol involvement. Though policy specificity is lacking at this time, the Safety Board encourages the EPAI’s efforts in this area. Health and Safety Program--In May 1993, the EPAI issued its Health and Safety Program “to protect the health and safety of all employees while on the job.” The project management starts with the job superintendent and rises upward through the project manager to the vice president of operations and then to the president. Each project is to have a health, safety, and compliance director. He alone is responsible for approving work plans and health and safety plans for all projects and for conducting periodic audits and reviews that ensure the health and safety of all employees. He may halt operations if there is any threat to the health of employees or to the environment. Each project must have a work plan that describes in detail all aspects of the job and the measures that are necessary to ensure the safety and health of all employees on the job. The Health and Safety program states that every effort will be made to anticipate and prevent emergency situations in all projects and that a responsible plan will enable personnel to effectively handle any occurrence. Before excavation begins, utility companies must be notified so that they can mark the position of any hidden pipelines or cables. Excavations deeper than 5 feet into which employees must enter will be sloped, shored up, or contained to protect the employees from collapsing soil. Excavation sites will be in- spected for proper precaut- ions. Activity will cease if em- ployee health and safety are endangered. EPAI’s Excavation Requirements

23 The work plan must address the specific prevention and response procedures to be taken to protect the environment and the health and safety of all people in the area. The site supervisor is responsible for implementing and overseeing emergency-response procedures on the site, and the work plan must fit in with the client's emergency-response plan, as well as with the capabilities and procedures of all local emergency agencies (such as fire and rescue companies). The work plan must list any specific training and skills necessary for the total completion of the project to ensure that the employees who are assigned to specific tasks are fully qualified to carry them out. Before the start of any project, the EPAI must give a written copy of the emergency-response plan to all employees, contractors, subcontractors, and other officials involved in the project. The plan must specify preemergency planning, personnel roles, lines of authority and communication, emergency-recognition and -prevention procedures, safe distances and places of refuge, site security and control, evacuation routes and procedures, emergency-alert and -response procedures, critique or response and follow-up, and personal protective equipment and emergency equipment available. Under the program, the EPAI is to conduct scheduled and unscheduled inspections of each project site to ensure that the project plan is being followed, and the EPAI is to notify any utility that has facilities that interfere with tank removal operations. The EPAI did not prepare an emergency response plan for the Gross Towers project. Regulations and Oversight The statutory requirements for rent-subsidized housing that is to be shared by the elderly are included in 42 U.S.C. 1437. That section charges the Secretary of HUD with issuing “minimum habitability standards for the purpose of assuring decent, safe, and sanitary housing for such families while taking into account the special circumstances of shared housing.” Title 24 CFR Part 882 lists HUD's requirements for shared housing. It specifies that such housing be "decent, safe, and sanitary" and then defines in paragraph 882.109 standards that have to be met before the housing can qualify as decent, safe, and sanitary. This paragraph includes criteria that have to be met for structure and materials, space and security, sanitary facilities, water supplies, lead-based paints, smoke detectors, and numerous other items. Part 882 also establishes HUD's right to periodically inspect project operations to ensure that the project is in full compliance with the HUD requirements. When HUD accepted these buildings for rent subsidies, it did not require gas detectors and alarms or EFVs for single, multifamily, or high-rise buildings. According to HUD staff members, the agency has not evaluated whether gas detectors with alarms or EFVs enhance the safety of tenants of shared housing.

24 The Philadelphia office of HUD, which is responsible for periodically inspecting housing authority projects, has consistently found that the housing authority complies with HUD requirements. HUD inspected the housing authority about every 3 years; the last inspection was about 2 years before the accident. Pennsylvania Damage-Prevention Statute--Since 1974, Pennsylvania has had an Underground Utility Line Protection Law intended to reduce accidents and promote cooperation among excavators and users of the underground. The law was revised in 1987 and 1991. The effective date of the current law is December 31, 1991, and under Pennsylvania's "sunset" provision, the law will expire on December 31, 1996. Requirements for Excavators Notify the one-call center not less than 3 nor more than 10 working days before excavating (any use of powered equipment or explosives in the movement of earth, rock, or other mineral). Exercise due care and take all reasonable steps necessary to avoid injury to or otherwise interfere with all lines where positions have been provided to the contractor by the users. Use prudent techniques for determining the precise location of buried facilities, such as hand digging to expose buried lines. Report immediately to the user any break or leak on its lines, or any dent, gouge, groove, or other damage to such lines or to their coating or cathodic protection, made or discovered in the course of the excavation or demolition work. Immediately alert the occupants of premises about any emergency that such person may create or discover at or near such premises. Requirements for Buried Facility Operators File notice in each county by voting wards in which it has facilities. Respond within 2 days to each excavation notice, either by marking with approved colors the locations of its facilities or by notifying the caller that it has no facilities in the area of proposed excavation. Respond to designer notifications either orally or by mail within 10 working days of the notice. Be a member of the one-call notice center. Selected Provisions of Pennsylvania’s Underground Utility Line Protection Law The law includes requirements for buried facility operators and any excavator (any person except the Pennsylvania DOT or people engaged in agricultural or resource extraction) who excavates for himself or for others. The law specifies several monetary and criminal penalties. The penalties can be imposed only by the Pennsylvania Attorney General, the local district attorney, or a person successfully petitioning those offices. In the case of the Gross Towers accident, neither the UGI, the local District Attorney, nor the Attorney General has initiated an enforcement action.

25 Pipeline Safety Oversight.--The Pennsylvania Public Utilities Commission (PUC) certifies to the U.S. DOT that its authority and requirements for intrastate natural gas pipelines classified as public utilities are essentially the same as the DOT's. (Public utilities does not include municipal gas operations or liquefied petroleum gas systems.) The PUC has the primary responsibility for the safety of the intrastate pipelines over which it has jurisdiction. Those intrastate natural gas pipeline systems in Pennsylvania that are not subject to the PUC's jurisdiction are subject to the DOT’s. Operators, including the UGI, are required to meet the excavation-damage prevention requirements at 49 CFR 192.614. On November 29, 1994, after it had investigated the UGI’s operations, the PUC said that the UGI’s damage-prevention program violated several Federal pipeline safety requirements. The PUC noted, for example, that the UGI did not inspect the service line during the course of the excavation, even though the notification had advised that the excavation was to be about 12 feet deep and even though the UGI's service line was near the area of the proposed excavation. The PUC also noted that except for the initial marking of the service line location, the UGI had had no communication about the excavation with either the EPAI or the housing authority. The PUC contended that had the UGI contacted either the EPAI or the housing authority, it might have found out that its service line had been uncovered and thus would have known that it had to take additional action. On December 28, 1994, the UGI responded to the PUC, acknowledging that its damage-prevention plan did not comply fully with paragraph 192.614 (b)(1) and (b)(2) and that the plan was being revised. The UGI stated that its practices and procedures complied with paragraph 192.614(b)(6)(i), but agreed that enhanced communications would improve the Operators must carry out a written program that complies with the Federal regulations to prevent damage to its pipeline by excavation activities. Excavation activities include excavation, blasting, boring, tunneling, backfilling, the removal of aboveground structures by either explosive or mechanical means, and other earth moving operations. Any of the duties required may be performed through participation in a public service program, such as a "one-call" system, but such participation does not relieve UGI of the responsibility for compliance with those requirements. According to subparagraph (b), the damage prevention program must, at a minimum: (1) Include the identity, on a current basis, of persons who normally engage in excavation activities in the area in which the pipeline is located. (2) Provide for notification of the public in the vicinity of the pipeline and actual notification of the persons identified in (1) above of the following as often as needed to make them aware of the damage prevention program: (i) The program's existence and purpose; and (ii) How to learn the location of underground pipelines before excavation activities are begun. (3) Provide a means of receiving and recording notification of planned excavation activities. (4) If an operator has buried pipelines in the area of excavation activity, provide for actual notification of persons who give notice of their intent to excavate of the type of temporary marking to be provided and how to identify the markings. (5) Provide for temporary marking of buried pipelines in the area of excavation activity before, as far as practical, the activity begins. (6) Provide as follows for inspection of pipelines that an operator has reason to believe could be damaged by excavation activities: (i) The inspection must be done as frequently as necessary during and after the activities to verify the integrity of the pipeline; and (ii) In the case of blasting, any inspection must include leakage surveys. Selected Excavation-Damage Prevention Provisions of 49 CFR 192.614

26 program's effectiveness. The UGI stated that it was exploring with the one-call system the possibility of informing all excavators that they should notify the one-call center should they expose buried facilities. On April 3, 1995, the PUC told the UGI it disagreed about the UGI’s procedures and practices meeting the requirements of paragraph 192.614 (b)(6)(i). The PUC noted that the UGI's practices failed to identify the excavation at Gross Towers as being hazardous to the service line despite the information the EPAI provided in its excavation notification. The PUC stated that the UGI should have recognized that the 12-foot-deep excavation would be likely to affect the service line and that the company should have either made follow-up site inspections to verify the integrity of the pipeline or should have asked the EPAI or the housing authority for additional information concerning the precise location of the excavation. The PUC asked the UGI to report the plans it had for eliminating the deficiencies in its procedures. On May 3, 1995, the UGI told the PUC that it would continue its efforts to promote enhanced communications through the one-call system. The UGI stated that after further evaluation of the PUC's opinion, it had decided to incorporate more prescriptive procedures into appropriate sections of its damage-prevention program. It said that it planned to use the procedures outlined in the Gas Piping Technology Committee's10 guide material, specifically section 2.8, “Inspecting Pipelines,” which provides guidance on complying with paragraph 192.614. The PUC told the UGI during a May 24, 1995, meeting that it did not consider the May 3 letter responsive because the UGI had not described specific steps it would take to eliminate the deficiencies that the PUC had identified. On June 12, 1995, the UGI asked the PUC to review a letter it proposed to send to the Pennsylvania One Call System. The letter asked the one-call system to maintain an effective, proactive approach towards substructure-damage prevention, including recommending that excavators premark areas of planned excavations. On October 4, 1995, the PUC told the UGI that its proposal was again not adequate to comply with paragraph 192.614(b)(6)(i) concerning inspections during and after excavation activities that could damage the integrity of the pipeline. The PUC asked the UGI to give it written revisions to the damage-prevention program by October 31, 1995, and to describe how the new plans would be implemented. On November 1, 1995, the UGI and PUC staffs met to discuss UGI’s damage-prevention practices and procedures. This meeting resulted in the UGI filing a November 21, 1995, letter with the PUC stating that although the UGI did not believe its current practices

10The Gas Piping Technology Committee (GPTC) is a technical committee that was established in 1970 pursuant to

an agreement between the Office of Pipeline Safety and the American Society of Mechanical Engineers (ASME). In 1990, the administrative support for the GPTC was transferred from the ASME to the American Gas Association. The GPTC's main purpose is developing and publishing the Guide for Gas Transmission and Distribution Piping Systems, which assists pipeline operators in their efforts to comply with Federal pipeline safety regulations, to comment on proposed rulemakings, and to propose amendments to those Federal rules.

27 caused the accident on June 9, 1994, it would revise its substructure damage-prevention program to mirror the guidelines in the Gas Piping Technology Committee Guide ANSI 2380.1. (See appendix E.) Additionally, the letter said, the UGI plans to supplement its procedures by including specific examples where follow-up inspections of excavation projects should be considered, including: premarked excavations extending through or close to UGI facilities, major excavations, such as building foundations, near UGI facilities, and deep, lengthy sewer projects near UGI facilities. The UGI advised that on completion of the new procedures, it would train all appropriate personnel on them. On January 3, 1996, the PUC advised the UGI that its April 3, 1995, position was unchanged. The PUC said it would assess the UGI’s revised damage-prevention program when it received it. OSHA Requirements Excavation-Damage Prevention--Title 29 CFR 1926, Subpart P, contains several worker safety requirements on excavation activities. In 1990, OSHA developed and issued a booklet, Excavation, to assist excavation firms and contractors in protecting workers from excavation hazards. The booklet is based on the requirements of 29 CFR 1926 and gives specific advice on preventing cave-ins and providing protective support systems. OSHA employs several methods of providing information to people subject to its regulations; its latest information system uses the Internet via the World Wide Web to provide assistance to excavators and contractors on complying with OSHA requirements. Responses to frequently asked questions, statistical data, news releases, OSHA pamphlets and publications, and a listing of available training materials can be obtained using a personal computer. Investigation Findings and Enforcement--OSHA determined that the EPAI foreman did not meet OSHA’s definition of competence, as stated in 26 CFR 1926.650 (b). Among the failures OSHA attributed to the foreman were that he had classified the soil type incorrectly, had improperly supported the gas line, did not recognize the hazard of the gas line, did not know the lifting capacity of the chain used in the failed attempt to lift the fuel tank, did not know the lifting capacity of the backhoe, and did not keep spoil from the excavation from the top edge of the excavation. On September 30, 1994, OSHA issued a Citation and Notification Penalty to the EPAI alleging, among other deficiencies, that:

1. EPAI employees had been exposed on May 23, to a fall hazard when they were

riding on a backhoe bucket to enter an excavation that was 10 to 12 feet deep.

28

1. The EPAI had not had a competent person inspect the jobsite, materials, and

equipment, frequently and regularly; the EPAI's designated competent person did not take prompt corrective measures on May 23 to eliminate or control hazardous practices.

1. On May 23, the EPAI did not properly protect and support the natural gas

pipeline, thus exposing employees to injury and contributing to the Gross Towers accident. OSHA fined the EPAI $54,300. At an informal conference held on October 13, 1994, EPAI officials advised OSHA that the EPAI had implemented a proactive employee safety and health program agreement, that the EPAI’s employees would attend a 1-day conference on removing underground storage tanks, that the EPAI’s management would frequently audit jobsites for safety and health compliance, and that supervisory personnel would be held accountable for any violations found. OSHA accepted the EPAI's modifications and reduced its fine by 40 percent. Paragraph 1926.650 (b) defines competent person as one “who is capable of identifying existing and predictable hazards in the surroundings, or working conditions which are unsanitary, hazardous, or dangerous to employees, and who has authorization to take prompt corrective measures to eliminate them." (The preamble to the final rule for 26 CFR 1926 advises that a "competent person" must have had training in, and be knowledgeable about, soils analysis, the use of protective systems, the use of protective systems, and the requirements of standard 1926 Paragraph 1926.651 (b) requires that the estimated location of utility installations, including gas lines, must be determined before opening an excavation. Consistent with local time constraints, such as those in Pennsylvania Act 38 and before beginning an excavation, excavators are required to contact utility companies/owners, advise them of the proposed work, and ask them to establish the locations of underground installations. When the excavator is approaching the estimated location of a marked buried facility, he is required to determine the exact location by safe and acceptable means. While the excavation is open, underground installations must be protected, supported, or removed as necessary to safeguard employees and people that live or work in the vicinity. Paragraph 1926.651 (i) requires protection of adjacent structures by support systems such as shoring if the excavation operations endanger them. Paragraph 1926.651 (k) requires daily inspections of excavations when employee exposure can be reasonably anticipated of the adjacent areas and of protective systems by a competent person for evidence of a situation that could result in cave-ins, failure of protective systems, hazardous atmospheres, or other hazardous conditions. That paragraph requires also that employees be removed from any hazardous condition until proper corrective action has been taken. Paragraph 1926.652 (a) requires protection of employees from cave-ins when in excavations 5 or more feet in depth. The protective system may be one of several described in the regulation, such as sloping, benching, or shoring. Selected OSHA Requirements from Title 29 CFR

29 Postaccident Tests and Inspections Gas Leakage Tests--Two days after the accident, the soil near the gas service line was tested for the presence of natural gas. Holes approximately as deep as the pipe were made in the soil next to the service line at approximate distances of 6, 10, 15, and 20 feet north of the building wall and at one location about 6 feet west of the service line and 10 feet north of the north building wall. Gas concentrations of 2, 18, 40, 40, and 36 percent of the lower explosive limit, respectively, were detected. At 10:55 p.m. on the day of the accident, workmen separated the service line at the meter in the boiler room and sealed the openings. They also severed the line just downstream of the service-line valve at Utica Street and sealed those openings. On the next day, they injected the closed off segment of the line with compressed air at 120 psig pressure. The pipe could not be pressured higher than 10 psig because the air was escaping from a then undetermined location. While continuing to pump air into the service line, the workmen inspected the vacant space beneath the first floor, and they found that air under pressure was entering the vacant space through the soil. They also found that air under pressure was escaping the soil around the service line meter riser pipe where it exited the ground at the north wall. The service line segment containing the compression couplings was cut about 1 foot north of the north compression coupling, removed, and preserved for further documentation. The end of the service line from which the compression couplings were removed was sealed. Air under 60 psig pressure was applied to the still-buried service line. After allowing the temperature to become stable, the pipe maintained the 60 psig pressure without variation. Pipe Inspection--The service line segment suspended over the excavation was removed for inspection and documentation. About 50 feet of the service line, including the suspended section, were removed. Examination revealed that the length of the suspended pipe segment was about 29 feet. Within several of the cuts in the pipe coating, the pipe metal appeared to have been mechanically damaged. There was no definitive pattern of damage from which to determine the precise spacing of the device or the devices that had damaged the coating. However, in two small areas, measurement between damages was 0.3 foot. The majority of the damage on the exposed pipe was found between 12 and 16 feet south of the north edge of the excavation. Metallurgy--The damaged pipe sections, including the compression couplings, were taken to the Energy Research Center at Lehigh University for laboratory examination. In its September 5, 1995, report, the Center documented 31 gouges in the surface of the pipe; 30 of the gouges were on the top half of the pipe. Fourteen of the 30 gouges were caused by an object traveling perpendicular to the pipe. The force that caused one of the deep gouges was strong enough to induce a localized surface stress that exceeded the yield strength of the pipe metal and, as a result, deformed the surface of the pipe permanently.

30 Phone Records--Safety Board investigators reviewed the computer records for the telephone used by the EPAI's foreman. The investigators were trying to confirm the calls made or received within 15 minutes of the explosion. Calls were made and received as indicated on the following table. Approx. Time11 (p.m.) Call In/Out/Complete Call Duration (secs.) Connection Time12 (secs.) Interval Between Calls (secs.) Phone Location 6:46:41 Out/Complete 13 25 9 UGI Switchboard 6:47:15 Out/Complete 87 95 5 UGI Emergency No. 6:48:55 Out/Complete 70 82 15 Home, EPAI V. P. 6:50:32 Out/Complete 39 47 173 UGI Emergency No. 6:54:10 Out/Complete 84 121 170 Housing Authority Answering Service. 6:59:01 Out/Incomplete 0 55 2 911/Allentown 7:00:02 Out/Complete 162 175 3 Home, EPAI V.P. 7:03 In/Complete 120 120 40 13 7:05:40 Out 540 Residential Phone 7:14 In/Complete 180 180 See footnote 13

11While the time interval between listed times is accurate, the cellular phone carrier believes that the clock times may

be in error by as much as 30 seconds. 12The connect time is the time interval between originating and disconnecting a call. 13Incoming calls not traced back to phone location.

31 ANALYSIS The issues related directly to the accident are discussed first. Then follow discussions of using EFVs to mitigate the consequences of ruptured gas service lines and of various measures that can and should be taken to help prevent underground pipeline damage. Exclusions The Safety Board examined several aspects (fatigue, medical fitness, toxicological testing, and training) of human performance to see whether any of them might have affected the excavation crewmembers enough to have caused or contributed to the accident. Based upon the evidence in the factual section of this report, all areas except training can reasonably be excluded. The Safety Board concludes that fatigue was not a factor. Each crewmember was found to have had a normal amount of rest, to have conducted normal activities during the 48 to 72 hours before the accident, and to have showed no evidence of circadian rhythm desynchronosis, which means that normal sleeping patterns had not been disrupted. Each had had a physical examination within the past year and had been found fit for duty. Although the on-scene emergency medical, fire, and police personnel did not report any behavior on the part of the EPAI crewmembers that could be construed as evidence of alcohol or drug use, the Safety Board is unable to positively conclude that drugs or alcohol use was not a factor because the EPAI did not test its employees after the accident. The Accident Two things protected the service line pipe from being pulled out of the compression coupling longitudinally: the pressure of the soil around the pipe and the resistance from the coupling gasket. The pipe separated from the coupling when longitudinal pipe forces in the northerly direction became greater than the resistance from the soil and the coupling gasket. The EPAI’s excavation on May 23 and June 9 caused the pipe to move partially out of the coupling and reduced the resistance to movement provided by the soil. (See appendix C, “Time Line of Events.”) When the excavation’s side wall collapsed, the pipe was no longer supported from beneath, and the weight of the pipe was added to the forces the soil and coupling had to resist if they were to prevent separation. The pipe deformation caused by the asphalt pavement striking the line probably caused the pipe to be pulled out partially from the coupling because of the reduction in the effective length of the pipe. However, because there was no evidence that gas was escaping from the pipe/coupling connection before June 9, it is

32 apparent that the activities of May 23 did not cause the pipe and coupling to separate completely. When the excavator resumed on June 9, its activities near the service line probably reduced the amount of restraint provided by the soil even more and increased the longitudinal force enough to cause the pipe to separate fully from the coupling. Using the impact tool to break the concrete tank support and moving the backhoe over the pipeline caused the soil to vibrate and probably further reduced the soil’s restriction of pipe movement. Also, the backhoe probably struck the line when being operated across it; the foreman's reports to both the UGI and the housing authority indicated that the pipe had been struck during recent excavation activities. Although the foreman denied after the accident that the backhoe had struck the line, the coating of the pipe showed evidence of mechanical damage, as did the pipe steel at one location. Also, the foreman's calls both to the housing authority and to the UGI show that at the time he believed his crew had hit the gas line while excavating. The Safety Board concludes that the excavating reduced the ability of the soil and compression coupling to restrain the pipe’s movement and exerted excessive longitudinal forces on the service line. Also, the numerous contacts the pipe had with the mechanized equipment stressed the pipe compression coupling joint. These excavation-induced stresses caused the pipe separation, which released natural gas into Gross Towers. Emergency Response Allentown and the housing authority recognized the unique challenges presented by having to respond to an emergency involving a densely populated high-rise building inhabited by elderly and handicapped people. The city and the authority worked together closely in developing and testing preparedness plans. The Safety Board attributes the efficient evacuation of the building to the preparedness of the city agencies and the authority. Because the city and the authority had been so careful about preparing the residents, they knew what to do before and during the evacuation. For example, the residents were able to instruct the untrained volunteer responders about how to evacuate people requiring assistance. The emergency responders put the fire out and took care of the displaced residents efficiently. The Safety Board concludes that the emergency response was well coordinated and effective in reducing further injury. Human Performance and the EPAI Workcrew General--The EPAI had several opportunities to prevent the separation of the service line. It could have supported (shored up) the excavation’s side walls during the excavation, as it was required to do by both its own health and safety program and OSHA. Had the walls been shored up, the one next to the service line would not have collapsed and undermined the line’s support. The EPAI would have known that the walls were not shored up had it had a

33 supervisor overseeing the project, as its own procedures required it to. Even after the wall collapsed, the EPAI still could have prevented the accident by telling the UGI that the service line was no longer supported, thus giving the company a chance to protect the line. The Safety Board concludes that the EPAI could have avoided the accident by shoring up the excavation, by having effective supervisory oversight, or by reporting the lack of pipe support and the damage to the UGI. The EPAI needs to ensure that the requirements of its health and safety program are followed on all future work projects, including the requirement that damage be reported to the owners of buried facilities. Once the line and coupling separated, the EPAI could have limited the consequences. When the EPAI foreman was told about the strong odor of gas within the building, he should have immediately called “911.” Contrary to his postaccident statement, telephone records show that he did not attempt to call “911” until after the explosion. Had he immediately reported the emergency to the fire department, it would have known almost 15 minutes before the explosion, giving it enough time to respond, notify the UGI, initiate evacuations and building ventilation, and, using the UGI responders, shut off the flow of gas into the building, which would have either prevented the explosion or reduced its force. The Safety Board concludes that the consequences of this accident could have been significantly reduced had the foreman promptly called “911” and had his helper promptly told the occupants of the building to evacuate. Although it was after normal business hours, the foreman first called the UGI's Lehigh Division business office (the EPAI had not obtained and provided the foreman with the UGI’s 24-hour emergency telephone number). Even after contacting the UGI, he did not say, and the UGI did not question, whether the odor of gas had been detected within the building. Had the UGI known that gas was already in the building, it probably would have told him to evacuate the occupants, which he could have done with the help of his crew and the bystanders. The UGI probably also would have notified the fire department, thus giving it more time to respond. The Safety Board's report14 on a July 22, 1993, pipeline accident, which cost 2 lives and injured 12 persons, also involved excavation damage and issues similar to the ones in this accident. The report discussed how important it is for excavators to notify local emergency- response agencies promptly. In that accident, the excavator notified the pipeline operator promptly after gas was released, but he did not notify the local response agencies until more than 20 minutes later. Had the fire department been notified earlier, it might have been able to save lives and prevent injuries. As a result of that accident, the Safety Board recommended that the American Public Works Association (APWA):

14Brief of Pipeline Accident: Northern States Power Company Gas Pipeline Accident, July 22, 1993, St. Paul, Minnesota ( DCA-93-MP-011).

34 Advise your members of the circumstances of the July 22, 1993, explosion in St. Paul, Minnesota, and urge them to develop and implement written procedures and training to prevent excavation-caused pipeline damage. (P-95- 24) Urge your members to call “911” immediately, in addition to calling the gas company, if a natural gas line has been severed. (P-95-25) On June 2, 1995, the APWA told the Safety Board that it would incorporate the lessons learned from the report on the St. Paul accident in its publication Public Works Management Practices, which it was in the process of rewriting. Also, the report and recommendations would be discussed at the September 1995 International Public Works Congress and Exposition. On July 2, 1995, the Safety Board thanked the APWA for its timely and effective response to the recommendations. The Board added that it looked forward to reviewing the APWA’s revised practices. Safety Recommendations P-95-24 and -25 were classified "Open--Acceptable Response." The Associated General Contractors and the National Utility Contractors Association, two organizations that represent the interests of most contractors, give contractors extensive guidance on excavation issues affecting employee safety. The Safety Board believes these associations should also support the APWA initiative by encouraging their members to notify the owners of damaged buried facilities, to notify local response agencies of emergencies, and to take initial lifesaving actions when a damaged buried facility endangers public safety. Training--Before the accident, the workcrew had not had any formal training in excavation and trenching or in actions to take as a unit to protect lives and property in an emergency. The lack of training may account for why the crew did not shore the excavation site or tell the UGI that the gas line was unsupported. The crew foreman, despite not having any information about the construction of the gas line, said that he thought the entire line was welded tubular steel. His assumption may have led him to believe that the line could be adequately supported by crossbucks. In any event, he made a critical choice in assuming that it would be safe to leave the gas line uncovered and exposed for 2 weeks. A more prudent course of action would have been to immediately inform the UGI that the line was exposed. Since the accident, the crew foreman and the heavy equipment (backhoe) operator, as well as other employees, have each received 8 hours of training in trench construction and safety and 24 hours of training in confined-space entry and rescue training from the Maryland Fire and Rescue Institute, a part of the University of Maryland. However, the EPAI has not developed procedures to guide the actions of its workcrews, nor has it given emergency- responder training to those of its employees who excavate. The Safety Board believes that the EPAI and all other contractor excavators should train their employees in notifying local response agencies of emergencies and in what to do to save lives, such as evacuating endangered members of the public, while waiting for the representatives of the response agencies to arrive.

35 The Safety Board concludes that the excavation crewmembers did not evacuate the residents and the foreman did not call the fire department before the explosion because they had not been trained in handling an emergency. Preaccident Events--The EPAI had detailed, written procedures based on OSHA's requirements. Had the procedures been followed, the accident would not have happened. The EPAI's procedures, as well as Federal regulations and the provisions of the housing authority’s contract with the EPAI, required the EPAI to take specific protective measures, such as protecting the wall from collapsing by shoring it up or sloping it; yet, the EPAI did not take the protective measures. It obviously did not incorporate the procedures in its work project since its workcrew had had no formal training in excavation and trenching safety or in protecting buried facilities within the excavation. Also, the EPAI's management did not inspect the project every day, as it was supposed to. The inspector should have been a "competent person" who could identify and eliminate any hazardous worksite conditions or remove the company’s employees if he decided the site was dangerous. Because the EPAI’s management failed to prepare the workcrew properly, the crew foreman did not notify the UGI about the unsupported line, left it unsupported for 2 weeks, and did not protect the line while performing operations that could damage it. The Safety Board believes that only the facility operator can assess the safety of gas lines and other buried facilities once they have been damaged or otherwise disturbed and that he can make the assessment only after investigating thoroughly, including reviewing his construction information. Consequently, the EPAI, as well as other excavators, should instruct its employees to notify the facility operator promptly any time excavating alters the support of a buried facility, deforms its structure, or harms its coating. UGI Operations and Procedures General--The UGI also had a chance to prevent the accident. Given the depth stated in the planned-excavation notice, the UGI should have viewed the proposed work as potentially endangering the integrity of the line. It could then have acted to protect the line from damage. Excavation-Damage Prevention--The UGI's procedures did not require it to review excavations next to service lines as it did excavations next to gas mains. Had the UGI identified the threat the proposed excavation posed to the service line, the UGI would have had ample time to get more information from the EPAI on the precautions the EPAI planned and to instruct the EPAI on the precautions it should take and the need to report any damage promptly. The UGI also would have been able to inspect the excavation and to take whatever actions were necessary to protect the line. The Safety Board concludes that by failing to recognize the potential hazards posed by the EPAI project, the UGI lost the opportunity to preserve the integrity of the service line. The Safety Board believes that the UGI should broaden its procedures to require the assessing of any proposed excavation that could cause damage that might significantly endanger public safety.

36 Damage Notification--Had the EPAI or the fire inspectors told the UGI about the damage, it would have had an opportunity to take corrective action. Additionally, the information probably would have convinced the UGI that it needed to inspect the project and tell the EPAI foreman about the need to take precautions and use the UGI's emergency telephone number if he had an emergency. However, neither the EPAI workcrew nor the fire inspectors were trained in what damage should be reported to a buried-facility owner. It is apparent that the UGI's efforts to increase the public’s awareness of the dangers of damaging its system during excavations has not been effective in encouraging people to report damage to the UGI immediately. Because city inspectors often see a construction activity on a daily basis and because contractors excavate next to UGI facilities so often, the Safety Board believes the UGI needs to convince the local governments and contractor groups that public safety is endangered when damage is not promptly reported. The UGI should also encourage contractors and inspectors to report any damage they see or suspect to facility owners immediately. Because the city’s fire inspectors saw on May 23 that the service line was unsupported, they could have prevented the accident. They showed proper concern about the safety of the line, especially after a piece of asphalt pavement fell on it and deformed it. However, not having been instructed to do otherwise, both inspectors relied on the EPAI foremen's assessment that the line was safe. It would have been more prudent of them to ask the pipeline owner for the assessment. The Safety Board concludes that the likely reason the fire inspectors did not tell the operator that its service line was damaged was because the inspectors did not understand the importance of notifying operators so the effects on a facility could be assessed by the operators and necessary action taken. Had the inspectors notified the UGI, it, the Safety Board believes, would have taken the necessary corrective actions, and the accident would not have happened. The Safety Board believes that the city should encourage its inspectors to report any damage to the facility owner and thus ensure that the potential effect on public safety is assessed by a qualified person. Consequently, the Safety Board encourages Allentown to cooperate with the UGI by instructing its inspectors to report observed or suspected damage to the facility owners. Additionally, the Safety Board believes that the International Association of Fire Chiefs, which represents most community fire departments, should likewise encourage its members to instruct their inspectors to report observed or suspected damage directly to buried-facilities owners. Rapid Shutdown of Failed Service Lines--The Gross Towers gas line was fully separated, and the gas under 55 psig pressure flowed essentially unobstructed from the service line into the building. An EFV would have operated quickly to stop the gas flow into the separated portion of the service line, thereby preventing the accumulation of enough gas to fuel an explosion. The Safety Board concludes that the consequences of the separation could have been significantly reduced and that probably no one would have been hurt or killed had the UGI installed an EFV in the service line.

37 When Gross Towers was reconstructed after the accident, the UGI did not offer the housing authority an opportunity to have an EFV installed. Even though the UGI voluntarily installs EFVs in some of its service lines, like most gas operators nationwide, it does not usually tell customers what an EFV is, what its benefits are, or that a customer can pay to have one installed. The UGI did not install an EFV in the reconstructed Gross Towers service line because it does not routinely assess the merits of installing EFVs in large service lines or in large gas services that incorporate the use of compression couplings installed in the line near the wall of a building. The use of an EFV in such lines would minimize the consequences of an accident in which the coupling separates from the line, allowing the release of a large amount of gas right next to the foundation of the building. Pennsylvania's Pipeline Safety Operations Premarking Proposed Excavations--Pennsylvania can reduce the chance of a gas line being damaged by excavation by requiring the excavator to use paint or flags to mark the area that he proposes to excavate before the facility operator marks the locations of buried facilities. Had the area of proposed excavation been marked when the UGI's employee marked the location of the service line, he could have seen how close the service line was to the proposed excavation. Had he known how close the line was, he probably would have told his supervisor that there was a potential problem. The Safety Board believes that Pennsylvania should make its excavation-damage prevention program more effective by requiring that the excavator mark the area to be excavated before the facility operators mark the locations of their facilities. Excavation-Damage Prevention Program--The Safety Board is concerned because Pennsylvania has not initiated any enforcement action under the State’s excavation- damage program. The Safety Board’s investigation shows that the gas line was severely damaged during excavation activities, that the damage had not been reported to the UGI for a period up to 2 weeks before the explosion, and that the EPAI did not warn the occupants of Gross Towers about the emergency conditions. The Pennsylvania program addresses each of these issues. Several States, including Connecticut and Massachusetts, require all excavators and buried-facility operators to participate in their damage-prevention programs. Also, they have recognized the ineffectiveness of trying to enforce damage-prevention laws through the courts. Both Connecticut and Massachusetts have a single agency that has the authority to administer the program for its State. The agency is responsible for overseeing compliance, assessing penalties, and educating related industries and the public about the program’s purpose, requirements, and penalties. The two States report that since converting to an administrative program, they have achieved effective compliance with their excavation-damage prevention programs and significant reductions in the amount of excavation-caused damage. In its first year of operating under administratively enforced sanctions, excavation notifications in Massachusetts increased 100 percent, and the number of pipeline-damage inci-

38 dents decreased from 1,200 to 300. The State reported that it had collected more than $300,000 in violation fines, which more than paid for its safety enforcement efforts. The manager of Connecticut's Call Before You Dig, the State’s one-call excavation-notification program, reported that improved publicity and enforcement of its damage-prevention program resulted in a 60-percent decrease in the number of excavation-caused accidents. In Pennsylvania, however, not all excavators and buried-facility operators are required to participate in the damage-prevention program, and enforcing the program is the responsibility of the attorney general's office, an office that must devote much of its time to prosecuting far more serious violations. The Safety Board concludes that Pennsylvania is unable to effectively prevent excavation-caused damage because not all excavators and buried-facility operators are required to participate in the State’s program, because excavators are not required to premark proposed excavations, and because the State does not have an effective way of overseeing and enforcing compliance with the program. Housing Authority Standards Detection of Released Gas--The Safety Board concludes that the consequences of the accident might have been significantly reduced had the room in which the service line entered the building had a gas detector capable of alerting the occupants and the fire department. Had there been a gas detector in the room in which the service line entered, the occupants of the building and the fire department would have had 15 extra minutes in which to react. The fire department would have had time to communicate with the UGI, which might have been able to close the gas line valve soon after the separation occurred, thus preventing the accident. More likely, the accident would have happened, but much less gas would have been available to fuel the explosion, which might have substantially reduced the number of casualties and extent of the damage. The Safety Board believes that the consequences of the service line separation might have been reduced had HUD or the housing authority required the installation of a detector. The Safety Board addressed in a 1976 report15 the benefit of using gas detectors to provide early warnings of gas leaks in buildings. It noted that gas detectors were available and in use and that although they were relatively expensive at that time, work was being done to produce dependable, moderately priced detectors. The report noted that many commercial buildings were then required to have smoke or heat detectors at strategic interior locations and that some of them, when activated, also activated fire sprinklers. The report stated that it seemed logical for similar requirements to be adopted for installing gas detectors in buildings. It therefore recommended that HUD:

15National Transportation Safety Board Pipeline Accident, Consolidated Edison Company Explosion at 305 East 45th Street, New York, New York, April 22, 1974 (NTSB/PAR-76/02).

39 Investigate the practicality and the availability of gas vapor detection instruments for installation at strategic locations in buildings. Based on the results of this investigation, recommend guidelines to appropriate State and local government agencies for regulations for the installation of gas detection instruments in buildings. (P-76-12) On June 28, 1976, HUD advised that gas detectors were technically possible but that it did not believe them to be practical. It advised that it would continue to review developments in the field and when a practical, cost effective detection system was developed, it would reevaluate its position. The Safety Board did not consider HUD’s review of gas detectors adequate and classified Safety Recommendation P-76-12 “Closed--Unacceptable Action.” Since 1976, much improvement has been made in gas detectors. Today area gas detectors, much like smoke detectors, can be purchased at hardware stores for less than $35.00 Like smoke detectors, these gas detectors have alarms that can be heard in adjacent offices and throughout most homes. More sophisticated equipment that is capable of sampling various locations within a room or building to detect low levels of gas and of activating building fire alarms if gas is detected are also available for a few hundred dollars to about $1,500. The cost for a gas detector with alarms suitable for commercial buildings is dependent on many factors, such as detection sensitivity, whether a building already has an alarm system to activate, and the number of locations to be monitored. In the case of Gross Towers, where only one room needed to be monitored and a building alarm system was present, a gas detector system to alert building residents and the housing authority’s answering service probably could have been installed at a reasonable cost. HUD needs to assess the safety benefit of requiring that all buildings in its rent subsidy programs that use natural gas have gas detectors that are capable of alerting both occupants and the local emergency-response agencies. Rapid Shutoff of Failed Service Lines--Although the building could have had features, such as exterior vented trash chutes, designed to impede the flow of gas through vertical openings, an EFV would have been a far more cost-effective method of preventing the massive release of gas into the building. However, neither HUD nor the housing authority was aware of the potential benefits of using EFVs, and HUD did not require EFVs for buildings that received Federal subsidies. Because HUD had never assessed the safety benefits that occupants of subsidized rental buildings would receive from EFVs, it did not require that an EFV be installed on the service line when the building was reconstructed. The Safety Board believes that HUD should now assess the benefits of requiring EFVs on all service lines to buildings it accepts into its rent subsidy programs. Also, working with the gas distribution operators that supply gas to HUD-approved buildings, HUD should determine the feasibility of installing EFVs on buildings that are already in its subsidy program.

40 Rapid Shutdown of Failed Service Lines When Gross Towers was built, systems already existed that could detect either a drop in pressure or an excessive flow of gas and respond by closing a valve on the gas supply line. Today, off-the-shelf EFVs suitable for a wide range of pipe sizes, pressures, and sensitivities and suitable for residential, small-commercial, and large-commercial service lines are available. Several EFV manufacturers have EFV systems also for large-use commercial services that can be adapted easily to meet increasing or decreasing gas flow volumes simply by changing an orifice. It is this kind of EFV probably that would be necessary to protect the service line to Gross Towers, since the amount of gas the building requires is both large and variable. Such an EFV would cost between $1,200 and $1,500; an off-the-shelf EFV suitable for protecting high-pressure residential service lines costs about $10 to $20. Even so, the cost per apartment in Gross Towers would be about $8 to $10, less than the cost of an off-the-shelf EFV for a single-family residential customer. The Safety Board believes that an EFV should have been installed in the service line before gas service was reestablished to the reconstructed building. Since it was not, the Safety Board believes that an EFV should be installed now. RSPA, the Federal agency that is responsible for the safety of pipelines and is regarded by the public as the leader on such issues, should have required the installation of EFVs on all new and renewed service lines with operating parameters that were consistent with those of commercially available EFVs. Regardless, however, of what RSPA did or did not require, it would have been prudent for the UGI, a company that recognizes the benefit of using EFVs, to have installed the EFV. At the least, the UGI should have told the housing authority about the benefits of using an EFV and offered the housing authority the chance to pay for having one installed. The use of EFVs for gas distribution-system service lines has generated considerable debate within the gas pipeline industry and within both State and Federal governments. (For the history of activities to foster the use of EFVs and for factual support of comments included below, see appendix B.) In 1971, the Safety Board first identified the need for gas operators to provide a means of rapidly detecting and shutting down failed pipeline segments. RSPA did not require EFVs in the 1970s even though several gas operators were using them successfully and studies showed that EFVs could enhance public safety and were technically and economically feasible and commercially available. The Safety Board initially advocated using EFVs on service lines to such buildings as schools and other buildings in which a large number of people gathered. Later, because EFVs became cheaper and more available, the Safety Board began advocating the installation of EFVs on all service lines. During the 1980's, RSPA took no action on requiring EFVs. Consequently the Safety Board included the use of EFVs on its 1990 list of most wanted safety recommendations, a list the Safety Board keeps of the safety recommendations that offer the greatest potential for saving lives.

41 In December 1990, RSPA issued an Advanced Notice of Proposed Rulemaking about requiring EFVs, but for almost 2 years did not complete the rulemaking. In October 1992, Congress passed Public Law 102-508 (106 STAT. 3290), which allowed the DOT Secretary 18 months to prescribe the circumstances in which natural-gas distribution-system operators would have to install EFVs. Under the same law, Congress gave the Secretary 2 years in which to require gas operators to tell their customers about the benefits of using EFVs and to offer them the chance to have EFVs installed at their own expense. In April 1993, RSPA issued a Notice of Proposed Rulemaking (NPRM). The NPRM proposed mandating the installation of EFVs in new and renewed single-family high-pressure service lines and cited the positive benefit/cost ratio that it had determined in its 1991 study would result from using EFVs. After reviewing the comments he received, the OPS director said in an August 1993 meeting with people interested in EFV use that the rulemaking process had not produced enough information for the OPS to proceed with a final rule. He suggested that the representatives of agencies and associations attending the meeting might want to participate in a negotiated rulemaking process. Because he would not agree to follow the results of a negotiated rulemaking, several representatives stated their desire to develop a consensus agreement. He agreed that if such an agreement were reached, he would publish the proposal as a supplemental rulemaking with a 30-day comment period. The AGA and the Safety Board staffs jointly held meetings with interested people to formulate an alternative proposal. Sixteen parties of interest, which later became known as the Joint Commenters, developed a consensus proposal that EFVs be required. They submitted the proposal to the OPS on December 14, 1993. They included the AGA, the American Public Gas Association (APGA), the Interstate Natural Gas Association of America, the National Association of Pipeline Safety Representatives (NAPSR), the National Association of Regulatory Utility Commissioners, the Gas Safety Action Council, the International Association of Fire Chiefs, eight EFV manufacturers, and the Safety Board. The Safety Board concurred with the proposal and through a letter filed with the Joint Commenters' proposal made its position known to RSPA and urged that prompt action be taken to implement the proposal. The Joint Commenters' proposal said that the organizations endorsing the proposal represented the most identifiable interests in this matter. The Commenters said that the 1991 OPS study contained many errors that biased it in favor of using EFVs. The proposal said: Much of the information necessary to accurately assess the costs and benefits of EFVs is incomplete or unavailable; therefore we support a cooperative effort between the American Gas Association and EFV manufacturers to begin collecting data on the in-service performance of the approximately 1 million EFVs that will be installed annually if the rule we propose is promulgated. The OPS published a Notice of Reopening Comment Period (Docket PS-118, Notice 4) on August 2, 1994, asking whether it should adopt the Joint Commenters’ proposal. The

42 Notice, however did not include the proposal; instead it said that the proposal could be reviewed in the public docket. The Notice also requested comments on the safety of the EFV bypass feature, on the effect of contaminants on EFVs, and on whether RSPA should wait for industry-sponsored committees to complete their standards before the OPS proceeded with the rulemaking. The Notice acknowledged that an OPS regulatory evaluation indicated that the use of EFVs would reduce the number of deaths, injuries, fires, explosions, and evacuations enough to result in an aggregate annual savings of $19 to $31 million. The Safety Board responded to the Notice, urging RSPA to accept the proposal and to expedite the issuance of a final rule. The majority of comments favored adopting the proposal; the OPS and RSPA disregarded that. They also disregarded the Joint Commenters' counsel that there was too little data to do a proper cost/benefit study. Instead, in 1995, the OPS developed another cost/benefit study, which was done by the same Transportation Safety Center staff that had done the 1991 study. The new study corrected some of the errors made in the old one, but included new ones. (See appendix B.) The new study concluded that using EFVs is not cost effective. On April 4, 1995, RSPA’s Administrator sent letters to the chairmen of the Senate and House committees and subcommittees that oversee pipeline safety, notifying them of RSPA's decision to not require EFVs. The letters said that RSPA had found no circumstance under which it should issue a Federal rule requiring the universal installation of EFVs and that, as required by 49 U.S.C. section 60110, the agency was planning to issue performance standards and customer-notification requirements for EFVs, thus encouraging a greater use of EFVs only where local conditions were appropriate. In a September 28, 1995, letter (see appendix D), the Safety Board told RSPA’s Administrator that the Board was extremely disappointed with RSPA's decision to not require EFVs. The Board noted that most of the 70 responses to RSPA's Notice of Reopening Comment Period supported adopting the Joint Commenters’ proposal. The letter noted that RSPA had again lost an excellent opportunity to increase the safety of gas customers and the public. The letter said that in investigations of distribution-pipeline accidents, the Safety Board continued to find strong evidence supporting the need for requiring that there be a way to quickly shut off the flow of gas to a failed pipe segment. While such a requirement would not prevent accidents, it would significantly reduce their consequences. Therefore, the Safety Board classified Safety Recommendation P-90-12 “Closed--Unacceptable Action.” The Safety Board concludes that RSPA was grossly ineffective during the previous 20 years in objectively assessing the benefits of EFVs and in advancing public safety through their use. The Board also addressed RSPA's plans to issue performance standards and customer- notification requirements for EFVs. The Board noted that the Natural Gas Pipeline Safety Act does not limit RSPA’s consideration of EFV use by type of customer, size of service pipe, or

43 operating pressure and urged RSPA to address in its performance standards only those parameters that relate to EFV operating capabilities, such as pressure drop, ability to reset after activation, bleed-by flow rate, and so forth, which are addressed in the Manufacturers Standardization Society’s recently approved standard “Excess Flow Valves for Natural Gas Service.” Further, the performance standards should not address such factors as service-line diameter, operating pressure, or type of customer because RSPA should not limit EFV use on the basis of the customer’s classification or the service line’s diameter. This point is particularly true when service line operating parameters are similar and commercial or residential service lines can be protected using the same style or model of EFV. The Board urged RSPA to ensure that information given to customers be accurate, straightforward, and easy to understand. The Board said that RSPA should require operators to give prospective EFV users the names, addresses, and telephone numbers of alternative sources of information, such as EFV manufacturers or consumer advocacy groups. The AGA, on July 14, 1995, petitioned RSPA to include certain limitations in its regulations about notifying customers: the customer should not be able to select the type or manufacturer of the EFV installed on his service line, and the gas system operator's responsibilities for the functioning of the EFV should be limited. Additionally, the AGA is seeking to further limit the effect of the congressionally- mandated customer-notice requirement. Even so, the Safety Board believes that the voluntary installation of EFVs by the gas industry will continue to increase as it has historically, primarily because of the positive experiences of pipeline operators that now use more than 1 million EFVs. Also, the Safety Board is confident that the number of gas operators that use EFVs will increase as the controversy over EFVs diminishes and as more operators begin learning for themselves the value of EFVs to their operations and to public safety. The Safety Board finds it unfortunate that EFVs have not been required for the more than 20 years since their use was first recommended. Had EFVs then been required, between one third and one half of today's almost 60 million gas customers would now be protected by EFVs. The operator as the seller of EFVs could be liable. The operator may not know who to notify about EFVs because the occupant may not be the owner. The local jurisdiction might limit the amount an operator could charge for an EFV; the jurisdiction might even forbid the operator to accept pay for installing the EFV. Problems the AGA Believes Operators May Face if EFVs Are Required

44 Excavation-Damage Prevention The accident at Allentown again demonstrates how devastating it can be when a pipeline is damaged by excavation. Since 1970, when the OPS first required that pipeline accidents be reported, the largest single cause of all pipeline accidents, including distribution- system accidents, has been excavation damage. Minimizing the consequences of excavation- caused accidents was the primary reason the gas industry began using EFVs. Based on the reports filed with the OPS in the last 10-year period for which data are available, 1985 to 1994, gas distribution fatalities have ranged from 5 to 21, or an average of 14, a year. The injury rate during the same time has ranged from 50 to 94 per year, or an average of 77 injuries a year. The number of reported distribution accidents has varied from 103 to 204 per year, or an average of 147. Distribution accidents account for a majority of the fatalities and injuries in the pipeline industry. Gas operators report excavation-caused accidents as outside force accidents, a category that includes damage to pipelines from any activity outside the control of the operator, such as fire or lightning. In 1993,16 26.9 percent of all reported distribution accidents

16The latest year for which this data has been determined. Development of this statistic requires manual review of all reports made to the OPS to identify those that occurred due by excavation activity because OPS's accident reporting forms do not include a classification for excavation-caused accidents. The operator must notify only single-residence customers whose service line pressures never fall below 10 psig pressure. The operator must install an EFV only if the customer agrees to pay all costs associated with its installation, maintenance, and replacement. Even when a customer wants an EFV and agrees to pay for it, the operator does not have to install one when a. The operator is not able to get an EFV that meets the performance standards. b. The service line has been installed under emergency or short-notice conditions. c. The operator determines that installing an EFV would interfere with necessary operation or maintenance activities. d. The service regulator and meter are visible and located within 12 feet of the gas main and at least 12 feet from the residence. e. The operator is under a jurisdiction that prohibits him from recovering all costs associated with EFVs. AGA’s Proposed Limitations

45 were caused by excavation, and these accidents accounted for 29.3 percent of the distribution injuries and 43.8 percent of the distribution fatalities. The Safety Board’s reports have consistently addressed the need to reduce the excavation-caused damage to pipelines and other buried facilities. Between 1968 and 1972, the Safety Board investigated a number of excavation-caused pipeline accidents having tragic consequences. In April 1972, the Board sponsored a pipeline damage-prevention symposium, inviting industry and government representatives to discuss the prevention of such accidents. Many proposals developed at the 1972 symposium led to Safety Board recommendations that resulted in the concepts and systems, such as one-call notification centers, now used to minimize excavation-caused damage to pipelines. The Safety Board also recommended that RSPA require pipeline operators to establish excavation-damage prevention programs. In 1982, RSPA required natural-gas pipeline operators to do so; and in 1995, RSPA required liquid pipeline operators to join in. The regulations allow operators to comply with portions of the requirements by participating in one-call notification systems Since the 1972 symposium, the Safety Board has continued to support the efforts of the APWA, the States, and the national organizations dedicated to reducing excavation damage to pipelines. It has advocated improving prevention in testimony before Congress and State legislatures, before groups interested in pipeline safety, and before such trade associations as the Interstate Natural Gas Association of America, the APGA, the AGA, and the API. The combined efforts of industry, State commissions, and the Safety Board and other Federal agencies during the 1970s led to a decrease in the number of accidents during the 1980s, despite an increase in pipeline construction and in urban development near pipeline right-of- ways. Even so, excavation-caused damage remains the largest single cause of pipeline accidents. Because of the number of excavation-caused accidents in recent years, the Safety Board reviewed several State damage-prevention programs in 1994 and identified several recurring unresolved problems. The Safety Board also identified some innovative State programs that show promise of significantly reducing exca- vation-caused damage. Arizona, Connecticut, Massachusetts, Minnesota, and Utah require universal compliance with their damage-prevention laws and impose sanctions through Mandatory participation by all affected parties, whether private or public. A true one-stop notification system in which excavators can alert all operators of buried systems. Swift, effective sanctions against violators of State damage-prevention laws. An effective education program for the public, contractors, excavation machine operators, and operators of underground systems that stresses the importance of notifying before excavating, accurately marking buried facilities, and protecting marked facilities when excavating. Common Elements of Effective State Damage- Prevention Programs

46 administrative rather than judicial action. While the programs differ from one another, they all contain similar provisions that contribute to their effectiveness. To foster improvements in State excavation-damage prevention programs, on September 8 and 9, 1994, the Safety Board and RSPA jointly sponsored an excavation- damage prevention workshop attended by more than 375 government and industry repre- sentatives. The workshop provided a forum in which participants could identify and recom- mend ways of improving prevention programs. Four panels designated by industry and government associations deliberated and achieved consensus on the following: the essential elements of an effective one-call notification system, the responsibilities of buried-facility operators, the responsibilities of excavators, and the ways in which a damage-prevention pro- gram should be administered. The Board published the proceedings of the workshop17 and is now analyzing the findings, its previous reports on excavation-damage accidents, comments filed by interested parties, and other related documents to develop recommendations for improving excavation-damage prevention programs nationwide.

17National Transportation Safety Board, Proceedings of the Excavation Damage Prevention Workshop, September 8-9,1994, Washington, DC (NTSB/RP-95/01).

47 CONCLUSIONS 1. Fatigue was not a causal or contributing factor. 2. Whether drugs or alcohol was a factor cannot be established because the workmen were not tested after the accident; the excavator’s management did not observe cause for tests, and Federal regulations did not require tests. 3. By reducing the soil’s capacity to restrain the movement of the pipe and by exerting forces on the service line that resulted in excessive longitudinal stress, the excavator caused the line to separate at a compression coupling. 4. The Allentown Housing Authority and the city of Allentown’s emergency response was well coordinated and effective. 5. The excavator could have prevented the accident by shoring up the excavation, by providing effective supervisory oversight, by ensuring that the excavation was properly shored, by telling its employees to notify owners when buried facilities were damaged, or by training its employees in the requirements of its own health and safety program and in the excavation, trenching, and shoring requirements of the Occupational Safety and Health Administration. 6. The gas company lost the opportunity to preserve the integrity of the service line because its procedures did not require a review of any unusual excavation near a gas service line that might damage the line and threaten public safety. 7. The likely reason the fire inspectors did not notify the gas company that its service line was damaged was because the inspectors did not understand the importance of notifying operators so the effects on a facility could be assessed by the operators and necessary action taken. 8. Had the service line had an excess flow valve, the consequences of the accident could have been substantially reduced; the likely result would have been no injuries or deaths. 9. Pennsylvania's excavation-damage program could be more effective if it (1) required each excavator and buried-facility operator to participate in the program, (2) required the excavator to mark the area he proposes to excavate, and (3) had an effective means of overseeing and enforcing the program’s provisions. 10. The consequences of this accident could have been significantly reduced had the excavator’s foreman promptly called “911” and had his helpers promptly told the occupants of the building to evacuate.

48 11. Before the explosion, the excavation crewmembers did not evacuate the residents and the foreman did not call the fire department because they had not been trained in handling an emergency. 12. The consequences of this accident might have been substantially reduced had a gas detector capable of alerting people throughout the building and at the nearest fire station been installed in the room where the service line entered the building. 13. In the past 20 years, the Research and Special Programs Administration has failed to effectively assess the benefits of excess flow valves and has failed to promote their use. PROBABLE CAUSE The National Transportation Safety Board determines that the probable cause of the natural gas explosion and fire at Gross Towers in Allentown, Pennsylvania, was the failure of the management of Environmental Preservation Associates, Inc., to ensure compliance with OSHA's and its own excavation requirements through project oversight. Contributing to the accident was the failure of the workmen from Environmental Preservation Associates, Inc., to notify UGI Utilities, Inc., that the line had been damaged and was unsupported. Contributing to the severity of the accident was the absence of an excess flow valve or a similar device, which could have rapidly stopped the flow of gas once the service line was ruptured. Also contributing to the severity of the accident was the absence of a gas detector, which could have alerted the fire department and residents promptly when escaping gas entered the building.

49 RECOMMENDATIONS As a result of its investigation, the National Transportation Safety Board makes the following recommendations: --to the Research and Special Programs Administration Require gas-distribution operators to notify all customers of the availability of excess flow valves; any customer to be served by a new or renewed service line with operating parameters that are compatible with any commercially available excess flow valve should be notified; an operator should not refuse to notify a customer because of the customer’s classification or the diameter or operating pressure of the service line. (Class II, Priority Action) (P-96-2) --to the States and the District of Columbia.: Require gas distribution operators to install excess flow valves in all new or renewed gas service lines, when operating conditions are compatible with commercially available valves, including service lines supplying schools, churches, and other places of public assembly. (Class II, Priority Action) (P-96-3) --to the UGI Utilities, Inc.: Require that people handling emergency calls determine whether escaping gas is likely to enter a structure, and if so, require that the information be quickly conveyed to “911.” (Class II, Priority Action) (P-96-4) Modify its excavation-damage prevention program to include the review and close monitoring of any proposed excavation near a gas service line, including any line with unanchored compression couplings, that is installed near a building and that, if damaged, might endanger public safety significantly. (Class II, Priority Action) (P-96- 5) Instruct members of local governments and contractor groups in its service area about the threat to public safety posed by a gas line that is unsupported or damaged, and emphasize the importance of reporting such information immediately to the facility owner. (Class II, Priority Action) (P-96-6)

50 --to Environmental Preservation Associates, Inc.: Instruct its employees on actions to take when buried facilities, such as gas lines, are unsupported or damaged; such actions should include alerting local response agencies and residents of threatened buildings, initiating evacuations, and notifying facility owners. (Class II, Priority Action) (P-96-7) --to the Governor of the Commonwealth of Pennsylvania: Require any person or entity that excavates to participate in the State's excavation- damage prevention program. (Class II, Priority Action) (P-96-8) Designate a single State agency responsible for the State's excavation-damage prevention program; give the agency the power to levy administrative penalties. (Class II, Priority Action) (P-96-9) Require each contractor to outline the area of the proposed excavation before asking the facility operators to mark the locations of their facilities. (Class II, Priority Action) (P-96-10) --to the city of Allentown Instruct fire and other city inspectors to advise facility owners, such as gas companies, immediately about any suspected damage to their buried facilities or any lack of structural support. (Class II, Priority Action) (P-96-11) Require as an excavation-permit condition that the excavator instruct his workmen in how to help members of the public in the immediate vicinity of an emergency, how to notify the local response agencies and the owner of a damaged facility, and how to evacuate anyone who might be in danger. (Class II, Priority Action) (P-96-12) --to the International Association of Fire Chiefs: Urge its members to instruct their inspectors to report observed or suspected damage to a buried facility, including lack of support, to the owner immediately. (Class II, Priority Action)(P-96-13) --to the Department of Housing and Urban Development: Require the installation of excess flow valves in new and renewed gas services to buildings that the Department has approved for Federal rent subsidies. (Class II, Priority Action) (P-96-14)

51 Evaluate the safety benefit of requiring the installation of excess flow valves in gas services to existing buildings and, where feasible, require their installation. (Class II, Priority Action) (P-96-15) Evaluate the safety benefits of using gas detectors in buildings approved by the Department for Federal rent subsidies as a means of providing building occupants and local emergency-response agencies with early notice of released natural gas within buildings; require that gas detectors be used in buildings in which the Department has determined that a gas detector would be cost effective and beneficial. (Class II, Priority Action) (P-96-16) --to the Allentown Housing Authority: Encourage UGI Gas Services, Inc., to install an excess flow valve in the gas service to any building the housing authority owns or manages. (Class II, Priority Action) (P-96- 17) Evaluate the safety benefits of using gas detectors in buildings that it owns or manages that are served with gas as a means of providing emergency-response agencies with early notice of released gas within buildings; install gas detectors in buildings in which it is determined that they would be cost effective and beneficial. (Class II, Priority Action) (P-96-18) --to the Associated General Contractors: Inform its members about the 1994 Allentown accident and encourage them to train their excavation employees in: (a) notifying local emergency-response agencies of any emergency conditions immediately; (b) helping members of the public who are in the immediate vicinity of an emergency, including evacuating anyone who is in danger; (c) notifying the buried-facility owner of any changes in the work plan; (d) notifying the buried-facility owner of any damage to or lack of support for his facility promptly and relying on the buried-facility operator to decide whether corrective action is needed. (Class II, Priority Action) (P-96-19) --to the National Utility Contractors Association Inform its members about the 1994 Allentown accident and encourage them to train their excavation employees in: (a) notifying local emergency-response agencies of any emergency conditions immediately; (b) helping members of the public who are in the immediate vicinity of an emergency, including evacuating anyone who is in danger; (c) notifying the buried-facility owner of any changes in the work plan; (d) notifying the buried-facility owner of any damage to or lack of support for his facility promptly and relying on the buried-facility operator to decide whether corrective action is needed.(Class II, Priority Action) (P-96-20)

52 BY THE NATIONAL TRANSPORTATION SAFETY BOARD JAMES E. HALL Chairman ROBERT T. FRANCIS II Vice Chairman JOHN A. HAMMERSCHMIDT Member JOHN J. GOGLIA Member February 26, 1996

53 APPENDIX A Investigation The National Transportation Safety Board was notified on June 9, 1994, by the National Response Center of a gas explosion damaging an eight-story building at Allentown, Pennsylvania. Upon being notified, the Safety Board dispatched an investigation team from Washington, D.C., comprising investigative groups for pipeline operations, survival factors, human performance, and site documentation. Hearing The Safety Board did not conduct a public hearing in conjunction with this investigation.

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55 APPENDIX B Rapid Shutdown of Failed Service Lines Since the early 1950s, some manufacturers have offered excess flow valves for large gas service loads, such as industrial facilities, schools, and hospitals. Gas-distribution system operators, who recognized the need to rapidly shut down smaller gas service lines after a rupture to improve public and customer safety, asked the Mueller Company of Decatur, Illinois, to develop a valve that could stop the gas flow on smaller service lines when the flow was excessive. In 1965, Mueller introduced an automatic safety shutoff valve, which became known as an excess flow valve (EFV). Since the mid-1960s, the use of EFVs on gas-distribution system service lines has generated considerable debate within the gas industry and within both State and Federal governments. The Safety Board has recognized since 1968 that pipeline operators need to be able to shut off the gas flow from a failed pipeline segment rapidly as a means of providing reasonable public safety. The Board advocated installing EFVs in gas service lines as near as practicable to their connections to gas mains. Its 1970 report1 cited an accident that would have likely had substantially less serious consequences had an EFV been installed in the gas service line: On May 29, 1968, a bulldozer working at the front of a children’s nursery in Hapeville, Georgia, broke a 1-inch medium pressure gas service line. The bulldozer operator reportedly was unable to locate the buried shutoff valve. In a few minutes, an explosion occurred in the nursery. The ensuing fire engulfed the frame dwelling. Nine people, including seven children, lost their lives. Three other children were seriously injured. The Board recognized that an EFV, although not then commercially available, had been developed and could function on high- and low-pressure gas service lines. Based on that study, the Safety Board recommended that the Office of Pipeline Safety (OPS): P-71-1 Conduct a study to develop standards for the rapid shutdown of failed natural gas pipelines and work in conjunction with the Federal Railroad Administration

1Special Study of Effects of Delay in Shutting Down Failed Pipeline Systems and Methods of Providing Rapid Shutdown, National Transportation Safety Board, December 30, 1970 (NTSB/PSS-71/1).

APPENDIX B 56 [the agency that then had safety regulatory jurisdiction over liquid pipelines] to develop similar standards for liquid pipelines. On October 30, 1972, a bulldozer struck and ruptured a 3/4-inch gas service line in a downtown area of Lake City, Minnesota. A department store adjacent to the ruptured service line, but not served by gas, exploded and later caught fire. Six people were killed, and 10 were injured. The Safety Board concluded that if a fail-safe device, such as an inexpensive EFV, had been installed on the service line, the flow of gas would have been stopped promptly. The Safety Board concluded that EFVs should be installed universally, and it recommended that the OPS: P-73-2 Undertake a study of fail-safe devices which will stop the flow of gas from ruptured lines. Based on the results of this study, OPS should consider amending 49 CFR 192 to require the installation of such devices at appropriate locations in gas distribution systems. On July 20, 1973, the OPS advised the Safety Board that it had contracted for a study on the rapid shutdown of failed pipeline facilities and on the pressure limiting of pipeline systems. The OPS study was completed in October 1974.2 The study recommended installing EFVs on all new gas service lines and service lines undergoing repair. Reasons included in the study in support of the recommendations were: • EFVs will improve public safety by reducing accident effects in gas service line ruptures, e.g. excavation and other damages.

• EFVs are commercially available, technically feasible, and are being used by gas distribution facilities.

• EFVs are economically feasible because they add less than 1 percent to the installation and maintenance costs of the gas distribution system. On April 22, 1974, a massive, low-order explosion demolished the west wall of a 25- story high-occupancy commercial building in New York City. The structure of the adjacent building was damaged, and glass was broken in other buildings in the area. No one was killed,

2"Rapid Shutdown of Failed Pipeline Systems and Limiting of Pressures to Prevent Pipeline Failure Due to Overpressure," Research Conducted by Mechanics Research, Incorporated of Los Angeles, California, for the Office of Pipeline Safety, U.S. DOT, October 1974 (PB 241-325).

APPENDIX B 57 but more than 70 people were injured. The Safety Board found that an overpressured pneumatic tank had rocketed upward, breaking an overhead, 6-inch-diameter, 1/4 psig pressure service line at a threaded joint. Gas escaped unabated into the building through elevator shafts until it was ignited by an undetermined source. The Safety Board's report3 on the accident recognized that the consequences could have been substantially reduced if an EFV had been installed in the service line. The report acknowledged that EFVs then commercially available were limited to gas systems operating at 3 or more psig pressure, that some valve manufacturers claimed to have EFVs that could function correctly at 1/4 psig pressure and higher, that the OPS had contracted a study to develop standards for rapid shutdown of failed pipelines, that the study was at that time complete and being reviewed by the OPS, and that the study concluded that the use of EFVs would benefit public safety. The Board noted that "The practicality of these EFVs has been argued, but the theory is sound, research is continuing, and work in this area should be expedited." Consequently, it recommended that the OPS: P-76-9A Determine the availability, the practicability, and the state of the art in the manufacture of EFVs for use on low-pressure gas distribution systems. Based upon the results of these findings, amend 49 CFR 192 to incorporate the use of these valves in commercial buildings. A November 1975 Department of Transportation report4 recommended that EFVs be installed on customer service lines because they are inexpensive. On July 30, 1976, the OPS advised that its study had reviewed the state of the art of the rapid shutdown of failed distribution systems and that its preliminary evaluation indicated that EFVs might be practical safety devices for certain conditions. However, the OPS also advised that the results of the study were not conclusive concerning the use of EFVs. On April 3, 1978, the OPS advised the Safety Board that its study on EFVs showed that they might have safety potential and that rulemaking action would be considered for its 1979 programs. In a December 1978 letter, the Chairman of the Safety Board urged the DOT's Materials Transportation Bureau (The OPS’s parent DOT organization) Director to act on the Board’s 1971, 1973, 1975, 1976, and 1978 recommendations that the MTB require the use of EFVs on all natural gas services. In an October 1979 letter, the Safety Board Chairman asked the DOT/RSPA (RSPA became the OPS’s parent DOT organization) Administrator to provide a status report on

3Pipeline Accident Report, Consolidated Edison Company Explosion at 305 East 45th Street, New York, New York, April 22, 1974 (NTSB/PAR-76/2). 4Study on Current Practices, Technologies, Problems, and Recommendations Relating to the Overall Safety of Gas Pipeline Distribution Systems, November 1975 (DOT/MTB/OPSO-76/01).

APPENDIX B 58 RSPA’s response to the Board’s numerous recommendations that RSPA require the installation of EFVs on all customer service lines. RSPA responded on November 30, 1979, saying that EFVs had too many problems associated with them to be effective. The letter advised that RSPA planned to hold a conference with major manufacturers of EFVs in January 1980 to discuss problems with the valves. RSPA advised that the Safety Board would be kept aware of the progress made. On October 24, 1979, an explosion and fire destroyed the Greene County Clerk's office building and the Greene County Courthouse in Stanardsville, Virginia, gutted a connecting building under construction, and damaged nearby buildings. Thirteen people were injured, and the property damage was extensive. The Safety Board's report5 stated that an excavator's backhoe had struck and broken the gas service line at the wall of the office building. Gas under 15 psig pressure had flowed unabated into the building until the gas was ignited by an undetermined source. The report reviewed the Safety Board's previous recommendations to RSPA about EFVs and discussed the OPS's October 1974 study on EFVs. The Board's report noted that the OPS was still reviewing the regulatory action it might take concerning EFVs and that consequently the Safety Board was recommending that the OPS: P-80-55 Expedite rulemaking to require the installation of EFVs on all newly installed and renewed high-pressure gas distribution system service lines. On January 29, 1980, RSPA conducted a 1-day conference in Washington, D.C., to gather information about EFVs. A February 26, 1980, OPS internal memorandum from the Technical Division to the Associate Director for Pipeline Safety Regulation reported on the meeting, saying that: Unintended EFV closures cited by operators as being a serious problem is not supported by evidence. The argument that foreign matter in existing gas systems could cause sticking and unintended closure is not especially significant, as such occurrences have been extremely rare. Furthermore, such conditions would probably cause a greater problem in meter assemblies, regulators, or customer safety-related equipment. An EFV would trap materials in the gas stream and prevent a more serious problem down line.

5Pipeline Accident Report, Columbia Gas of Virginia, Inc., Natural Gas Explosion and Fire, Stanardsville, Virginia, October, 24, 1979 (NTSB/PAR-80/3).

APPENDIX B 59 The memorandum called for further review of the EFV’s ability to operate properly after being dormant in a service line for several years and of the EFV’s reliability and serviceability. However, the Technical Division concluded that "the potential safety benefits to be gained from installing EFVs where needed appear to outweigh the cited problem possibilities." The Associate Director for Pipeline Safety Regulation was advised that should the Office issue an Advance Notice of Proposed Rulemaking (ANPRM) to gather comments and information on using EFVs, it should also ask the following question: At what locations should EFVs be required on service lines, e.g., service lines to public places of assembly (schools, churches, hospitals, theaters), commercial, high rise office buildings and apartments, and multifamily units, particularly those located in business districts where subsidence is a problem or in other high risk areas; service lines to mobile homes subject to high winds, tornadoes, hurricanes, or other drastic movements; or temporary service lines? On September 19, 1980, the Safety Board issued its report6 that analyzed OPS accident data on plastic pipe distribution systems. Analyses of the data indicated essentially no difference in the incident rate for plastic and steel service lines. The Safety Board encouraged the installation of EFVs in all new service lines, stating that "these valves cannot prevent damage to plastic pipe, but in some circumstances can minimize the consequences of the damage." On October 9, 1980, a 2-inch compression coupling on the upstream side of a gas meter set assembly in the boiler room of the Simon Kenton High School in Independence, Kentucky, separated from the gas service line. Gas at 165 psig pressure flowed into the room, ignited, and exploded, killing a student in an adjacent classroom. About 30 minutes later, there was a second explosion, which injured 37 people and extensively damaged the high school building. The Safety Board's report7 found that had an EFV been installed on the service line, the severity of the explosion might have been lessened and the second explosion might have been avoided. The Safety Board noted that it had investigated 13 other pipeline accidents since 1972 in which EFVs could have lessened the severity of the losses. Because the OPS still had not determined what action it might take on requiring the use of EFVs, the Safety Board initiated a special study8 to better define the potential uses of the valves, and it recommended that RSPA:

6National Transportation Safety Board Special Study, Analysis of Accident Data From Plastic Pipe Natural Gas Distribution Systems, (NTSB/PSS-80/1). 7Pipeline Accident Report, Union Light, Heat, and Power Company, Natural Gas Explosion and Fire, Simon Kenton High School, Independence, Kentucky, October 9, 1980 (NTSB/PAR-81/01). 8Special Study, Pipeline Excess Flow Valves, September 1981 (NTSB/PSS-81/01).

APPENDIX B 60 P-81-9 Initiate rulemaking to require the installation of EFVs on all newly installed and renewed high-pressure gas distribution service lines with priority given to service lines supplying schools, churches, and other places of public assembly. Almost 10 years after the Safety Board first recommended developing a way of rapidly stopping the flow of gas from failed pipelines, the OPS had taken virtually no action to require the use of EFVs. During those years the Safety Board investigated many accidents in which it found that fatalities, injuries, and property damage probably would not have occurred or would have been substantially less severe had the service line had an EFV. Consequently, to motivate action by the OPS on EFVs, in 1981 the Safety Board performed a study9 to characterize the conditions under which the installation of EFVs appeared to have safety potential. Among other things, the study found that: In 23 percent of the distribution-system accidents reported to the OPS, an EFV could have been used and would have been effective. This included 8 percent of the accidents involving fatalities and 20 percent of those that caused personal injury. The reasons most often given by company managements for not using EFVs were concerns about their cost effectiveness, the potential of false valve closure, and the belief that current gas system designs were inherently safe. The Safety Board concluded that EFVs save lives, protect property, and generally enhance public safety. Based on its findings, the Safety Board concluded that additional documentation on EFV effectiveness should be undertaken, and it recommended that the Gas Research Institute (GRI): P-81-35 Plan and conduct a test and evaluation of existing EFVs to determine and document, on a comparable basis, their operating and design characteristics, such as reliability, service pipe size and length, operating pressure range, maximum service load, and susceptibility to contamination. P-81-36 Determine the conditions and locations (other than those for which the Safety Board is recommending immediate regulatory action--i.e., high pressure single- family residential services) for which EFVs can be effective in preventing or minimizing the potential for various types of accidents resulting from leaks on high pressure service lines. Among the conditions which should be evaluated are

9Special Study, Pipeline Excess Flow Valves, September 1981 (NTSB/PSS-81/01).

APPENDIX B 61 gas demand variations, minimum operating pressure, service line size, length, and configuration, major leaks on house piping, cleanliness of gas, and effect on peak shaving operations. The Safety Board also recommended that RSPA: P-81-38 Initiate rulemaking to require the installation of EFVs on new and renewed single-family residential high-pressure services which have operating conditions compatible with the rated performance parameters of at least one model of commercially available EFV. P-81-39 Using the findings of the GRI concerning additional locations where effective use can be made of EFVs to prevent various types of accidents, extend the requirements for the use of EFVs. On August 11, 1982, RSPA responded that it had reviewed the Safety Board's 1981 study and was interested in the safety benefits of EFVs. It also informed the Safety Board that the GRI had agreed to undertake the test and evaluation program recommended by the Safety Board and that the results would probably be available within the next year. RSPA stated that it appeared prudent to await the results of the GRI's work before addressing the entire EFV question in one broad, comprehensive action if rulemaking were deemed justified. On October 25, 1982, the Safety Board agreed that it was reasonable for RSPA to wait. The Safety Board also said that in the interest of consolidating efforts on safety- recommendation activity, the Board would classify Safety Recommendations. P-73-2, P-76-9A, P-80-55, and P-81-9 "Closed-Superseded" and assess RSPA's actions on EFVs under two more recent recommendations: Safety Recommendations P-81-38 and -39. The GRI study was not immediately forthcoming. It was not until September 6, 1984, that the Safety Board received a copy of a GRI's draft final report and a request for comments. Among others receiving the draft final report for comment were the American Gas Association (AGA), EFV manufacturers, and the OPS. All but the OPS commented, and all except the AGA and one EFV manufacturer identified numerous errors and other deficiencies in the report and said that the GRI needed to rework the project and to produce a factual, accurate, and objective report. The deficiencies the commenters mentioned included the EFV costs, which were unrealistic because the GRI had averaged costs reported by all responding gas operators with no independent verification, the use of inaccurate averaging procedures in

APPENDIX B 62 assessing performance and costs, and serious flaws in the GRI's assessment of the role of EFVs in service line accidents. The GRI issued a report10 in 1985 that documented the characteristics and performance of commercially available EFVs for residential applications and described the conditions that held potential for using EFVs. In developing the report, the GRI had ignored most of the comments, including the technical ones. The report's recommendations primarily addressed the need for additional tests and research. In a June 21, 1985, memorandum, Safety Board staff advised the Board Members of its interactions with the GRI. The memorandum reported that GRI staff had provided progress reports to Safety Board staff since the beginning of the GRI EFV project. Safety Board staff had consistently advised the GRI project manager about how important it was to public safety that his work be objective, statistically valid, and well documented. After a review of the GRI's quarterly report, Safety Board staff was concerned about the objectivity of GRI's work products; and in a May 9, 1984, letter Safety Board staff pointed out its concern about the GRI’s lack of objectivity and about the GRI’s inappropriate and unsupported statements in its seventh quarterly report. On June 22, 1984, the project manager acknowledged Safety Board staff's concerns and gave his assurance that the problems would be corrected in the study while others would be properly treated in another study report. After reviewing GRI's September 1984 Draft Final Report, Safety Board staff advised the GRI project manager on October 17, 1984, that although only limited time had been allotted for review and comment, staff had easily identified 30 areas that needed attention. Safety Board staff supplied examples in support of its findings. Staff stated in its response that the GRI report was severely deficient and much improvement was needed for it to be viewed as unbiased, comprehensive, and useful. The project manager acknowledged the concerns raised by Safety Board staff and advised that he would stress the need for objectivity in the report rewrite. On May 17, 1984, Safety Board staff received by mail a copy of the GRI report rewrite and minutes later received a telephone call from the project manager urging prompt review and comment. To expedite the review, staff began checking the report against concerns previously voiced. It became immediately obvious that the GRI project manager had not addressed concerns expressed by Safety Board staff or by others who had responded to GRI's Draft Final Report. Safety Board staff advised the Board Members that it was obvious that the GRI had no intention of providing an objective document for use by the industry, the public, or the Safety Board. In December 1985, the GRI published its report Cost and Benefits of Excess Flow Valves in Gas Distribution Services. The stated objective of the report was to compare the cost and benefits of installing EFVs in gas distribution services operating at pressures equal to or

10Final Report (April 1982 - August 1984), Assessment of Excess Flow Valves in Gas Distribution Service Lines, Gas Research Institute, Chicago, Illinois 60631, August 1985.

APPENDIX B 63 greater than 10 psig. Many of the report’s conclusions were based on the GRI’s August 1985 report. Among the findings were the following: Certain EFVs available today are reliable and require a minimum of maintenance. The problems that occasionally arise with new EFVs are largely attributable to human error. Although it may not be justifiable on the basis of a cost-benefit analysis basis, societal perception of risk suggests that it would be prudent for the gas distribution industry to utilize a specially designed reliable gas detection/alarm/shut-off system to protect buildings designed for public assembly against all combustible gas leaks. Existing EFVs are not adequate for this purpose, but a reliable system can be developed from existing technology.11 The potential for a large volumetric loss of gas from a ruptured farm tap suggests that it would be economically prudent to install an EFV on farm taps even though the risk to the public from such an event is small. The use of EFVs having low bleed-by flow rates on service stubs attached to medium- and high-pressure mains intended for new housing developments should be considered by the gas industry from economic, convenience and employee safety standpoints. On March 17, 1986, RSPA advised the Safety Board that since the GRI report did not demonstrate a definite cost benefit or confirm the reliability of EFVs, it was not practical or reasonable to propose safety regulations that could impose significant economic or operating burdens on the industry with questionable benefits to the public. RSPA did not address the adequacy of the GRI report or the numerous comments GRI received concerning deficiencies in its work. On August 11, 1986, the Safety Board told RSPA about the numerous deficiencies in the GRI report. The Board said that it was clear that the GRI work did not satisfy the intent of Safety Recommendations P-81-35 and -36 and that consequently, RSPA would not receive the guidance it needed to accomplish the intent of Safety Recommendation P-81-39. The Board classified Safety Recommendation P-81-39 "Closed--Reconsidered" and advised RSPA that it had not tied compliance with Safety Recommendation P-81-38 to the findings of the GRI study and did not believe that the GRI study was relevant. Because RSPA's letter did not include plans for acting on the recommendation, the Safety Board classified it "Closed--Unacceptable Action" and urged RSPA to take the actions necessary for requiring the installation of EFVs on all new and renewed single-family residential high-pressure services.

11Since the late 1950s, MAXITROL has manufactured a valve suitable for use as an EFV for large-volume gas flows that could be installed in gas service lines to buildings that are used for public assembly and for multi-tenant dwellings.

APPENDIX B 64 After much study of the GRI reports and many discussions between GRI and Safety Board management during the development of the reports, on October 26, 1987, the Safety Board told the GRI that the Board had rejected the GRI reports as biased. The Board said Safety Recommendations P-81-35 and -36 were classified "Closed--Unacceptable Action." In the GRI’s November 13, 1987, response the president suggested that the Board had not been fair when it classified the safety recommendations and that the Safety Board and the GRI have a meeting. On November 25, 1988, a residence in Kansas City, Missouri, exploded, killing a 2- year-old boy and injuring five other persons. An attempt was made to repressure the 1 1/4-inch- diameter steel service line to the house, but it would not hold pressure. A meter was connected to the service line, gas at 28 psig pressure was fed into the service line, and the rate of gas escape was measured and determined to be 1,200 cubic feet per hour. Uncovering the service line revealed a large opening at the bottom of the pipe at a threaded joint. The opening had been caused by a combination of joint weakening from corrosion and downward pressure from soil settlement. Because of the documented gas flow rate from the undisturbed, failed pipe joint, the Safety Board concluded that the consequences of the accident would have been substantially reduced had the service line been equipped with an EFV.12 On March 21, 1988, GRI management met with Safety Board management to discuss the Safety Board's concerns about the GRI’s lack of objectivity and accuracy. Although GRI management acknowledged the merits of many Safety Board concerns, it stated that further work to correct deficiencies would not be performed because the GRI had already devoted too much time and money to the project. After reconsidering the GRI's work, on September 27, 1988, the Safety Board Chairman advised the GRI that the Board had concluded that the GRI had not met the objective of Safety Recommendation P-81-36 and that the report was biased and not at all objective regarding where EFVs could be used to improve public safety and prevent death, injury, and property damage. The status of the recommendation remained "Closed-Unacceptable Action.” On February 10, 1989, a residence in Oak Grove, Missouri, exploded, killing two people.13 An attempt was made to repressure the steel service line, but, like the Kansas City service line, it would not hold pressure. Uncovering the service line revealed a large opening at the bottom of the pipe at a threaded joint similar to the November 25, 1988, pipe rupture at Kansas City, Missouri, in failure opening size and failure mechanism. The Safety Board,

12National Transportation Safety Board Pipeline Accident Report, Kansas Power and Light Company, Natural Gas Pipeline Accidents, September 16, 1988 to March 29, 1989, (NTSB/PAR-90/01). 13National Transportation Safety Board Pipeline Accident Report, Kansas Power and Light Company, Natural Gas Pipeline Accidents, September 16, 1988 to March 29, 1989,(NTSB/PAR-90/01).

APPENDIX B 65 because of the similarities in these two accidents, concluded that the consequences of this accident would have been substantially reduced had the service line been equipped with an EFV. On October 10, 1990, the Safety Board approved the development of a "Most Wanted" safety recommendation list to highlight recommendations that, if implemented, offered the greatest potential for saving lives. Included on the list was the need to use EFVs in gas service lines. The two safety recommendations cited were Safety Recommendations P-90-6 and -12, calling for the American Gas Association and the American Public Gas Association to encourage their members to advise their customers of the safety benefits of EFVs and offer them an opportunity to have an EFV installed in their high-pressure gas service line and calling for RSPA to require the installation of EFVs in new and renewed single-family residential high- pressure service lines. Soon after EFVs were included on the "Most Wanted" list, on December 20, 1990, RSPA issued its first rulemaking on EFVs (55 FR 52188). The Advanced Notice of Proposed Rulemaking (ANPRM) requested information to aid RSPA in choosing (1) to require the installation of EFVs in all new and existing service lines over an appropriate period of time, (2) to require the installations of EFVs in all new and replaced service lines operating at 5 psig pressure or above, or (3) to make no changes to the existing regulations. The ANPRM asked for information about gas operators who had used EFVs but no longer were, operators who were then using EFVs, and operators who had never used EFVs. Contrary to RSPA's claim to Congress, the 1991 cost/benefit study did not accompany the NPRM. Rather, the study, dated November 22, 1991, was placed in the public docket without notice on September 12, 1992. While some people learned of the study by searching the public docket and made the study known to others, RSPA made no public comment about the study until it issued its April 21, 1993, NPRM. RSPA's files indicate 177 responses to the ANPRM; however, several entries were not rulemaking responses; rather they were RSPA staff memorandums to document RSPA employee conversations on EFV-related questions. Thirty-three of the responses entered in the docket were form letters sent in from Georgia municipalities in response to a Georgia Public Service Commissioner’s request, and 71 responses were photocopies of RSPA's ANPRM questionnaire with blanks filled in with handwritten numbers on service-line operating pressure ranges and numbers of services installed new or renewed; seldom was there any response to the many questions RSPA had asked, and most often those filings were not signed. Except for the few users of EFVs who had provided detailed information, the responses were not informative enough to aid RSPA in deciding which of the three alternatives it should pursue.

APPENDIX B 66 RSPA's April 1993 preamble in its later NPRM characterized the commenters to this ANPRM as: Category/Description No. of Operators Total No. Services 1a-Never used EFVs 139 22.4 million 1b-Once used EFVs but no longer use 16 5.6 million 1c-Now use EFVs 22 4.7 million Total 177 32.7 million On February 20, 1991, H.R. 977, the Pipeline Safety Act of 1991 was introduced in the House by Representative Curt Weldon. Included in that bill was a mandate for RSPA to require gas operators to install EFVs on all new and renewed gas service lines used to serve single family high-pressure gas service lines. Among his many comments supporting the bill, Representative Weldon stated, "Until now, natural gas safety has never been publicly questioned because natural gas accidents have been poorly catalogued by the Federal Government...The costs associated with natural gas explosions are also grossly underestimated, as are the actual number of deaths." He said that accident cost estimates are generally made by an official at the scene based on his first observations and the deaths that occur instantly are the only ones reported. He said that the expenses of the following are generally not included: what insurance companies pay claimants, the cost of the firemen, policemen, and equipment at the scene; the cost of evacuating residents; the cost of lost business and destroyed personal goods, the cost of the gas lost in fire or to the atmosphere; and the cost of repairing the gas line. He stated that the importance of these facts to the welfare and safety of the public is that if a Federal regulation is to be issued, it must first pass the test of a cost/benefit analysis. On October 5, 1991, S. 16628, the Pipeline Safety Bill of 1992 was introduced in the Senate by Senator Lautenberg of New Jersey. Included in that bill was a mandate for RSPA to require gas operators to install EFVs on all new and renewed gas service lines used to serve single family high-pressure gas service lines. On November 22, 1991, RSPA completed its report Excess Flow Valve Benefit/Cost Analysis, which had been prepared by the Volpe National Transportation Systems Center. Without noting exceptions to the procedures or data used, RSPA's report cited an August 26,

APPENDIX B 67 1991, EFV cost/benefit study14 performed for the GRI. RSPA reported that using the figures developed in that study, the benefit-to-cost ratio would be 0.07, i.e. less than beneficial. Even in light of the study cited, RSPA's study found that the estimated benefit-to-cost ratio of installing EFVs was between 1.04 to 1.73. It concluded that since the benefit-to-cost ratio was greater than 1.00, the installation of EFVs on all new or renewed single-family residential natural gas services was expected to be cost beneficial. On review of the RSPA report, the Safety Board found it to be replete with errors and unsupported assumptions. A September 4, 1992, Safety Board staff memorandum cited several deficiencies with the RSPA study and said that the Board can not "endorse or use RSPA's analysis in support of mandatory installation of EFVs any more that we could endorse use of the GRI’s report that was replete with unsupported assumptions." RSPA's lack of action on requiring the use of EFVs was recognized by Congress. On October 24, 1992, Public Law 102-508 (106 STAT. 3290) became law and required the DOT Secretary to issue regulations within 18 months prescribing the circumstances, if any, under which operators of natural gas distribution systems had to install EFVs. The law also required the Secretary to issue within 2 years requirements for gas-distribution system operators to notify, in writing, their customers with lines in which EFVs were not required by law, but could be installed in accordance with performance standards prescribed by the Secretary, of the availability of EFVs and the benefits to be derived from installing them. Reacting to the requirements of Public Law 102-508, on April 21, 1993, RSPA issued its Notice of Proposed Rulemaking (NPRM), "Excess Flow Valve Installation on Service Lines; Proposed Rule." The NPRM proposed mandating the installation of EFVs in new and renewed single-family high-pressure gas service lines, citing the positive benefit/cost ratio determined in the Volpe Center's 1991 report and the fact that EFVs would cost only $20. There were more than 160 docket entries for the April 1993 notice. Most of the responses addressed the deficiencies in RSPA's cost benefit study and criticized RSPA's proposal to allow use of positive shutoff EFVs only, rather than commenting on whether EFVs should be required. In general, it appears that a majority of the commenters acknowledged the usefulness of EFVs and at the same time expressed the belief that their use should be voluntary rather than mandatory. As with the previous notice, it was not possible to categorize most comments as being favorable to using or not using EFVs or to differentiate the comments according to companies that did use, those that had used but no longer did, and those that had never used EFVs. Also as with the previous notice, there were many form-letter responses, primarily from municipal-owner gas systems. Several companies were innovative with their filings: they submitted comments under as many as four different names.

14Risk and Industrial Safety Consultants, Inc., Cost Benefit Analysis of Excess Flow Valves: An Update, A topical report prepared for the Environmental and Safety Research Department, Gas research Institute, Chicago, August 26, 1991.

APPENDIX B 68 Comments to the NPRM advised RSPA that EFVs were commercially available and were being used for nonresidential as well as residential gas services. RSPA was told that EFVs could operate properly down to 5 psig pressure and that EFVs for protecting higher capacity gas service lines for multiple residential, commercial, and industrial facilities had been available for many years The same information had been given to RSPA in responses to its 1990 ANPRM. EFVs ranged from 1 1/4-inch to 8 inches in diameter and could be used on gas pressures up to 100 psig at the EFV inlet. RSPA was informed that EFVs were available also for multiple meter applications and for small commercial applications that had service lines up to 1 inch in diameter. Additionally, some manufacturers had since the early 1950s offered large EFVs for such large commercial gas service loads as schools, hospitals, and industrial facilities. The GRI commented on deficiencies and errors in RSPA's cost benefit study and supported its contentions by citing information in the GRI reports already characterized as deficient by the Safety Board and others. A State regulatory agency commenting on RSPA's characterization of the comments to the ANPRM took exception to RSPA's statement that all commenters were opposed to the mandatory use of EFVs. It then separated the comments into two categories: those opposed to EFV use (155), and those endorsing EFV use by being proactive in their use (22). The agency then stated that RSPA had received responses from 155 operators who were anti-EFV and intended to oppose mandatory use of EFVs rather than to create a better regulation. The agency characterized the 22 EFV-user commenters as also opposing mandated use, but as having sent their comments with the intent of helping in the drafting of viable, palatable requirements on using EFVs. The agency then stated that it appeared that RSPA had overlooked the constructive comments of the 22 EFV user commenters and had instead constructed the proposed rule around the negative comments of those non-user operators. The agency then provided comments based on information obtained from a survey of gas system operators in its State representing more than 90,000 service lines equipped with EFVs. In closing, the agency said: The intent of the EFV mandate is to protect the public from incidents arising from excavation damage. Based on the above evidence, it is evident that devices are presently in use that meet that goal. Those devices have never failed to act in a model employing 90,000 units over a span of 18 years. The cost-effectiveness is manifested in the voluntary usage of EFVs in a State with a decline in third- party damage to gas pipelines. The agency then provided comments for improving the proposed EFV requirement it had obtained from gas operators in its State. The agency characterized the gas operators as favoring the use of EFVs even though there was an effective excavation-damage prevention program in the State, as opposed to favoring any mandatory requirement for using EFVs and as

APPENDIX B 69 opposed to favoring the proposed rule, which seemed to neglect the performance standards the gas operators had used and proven by experience to be successful. One company's response characterized its system as the nation's largest user of EFVs with about 20 years experience in their use. Its comments advised that it did not support mandatory use of EFVs, but that an EFV was a "good, inexpensive, relatively unsophisticated device which can add significantly to the group of safety features in a natural gas distribution system." Its detailed comments criticized RSPA's rulemaking proposal for adding nonessential requirements that tended to make the use of EFVs less desirable or unnecessarily costly. The response advised that in nearly 20 years it had had only one or two instances that might be attributable to a defective EFV and that it used more than 200,000 EFVs of the bleed-by type. An individual with many years experience in using EFVs called RSPA's proposal counterproductive because, he said, it had taken a relatively simple concept and created a very broad proposal that was far more sophisticated and costly than necessary. A Congressman said he was worried that the proposal could restrict rather than encourage the use of EFVs. He stated his belief that the proposal did not reflect existing technology and therefore did not provide the utmost in safety for firefighters and rescue personnel. He stated that many of the more than 9,000 fires annually resulted in firefighters being exposed unnecessarily to the dangers of uncontrolled gas escaping from piping where it connects to the building because manual shutoff valves were inaccessible and frequently valuable time was lost while firefighters waited for the gas company to reach the scene to shut off the flow of gas. He commented that RSPA's proposal ignored data gathered in previous rulemaking proposals, including RSPA's cost/benefit analysis on EFVs with a by pass feature, and that the stringent performance standards RSPA proposed to impose added significant costs unnecessarily. To emphasize his point, he noted RSPA's improper use of data from one company on EFV high false closure rates resulting from improper installation and from human error. He stated that if operator error was a problem, the solution was not to require added performance standards for the EFVs; rather, it was to require the appropriate education and training of the operators. The International Association of Fire Chiefs (IAFC) commented in support of the proposal to use EFVs on new and renewed services and expressed its support for requiring the retroactive installation of EFVs on all gas services. The IAFC commented that its members believed that the estimated 1,000,000 plus EFVs to be installed annually would help validate the effectiveness of EFVs while initiating their widespread use as a welcome safety feature, especially to firefighters. A valve manufacturer advised RSPA that of the approximate 800,000 of its valves installed in gas systems, about 900 activated each year and turned potential fires and explosions into routine repair situations causing little or no damage. Additionally, this commenter advised

APPENDIX B 70 RSPA of the experiences of several gas company operators: EFVs installed in their systems had activated and significantly reduced the losses that would have occurred had an EFV not been installed. The companies were: A New Jersey gas operator advised that it had installed 18,000 EFVs since 1980. Since that time, 125 EFVs had activated to prevent incidents. A Pennsylvania gas operator advised that it had installed 50,000 EFVs and that more than 17 activated annually in response to outside-force damage events. A Massachusetts gas operator advised that it had installed more than 40,000 EFVs and that more than 40 activated annually in response to outside-force damage events. A New York gas operator advised that it had installed 4,000 EFVs since October 1990. In the first 8 months, 40 had activated in response to outside-force damage events. An Ohio-based gas operator advised that it had installed 8,000 EFVs in a four-State area. Between January 1992 and June 1993, 144 EFVs had activated in response to outside- force damage events. A South Carolina gas operator advised that it had installed 280 EFVs since October

1. Through June 1993, 15 EFVs had activated in response to outside-force damage events.

On June 14, 1993, a motorist struck a high-pressure (450 psig) farm tap, breaking the service pipe. The EFV in the service immediately stopped the flow of gas. According to the gas system superintendent, without the EFV, a house would have been destroyed by fire, and several gas operator employees would have been severely injured or killed. A Massachusetts gas operator reported that during a hurricane in October 1991, 22 houses were moved on their foundations, breaking their gas lines. All EFVs activated properly to stop the flow of gas into the houses, where it could have exploded. An Ohio gas operator reported it had installed only 150 EFVs. An automobile struck a high-pressure farm tap equipped with an EFV, shearing the service line at ground level. The EFV activated properly, stopping the flow of the escaping gas and preventing an explosion. Another Ohio gas operator advised that it had installed over 200,000 EFVs. When an electric-utility employee burned through an exposed plastic service line equipped with an EFV, the escaping gas ignited; but the prompt activation of the EFV shut off the flow of gas, causing the fire to extinguish. According to the gas operator, had the EFV not been installed, the employee would probably have been killed.

APPENDIX B 71 A valve manufacturer cited statistics indicating that gas operators responded annually to more than 30,000 instances of damage to pipelines caused by excavators who had not notified the gas operators in advance so the location of the pipelines could be marked before excavation. The commenter advised that EFVs could prove quite useful in minimizing gas releases in such instances. In a 2-month period, the Safety Board investigated two fatal accidents with consequences that could have been reduced significantly if an EFV had been installed. On June 9,1993, a house in Aberdeen, New Jersey, exploded, killing three people and injuring three others.15A contractor excavating to replace a 2-inch-diameter gas main struck and ruptured at two locations an unused service-line segment. The contractor repaired the ruptured pipe segment near the excavation, but was unaware of the second rupture. Gas flowed into an old house foundation that lay beneath asphalt paving and into the residence, where it exploded. The Safety Board determined that the potential for the building to have exploded would have been minimal had the service line been equipped with an EFV. The report noted also that the Safety Board has recommended the use of EFVs for more than 20 years and continues to believe that EFVs should be installed on all new and renewed gas service lines. On July 22, 1993, a backhoe hooked and pulled apart a 1-inch high-pressure, plastic service line, breaking it at an elbow fitting within a foot of the building’s foundation wall.16 Venting gas rapidly flapped the canvas entry awning over the doorway, damaged lighting under the canopy, and migrated through the foundation wall into the building. About 20 minutes after the service line was damaged, an explosion occurred, followed by a natural gas-fueled fire. The explosion force caused part of the building to land on and flatten an automobile traveling on an nearby street, and the driver died instantly. The explosion and ensuing fire also killed a building occupant and a person outside the building, and they injured 12 people. On August 13, 1993, the OPS director met with people and representatives of associations interested in the EFV rulemaking to discuss entering into a rulemaking negotiation. Representatives of the Safety Board, congressional staffs, pipeline companies, State pipeline safety regulatory bodies, pipeline industry trade associations, consumer groups, and EFV manufacturers attended. The OPS director stated that the rulemaking process had not yielded sufficient information for the OPS to proceed with a final rule. The director of the OPS said that it appeared that a negotiated process was needed due to the contentious nature of the proposed EFV rule. He suggested that interested parties might want to participate in a negotiated

15Pipeline Accident Brief Report, Northern States Power Company Explosion and Fire at St. Paul, Minnesota, on July 22, 1993 (DCA-93-MP-011). 16Pipeline Accident Brief Report, New Jersey Natural Gas Company Explosion and Fire at Cliffwood Beach, New Jersey, on June 9, 1993 (DCA-93-FP-008).

APPENDIX B 72 rulemaking process, and he then explained the procedures. After much discussion, those in attendance expressed concern that their participation would be unproductive since RSPA would not be bound by the results of the negotiations. Many also said that the process was unnecessarily lengthy and cumbersome. The OPS director then stated that the negotiation process probably would be too long to meet RSPA's statutory time frame for issuing a final rule. None in attendance supported OPS's proposed negotiated rule process. Several people suggested that those who were interested should meet to develop a consensus agreement on using EFVs. The OPS director agreed that the OPS would publish an alternative proposed consensus rule developed by a group of "interested parties" (gas industry, State regulators, congressional committee staff, and the Safety Board) as a supplemental rulemaking and said he would provide a 30-day period for comments. Consistent with the OPS director's agreement, the American Gas Association (AGA) and the Safety Board staffs jointly held meetings to determine whether there was sufficient interest to formulate an alternative proposal for submission to the OPS. Sixteen parties of interest, which later became known to the OPS as the Joint Commenters, expressed their desire to unite in a common effort to develop a unified, supportable position. Participants in the effort included the AGA, the American Public Gas Association (APGA), the Interstate Natural Gas Association of America (INGAA), the National Association of Pipeline Safety Representatives (NAPSR), the National Association of Regulatory Utility Commissioners (NARUC), the Gas Safety Action Council (GSAC), the International Association of Fire Chiefs (IAFC), eight EFV manufacturers, and the Safety Board. These interest groups, as well as several gas distribution operators, held several meetings and corresponded on proposals by FAX, mail, and telephone to develop a proposal as a means of ending the OPS's many years of unproductive deliberations. On December 14, 1993, the Joint Commenters filed their proposal with the OPS. Those comments were endorsed by the AGA, APGA, INGAA. GSAC, five EFV manufacturers, and, by separate letters, by the Safety Board. The Joint Commenters said that the organizations endorsing the proposal represented most identifiable interests in the matter and that the proposed-rule language was a consensus agreement. The commenters also told the OPS: Much of the information necessary to accurately assess the costs and benefits of EFVs is incomplete or unavailable; therefore we support a cooperative effort between the American Gas Association and EFV manufacturers to begin collecting data on the in-service performance of the approximately 1 million EFVs that will be installed annually if the rule we propose is promulgated. RSPA published its Notice of Reopening Comment Period (Docket PS-118, Notice 4) on August 2, 1994. RSPA requested comments on whether it should adopt the Joint Commenters’ proposal but, contrary to the commitment made by the OPS director, did not include the proposal in the Notice. Instead, the Notice said the proposal had been placed in the

APPENDIX B 73 public docket for review. Other than a mere mention of the Joint Commenters’ proposal and a statement that RSPA desired to receive comments on it, RSPA devoted the rulemaking discussion to eliciting comments on the safety of the EFV bypass feature, the effect of contaminants on EFVs, and whether RSPA should await completion by industry-sponsored standard committees before proceeding with the EFV rulemaking--items not mention in the Joint Commenters’ proposal. The Notice stated that RSPA's regulatory evaluation indicated that an aggregate annual savings of $19 to $31 million would result from reduced deaths, injuries, fires, explosions, and evacuations. The Safety Board urged RSPA to accept the Joint Commenters’ proposal and to expedite issuance of a final rule. A review of RSPA's docket index indicated that there were 74 responses to Notice 4, but only 70 responses were included. Of the 70 responses, 38 supported the Joint Commenters’ proposal, 3 neither supported nor opposed EFVs, 5 opposed requiring EFVs (but 2 of the 5 urged RSPA to use the Joint Commenters’ proposal if EFVs were mandated, and 1 advised that it was developing an EFV standard), and 24 (one company filed two opposing responses) either did not support using EFVs because they were not convinced that enough research had been performed or because they were strongly opposed to using EFVs. The AGA and the APGA, (the two industry associations that represent most of the more than 1,400 gas-distribution pipeline operators) agreed to accept the Joint Commenters’ proposal. Many commenters stated again their objection to RSPA requiring the installation of EFVs; but overwhelmingly, the commenters continued to disagree with RSPA's characterizations of problems RSPA associated with using automatic-reset valves versus manual-reset valves and with RSPA's obvious desire to allow the use only of manual-reset EFVs. On September 27, 1994, 17 congressional representatives cosigned a letter to the DOT Secretary, expressing their extreme disappointment with the DOT's response to the serious problem of pipeline safety in this country and then criticizing RSPA for languishing rather than making a decision about EFVs. The cosigners said that the EFV issue was of great importance to them and urged the Secretary to look into their concerns. RSPA disregarded the counsel of the Joint Commenters that the data necessary to perform an objective, effective cost/benefit study was not available, as well as the counsel of those who responded to the Notice of Reopening of Comment. In 1994/95, again using the same Volpe National Transportation Safety Institute employees who performed the flawed 1991 EFV benefit/cost study, RSPA developed what it termed a "cost/benefit study."17 The new study did not acknowledge the extent and severity of criticism from the AGA, CSAC, and others of RSPA's incorrect use of data in the 1991 study. The AGA found the 1991 study flawed enough to cause irreparable harm to the gas industry, and it seriously considered suing RSPA to prevent it from releasing the study.

17"Excess Flow Valve Benefit/Cost Analysis,” January 1995.

APPENDIX B 74 Although not much had changed about EFVs since RSPA’s previous study, except that EFV manufacturers had lowered the price, the new study reported that the benefit-to-cost ratios for the installation of automatic-reset and manual-reset EFVs were 0.25 and 0.20, respectively. The report concluded that because the benefit-to-cost ratios were less than 1.00, the installation of EFVs on all new or renewed single-family residential natural gas services was not expected to be cost beneficial. The 1995 cost/benefit study corrected some of the errors in the 1991 study, but added new ones. RSPA's 1995 study used only two accidents to determine the benefits of using EFVs, even though RSPA was aware of many other accidents in which EFVs had operated to minimize the consequences. In addition to the published articles on EFV activations that minimized accident consequences in Bay State Gas's system, the Popular Grove Utility District in Atoka, Tennessee, described in its comments to RSPA's Docket No. 118, Notice 4, two incidents that had occurred recently in which EFVs had significantly reduced potential losses. They were as follows: In the winter of 1993 in the western part of our district, the local fire department was called to a house fire at 799 Grimes Road. When they arrived, the house was fully involved, and the gas meter and regulator were about to be melted by the intense heat. According to a fireman at the scene, as soon as the meter and regulator melted down, the EFV activated and shut the gas flow down to where there was only a small flame on the riser pipe. This past summer, the driver of a car lost control of his vehicle, left the road and ran under a house located at 7590 Mt. Carmel Road. Our gas meter was located on the same side of the house and was clipped off by the car, leaving only the riser, which was only releasing a small amount of gas because the EFV was activated by the sudden surge of gas. The occupant of the car was unconscious and had to be removed by the E.M.T.s, as I understand. When the valve closed, this greatly reduced the danger to the occupant and the emergency personnel that were working the accident. The gas system manager added that although the system had been operating only a short time (since September 1993), his experience with EFVs had always been positive and EFVs had saved his system money and helped to save lives and property. On March 9, 1995, the OPS director, testifying before the Subcommittee on Energy and Power of the House Committee on Commerce, announced that the DOT had decided not to issue a final rule requiring the installation of EFVs on gas service lines. Instead, the DOT elected to comply with the provisions of the Gas Pipeline Safety Act of 1992 (106 STAT. 3290) that require it to issue technical specifications on using EFVs and require pipeline

APPENDIX B 75 operators to notify their customers of the availability of EFVs. The OPS director stated that the RSPA Administrator believed that this approach contributed to a sensible regulatory system that protected the American people without imposing an unnecessary cost on society. The two-accident sample RSPA used in its 1995 study to assess EFV effectiveness is statistically insignificant. Even so, RSPA incorrectly assessed what happened in the two accidents it did use. Although a life was saved when an EFV operated properly in one of the accidents, RSPA attributed its benefit as only 1/5 of the $2.6 million used by the study as the value of a life. That error was further compounded by using 57 percent as an assumed EFV effectiveness percentage. When Safety Board representatives met with RSPA on March 16, 1995, it questioned RSPA about the basis for the effectiveness percentage. A RSPA economist explained that 95 percent effectiveness was initially used, but that number was reduced because a National Highway Traffic Safety Administration (NHTSA) analyst, not knowledgeable about EFVs, said he believed the number was to high. RSPA stated that even though it had no justification for a different percentage, it offered 57 percent as the effectiveness percentage, and the NHTSA analyst accepted it, saying that it seemed about right. Other parts of RSPA's study appear to include similar insupportable numbers and assumptions. Safety Board representatives asked RSPA ones why RSPA insisted on performing a cost/benefit study even after being advised by the Joint Commenters that data sufficient to perform an valid study did not exist. RSPA acknowledged that the available data was insufficient, but then stated that it was obliged by Department rules to produce a study. The Safety Board suggested that with RSPA's persistence on performing some type of cost/benefit study, that it should perform a sensitivity analysis of the data used to assess the effects of the large variances on costs and other information submitted by EFV users and EFV non-users and, as well, the potential effects of various assumptions that RSPA could make rationally to fill the information gaps where data was not available. RSPA acknowledged that the cost/benefit ratio could vary widely, depending on the cost selections and assumptions; but it insisted that operators who provided data were obliged to provide accurate, unbiased data in response to rulemakings. Although it had done nothing to test the extent of variance, RSPA stated that it did not believe such an analysis was necessary. RSPA's 1991 and 1995 cost/benefit studies already show that the cost/benefit ratio can range from positive to negative when assumptions are used as a substitute for data. On April 4, 1995, the RSPA Administrator sent letters to chairmen of Senate and House committees and subcommittees that had oversight responsibility on pipeline safety. Those letters advised that the RSPA found no circumstance under which RSPA should issue a Federal rule requiring the universal installation of EFVs and that, as required by 49 U.S.C. section 60110, RSPA was planning to issue performance standards and customer-notification requirements for EFVs. The Administrator advised that each of these actions was designed to encourage the increased use of EFVs where appropriate, based on local conditions. A report entitled Excess Flow Valves, prepared by RSPA and dated March 1995, was attached to each

APPENDIX B 76 letter as support for RSPA's decision. The report contained many inaccurate and/or misleading statements, including the following: (Safety Board response follow each statement.) 1. Neither RSPA nor the Sate pipeline programs in Missouri and Kansas believe that any of the accidents addressed in the Safety Board's report on service line failures in the Kansas City, Missouri, area were of the type that could have been mitigated by EFVs since they involved corrosion leaks, not ruptures. Comment: Two of the three Kansas City service-line accidents were ruptures at pipe joints that had been weakened by corrosion and failed due to earth settlement. In the first case, before the joint was repaired, Missouri Public Service Commission personnel measured the rate at which gas was being released from the failed joint. They determined, based on leakage rate, the service line length and the location of the failure and that one of several commercially available EFVs would have activated to promptly stop the flow of escaping gas. The second corroded-joint failure was also judged to have released gas at a rate sufficient to have activated an EFV, promptly stopping the gas flow. In the third accident, gas flowed from corrosion holes in the service line. Although EFVs are not normally considered to be effective in stopping the flow of gas from corrosion holes, the size of these holes permitted the release of gas at a rate that might have activated an EFV. 2. There were 190 comments to RSPA's December 1990 Advance Notice of Proposed Rulemaking that requested information on EFVs. Comment: See pages 65-66 for comments on ANPRM docket contents. 3. There were 140 written comments in response to RSPA's April 1993 Notice of Proposed Rulemaking [Notice 2] proposing to require the installation of EFVs. Comment: See pages 67-71 for comments on NPRM docket contents. 4. A group calling itself the Joint Commenters, representing previously adversarial positions, advised that it would support a rule incorporating the alternative regulatory language that it recommended. RSPA issued a Notice of Reopening Comment Period in August 1994 and received 70 comments. That rulemaking language was supported by NTSB, several members of Congress, EFV manufacturers, the Gas Safety Action Council, and the pipeline programs in New York and Massachusetts. However, the rulemaking has been opposed by virtually the entire gas distribution industry, the American Gas Association, and its member companies, the National Association of Pipeline Safety Representatives (NAPSR) (our State partners), and the National Association of Regulatory Utility Commissioners (NARUC).

APPENDIX B 77 Comment: See pages 65-66 for information on the Joint Commenters proposal and RSPA's Notice of Reopening of Comment Period. 5. In preparing the 1991 cost/benefit analysis of RSPA's proposal to require the installation of EFVs on new and renewed single family residential gas service lines operating at 10 psig or more, the Volpe National Transportation Systems Center (Volpe Center) used all available data, including data from the questionnaire in RSPA's ANPRM and response thereto. The analysis resulted in a positive cost/to benefit ratio. As anticipated, the responses received during the rulemaking proceeding provided considerable new information and data for the cost/benefit analysis, and commenters highlighted problems with various aspects of the cost/benefit analysis that had accompanied the NPRM. Comment: See pages 66-71 for information on RSPA's cost benefit studies.

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79 APPENDIX C TIME LINE of EVENTS February 1994 Allentown Housing Authority advertised for bids to remove 8,000- gallon buried fuel tank. March 21, 1994 Housing authority signed contract with EPAI for tank removal. May 18, 1994 Allentown issued permit to Environmental Preservation Associates, Inc. (EPAI) for removal of tank. May 19, 1994 1:26 p.m.

EPAI provided notice of proposed excavation at Gross Towers on May 23, 1994, to Pennsylvania one-call notification center. 2:25 p.m. UGI Utilities, Inc. (UGI) employee telephoned EPAI, leaving the message that it had a gas service line to Gross Towers. May 20, 1994 8:21 a.m. UGI employee marked the location of its service line to Gross Towers. May 23, 1994 EPAI moved equipment to Gross Towers to begin tank removal operations. During excavation to remove tank, the west side of EPAI's unshored excavation collapsed, exposing and undermining the support for 20 - 25 feet of the Gross Towers gas service line. City inspector observed portion of asphalt parking lot pavement fall onto and deform a portion of the undermined Gross Towers gas service line. Two city inspectors at different times commented to the EPAI foreman about the safety of the unsupported gas line.

APPENDIX C 80 While the EPAI crew was attempting to lift the tank from the excavation, the cable/chain sling broke, allowing the tank to fall toward the unsupported gas line. Witnesses to this event believed that the tank did not strike the gas line. The EPAI crew took soil samples for later testing from locations around the concrete support that remained in the excavation. Without notice to UGI, the EPAI crew placed cross bucks on end between the unsupported service pipe and the soil, placed plastic sheeting on the excavation slopes, placed a plastic barrier around the excavation, and left Gross Towers. No one reported smelling the odor of gas. June 9, 1994 8:00 a.m. The EPAI foreman arrived at Gross Towers to complete the tank removal project, which now also required removal of the concrete support and soil from beneath it because tests showed that the soil contained fuel. The foreman observed that the area looked unchanged. 9:00 a.m. The EPAI foreman mentioned to a housing authority employee that the gas line needed to be supported. 12:30 p.m. The EPAI backhoe arrived at Gross Towers. 1:30 p.m. The crossbuck supports earlier placed beneath the unsupported gas line were removed. The foreman noticed no movement of the pipe on removing the crossbucks. A hydraulic hammer attached to the backhoe bucket was used to break up the concrete support within the excavation. The backhoe bucket was used to remove the broken pieces of concrete and load them into a dump truck. In so doing, the path of the backhoe to the dump truck was across the unsupported pipe.

APPENDIX C 81 6:40 p.m. The backhoe was repositioned to the west side of the excavation. To reach the west side, the tread-mounted backhoe was driven across the buried portion of the gas pipe near its connection to a compression coupling. 6:45 p.m The gas service line separated from a compression coupling near the north wall of Gross Towers. An EPAI employee smelled the odor of gas, heard a woman on the third floor shout that she smelled a heavy odor of gas, ran to and opened the boiler room door, smelled a heavy odor of gas, and informed the EPAI foreman of his observations. The foreman told the backhoe operator to shut off his machine. 6:46 p.m. The EPAI foreman dialed the UGI switchboard telephone number, which connected him to a recording that provided the UGI after- hours emergency telephone number. 6:47 p.m. The EPAI foreman called the UGI emergency telephone number (Central Gas Control), advising of a gas leak at Gross Towers and that the gas line had been hit during digging. 6:48 p.m. The EPAI foreman called the home of the EPAI Vice President. 6:?? p.m. The foreman instructed his crew to trace the gas line back toward Utica Street to shut off the gas valve. 6:50 p.m. The EPAI foreman called the UGI emergency telephone number, advising that they definitely hit the gas line and broke it. 6:54 p.m. The EPAI foreman called the housing authority telephone number, which was routed to an answering service. He advised that they were digging and think they "got" the gas line. 6:58 p.m. A city policeman working near Gross Towers reported by radio to the Allentown Communication Center that an explosion had just occurred. 6:59 p.m. The EPAI foreman dialed "911" but was unable to be connected. 7:00 p.m. The EPAI foreman called the home of the EPAI Vice President.

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APPENDIX D September 28, 1995, Letter from Safety Board to Research and Special Programs Administration on Excess Flow Valve Recommendation

APPENDIX D 84

APPENDIX D 85

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APPENDIX E Gas Piping Technical Committee Excavation Damage Prevention Guidelines

APPENDIX E GPTC GUIDE FOR GAS TRANSMISSION AND 192.614 DISTRIBUTION PIPING SYSTEMS - 1990-91 shall carry out in accordance with this section a writtenprogram to prevent damage to that pipeline by excavation activities. For the purpose of this section, “excavation activities” include excavation, blasting, boring, tunneling, backfilling, the removal of above ground structures by either explosive or mechanical means, and other earth moving operations. An operator may perform any of the duties required by paragraph (b) of this section through participation in a public service program, such as a “one-call” system, but such participation does not relieve the operator of responsibility for compliance with this section. (b) The damage prevention program required by paragraph (a) of this section must, at a minimum- (1) Include the identity, on a current basis, of persons who normally engage in excavation activities in the area in which the pipeline is located. (2) Provide for notification of the public in the vicinity of the pipeline and actual notification of the persons identified in paragraph (b)(l) of the following as often as needed to make them aware of the damage prevention program: (i) The program's existence and purpose; and (ii) How to learn the location of underground pipelines before excavation activities are begun. (3) Provide a means of receiving and recording notification of ptenned excavation activities. (4) If the operator has buried pipelines in the area of excavation activity, provide for actual notification of persons who give notice of their intent to excavate of the type of temporary marking to be provided and how to identify the markings. (5) Provide for temporary marking of buried pipelines in the area of excavation activity before, as far as practical, the activity begins. (6) Provide as follows for inspection of pipelines that an operator has reason to believe could be damaged by excavation activities: (i) The inspection must be done as frequently as necessary during and after the activities to verify the integrity of the pipeline; and (ii) In the case of blasting any inspection must include leakage surveys. (c) A damage prevention program under this section is not required for the foilowing pipelines: (1) Pipelines in a Class 1 or 2 location. (2) Pipelines in a Class 3 location defined by g 192.5(d)(2) that are marked in accordance with S 192.707. (3) Pipelines to which access is physically controlled by the operator. (4) Pipelines that are part of a petroleum gas system subject tos 192.11 or part of a distribution system operated by a person in connection with that person’s leasing of real property or by a condominium or cooperative association. 1 SCOPE Note 192.614(c) which programs. 2 WRITTEN PROGRAM GUIDE MATERIAL lists pipelines excluded from the requirements related to damage prevention Written procedures should state the purpose and objectives of the damage prevention program, and provide methods and procedures to achieve them. Applicable state and local requirements should be reviewed. The procedures should also include the following. ADDENDA NO. 1, AUGUST 1991 177 88

APPENDIX E GPTC GUIDE FOR GAS TRANSMISSION AND 192.614 DISTRIBUTION PIPING SYSTEMS - 1990-91 2.1 Definition of excavation activities. In defining excavation activities to be covered by the damage prevention program, the operator should review the definition in 192.614(a) and applicable state and local requirements. 2.2 One-call systems. The operator should consider participation in an existing one-call system or establishing a one-call system. Applicable state and local requirements should be reviewed. The operator is cautioned that a one-call system may not satisfy all the requirements of 192.614. 2.3 Identifying entities to be informed of the program. (a) Excavators. The sources listed below may be helpful when preparing the list of entities engaged in construction activities. The procedure should provide for a periodic review of the list to Insure that it is current. (1) One-call center. (2) Contractor licensing agencies. (3) Contractor associations. (4) Local utilities. (5) Pipeline companies. (6) Insurance carriers. (7) State, county, and local road maintenance offices. (8) Company records. (9) Farmers and adjacent landowners. (10) State, county, and local permitting agencies. (11 ) Telephone yellow page directory listing such as the following: (i) Excavating and earth moving contractors. (ii) Construction contractors. (iii) Blasting contractors. (iv) Well drilling and boring contractors. (v) Landscaping contractors. (vi) Land leveling and subsoiling contractors. (vii) Dredging companies. (viii) Plumbers. (ix) Fence erectors. (x) Power line contractors. (b) The public. The public in the vicinity of the pipeline should be identified. 2.4 Methods of informing entities of the program. Methods of informing entities should Include one or more of the following. (a) Excavators. (1) Mailing addressed to the excavator. (2) Telephone. (3) Telegram. (4) Personal visit. I The Operator should consider documenting these actions. Procedures for periodic renotification of excavators should be established based upon utilization of the program. (b) The public (1) Mailings. (2) Bill stuffers. ADDENDA NO. 1, AUGUST 1991 178 89

APPENDIX E GPTC GUIDE FOR GAS TRANSMISSION AND DISTRIBUTION PIPING SYSTEMS - 1990-91 192.614 (3) Handouts. (4) Newspaper, magazine, television and radio advertisements. (5) Speakers supplied to local groups. (6) Utilizing permitting authorities and public officials to disseminate information. (7) Joint mailings with other utilities. (8) Vehicle advertising sign boards. (9) Bumper stickers. (10) Notices in telephone directories. (11) Public education programs related to 192.615(d). (12) School programs. 2.5 Information to be communicated. Entities that may engage in excavation activities should be informed of the purpose of the program and how they can learn the location of underground pipelines before commencing excavation activities. 2.6 Receiving excavation notification, The operator should establish a telephone number and mailing address for receiving notifications of planned excavation activities. Provisions should be made for recording all notifications received (such as log, form or memo) and for the retention of such records. The notification should include the following. (a) Name of person giving notification. (b) Name of entity which will be conducting excavation activities. (c) Telephone number for contacting the entity. (d) Location of the planned excavation activities. (e) Date and time of commencement of excavation activities. (f) Type and scope of excavation activities. 2.7 Responding to excavation notification. (a) Preparation. The operator should deveiop procedures for responding to notifications of intent to excavate. Consideration should be given to the following. (1) Information about the location of facilities may be obtained from maps, records or field investigation. (2) Standards should be developed for marking facilities consistent with the field conditions (Including items such as the use of paint on paved areas and stakes, signs or flags in unpaved areas). (3) Trained personnel should be available to mark facilities as necessary, (b) Response. Where facilities exist in the area of excavation activity, the operator should respond to the notification prior to the planned commencement of the excavation activity. The operator should consider documenting the responses. The response should Include the following. (1) The entity should be advised how and when the facilities will be marked. (2) If there is a potential for misunderstanding concerning the location of facilities or the procedure for marking, an on-site meeting should be suggested. (3) The operator should point out that the marking represents only the approximate horizontal position of the facilities and that the facilities should be exposed by hand excavation to verify their location. (4) Any maps, drawings, or records supplied to an excavator to assist in locating underground facilities should be reviewed for accuracy. Unless field checked, it is suggested that they be marked with a note such as “Not responsible for accuracy, verify by hand digging”. ADDENDA NO. 1, AUGUST 1991 179 90

APPENDIX E GPTC GUIDE FOR GAS TRANSMISSION AND 192.614 DISTRIBUTION PIPING SYSTEMS - 1990-91 (5) When time permits, a pre-excavation meeting may be held with the excavator to discuss all aspects of the planned excavation activities and marking schedules, and to establish lines of communication. (6) The operator should advise the excavator of the excavator’s responsibility to provide support and protection for exposed piping and the need to properly backfill to prevent settlement. 2.8 Inspecting pipelines. (a) Need and schedule. Each notification should be evaluated to determine the need for and the extent of the inspection. Where required, the inspection may include periodic or full-time surveillance and may include leakage surveys. The operator should consider maintaining field contact with the excavator during the excavation activities to avoid potential problems and to promptly resolve any problems that may arise. The following factors should be considered in determining the need for and extent of inspections. (1) The type and duration of the excavation activity involved. (2) The proximity to the operator’s facilities. (3) The type of excavating equipment involved. (4) The importance of the operator’s facilities. (5) The type of area in which the excavation activity is being performed. (6) The potential for a serious incident should darnage occur. (7) The past experience of the excavator. (8) The potential for damage occurring which may not be easily recognized by the excavator such as improper support during excavation and backfill. (b) Settlement. The operator should pay particular attention, during and after excavation activities, to the possibility of joint leaks and breaks due to settlement when excavation activities occur, especially in threaded-coupled steal and mechanical compression joints. (c) Cast Iron pipelines. See Guide Material Appendix G-18, “Cast Iron Pipe.” (d) Plastic and steal pipelines. The operator should inspect plastic pipelines for gouges and steel pipelines for coating damage and gouges, when necessary, before the exposed pipeline is back-filled. (e) Blasting. Leakage surveys should be conducted on pipefines that could have been affected by blasting. For additional guidelines related to blasting activities, see Guide Material Appendix G-16. 192.615 FEDERAL STANDARD 192.615 Emergency plans. (10-1-76) (a) Each operator shall establish written procedures to minimize the hazard resulting from a gas pipeline emergency. At a minimum, the procedures must provide for the following: (1) Receiving, identifying, and classifying notices of events which require immediate response by the operator. (2) Establishing and maintaining adequate means of communication with appropriate fire, police, and other public officials. (3) Prompt and effective response to a notice of each type of emergency, including the following: (i) Gas detected inside or near a building (ii) Fire located near or directly involving a pipeline facility. ADDENDA NO. 1, AUGUST 1991 180 91

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APPENDIX F Abbreviations Used in this Report

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Abstract: On September 22, 1993, barges, being pushed by the towboat MAUVILLA in dense fog, struck and displaced the Big Bayou Canot railroad bridge near Mobile, Alabama. Shortly after, the Amtrak Sunset Limited struck the displaced bridge and derailed. Forty-two passengers and 5 train crewmembers were killed; 103 passengers were injured. The towboat crew was uninjured. The major safety issues discussed in this report include towboat operator training and evaluation, bridge risk assessment, bridge identification, emergency response and evacuation procedures, and event recorder crashworthiness. As a result of its investigation, the Safety Board issued safety recommendations to the U.S. Department of Transportation; the U.S. Army Corps of Engineers; the U.S. Coast Guard; the National Railroad Passenger Corporation; the Federal Emergency Management Agency; The American Waterways Operators, Inc.; the Warrior & Gulf Navigation Company; the Association of American Railroads; and the American Short Line Railroad Association. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Information about available publications may be obtained by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 L'Enfant Plaza, S.W. Washington, D.C. 20594 (202) 382-6735 Safety Board publications may be purchased, by individual copy or by subscription, from: National Technical Infonnation Service 5285 Port Royal Road Springfield, Virginia 22161 (703) 487-4600

DERAILMENT OF AMTRAK TRAIN NO.2 ON THE CSXT BIG BAYOU CANOT BRIDGE NEAR MOBILE, ALABAMA SEPTEMBER 22, 1993 RAILROAD-MARINE ACCIDENT REPORT Adopted: September 19, 1994 Notation 6167B NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594

CONTENTS EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v INVESTIGATION The Accident 1 The bridge collision sequence 1 The derailment sequence 5 Postaccident events 8 Injuries 13 Passengers and Crew . . . . . . . . . . . . 13 Damage 14 Big Bayou Canot railroad bridge . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 MAUVILLA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Sunset Limited 16 SAFETY ISSUES Exclusions 17 Toxicological Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Pilot's Activities Before the Accident 22 Pilot's Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Loss of Situational Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Warrior & Gulf Navigation 28 Towboat Operator Training 28 Industry Training Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Personnel Evaluation 31 Licensing Requirements 32 Towboat Navigation Equipment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Radar . . . . . . . . . . . . . . . . . . . . 34 Charts 35 Compasses 36 Bridge-Related Factors 37 Bridge vulnerability to vessel collision . . . . . . . . . . . . . 38 Track and bridge alignment protection 41 Bridge lighting protection 42 Waterway bridge protection 44 Comprehensive bridge risk assessment 45 iii

Emergency Response 51 Portable Emergency Lighting 52 Safety Briefings 52 Adequate Passenger Lists 55 Event Recorder Crashworthiness 55 Disaster Preparedness 56 CSXT notification 56 Emergency drills 56 MCEMA critique of emergency response 57 Bridge Identification 58 CONCLUSIONS Findings 59 Probable Cause. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 RECO~ENDATIONS 62 iv

EXECUTIVE SUMMARY On September 22, 1993, about 2:45 a.m., barges that were being pushed by the towboat MAUVILLA in dense fog struck and displaced the Big Bayou Canot railroad bridge near Mobile, Alabama. About 2:53 a.m., National Railroad Passenger Corporation (Amtrak) train 2, the Sunset Limited, en route from Los Angeles, California, to Miami, Florida, with 220 persons on board, struck the displaced bridge and derailed. The three locomotive units, the baggage and dormitory cars, and two of the six passenger cars fell into the water. The fuel tanks on the locomotive units ruptured, and the locomotive units and the baggage and dormitory cars caught fire. Forty-two passengers and 5 crewmembers were killed; 103 passengers were injured. The towboat's four crewmembers were not injured. The National Transportation Safety Board determines that the probable causes of Amtrak train 2's derailment were the displacement of the Big Bayou Canot railroad bridge when it was struck by the MAUVILLA and tow as a result of the MAUVILLA's pilot becoming lost and disoriented in the dense fog because of (1) the pilot's lack of radar navigation competency; (2) Warrior & Gulf Navigation Company's failure to ensure that its pilot was competent to use radar to navigate his tow during periods of reduced visibility; and (3) the U.S. Coast Guard's failure to establish higher standards for inland towing vessel operator licensing. Contributing to the accident was the lack of a national risk assessment program to determine bridge vulnerability to marine vessel collision. Safety issues discussed in the accident report include towboat operator training and evaluation, bridge risk assessment, bridge identification, emergency response and evacuation procedures, and event recorder crashworthiness. The Safety Board makes recommendations addressing these issues to the U.S. Department of Transportation; the U.S. Army Corps of Engineers; the U.S. Coast Guard; Amtrak; the Federal Emergency Management Agency; The American Waterways Operators, Inc.; the Warrior & Gulf Navigation Company; the Association of American Railroads; and the American Short Line Railroad Association. v

INVESTIGATION The Accident The bridge collision sequence.--About 12:55 a.m. on September 22, 1993, the towboat MAUVILLA, pushing six barges in a two-row, three-column combination (see p. 6), departed the National Marine Fleet (mile 5) on the Mobile River.! The crew comprised a captain,2 a pilot, and two deckhands. The pilot, who had assumed the watch from the captain at 11:30 p.m. on September 21, 1993, said that before departing northbound, he had allowed a faster tow, the THOMAS B. McCABE, to pass. (See figure 1 for a synopsis of times relevant to this accident.) SEQUENCE OF EVENTS Sunset Limited 9/21/93 9:30 p.m. Crew on duty, New Orleans 11:30 p.m. 11 :34 p.m. Train 2 departed New Orleans 9/22/93 12:55 a.m. 2:15 a.m. MAUVILLA Pilot on watch Departed National Marine Fleet, mile 5, Mobile River Radioed THOMAS B. McCABE 2:30 a.m. 2:33 a.m. 2:53 a.m. 2:56 a.m. 2:57 a.m. 3:00 a.m. Arrived Mobile Departed Mobile 2:45 a.m. Derailment Assistant conductor radioed "MAY DAY" CSX dispatcher notified CSX called 911 3:05 a.m. 3:07 a.m. 3:08 a.m. Hit bridge Radioed "MAY DAY" --lost tow, need help Reported fire via radio Coast Guard advised captain of accident Figure 1.--Times relevant to accident. IOn U.S. Army Corps of Engineers (USACE) river charts, river miles along the Black Warrior/Tombig- bee/Mobile River system are measured northbound in miles beginning at the Bankhead Tunnel (mile 0), Mobile, Alabama. 2In accordance with standard marine terminology for river towboats, the terms "captain" and "pilot" are used to differentiate between the MAUVILLA's two operators. The captain is the senior licensed operator and is in charge of the vessel; he stands the 0600-1200 and 1800-2400 watches. The pilot stands the 0000-0600 and 1200- 1800 watches. Each is required to have a Coast Guard license as operator of uninspected towing vessels (OUTV) (see Licensing Requirements, pp. 32-34). 1

He stated that visibility was good3 and recalled learning from marine radio conversations shortly before he departed that conditions were foggy north of his position. He could see the THOMAS B. McCABE's stem lights until that vessel rounded a bend in the Mobile River at Bayou Sara (about mile 8.2). The MAUVILLA's position at the time, according to the pilot, was near the south end of Twelve Mile Island (mile 7), and he recalled visibility beginning to become "hazy" there (see figure 2). The pilot testified that as he passed Catfish Bayou at mile 8.6, "it started getting foggier and foggier on me." Between Catfish Bayou and the north end of Twelve Mile Island (mile 9.6), the pilot contacted the operator of the THOMAS B. McCABE and asked about the fog; the reply was, "it's shut out" (zero visibility). The THOMAS B. McCABE's operator said he was going to continue, and the MAUVILLA's pilot stated that he "was going to try to get me a line," that is, moor his tow by securing it with a line to a tree or other structure on the riverbank. The two vessels were about three-quarters of a mile apart at this point, according to the THOMAS B. McCABE's operator, who said he could still see the glow of the MAUVILLA's lights. As the MAUVILLA approached the north end of Twelve Mile Island, the "fog shut in, " according to the pilot. The fog was dense enough that the pilot could not see the head of the tow, and he began to look for a place to tie to the bank. The pilot said he thought he was between Thirteen Mile Marsh, which is between miles 10 and 12, and the CSXT Fourteen Mile railroad bridge,4 which crosses the Mobile River at mile 13.3. He ordered the on-duty deckhand onto the lead barge on the starboard side to try to snag a tree so that a mooring line could be placed around it to secure the tow. The pilot used his searchlights to locate a tree. After at least two unsuccessful attempts to snag a tree, according to the pilot, he ordered the on-duty deckhand, whom he could not see from the wheelhouse, back to the towboat, fearing the deckhand might injure himself in the dense fog or fall overboard. He said he had reduced the vessel's speed at this point but was unable to estimate how fast he was moving. While trying to locate a tree, the pilot stated that he noticed his swing meterS indicate a tum to port and he observed two banks on the radar screen as the tow and barges straightened. The last navigation aid that the pilot recalled seeing before the accident was a red navigation dayboard on his starboard side before he reached the north end of Twelve Mile Island (probably the dayboard at mile 9.2). 3According to the National Weather Service, fog, which can form very quickly in this area, was not forecast for the area near Mobile on September 22, 1993. At 2:56 a.m. on the night of the accident, the National Weather Service weather report for the area was clear below 12,000 feet, 4 miles visibility, and 72 degrees Fahrenheit. 4Although mariners know it as the Fourteen Mile railroad bridge, its official name is the Mobile River bridge. It is one of three railroad swing bridges in the area; the Bayou Sara at mile post (MP) 658.3 and Tensas River (MP 651.6) are the other two. The Mobile River bridge (MP 653.5) is manned at all times by a bridge tender, who has radio communications with trains and marine traffic on the river. 5A gyroscopic device that indicates a rate of tum of the tow's head, often before visual cues of the tum are apparent. It does not indicate the amount of heading change. 2

Mobile River 14._ N " ACCIDENT SITE Big Bayou Canot ~-.. Bayou Sara RR Swing Bridge HOL CL. 64' Vert. CL. 3' (closed) NOT TO SCALE "14" Mile RR _ ]~.....__ Swing Bridge HOL CL. 146' Vert.CL. 4' (closed) Mobile- Tensas Cutoff Thirteen Mile Marsh Figure 2.--Mobile River chart. 3

The pilot explicitly stated that at no time did he see the intersection formed by the Mobile River and Big Bayou Canot either visually or by radar. He also said that he never considered "pushing in," that is, placing his barges into the bank and using engine maneuvers to hold the tow in place. According to testimony, he thought he was in the Mobile River and was proceeding to the Mobile-Tensas cutoff to tie to a tree he knew to be there; in fact, he had entered the Big Bayou Canot, a waterway not usually used by commercial traffic. He could not recall how long the on-duty deckhand remained on the barges or ·how far the MAUVILLA traveled while he attempted to snag a tree. 6 After returning to the towboat, the deckhand stood by in the galley while the pilot maneuvered the tow and barges back into the waterway. The pilot stated that as he maneuvered slowly upstream, he saw an object on his radar that appeared to be lying across the waterway. No river charts were on board the towboat, nor were they required to be. 7 He recalled contacting the THOMAS B. McCABE to ask whether that vessel's operator had seen a towboat tied along the bank as he proceeded up the Mobile River. The THOMAS B. McCABE's operator replied that he had not. The MAUVILLA's pilot said he never considered the object might have been something other than another towboat and barges that had swung out from the bank. In fact, the object was the single-track Big Bayou Canot railroad bridge, which has a vertical clearance of about 7 feet and is part of the CSXT system. The MAUVILLA continued moving toward the bridge. The pilot continued to glance at his radar even though, as he later testified, he did not know what scale it was on and had made no adjustments to it after coming on watch. He said he was "idling along at 1 or 2 knots" and twice tried to make radio contact with the presumed tow operator and also shined his lights at the object, to which he intended to tie alongside. He did not order the on-duty deckhand to move to the head of the tow so that he could advise him how close the tow was to the object. Although he observed his approach to it and saw what he believed were the banks of the Mobile River on radar, he stated he could not judge the distance from the object to the head of his tow. At some point as he continued toward the bridge, the pilot placed the throttles of the MAUVILLA in reverse. He testified that he was "still trying to figure out what was in front of me. And I never could." He said he felt a "bump" and thought he had run aground. The deckhand on duty testified that he also felt the "bump" while sitting in the galley and noted the time as 2:45 a.m. In fact, the lead port and starboard barges of theMAUVILLA had struck the south and center piers of the bridge's through-girder span (the other two sections of the bridge were a truss section and a timber trestle; see figures 3 and 4). The forward center barge, which protruded about 5 feet ahead of the port and starboard barges, struck the east girder between these two piers, displacing the south end of the girder span 38 inches to the west. Following the displacement, the east girder obtruded into the space traversed by trains. The port string of 6The THOMAS B. McCABE's operator recalled a conversation about 2: 15 a.m. during which the MAUVILLA's pilot stated that he almost "had a line caught." 7Charts for the area that are typically carried aboard inland river towing vessels include the USACE "Photographic Charts for the Black Warrior-Tombigbee Rivers" and a graphic charts booklet, "Lower Black Warrior-Tombigbee Waterway-Waterway Charts." These charts show the Big Bayou Canot bridge as a trackline over the waterway but do not state its name, clearances, or the fact that it is a fixed bridge. 4

barges broke free from the tow, and the pilot ordered the on-duty deckhand on deck. When the captain, awakened by the "bump" at 2:45 a.m., arrived in the wheelhouse, the pilot described his location as "between Twelve Mile Island and Thirteen Mile Marsh, some- where in that neighborhood." The pilot, who had been in the mouth of the Big Bayou Canot at least once before, still thought he was on the Mobile River. None of the MAUVILLA crew was aware at this point that the tow had struck a bridge. In the process of trying to retrieve the loose barges, the MAUVILLA backed into the east bank of the Big Bayou Canot, where it remained pinned for about 8 minutes, until about 2:53 a.m. Figure 3.--Last inspection photograph of Big Bayou Canot railroad bridge before accident. The derailment sequence. --At 10 p.m. on September 21, 1993, Amtrak train 2, the Sunset Limited, arrived in New Orleans, Louisiana, where it was delayed 34 minutes for repairs to an air conditioner and a toilet on two cars. The five-person operating crew included an engineer, two assistant engineers, a conductor, and an assistant conductor. A mechanical department rider was also on board to make minor repairs to passenger equipment en route. The operating crew had reported for duty in New Orleans at 9:30 p.m. Train 2 departed New Orleans, en route to Miami, Florida, at 1l:34p.m. Twelve on-board service (OBS) crewmembers, including anOBS supervisor, were also on board. The train arrived in Mobile, Alabama, about 2:30 a.m. on September 22, 1993, and the conductor helped passengers in Mobile detrain and board. According to the conductor's delay report, the train departed Mobile at 2:33 a.m., 33 minutes behind schedule, with 202 passengers on board. After departure, the assistant conductor and a train attendant walked through the train collecting tickets. They met the conductor at the upper level of the dining car, where they planned to do paperwork. 5

------") N f---- 23'----1

1-------141' 2"-----~

-- WGN 490'

237

" -._------- ::t,..----------;fff---flH:tM:i;#----m-- Figure 4.--MAUVILLA tow configuration and Big Bayou Canot bridge. 6

The conductor described the trip from Mobile to the accident site as uneventful. He said the locomotive crew called all signal indications over the radio, and he repeated them over his portable radio. 8 According to the assistant conductor, he last talked with the locomotive crew before the accident when the engineer called to thank him for bringing coffee at Mobile. The assistant conductor last remembered the locomotive crew calling the signal at Bayou Sara, mile post (MP) 658.4; the call was "clear" and the conductor repeated it to them shortly before the derailment. The train accelerated toward the Big Bayou Canot bridge and, traveling about 72 mph (authorized speed was 70 mph), struck the displaced bridge girder and derailed at MP 656.7 about 2:53 a.m. (see figure 5). Figure 5.--Photograph of accident site. Following the derailment, the three locomotive units came to rest on the east side of the bayou. Part of the lead unit, 819, was buried in about 46 feet of mud, and the part protruding above the embankment burned. The second unit, 262, also burned. The fuel tank of the third unit, 312, separated from it, and all equipment along the bottom of the unit below the frame was sheared off. 8A crewmember at the front of the train must announce all track side signals, which govern the train's movement, over railroad radio to a crewmember on the train, and the latter must repeat them over the radio to the former. 7

Baggage car 1139 and dorm-coach 39908, also on the east side of the bayou, were gutted by fire, and parts of both cars sustained major structural damage. About half of coach 34083, which rested against the bridge after the accident, was submerged, and coach 34068 was almost totally submerged. The next four cars, coach 34040, lounge 39973, diner 38030, and sleeper 32067, remained on the bridge. All passenger cars were double-decker cars. (See figure 6.) Both the conductor and the assistant conductor were in diner 38030, the next-to-the-Iast car. The latter said the accident took place without warning--no setting up of the brakes, no hom blast, and no communication from the locomotive crew. He was thrown onto the table in front of him and then into the middle of the car. The conductor was thrown over him. When the train stopped, the conductor attempted to contact the engineers on the lead locomotive unit using his portable radio but received no reply. Postaccident events.--After the derailment, the pilot of the MAUVILLA heard a "swishing noise" and saw a fire. He directed the on-duty deckhand to awaken the rest of the crew, and while the deckhand was doing so, the pilot maneuvered the tow to reestablish control of the port string of barges. As a result of these maneuvers, the tow was pushed against the northeast bank of the bayou, trapping the MAUVILLA between the port string of barges, which had been stripped and moved aft, and the bank. The pilot radioed the Mobile River bridge tender on VHF/FM channel 13 and asked whether anyone had reported a fire; the tender replied, "No." When the on-duty deckhand went on deck (following the bridge collision), he saw the port string of barges slipping aft and also noticed that the starboard winch wire, which secured the starboard side of the towboat to the aft barge on the starboard string, was broken. He subsequently saw flames and said he heard "a hiss like a roar but not a boom or nothing like that." The on-duty deckhand estimated that the fire started 5 to 10 minutes after he felt the "bump." He stated that the port string of barges slipped about 80 feet aft, boxing in the MAU- VILLA next to the bank. Meanwhile, about 2:56 a.m. train 2's assistant conductor made a "Mayday, Mayday" transmission over the railroad-designated radio that was heard by CSXT train 579, waiting at MP 660.4, whose crew repeated it to the yardmaster at the Sibert Yard, Mobile. Also about 2:56 a.m., the assistant terminal trainmaster at Sibert Yard heard train 2 transmitting Mayday over the radio. The yardmaster at Sibert Yard notified the train dispatcher in Jacksonville, Florida, at 2:57 a.m. and the Mobile Police Department's 911 operator about 3 a.m. that train 2 had derailed. The telephone number for the Coast Guard in the Mobile telephone directory was incorrect, and both the yardmaster and the CSXT representative in Mobile did not succeed in their first attempts to contact the Coast Guard. The bridge tender at the Mobile River bridge and the engineer of train 579 also radioed the train dispatcher in Jacksonville about 2:56 a.m. that train 2 was transmitting a Mayday call. Immediately thereafter, the train dispatcher tried to contact train 2 but was unsuccessful. Train 579's engineer advised the dispatcher that train 2 had derailed at the Mobile River bridge, which is where the assistant conductor said he thought the train was when he made his Mayday call, and was on fire. The Mobile River bridge is about 3.2 miles north of the actual accident site. 8

BIG BAYOU CANOT

Approximate

South Abutment

-

-_Y(a!erline APProxi~~~-S---- --~>N Steel Girder Bridge -. ---------·i·~l Timber Trestle Locomotive 819 Locomotive 262 I 192' 5.5"-1 ,- 72'--1 West Girder ---'="~-.J'f~-~f'/ " TO~ 34040· Coach ~ f!34?Js3 C~" h A-1139 Baggage Car .... .. ~... -... Partially 34068 Coach'. -,') Submerged . . Submerged -. East Girder Point of derailment MP-656.7 38030 Diner 32067 Sleeper I 1366'

; 270' I

141' 2" ___ T? Mobile 165'9"::t, _ Sibert Yard 1

_ r -='l "'~:. ( m t= ;;; ,y...... : MP-657 Direction of train ~ NOT TO SCALE 1.0 Figure 6.--Diagram of accident scene.

Between 3:02 and 3:05 a.m., the Mobile Police Department's 911 operator contacted the Mobile Fire Department and the Coast Guard. Police, fire, and Coast Guard personnel began notifying other emergency responders; more than 60 local departments eventually responded. Train 2's OBS supervisor, using a cellular telephone, called the Mobile 911 operator about 3:05 a.m. and provided additional information about the accident location and what was taking place at the site. The OBS supervisor did not know the exact location of the derailment, however. For about 18 minutes--from 3:02 to 3:20 a.m.--confusion ensued as the Mobile, Saraland, and Chickasaw 911 operators tried to locate the accident site. Exactly where train 2 had derailed was unclear, and no roads lead into the area, which is heavily wooded swampland. Before they knew they would have to respond by water or rail, the emergency responders searched by land for the accident site. Also about 3:05 a.m., the captain of the MAUVILLA, concerned about his situation with the barges, broadcast a distress message on VHF/FM channel 16: "Mayday, Mayday, Mayday, the motor vessel MAUVILLA [garbled], got a tow broke up right below anchorage end of pier and seems to have a cable or something wrapped in the wheel, barges adrift southbound... .If anybody down there can help rounding them up, I would appreciate it. "9 The U.S. Coast Guard Group Mobile (Group) received the radio transmission; the radio operator on watch responded and asked for a position. to The MAUVILLA's captain replied: "We're between the upper end of Twelve Mile Island [mile 9.6] and the old maritime cut [Mobile-Tensas Cutoff, mile 12.1, Mobile River], somewhere in that area and I'm not exactly sure on the mileboard over." Responding to the Group radio operator's questions about 3:06 a.m., the captain said that four people were on board, that the MAUVILLA was unable to move, and that the vessel was in no danger of sinking. He added, "I believe we are right on top of this thing." About 3:07 a.m., the Group told the captain that a train had derailed. The captain replied, "I believe we're right below the train....They's a helluva fire up here in the middle of the river and there ain't supposed to be no fire up here and, like I say, I don't know exactly where we at. It's so foggy I can't tell...by looking on the radar, so there's something bad wrong up here." The Group's radio operator asked the captain about 3: 11 a.m. whether he was involved in the train derailment. He replied: "I can't tell you for a hundred percent whether I'm involved in it or not. We are right below it, I'm not sure what's going on. I come up here it was so foggy I can't tell where I'm at....1 can't get away from the barges where I'm at. I'm gonna try to get out of here and see if I can't go up there and help somebody." When the captain arrived in the wheelhouse shortly after he felt the "bump" and assumed control of the tow from the pilot, the starboard quarter of the towboat was up against the bank, 9The vertical clearance of the Big Bayou Canot railroad bridge, about 7 feet, was not sufficient to allow the barges to pass under it. The starboard lead barge, for example, had a freeboard (height of the hull above the waterline) of about 5 feet 10 inches, and its cargo hopper extended an additional 2 feet, for a combined total height of about 7 feet 10 inches. lCYfhe Coast Guard Group Mobile continually records radio transmissions. Times were taken from a transcript of the Group's tape recordings. 10

limiting the vessel's movement. After extensive maneuvering of the MAUVILLA's engines and rudders, he was able to free the towboat from its position between the bank and the port string of barges. The captain ordered the deckhands to release the towboat from the tow (the four barges that remained together), maneuvered the MAUVILLA to the port side of the tow, and pushed all six barges into the bank. Leaving the barges pushed into the northeast bank, he moved the towboat toward the fire. Meanwhile, the assistant conductor (after broadcasting the Mayday transmission) and the train attendant had started toward the front of the train, and the conductor headed toward the rear. The assistant conductor said he planned to send passengers back to the conductor for evac- uation. When he reached the front of the train, the assistant conductor saw that the center section of the bridge was missing and that two cars were in the water below him. He also saw other cars on fire, the lead locomotive unit nose down in the water, and a locomotive unit next to it burning. The OBS supervisor and three OBS crewmembers (the other eight OBS crewmembers were in the dorm-coach, which was burning on the east side of the bayou) began evacuating the cars that remained on the bridge. They told the passengers to remain calm and evacuated them to the tracks at the rear of the train. The assistant conductor asked whether any medical practi- tioners were on board; a passenger who was a nurse responded, volunteering to provide first aid at the rear of the train. The assistant conductor returned from the front of the train and went to the east bank of the bayou. He radioed the mechanical department rider, who was in one of the cars on the bridge, and directed him to help set up a relay system in the water with passengers who could swim. The assistant conductor instructed passengers participating in the relay to space themselves "about 20 yards apart" and to "swim out and meet these elderly people [who were evacuating from submerged cars] and swim them to the next guy and so forth, on up to the bank." The relay passed people from the middle of the waterway to the west bank of the bayou. According to passengers in the totally submerged car (coach 34068), the lower level and front section of the car filled with water in seconds, limiting the time passengers in those sections had to evacuate. The center and rear sections on the upper level remained out of the water for about 10 minutes, and passengers evacuated through the open rear door and window exits on the upper level. The assistant conductor told passengers atop the coach that was partially submerged and sinking (coach 34083) to swim to the east bank toward the rear of the train. Passengers inside this coach stated that the lower level and rear of the car filled with water in seconds, limiting the evacuation time for passengers in those sections. Bridge timbers held the upper level and front of the car out of the water; passengers in those sections evacuated through the window exits on the upper level in about 30 minutes. Six OBS crewmembers evacuated from the dorm-coach, which was on fire. They entered the water, were rescued by the crew of the towboat MAUVILLA, and then helped passengers 11

out of the water. Two OBS crewmembers died in their bedrooms, which were in the section of the dorm-coach that sustained major structural damage. The engineer and two assistant engineers in the locomotive cab that was buried in mud died. About 3:19 a.m., the captain of the MAUVILLA called and advised the Coast Guard Group that he had his barges under control. He further stated that he would try to render assistance to survivors. The MAUVILLA's deckhands launched the towboat's skiff, which was near the wreckage on the east side of the river, and one deckhand rowed to people in the water and pUlled them aboard. He returned several times to pick up additional survivors. When smoke from the burning oil and wreckage filled the MAUVILLA's wheelhouse, the captain was forced to back the towboat away. Meanwhile, the six barges had slipped off the bank and were drifting toward the bridge. After pushing them onto the bank a second time, the captain returned to the accident site and continued to rescue survivors from the water. By 3:20 a.m., the Coast Guard Station Mobile's 19-foot, rigid-hull inflatable (RBI) boat was under way to the accident site. About 3:24 a.m., the Group broadcast an "Urgent Marine Information Broadcast," stating "there has been a report of an Amtrak derailment at the junction of Bayou Sara Creek and Mobile River at Twelve Mile Island. There have been reports of persons in the water. All mariners are requested to assist if possible. " The captain of the MAU- VILLA, still unaware of his location, called the Group about 3:25 a.m. and said: "We have a mess up here, this train has run off the Fourteen Mile Railroad bridge....The bridge is open, the train has run off of it and it's burning. . . ." About 3:59 a.m., the MAUVILLA's pilot, talking on the radio to the operator of the towboat SCOTT PRIDE,11 which was approaching the accident site, stated: "I made a wrong turn. I guess I can tell you. You know when you come out of the upper end of Twelve Mile Island you got a left, a river [Big Bayou Canot], go back to your left.... " About 4 a.m., when the assistant conductor noticed the SCOTT PRIDE moving toward him, he worked his way back to the bridge and onto the pier on the Mobile end. From this vantage, he began waving his flashlight at the towboat. The assistant conductor said he was concerned that the SCOTT PRIDE would hit the submerged coach or the people in the water. When the towboat got close enough to the bridge pier, he jumped onto it. The crew of the SCOTT PRIDE pulled 20 people out of the water. The crew of the MAUVILLA rescued 17 people from the water. The Mobile fireboat RAMONA DOYLE, which had to navigate using radar because of the dense fog, arrived about 4 a.m. and, after determining that no other people remained in the water, started fighting the fire. When the towboats and traincrew had rescued most of the people from the water, the conductor and assistant conductor began taking a head count of the passengers and passed out blankets and pillows. The OBS supervisor distributed cushions, and the assistant conductor informed the llAbout 3 a.m., the operator on watch on the SCOTT PRIDE, which was in the Mobile River near the Chickasaw Creek railroad bridge, had overheard radio transmissions between the Fourteen Mile and Chickasaw Creek railroad bridge tenders about a train derailment. After confirming the derailment with the Chickasaw Creek bridge tender, he proceeded up the Mobile River, arriving at the Big Bayou Canot about 4 a.m. 12

passengers that a train would take them back to Mobile. About 4:04 a.m., the Coast Guard launched helicopters from the nearest air search and rescue (SAR) unit, which was in New Orleans. About 4:25 a.m., the Coast Guard's RHI boat arrived and started assisting passengers. The SAR controller testified that the RHI encountered patches of very dense fog while en route to the scene; at times, the crew could not see the bow. The pilot of a Coast Guard aircraft that arrived on scene about 5: 10 a.m. said he found visibility clear at 500 to 1,000 feet; he reported communications with Coast Guard boat crews during which the crews mentioned dense fog while traveling upriver. The glow from the fire helped responders locate the accident site. When Coast Guard helicopters arrived on scene about 5:20 a.m. and started assisting passengers, the fog had dissipated. The MAUVILLA transported the survivors it had rescued to a triage area at the Scott Paper Company pier in Chickasaw, after which the towboat pro- ceeded to the Warrior & Gulf Navigation (W&GN) yard and moored. Coast Guard, local emer- gency medical services personnel, and other towboats that responded to the distress call also took survivors to the two triage sites established at the Scott Paper Company in Chickasaw. The last survivors were treated and transported to local hospitals or hotels by 8:30 a.m. Injuries Injury Type* Operating Crew OBS Crew Passengers Total Fatal 3 2 42 47 Serious 0 0 4 4 Minor 2 6 99 107 None 1** 4 57 62 Total 6 12 202 220 *Title 49 Code of Federal Regulations (CFR) 830.2 defines "fatal injury" as "any injury which results in death within 30 days of the accident." It defines "serious injury as "an injury which: (1) requires hospitali- zation for more than 48 hours, commencing within 7 days from the date the injury was received; (2) results in a fracture of any bone (except simple fracture of fingers, toes, or nose); (3) causes severe hemorrhages, nerve, muscle, or tendon damage; (4) involves any internal organ; or (5) involves second- or third-degree bums, or any bum affecting more than 5 percent of the body surface." **The mechanical department rider is included with the operating crew on the injury table. Passengers and Crew The ticket count on the day after the accident indicated that 189 passengers and 18 employees were on board the Sunset Limited. Rescuers recovered 3 unticketed infants, bringing 13

the passenger and crew count to 210. Their ages ranged from less than 2 to 84 or 85. An Amtrak representative later told Safety Board investigators that after the accident, 10 additional people reported that they had been passengers on the train. Because passengers board and exit at various stops and because some passengers purchase tickets on board instead of making reservations, Amtrak could not determine whether these 10 people were on train 2 during the derailment. Nonetheless, they have been included in the passenger and crew count, bringing the total to 220. According to the Alabama Department of Forensic Sciences medical examiner in Mobile, autopsy reports show that 42 passengers died from asphyxia due to drowning. Three locomotive engineers died as a result of asphyxia and blunt force trauma while inside the lead locomotive unit cab that became filled with mud. Two OBS crewmembers in a section of the dorm-coach that sustained major structural damage died as a result of smoke inhalation. Survivor injuries included contusions, fractures, abrasions, lacerations, strains, and mul- tiple trauma. Injured survivors were treated at five local hospitals. Damage Big Bayou Canot railroad bridge. --The through-plate girder span was destroyed. The following components also sustained damage: all bridge ties on the south through truss span, nine floor beam braces, two floor beam hangers, the flange angles on the end post, the ballasted deck timber trestle, and the south five panels. The nose of the south pier sustained some concrete spalling (chipping or scaling) from the MAUVILLA's lead port barge (see figure 7). The east edge of the sole and filler plates for the east girder's south bearing came to rest on the west edge of the east pedestal and the west edge of the pier cap plates. The west girder plates were found on the pier cap adjacent to the west edge of the west pedestal. The bottom of the east girder sole plate had large radius lateral striations (grooves or channels), and the west sole plate had straight lateral striations. About 15 feet of the top flange of the east girder, beginning at the south girder face, was separated from the web. Part of the top of the plate over this 15-foot section was "accordianed"; the rest of the top flange was comparatively undamaged. The web sustained two tears, one extending from the top to the bottom flange and a large horizontal tear between the fourteenth and seventeenth stiffeners. The bottom flange had two indentations, 21 inches and 22 inches wide, respectively, on the bottom east side. The girders, which were about 40 feet apart laterally at the widest point, were displaced some 70 feet to the north. The northernmost and two southernmost floorbeams remained connected to both girders. The other eight floorbeams were severed from the east girder but re- mained connected to the west girder. The stringers remained connected to the floorbeams. Concrete had broken off the east angular nose of the pier that supported the south end of the girders and off part of the north edge of the pier cap. Surface evidence indicated the fractures were recent. 14

Figure 7.--Collision marks on Big Bayou Canot bridge. During salvage operations, divers assessed the alignment and general condition of the perimeter piles in the cluster supporting the pivot pier. The piles appeared to be in good condi- tion and in alignment after the accident. Portions of the concrete pedestal and some mat timbers were found 50 feet north of their original location. The continuous welded rail and the track structure on the 165-foot truss section of the bridge sustained extensive damage from massive buff forces during the derailment. The 140-foot through-girder span was displaced 38 inches by the barge and was subsequently destroyed when train 2 struck the displaced girder, knocking the track and bridge section off the piers and piling. The railroad track structure was also displaced, but the rail was not broken. About 500 feet of track on the timber trestle, the third section of the bridge, was destroyed during the derailment. The signal system, a traffic control system (TCS) operated by a train dispatcher in Jack- sonville, Florida, was not damaged when the barge rammed the bridge and thus continued to function even though the track on the through-girder span had been displaced. The train dispatcher had no indication of any problems with the track structure on his TCS signal control board, and all signals were clear (proceed) when the derailment occurred. MAUVILLA.--The vessel's propulsion, steering, radios, searchlights, and all other mechanical and electronic equipment functioned properly after the accident. The MAUVILLA 15

was drydocked at W&GN's yard on September 27, 1993, for a hull survey. The marine investi- gative group noted no apparent damage to the hull, rudders, or propellers. Inspection revealed no evidence of a wire or other item having been wrapped around the propellers or rudders. The lead port (WGN 285) and starboard (WGN 208) barges (see figure 8) were slightly dented where they struck the bridge's concrete piers, and the center lead barge (WGN 258) had six marks on its headlog where it struck the vertical stiffeners on the bridge span (see figure 4). The other three barges were undamaged. Figure 8.--Collision marks on barge. Sunset Limited.--After the lead locomotive unit struck the bridge girder that had been displaced by the MAUVILLA, the three locomotive units, baggage car, dorm-coach, and two passenger cars on the head end fell into the water. The locomotive units, baggage car, and dorm- coach all caught fire and were destroyed. One passenger car sustained extensive damage and one was destroyed. The four passenger cars that remained on the bridge received minor damage. Damage and rerouting cost estimates, based on data provided by CSXT, Amtrak, and W&GN, are as follows: 16 Rail Equipment Track and Bridge Rerouting Marine Equipment Pollution Cleanup Total $ 16,000,000 $ 2,000,000 $ 1,700,000 $ 1,250 $ 117,000 $ 19,818,250

SAFETY ISSUES Exclusions Investigators eliminated several factors as safety issues in this accident. They included train operations, track and signals, train equipment, and traincrew qualifications. The Safety Board reviewed event recorder tapes, transcripts of interviews with the oper- ating crew, and crew deposition statements. This review disclosed no anomalies or deficiencies in train 2's operation. Postaccident inspection of track through the bridge and its approaches revealed no defects or deviations from Federal Railroad Administration (FRA) standards. Before the accident, the CSXT had last inspected the track structure over Big Bayou Canot bridge on September 19, 1993, and the FRA had done so on September 13, 1993; neither inspection uncovered any defects. The track is maintained to class 4 standards. 12 CSXT and Amtrak tests in July, August, and September 1993 revealed no rail defects. Postaccident inspection and testing of the signal system showed that it functioned as designed. Neither postaccident equipment inspection nor crew testimony indicated any equipment failure on train 2. Lead locomotive unit 819, a new General Electric (GE) design PH40 model delivered to Amtrak on September 1, 1993, derailed at a speed of about 72 mph, traveled some 270 feet through the air, and was buried in about 46 feet of mud. The trailing locomotive units, 262 and 312, were F40PH models that also came to rest in the bayou. The fuel tanks on each of the three locomotive units ruptured, spraying fuel over the trestle and Bayou Canot, and ignited. That part of the lead unit protruding above the mud burned. Both trailing units were destroyed by fire. The fuel tanks on lead unit 819 incorporated recent design enhancements, including computerized and vented cells to maintain equalization and to minimize spills in the event of a rupture. In its 1992 rail fuel tank safety study, 13 the Safety Board made the following recom- mendation to the FRA: R-92-10 Conduct, in conjunction with the Association of American Railroads, General Electric, and General Motors Electro-Motive Division, research to determine if the locomotive fuel tank can be improved to withstand forces encountered in the 12Class 4 track must be inspected at least twice weekly by a certified track inspector and maintained in a condition that will allow passenger trains to operate over it at a maximum speed of 80 mph. 13Safety Study--Locomotive Fuel Tank Integrity (NTSB/SS-92/04). 17

more severe locomotive derailment accidents or if fuel containment can be improved to reduce the rate of fuel leakage and fuel ignition. Consideration should be given to crash or simulated testing and evaluation of recent and proposed design modifications to the locomotive fuel tank, including increasing the structural strength of end and side wall plates, raising the tank higher above the rail, and using internal tank bladders and foam inserts. In its February 10, 1993, response, the FRA stated that it would act on this recommendation and, together with the Association of American Railroads (AAR), GE, and General Motors Electro-Motive Division, would collect data on fuel tank integrity; it intends to periodically update the Safety Board on the status of this effort. Safety Recommendation has been classified "Open--Acceptable Response." On December 13, 1993, during the Safety Board's public hearing on the Mobile accident, the FRA's Director of the Office of Safety Enforcement testified that the Congress has directed the FRA to examine the issue of locomotive (including fuel tank) crashworthiness. He stated that the FRA has a research project under way and is considering simulation of locomotive crashes to determine how certain locomotives would perform. He noted that the agency's report is due to the Congress in early 1995. The Safety Board hopes that in conducting this research, the FRA will reconsider its previous decision to include only locomotives built after August 1, 1990. Train 2's operating crew were fit to perform the duties to which they were assigned. All five men were rested in accordance with applicable regulations, and all were qualified on the operating rules. In addition, each had passed Amtrak's most recent physical examination. Toxicological Issues Neither alcohol nor illicit drug use appears to have been a factor in the accident. The lead locomotive unit in which the three engineers died was not recovered until 1:20 p.m. on September 24, and thus their bodies were submerged for more than 58 hours before test samples could be collected. Toxicological test results for the three men showed evidence of alcohol in their bodies. Laboratory reports noted that all samples were decomposed, and the alcohol levels detected were consistent with expected postmortem generation of alcohol. Both the conductor and assistant conductor of train 2 stated that they knew of no evidence that any of the engineers had consumed alcohol immediately before or during the trip, and the engineers' medical and personnel records contained no information relating to alcohol-related incidents or problems. The Safety Board therefore believes that the toxicological evidence of alcohol in the bodies of the three engineers resulted from postmortem microbial production of ethanol rather than from antemortem ingestion of alcohol. Blood and urine specimens were not collected from the conductor and assistant conductor until some 9 hours after the accident because all supervisory personnel were responding to the accident. Those specimens tested negative for alcohol and drugs. But because of the 9-hour lapse between the accident and specimen collection, the Safety Board cannot conclusively state that 18

alcohol was not present in the conductor and assistant conductor at the time of the accident. Urine specimens from the four MAUVILLA crewmembers were obtained on the morning of September 21, 1993, for the random drug testing required by 46 CFR 16.230. The specimens tested negative for the presence of the five drugs specified in 49 CFR Part 40, that is, the metabolites ofmarijuana, cocaine, opiates, phencyclidine, and amphetamines. Subsequent Safety Board tests on samples taken from the MAUVILLA's captain revealed the presence of nor- propoxyphene, caffeine, nicotine, cotinine, ibuprofen, and acetaminophen. Norpropoxyphene is the metabolite of propoxyphene, a mild narcotic analgesic drug found in Darvon, a prescription drug for alleviating pain. The captain said that he took Darvocet N 100, as necessary, for pain from an old shoulder injury. Possible side effects of Darvocet include dizziness and drowsiness. Although the captain was not on watch at the time of the accident, the Safety Board is concerned about the possible effects of medication on performance. Unsupervised use of medica- tion, both prescribed and over-the-counter, by operators in the transportation industry has been an issue in previous accidents. 14 Operators may not understand the potential dangers of many medications, including their effect on performance, and therefore may use them inappropriately. Consequently, the Safety Board concludes that companies such as W&GN should establish proce- dures that encourage towboat operators to inform management when they are taking medication, determine whether such medication may affect their performance of duties, and arrange for a qualified relief, if necessary. The Safety Board has urged employers in the transportation industries to implement edu- cational programs for employees that describe and illustrate possible consequences ofmedication use. As a result of its investigation of the December 17, 1991, derailment of Amtrak's Silver Meteor in Palatka, Florida, the Board asked Amtrak on August 17, 1993, to: R-93-17 Develop and implement an educational program for employees that describes and illustrates potential consequences of medication use to enable employees to make an informed decision about the relationship between their use of prescribed and over-the-counter medications and their fitness for duty. In its October 14, 1993, response, Amtrak stated that it was prepared to develop and implement such a program. The Safety Board classified this recommendation "Open-Acceptable Response" on February 10, 1994, pending further response from Amtrak. The Safety Board has also discussed the need for employers to be aware that employees are taking medication so that the employers can determine the potential effects on fitness for duty. As a result of its investigation of the grounding of the M/V REGINA on February 15, 14See, for example, Marine Accident Report--Grounding ofthe Panamanian-Flag Passenger Carferry MIV A. REGINA, Mona Island, Puerto Rico, February 15, 1985 (NTSB/MAR-86/02) and Railroad Accident Report-- Derailment ofAmtrak Train 87, Silver Meteor, in Palatka, Florida, December 17,1991 (NTSB/RAR-93/02/SUM). 19

1985, the Safety Board recommended on February 27, 1986, that the operator of the REGINA and the U.S. Coast Guard, respectively: M-86-13 Establish a procedure to require that your vessel masters and watchstanding officers report when they are taking any medication, determine whether such medication may affect the performance of their duties, and arrange for a qualified relief if necessary. M-86-15 Require that masters and watchstanding officers on U.S. passenger vessels carrying 50 or more passengers, including ferries, report to the vessel's operation company when they are taking any medication so that a medical determination can be made as to the effect of such medication on their ability to perform watchkeeping tasks properly. Safety Recommendation M-86-13 was classified "Closed--No Longer Applicable" on October 19, 1987, because the company operating the REGINA no longer operated the vessel between Puerto Rico and the Dominican Republic. However, a different company operating in the same area stated that a directive had been issued requiring all masters and watchstanding officers of the vessel to report when any medication is being taken. When such a report is received, the officers confer with a physician to determine the possible effects of the medication on the employee's performance. The Safety Board classified Safety Recommendation M-86-15 "Closed--Acceptable Alternate Action" on December 23, 1993, after the Coast Guard implemented a regulation requiring the vessel owner, charterer, managing operator, agent, master, or person in charge to exercise due diligence to ensure that the vessel is not operated by individuals who are intoxicated (including intoxication caused by legal drug use). Considering these experiences with medication use by transportation industry employees and the events in this accident, the Safety Board concludes that the industry needs to develop intensive educational programs for employees that stress the relationship between medication and possible effects on fitness-for-duty status. The Safety Board believes that the Secretary of Transportation should require that each modal operating administration issue notices, bulletins, circulars, or other documents that stress the need for transportation industry employees to report any use of over-the-counter or prescription medication so that a determination can be made concerning the effect of such medication on the employees' fitness for duty. The urine specimen collected from the MAUVILLA's pilot tested positive for glucose and contained caffeine and ibuprofen. The pilot's personnel records indicated that he had been diagnosed as having diabetes mellitus in August 1982; his physician stated in a letter that the pilot was an insulin-dependent diabetic who monitored his glucose closely. The physician also said he believed the pilot's condition would not preclude him from discharging his duties as a 20

"boat pilot." The letter was given to the pilot for submission with his application for an Operator of Uninspected Towing Vessels (OUTV) license, which the Coast Guard eventually granted after requesting and receiving additional information about his diabetic condition. The pilot's most recent physical examination before the accident took place on July 23,

1. It included a vision and hearing test, and the physician noted that the pilot could safely

continue employment in his current position. The pilot said he took insulin twice a day and had done so the evening before the accident, as prescribed. He stated that he "felt fine" and rested upon assuming the watch at 11:30 p.m. The Safety Board concludes, based on information obtained from his employer and a statement from his doctor, that the pilot had been able to control his diabetic condition satisfactorily since 1982 and that the disease most likely did not preclude him from operating the MAUVILLA safely. Because all supervisory personnel were responding to the accident, toxicological samples from the MAUVILLA's crew were not collected and tested until about 10 hours after the accident. Because of the lO-hour lapse, the Safety Board cannot conclusively state whether alcohol was present in any of the MAUVILLA's crewmembers at the time of the accident. The Safety Board is concerned about the delay in obtaining samples from both the MAUVILLA crew and the surviving traincrew members, even though the testing took place within Federal timeliness standards in effect at the time, that is, "as soon as practicable." Alcohol at a blood concentration level of 0.10 percent (the legal intoxication level in most States) is eliminated from the body in 6 to 7 hours. Although drugs and their metabolites are eliminated more slowly than alcohol, a 6- to 7-hour delay can also allow drug levels to fall below the testing thresholds established by law. The Safety Board has long been concerned about drug testing inconsistencies among the transportation modes and about delays in obtaining toxicological samples after accidents. This accident underscores the need for the Coast Guard to develop improved procedures concerning postaccident sampling for toxicological testing. The Coast Guard, which regularly responds to marine accidents and attends to matters of postaccident testing, is fully aware of the law and therefore should provide guidance to employers. However, the Coast Guard has not provided its investigating officers with guidelines for informing marine employers about the law, for stressing the need for timeliness in testing crewmembers, and for assisting marine employers in accomplishing timely postaccident sampling. In several previous accident investigations, the Safety Board has addressed the need for improved postaccident drug and alcohol testing procedures. 15 The Safety Board believes that the Coast Guard should provide guidelines to boarding officers who investigate marine accidents about informing marine employers of their responsibility to conduct toxicological testing as soon as practicable following a serious marine incident and about providing assistance when necessary lSSee, for example, Marine Accident Report--Grounding ofthe United Kingdom Passenger Vessel RMS Queen Elizabeth 2 near Cuttyhunk Island, Vineyard Sound, Massachusetts, August 7, 1992 (NTSB/MAR-93/01) and Highway-Marine Accident Report--US. Towboat CHRIS Collision with the Judge William Seeber Bridge, New Orleans, Louisiana, May 28, 1993 (NTSB/HAR-94/03). 21

(for example, supplying sampling kits and making arrangements for testing with local approved laboratories). This accident reinforces the need for such guidelines, and the Safety Board looks forward to prompt implementation of Safety Recommendation M-94-11, which calls on the Coast Guard to adopt them. 16 Similarly, although blood and urine specimens were obtained from survlvmg train crewmembers in accordance with Federal timeliness standards then in effect, that is, "as soon as possible, " the Safety Board regards the delay in testing as unjustified. Provisions of the Omni- bus Transportation Employee Act of 1991 required that the Federal Aviation Administration, the Federal Highway Administration (FHWA), the FRA, and the Federal Transit Administration promulgate comprehensive alcohol use and detection programs. The new alcohol and drug testing regulations, published in the Federal Register on February 15, 1994, address for the first time the issue of timeliness. They require that postaccident testing be conducted "as soon as prac- ticable" and set time limits within which testing for alcohol should be accomplishedY The marine industry was not included in the act because the Coast Guard already had regulations on alcohol use, including mandatory postaccident alcohol testing. The pipeline indus- try was excluded because, unlike other forms of public transportation, it does not transport people. The Research and Special Programs Administration, which regulates the pipeline industry, nonetheless implemented regulations similar to those ofthe other Department of Trans- portation (DOT) operating administrations. The Coast Guard did not, and its regulations per- taining to timeliness of postaccident toxicological testing do not conform with those of the other DOT operating administrations. The Safety Board concludes that delays in obtaining samples from vessel crewmembers, which prevented definitive determination of whether alcohol was a factor in this accident, could continue to be a factor in marine accidents because Coast Guard regulations pertaining to timely postaccident toxicological testing do not conform with those of the other DOT operating admin- istrations. The Safety Board believes that the Coast Guard should amend 46 CFR 4 and 16 to specify the time limits, not to exceed 8 hours, within which employers must conduct postaccident alcohol testing. Pilot's Activities Before the Accident On Friday, September 17, and Saturday, September 18, 1993, the pilot remained at home and ran errands. He retired shortly before midnight on both evenings. On Sunday, September 16Highway-Marine Accident Report--U.S. Towboat CHRIS Collision with the Judge William Seeber Bridge, New Orleans, Louisiana, May 28, 1993 (NTSB/HAR-94/03). 17If an alcohol test is not administered within 2 hours (4 hours in the case of FRA-regulated employers) following an accident, the employer is to prepare and maintain on file a record stating why the test was not promptly administered. If the alcohol test is not administered within 8 hours, the employer is to cease attempts to conduct the test and state in the record why it was not administered. 22

19, he awakened about 7 a.m., took a shower, and administered his insulin. He then ate break- fast and left for work about 9 a.m. At 10:35 a.m., the pilot and a deckhand left W&GN and drove to mileboard (MB)18 185 or 186 on the Mobile River to meet the MAUVILLA, which was traveling south toward the Mobile, Alabama, area. W&GN had arranged for the vessel to stop at MB 185.5 to allow the pilot and the deckhand to board. The pilot said he was scheduled to meet the MAUVILLA to relieve a pilot or captain who had become ill. He boarded the vessel at 12:45 p.m., had lunch, and then went on watch. At 6 p.m., he went off watch; after taking a shower and eating supper, he went to bed. He woke up at 11 p.m. and assumed the watch at 11:45 p.m. He stood watch until 5:30 a.m. on Monday, September 20, when he was relieved by the captain. After administering his insulin shot, the pilot went to bed; upon arising at 11 a.m., he ate lunch and then relieved the captain. He stood watch until 6 p.m., exercised for 1/2 hour, took a shower, ate supper, and retired until 11 p.m. He assumed the watch from the captain at 11:45 p.m. The pilot stood watch until 5:45 a.m., Tuesday, September 21, at which time the captain relieved him. He then administered his insulin shot, had breakfast, and went to bed, sleeping until 11 a.m. After taking a shower and eating lunch, he relieved the captain at 11 :40 a.m. and stood watch until 6 p.m., when the captain relieved him. He took a shower, administered his insulin, and had supper. After returning to his room, he read for a while and slept until 11 p.m. The MAUVILLA arrived at the National Marine Fleet about 11 p.m. to pick up two additional barges. The pilot assumed the watch at 11:30 p. m., and the MAUVILLA departed the National Marine Fleet at 12:55 a.m. on September 22. Pilot'5 Performance About 1/2 hour elapsed between the time the fog set in and the time that the MAUVILLA rammed the Big Bayou Canot bridge. The last navigation aid that the pilot recalled seeing before reaching the north end of Twelve Mile Island was a triangular dayboard, which was probably the dayboard at mile 9.2, about 1/2 mile from the mouth of the bayou. Ifthe MAUVILLA was traveling from mile 9.2 at 2 or 3 mph, as the pilot estimated it was, the vessel would have arrived at the Big Bayou Canot in 10 to 15 minutes. During the accident investigation, Safety Board staff boarded the MAUVILLA to observe the radar displays19 presented by the banks of the Mobile River and by the juncture of the river and the Big Bayou Canot. The investigator did so on both the 1/2-mile and the I-mile range scales, and the radarscope clearly displayed the banks and the juncture of the two waterways. According to testimony, the pilot found himself in increasingly heavy fog as he proceeded 18Boards are daybeacon navigation aids colored to indicate the proper side of the waterway; they indicate their location by a mile/tenths of a mile distance from mile 0 on a waterway. 1"W&GN records show that the MAUVILLA's radar was last serviced before the accident on September 5, 1993, and was operating properly. 23

to the north end of Twelve Mile Island. In accordance with company pOlicy20 and after con- ferring with the THOMAS B. McCABE's operator about visibility conditions ahead, the pilot decided to stop his tow and "tie up." Towboat operators on the Western Rivers commonly tie up to trees on the riverbank during periods of restricted visibility. Both the Coast Guard and the U.S. Army Corps of Engineers (USACE) are aware that "tying up" is an accepted practice throughout the river system and do not prohibit it. Except for "pushing in" (shoving the tow onto the riverbank) and using engine and rudder maneuvers to hold the tow in place, towboat operators have no other option if they need to stop when they are away from a dock or mooring facility. They often need to stop due to fog while navigating through sparsely populated areas such as this one. The Safety Board believes that because the dense fog made safe operations difficult, the pilot's decision to tie up and await better visibility conditions was a prudent one. The pilot indicated that he was unable to see either riverbank at the time he decided to stop. The deckhand on watch testified that he could see "a barge length ahead of me," that is, about 200 feet. The Safety Board believes that the pilot maneuvered his tow closer to the river- bank to try to visually locate a suitable tree to tie up to. He testified that he searched for a tree with his spotlights and twice tried, but failed, to snag one. After these unsuccessful attempts, the pilot told his deckhand to return to the towboat because he wanted to proceed to the Mobile- Tensas Cutoff, about 3 miles north of the intersection of the Big Bayou Canot and the Mobile River, where he knew there was a tree suitable for mooring. To continue upriver and avoid entering the Big Bayou Canot, a tow following the river curvature must stop its leftward movement (see figure 9). When the shorelines are visible, cues are available to guide an operator through the intersection. When the shorelines are obscured, an operator needs radar information to stay on the intended courses. He or she has to correlate the radar information with chart information or memory of the waterway's geography to deter- mine the tow's location and choose the proper waterway. Heading upriver about mile 9.1, the Mobile River begins curving to the left and spans an arc of about 95 degrees to the entrance of Big Bayou Canot, a distance of about 0.8 mile. Although the pilot said he did not see the intersection of the two waterways on the radar, it should have appeared on the radarscope about the time the tow passed mile 9.1 and should have remained there even after the MAUVILLA entered Big Bayou Canot if the radar was set to the II2-mile scale. Even if the radar was set to the 1I4-mile scale, the triangular point of land marking the north end of the intersection should have appeared on the radar shortly after the tow entered the intersection. 20Both the pilot and W&GN general manager testified that company policy was to stop and tie up a tow when visibility deteriorated to near zero. In the general manager's words, "When a pilot encounters fog of such density that he feels he cannot continue the trip under the existing conditions, the policy is for the pilot to find a suitable place to tie off and wait until the fog lifts." 24

NVl Figure 9.--Three USACE aerial photographs showing the Mobile River and the Big Bayou Canot.

The radar presentation varies as the tow proceeds, and the images must continually be interpreted because the outlines may differ from those shown on charts or sighted visually. The pilot either did not observe the radar sufficiently to obtain the information available, was inade- quately trained to understand what the radar presented, or both. He testified that after receiving his license, W&GN "trained me as a copilot for almost a year, I believe. I went through to copilot training. That's learning how to operate the boat, running the rivers, and how to operate the radar." The pilot said he learned how to use radar through "on-the-job training," noting that he had not operated the type or model of radar on the MAUVILLA but had been exposed to and operated other models. He testified that he had received no formal training in the use and interpretation of radar: "Not going to school. Not for radar, no." When he noticed the MAUVILLA's swing meter indicate that the head of the tow was moving left, the pilot said he observed the banks but no "intersection" on the radar and did not realize he was headed into the Big Bayou Canot. Safety Board investigators noted that at 1/2- mile or greater range settings, the image of an intersection is visible on the radarscope at various points when a vessel is proceeding through the intersection. The pilot's failure to notice that he had departed the Mobile River suggests that he did not look at the radar long enough, perhaps because he was simultaneously engaged in maneuvering the vessel, talking on the radio to the deckhand, and using his searchlights. The Safety Board believes the pilot became so preoccupied with his search for a tree that he failed to avail himself of the radar equipment that could have compensated for both the darkness and the fog. The Safety Board concludes that had the pilot used the radar as visibility deteriorated, he would have observed the intersection formed by the Mobile River and the Big Bayou Canot and could have avoided turning his tow and barges into the wrong waterway. Other than radar, no means of determining his heading was available, since the towboat was not equipped with a compass. If the pilot had access to a compass and had known the general heading of the Mobile River at his location, he might have noticed that he was steering northerly rather than easterly. The Safety Board concludes that the pilot was at a disadvantage because W&GN had not provided him with a compass. The pilot said that shortly after maneuvering his tow from the riverbank (to snag a tree) back into the waterway (the Big Bayou Canot), he observed an object on the radar that he believed to be another tow. The object, as displayed on the radarscope, appeared to extend across the waterway, and the pilot thought that a tow might have swung out into the river, as was possible if it had been moored by the bow only. His decision to try to moor to this supposed "tow" was compatible with towboat practices. The pilot did not act prudently, however, in approaching another tow at a 90-degree angle when visibility was limited and a deckhand was not at the head of the tow. The Safety Board believes that the pilot should have more fully assessed the situation before trying to tie up to an object he had seen on radar but been unable to contact by radio. If he had sent the deckhand to the head of the tow, for instance, the hand might have been able to identify the object as the railroad bridge and warn the pilot in time to avoid this accident. The Safety Board concludes that the pilot exercised poor decisionmaking by continuing his approach to an unidenti- fied object under the prevailing conditions without summoning help from other crewmembers. 26

Loss of Situational Awareness Perhaps the most vexing question in this accident is: How did the pilot become disori- ented on the Mobile River in an area he had traversed many times as a deckhand and a towboat operator?21 When asked about his experience operating a tow at night, the pilot replied, "Well, I have a lot of experience operating at night, but we don't operate in fog." The Safety Board believes that the pilot ceased to navigate effectively and safely when visibility deteriorated to the point that he could no longer see the riverbanks. In other words, the pilot lost situational awareness, which one source defines as "an accurate perception of the factors and conditions that affect a vessel and its crew during a specific period of time. In simpler terms," according to the same source, "situational awareness is knowing what is going on around you. "22 While the pilot's attempt to moor his tow was a prudent action in the Safety Board's view, it did not relieve him of responsibility for remaining aware of the MAUVILLA's orientation and position on the river, that is, for the safe navigation of his vessel. The pilot apparently became increasingly preoccupied with the task of tying off at the expense of tracking the tow's position. When he abandoned the immediate effort to find a mooring spot and redirected his attention to navigating, he had lost track of 10 to 15 minutes, during which time the tow had entered the mouth of the Big Bayou Canot. The Safety Board concludes that under the circumstances, the pilot acted imprudently in deciding to continue to navigate when he could not find a tree to which to tie up. The pilot could have avoided losing situational awareness if he had recognized that he became task-saturated in trying to find a suitable mooring spot while simultaneously navigating the tow. Sound resource management23 dictates that W&GN should have had a written policy to address situations such as this one. Crewmembers are often unaware of either the fact that they overload themselves or the remedies available to them to prevent task saturation unless they receive instruction in resource management principles. Companies can enhance basic crew resource management by establishing a corporate policy that recognizes the need for and encourages the practice of good judgment and effective communication among crewmembers. The Safety Board believes that W&GN should make its employees aware that task overload can occur. The Safety Board further believes the company should establish procedures that enable towboat operators on watch to identify potentially hazardous situations that materially increase watch operators' workload and allow them to enlist the aid of off-watch operators or other competent crew. 21The pilot, who testified to having operated towboats on the Mobile River, the Black Warrior River, the Tennessee Tombigbee Waterway, and the Mississippi River, stated that he had passed the mouth of the Big Bayou Canot on a towboat 2 days before the accident. 22Geiss-Alvarado Associates, Human Error Accident Training, U.S. Coast Guard training manual, July 1991. 23The effective use of all available resources (people, equipment, and procedures) to achieve a safe and efficient operation. 27

Warrior & Gulf Navigation W&GN, organized in 1940, has about 225 employees, of whom 45 are towboat captains or pilots and 54 are deckhands. The remaining employees are managers, support personnel, and terminal operators. The company and The American Waterways Operators, Inc., (AWO)24 consider W&GN a medium-size inland towing operation; it has about 250 barges and 24 towboats. About 10 of the former are covered hopper barges (200 feet long and 35 feet wide); the remainder are open hopper barges (195 feet long and 35 feet wide). The towboats built in the 1970s are 1,800 horsepower, and those built in 1982 are 2,100 horsepower. The company typically moves six barges in a tow and occasionally eight. In fast current or high water conditions, tow size is usually held to four barges. One operator and one deckhand stand watch on a towboat on a 6 hour-on, 6 hour-off rotation, which is typical for the type of towing operation the company is engaged in. The general manager stated that the equipment provided on W&GN towboats is more than that required by regulation and probably more than that provided by other companies. He believes the training provided to operators and deckhands is above average for a company of its size. Safety Board investigators were able to obtain the accident record for W&GN compiled by the Coast Guard Marine Safety Office, Mobile, Alabama. From 1982 until the date of this accident, W&GN vessels were involved in three minor pollution incidents (less than 100 gallons of oil spilled) and no medium or major incidents. The record also shows 3 fires on board W&GN vessels, 6 barge groundings, 2 barge strikings of unmarked underwater objects, 3 barge structural failures, 1 accidental death of a deckhand, 3 founderings, 3 collisions with an aid to navigation, 3 collisions with bridges, 18 other collisions, and 2 accidents of an unspecified nature that were not classified for recordkeeping purposes. Thus, in 12 years, the company has experienced 45 reportable marine casualties, inclu- ding this accident, or 3.75 accidents per year, which is less than 0.2 accidents per towboat-tow per year. A local Coast Guard official stated that he thought W&GN's accident record was better than average for inland towing companies. Coast Guard headquarters does not maintain accident rates for towing companies; therefore, no comparison could be made with the industry overall. Towboat Operator Training Although W&GN operations complied with Coast Guard licensed operator manning regulations, the company did not ensure that the pilot ofthe MAUVILLA was adequately trained in the use of radar. Had the pilot been adequately trained to use radar, he should have recog- nized the juncture of the Big Bayou Canot and the Mobile River on the radarscope. When he 24A national trade association that represents 350 companies, including 200 that move cargo by tug, towboat, and barge. The AWO also represents shipyards that build and repair barge and towing vessels. It advises members about legislation affecting the industry and comments to regulatory agencies on matters of interest to members. The U.S. towing industry numbers about 700 companies. They operate some 5,800 tugs and towboats that move 27,000 barges transporting dry cargo and some 4,000 tank barges transporting bulk liquid cargo. 28

inadvertently departed from his course, he should have been able to interpret his position on the radar and respond to the change in course appropriately. To locate a suitable place to secure their tows and wait for visibility to improve, towboat operators need to be trained in use of radar to navigate. The Safety Board found that W&GN did not provide the pilot with radar training beyond the rudimentary experience gained on the job. W&GN hired the pilot as a deckhand on April 23, 1980. His personnel records show that the company advanced him tuition to attend "sea school" in September 1988, and the pilot stated that he completed "sea school" to prepare him for his OUTV examination. On October 12, 1990, following several unsuccessful attempts, he passed the Coast Guard licensing examination for OUTV25 Upon Western Rivers. W&GN promoted him to operator trainee on November 8,1990. The company promoted him to operator second class (pilot II) on October 12, 1991, and to operator first class (pilot I) on January 12, 1993.26 After obtaining his license, the pilot testified, he entered W&GN's towboat operator training program, remaining in it for about a year. This program, he said, consisted of on-the- job training (OJT) under the tutelage of an experienced operator, who taught him how to operate the boat, "run the river," and operate the radar. He received no structured radar navigation training, and W&GN did not formally evaluate his radar navigation proficiency before allowing him to serve as an unsupervised towboat operator. Nonetheless, before September 22, 1993, the pilot had no reportable marine accidents. W&GN's general manager testified that he was aware of no written company policy concerning the hiring and training of towboat operators. In fact, although W&GN occasionally hires licensed towboat operators, it more commonly trains its deckhands to fill such positions. After the deckhands receive an OUTV license, W&GN's practice is to place them in its towboat operator training program, at which point they become "operator trainees. " The general manager stated that he did not know whether operator trainees have the opportunity to listen to lectures, review written material, or demonstrate proficiency in the position based on a written test. He said that the W&GN towboat operators who conduct the training do not themselves receive formal instruction in their role as trainers. Nor does the company give written guidance to its assistant fleet captain, whose responsibilities include oversight of towboat operator training and evaluation. W&GN's OJT program, as described by the general manager, largely consists of observing wheelhouse operations. After obtaining an OUTV license, trainees receive 6 to 12 months of OJT, which includes standing watches under a vessel operator's supervision. During this time, they are expected to obtain a working knowledge of all aspects of towboat operations, including maneuvering a vessel, use of radar and other equipment, and the geographical areas over which they will operate. 25The MAUVILLA's captain, who had worked on towing vessels since 1974, also held a valid OUTV license. 26The duties of the two positions are essentially the same; the salaries are different. 29

The general manager testified that the purpose of radar on W&GN's towboats is to allow operators to locate banks to tie off vessels and barges and to avoid obstructions in the waterway. The company instructs trainees not to navigate in fog but to find a suitable place to tie up when visibility deteriorates to the point of being completely "shut-out." The pilot stated that from 1984 until 1988, while serving as a deckhand, he was also "going up to the wheelhouse learning how to operate the vessel." After completing his duties as deckhand, the pilot said he went to the wheelhouse and steered the vessel for 1 to 2 hours under the operator's direction, usually during daylight. He explained that during this period, he learned, by observation, how to operate the radar and observe the swing meter. Records show that the pilot began entering information about his training in a "Pilot Trainee Log" on January 1, 1991. He recorded dates, times on watch, position by MB, number of hours steered, and descriptions of the tow. The logs indicate that the pilot steered a towboat on some 150 occasions between January 1, 1991, and September 2, 1991, the date of the last entry. He steered a towboat, on average, just under 5 hours per voyage, during both daylight and nighttime, in various locations from MB 0 to MB 367, Mobile, Black Warrior, and Tombigbee Waterways. In October 1991, the W&GN port captain recommended that the pilot be promoted to pilot second class (pilot II). The pilot probably received adequate OJT in towboat and barge maneuvering and was quite likely qualified to operate vessels under most conditions. Nonetheless, he did not use his radar properly on the night of the accident and certainly was not using it to detennine his posi- tion on the river. The Safety Board concludes that W&GN did not adequately train the pilot to navigate by radar. If the pilot had received formal radar training, he might have known how to use the radar when visibility began to deteriorate. Considering that W&GN had equipped all its towboats with radar before September 22, 1993, the argument for radar training is compelling. The Safety Board believes that a structured radar training program enhances an operator's ability not only to determine his position but also to navigate his towboat to a safe mooring location and that this training should be required of all operators of radar-equipped towboats. Industry Training Standards One towing industry representative testified that his company prefers to train towing vessel operators in-house through a 5-year program before they take the Coast Guard exam- ination for an OUTV license. He said participants are evaluated twice a year. In addition, the company monitors participants' performance in areas such as vessel personnel turnover and safety violations to determine whether inappropriate operational patterns are developing. Another industry official stated that his company has established a "steersman program, " from 1 to 3 years in duration, to provide training for prospective towboat operators. A partici- pant's only responsibility is to learn, according to the official. He said trainees are "observed constantly" and gradually assigned to more demanding routes or tows until they are qualified to stand watch alone. Following passage of the 1972 towing license law, he said, "We [in the towing industry] were going to have to do much more in the form of training and preparation 30

for these people [OUTV operators] before we would entrust our vessels to them." An AWO representative testified that training programs such as the two described are fairly widespread in the industry. He said that these two programs "have more definition" and "they're more structured. But I think the concepts that are embodied in their programs you will find even with smaller operators, although they are probably less sophisticated." At least one of the programs requires that its trainees learn to use waterway charts, as well as "all navigation equipments," including radar, while steering a vessel. The Coast Guard licensing test cannot assess the extent to which an applicant has the vessel-handling and equipment-use skills needed to operate a vessel under varying conditions of visibility, current flow, tow size, and so forth. Therefore, employers have the responsibility to train and evaluate their operators before placing them in charge of a navigation watch. The limited information available concerning towboat operator training suggests that in the case of smaller companies, such training may not go beyond that to which the W&GN general manager attested. The Safety Board believes that the industry, including W&GN, should provide operators with the radar skills necessary to navigate radar-equipped towboats safely in poor visibility. Personnel Evaluation W&GN's assistant fleet captain and vessel operators periodically evaluate operator trainees and recommend whether they should be promoted to pilot II and pilot I. The assistant fleet captain testified that he rides with a trainee when the individual enters the training program, evaluates the person's performance in writing after that ride, and evaluates the trainee's progress again in about a month. He continues to do an unspecified number of such evaluations, even after the trainee has been promoted to pilot II (that promotion allows an individual to stand watch alone while operating the vessel). The assistant fleet captain said that after an individual has become a pilot II, evaluations are not necessarily written. The pilot of the MAUVILLA had received 16 written evaluations between January 25 and September 30, 1991, while he was in training, and subsequently received written evaluations on April 5, April 12, and August 30, 1993. All rated him either "good" or "excellent"27 in every area of performance--"safety consciousness, respects authority, ability to get along with other crewmembers, knowledge of position, quality of work, and aptitude for learning." W&GN was unable to locate any written evaluations for the pilot for the period from September 30, 1991, to April 5, 1993. The Safety Board believes that systematic, written evaluations of an individual's per- formance are essential because they allow the organization to continually assess those skills and abilities critical to a position. In addition, written evaluations can highlight deficiencies, thereby serving as a valuabletool for effecting changes in work habits. Such evaluations indicate whether an individual is meeting the employer's stated goals. By providing documented, periodic feed- 27The four rating levels for each category were "poor," "fair," "good," and "excellent." 31

back concerning skills and abilities, they also give employees information that can be used to improve their performance. W&GN's evaluation form is a check-off sheet rather than an in-depth assessment form for assessing an operator's skills and abilities. Whether management, using this form, could accurately evaluate an individual's abilities is questionable. The criteria for the four rating levels are not listed on the form, and the six areas of performance evaluated are too general to allow meaningful assessment of an operator's skills. For example, "knowledge of position" is not defined. The Safety Board concludes that operators should be evaluated on their proficiency in use of wheelhouse equipment such as radar (under various visibility conditions and circum- stances, including finding a suitable place to tie oft), the swing meter, and rudders (including backing rudders) and engines in high water and high current conditions. The Safety Board also concludes that W&GN's written evaluation form did not fully identify and assess those skills critical to vessel operation, thereby limiting its value as a management tool for ensuring safe vessel operations. Licensing Requirements Before September 1973, only individuals who were on watch in the wheelhouse on steam- powered towing vessels were required to have a Coast Guard license. After World War II, diesel-powered vessels gradually replaced steam towing vessels. Motor- or diesel-driven towing vessels were not required to have licensed wheelhouse operators. Following an increasing number of casualties involving uninspected towing vessels in the 1960s and early 1970s, the Congress enacted the Towing Vessel Operator Licensing Act of 1972, which requires that indi- viduals standing navigation watch on uninspected towing vessels at least 26 feet long hold an OUTV license. Since the MAUVILLA was 85 feet long, both the captain and pilot were required to have such a license. The licensing regulations recognize the limited formal educa- tional background of many towboat operators by reducing the scope of knowledge required to obtain a license. The Coast Guard establishes minimum training and experience standards for OUTV license applicants, who must furnish references that establish sufficient character to hold a position of that responsibility. An individual must also present evidence of 3 years of experience on specified vessels, including at least 6 months training or duty in the wheelhouse of a towing vessel. The regulations do not prescribe the level or type of wheelhouse training in vessel handling or equipment use. Evidence of service for an OUTV Upon Western Rivers license takes the form of a letter from the employer attesting to the candidate's service. The letter usually does not elaborate on what training a candidate has received; rather, it states that the individual has received training or has had duty in the wheelhouse. Before a candidate is allowed to take the licensing test, he or she must pass a physical examination, drug screening, and first aid and CPR courses. Depending on the scope of operation and route covered, the test for operators of unin- spected towing vessels, such as the MAUVILLA, consists of four parts: general (60 questions), navigation rules (30 questions), general navigation (15-20 questions), and navigation problems 32

(10-20 questions). Between 1987 and 1990, the Coast Guard updated the OUTV Upon Western Rivers test, increasing the number of question variations in each module. The purpose of the changes was to better reflect the knowledge requirements and duties of operators; the substance of the examination remained the same. License applicants must pass all four modules, and they have three opportunities for passing each one before failing the test. The Coast Guard does not limit the number of times an applicant may be examined for this (or any other) license. If a candidate does not pass all four modules in a 3-month period, he or she is counted as a test failure. The failure rate for the OUTV license, based on the latest records available, is as follows: 6.4 percent in 1989 (26 of 283 candidates), 6.8 percent in 1990 (92 of 1,263 candidates), and 2.9 percent in 1991 (12 of 398 candidates). The Coast Guard does not compile data on the number of retakes or the number of times an individual is reexamined before passing a test. To monitor the licensing program, the Coast Guard is developing a system to retrieve pass-fail data on candidates; implementation is expected in early 1995. To meet requirements for the license, an operator does not have to be trained in the use of radar, and the MAUVILLA pilot was not so trained. Marine employers should ensure that their operators have essential skills, even though such skills are not required to obtain the Coast Guard license. As this accident shows, regardless of the tow size, towboat operators need to be qualified and proficient in navigating and operating in restricted visibility. Because radar skills are necessary for safe operation of a vessel in restricted visibility, the Safety Board believes that the Coast Guard should establish higher standards for inland towing vessel operator licensing. Like the MAUVILLA's pilot, OUTVs typically learn to use radar through OJT. The knowledge imparted and skills learned through OJT vary, and a formal written examination is rarely given. The accident involving the MAUVILLA illustrates the shortcomings of such an approach to acquiring radar skills. Had the pilot received formal training in and been tested for radar skills, he should have been able to navigate his vessel properly without becoming lost. If the pilot had known how to navigate using radar, the MAUVILLA could have proceeded when the fog developed until the pilot was able to safely stop the tow. Operators need radar naviga- tional skills because tows are not always in locations suitable for stopping when fog occurs. While the prudent course of action is to stop the tow until visibility improves, pilots must con- tinue to operate until they find a safe place to stop. Deck officers licensed to stand watch on radar-equipped, inspected vessels of 300 gross tons or more must successfully complete a Coast Guard-approved radar observer course to obtain their original license (have "radar observer" endorsed on the license with the date of completion) and must successfully complete a refresher course every 5 years thereafter. In the case of OUTVs, only those holding a license for ocean waters are required to have a radar observer endorsement. As this accident demonstrates, radar observer training should be required of all OUTV licenseholders. Inland Navigation Rule 7(b), which applies to OUTVs, states: "Proper use shall be made of radar equipment if fitted and operational." Safe operation of a vessel includes proper use of radar, and only if a person successfully completes radar observer training at approved facilities can minimum proficiency in radar use be ensured. 33

The formal radar observer training currently available focuses on navigation of vessels offshore and in harbors. It emphasizes skills such as plotting of courses and collision avoidance maneuvers between vessels, which are useful on offshore waters and in harbors. This training is not directed at inland river navigation. The Coast Guard should develop radar observer course standards that, in addition to collision avoidance, teach navigation skills necessary for safe river operations. The Safety Board believes that current minimum licensing requirements are insuf- ficient and that maritime safety would be enhanced by requiring that OUTVs be trained to use radar properly in a Coast Guard-approved radar observer course. As a result of this accident, the Commandant of the Coast Guard directed that a review of safety issues relating to uninspected towing vessels be conducted. The review, completed on December 1, 1993, resulted in 19 recommendations concerning licensing, radar observer training, equipment requirements, and other issues. The Commandant accepted all of the recom- mendations and forwarded his action plan to the Secretary of Transportation. The Coast Guard held a public meeting on April 4, 1994, to discuss safety issues, including manning, inspection, licensing qualifications, and navigation equipment, and to develop additional information in preparation for changes to towing safety regulations. The Coast Guard is to report its findings on manning and inspection of towboats by July 31, 1994, and is to publish a notice of proposed rulemaking for towing vessel navigation equipment by December 1994. Changes in towing vessel license requirements, such as levels of qualification (restrictions on route, towing vessel gross tonnage or horsepower, and towing configuration) and successful simulator course completion, are expected to be published by midsummer 1994. Towboat Navigation Equipment Title 46 CFR Parts 24 through 28 set forth equipment requirements for uninspected vessels. The regulations cover life preservers and other lifesaving equipment; fire extinguishing equipment; emergency position indicating radio beacons for vessels on the high seas; and cooking, heating and lighting systems, as well as other equipment; they do not cover navigation equipment. Thus, the MAUVILLA, an uninspected towboat of less than 1,600 tons, was not required to be fitted with a radar, charts, or a compass. Radar.--Like almost all uninspected towing vessels,28 the MAUVILLA did have a radar, which is an important navigation aid widely used to detect the presence or movement of objects in a waterway. To require that radars be installed on uninspected towing vessels would be to regulate what is accepted practice and would not be an imposition on the industry, but it would prevent such vessels from operating legally unless their radar was in proper working order and would encourage operator reliance on radars. Operators trained in radar observation would be more likely to use radar and would know how to use it properly. They would also be less likely 28The most common exceptions are tugs and towboats that operate in limited confmes such as fleeting areas or shipyards. 34

to become disoriented in fog. Proper use of radar by the MAUVILLA's pilot could have pre- vented this accident. The Safety Board concludes that all uninspected towing vessels, except those operating in very limited areas, should be required to have a radar installed. The Safety Board believes that the Coast Guard should require that towing vessels be equipped with radars and that towing vessel operators be trained in its use for navigation. Charts.--Graphic representations of the geographic features of a waterway, or charts, are another aid to safe navigation. They depict landmarks, hazards to navigation, bridges, and other features an operator may need to be aware of to safely guide the vessel. Most trainee operators use river charts to help familiarize themselves with the rivers they navigate. Many river towboat operators carry their own charts, known as "bar books" or "bar charts," which are generally USACE waterway charts annotated by the operators to assist them in navigating a waterway. On the night of the accident, the MAUVILLA had no charts on board, and the pilot did not have his personal set with him. The pilot had marked geographic and other information on a personal set of charts but did not usually carry them with him after he had been trained on the river. He testified, "I used to carry my chart with me all the time. I had it about a month, I guess, and I started leaving it at home." He added, "Once you know the river and places, positions where you'll be at, you don't have to have it. Nobody requires you to have a chart because you don't navigate by the chart." W&GN's general manager testified that "charts are not required as standard operating equipment on Warrior & Gulf vessels or any other towboats or vessels under 1,600 gross tons. " He said company "policy is to encourage our pilot trainees or anyone else who wishes to use a chart to do so, if it will help them to familiarize themselves with the river system. " Had the pilot, mistakenly thinking he was on the river rather than the bayou, looked at a chart as he approached the Big Bayou Canot bridge, the chart alone would not have helped him. But if he had used a chart, in conjunction with radar, to track his progress as soon as visibility began to decrease, he could have avoided making a wrong turn into the bayou and thus prevented the accident. Most towboat operators who operate frequently over the same route become very familiar with that waterway. During clear visibility, especially in the daytime, they have no need to refer to charts and generally do not do so. But when towboat operators are in unfamiliar waters or when visibility is low, whether due to fog, rain, sleet, snow or other cause, charts are important reference tools. Because visibility can deteriorate rapidly and with little notice, charts should be available in the pilothouse at all times. The Safety Board concludes that the Coast Guard should require that all uninspected towing vessels have charts on board appropriate for the vessels' route. In addition, the Safety Board believes that the AWO should urge member companies to equip their towing vessels with appropriate charts and to implement a method of assessing their vessel operators' navigation skills, including use of radar. The USACE and the National Oceanic and Atmospheric Administration (NOAA) make available paper navigation charts for use by mariners. The USACE does so for the inland river system, and NOAA provides such charts for harbors and adjacent coastal areas, the Great Lakes, and some rivers in which ocean vessels operate (for example, the Mississippi River from the 35

Gulf of Mexico to Baton Rouge, Louisiana). Recent advances in computer technology have made possible the development of digitized electronic charts that can be presented on a video screen. NOAA is digitally scanning all of its charts, which number about 1,000, and expects to complete the project by the end of 1995. Beginning in fall 1994, NOAA, in cooperation with a commercial enterprise, will issue about 400 charts on floppy disks, which are expected to cost about the same as the paper charts. The USACE does not plan to digitize its river charts for distribution to users, but it has digitally scanned its St. Louis-to-New Orleans charts for internal use in survey and river maintenance operations. USACE charts for the Tombigbee River from Demopolis, Alabama, to the Tennessee River are also being digitized for internal use and should be completed next year. The NAVSTAR Global Positioning System (GPS) provides a higWy accurate29 navigational aid that is available worldwide, and international organizations are cooperating to develop standards for GPS equipment and electronic charts. Navigating in rivers and restricted waters requires a more accurate system, and the differential GPS (DGPS) is being developed to meet this need. 30 DGPS land stations, which have broadcast ranges of up to 240 miles, broadcast corrections for use by GPS receivers. The station network for the U.S. east and south coasts is being tested and evaluated, and the entire network is scheduled to be operational by January

1. The USACE, in cooperation with the Coast Guard, has built DGPS stations in St. Louis,

Missouri; Memphis, Tennessee; and Vicksburg, Mississippi. The DGPS station network for the Mississippi River, which is also being tested and evaluated, is expected to be operational by June

1. The Coast Guard plans to build 11 more DGPS stations in the Western Rivers area.

Digital chart technology, coupled with GPS navigation technology, has made possible continuous electronic representation of navigational positions on computer. Mariners have long plotted their positions based on where they were rather than where they are. Electronic charting will give them continuous, real-time data, allowing them to monitor their positions by looking at the screen. The Safety Board welcomes these advances in technology, which should significantly improve navigation safety. If an electronic charting system and the DGPS had been available and installed on inland towing vessels such as the MAUVILLA, the accident at the Big Bayou Canot railroad bridge could have been avoided. The Safety Board believes that the Coast Guard and the USACE should promote the development and application of low-cost electronic charting navigation devices for inland rivers. Compasses. --Most inland river towing vessels do not have a compass on board, nor do they usually need one to navigate rivers safely. Nonetheless, a compass can be a useful, inexpensive navigation aid that allows an operator to determine the vessel's heading and to verify information obtained from the radar. Used in conjunction with charts and radar, a compass can enable an operator to determine his heading without having to rely on visual cues. It can indicate 2911 can give positions accurate to 100 meters. 30Accuracy is in the 8- to lO-meter range, and greater accuracies are possible. Newer aps receivers are of higher quality and yield greater accuracy, which is also a function of the vessel's closeness to the naps station. 36

the amount of heading change, a particularly important feature when no visual cues are available, as is the case during dense fog, for example. If the MAUVILLA had been equipped with a suitable compass and if the pilot had been trained to read one, he would have been able to determine the amount of heading change between the Mobile River and the Big Bayou Canot, and this cue alone may have alerted him to the fact that he was in the wrong waterway. The difference in compass headings between the two bodies of water is about 95 degrees. As a result of its investigation of the collision of the towboat FREMONT and tow with the containership JURAJ DALMATINAC, in the Houston ship channel on December 21, 1992,31 the Safety Board recommended on January 21, 1994, that the Coast Guard: M-93-41 Require that tugs and towboats operating on the navigable waters of the United States be equipped with a suitable compass. On April 26, 1994, the Coast Guard responded that it concurs with the recommendation and has initiated rulemaking that will address this issue. Pending publication of the final rules, the Safety Board has classified Safety Recommendation M-93-41 "Open--Acceptable Response." The Coast Guard is also studying the need for radar, swing meters, and navigation charts aboard towing vessels. The Safety Board made a similar recommendation to the AWO: M-93-46 Recommend that member companies operating tugs and towboats on the navigable waters of the United States equip their vessels with a suitable compass. The AWO supports this recommendation and disseminated it to AWO members in the February 11, 1994, issue of the AWO Letter. In some areas of the Western Rivers system, according to the AWO, a swing meter may be more appropriate than a compass. The Safety Board has classified M-93-46 "Closed--Acceptable Action." Bridge-Related Factors The Mobile and Montgomery Railroad built the original bridge at this location--two truss 31Marine Accident Report--Collision of the U.S. Towboat FREMONT and Tow with the St. Vincent and the Grenadines-Registered Containership IURAI DALMATINAC, Houston Ship Channel, December 21, 1992 (NTSB/MAR-93/02). 37

spans and a trestle--between 1880 and 1885, having been granted permission to do so by act of Congress. In 1909, the Louisville and Nashville Railroad, which had purchased the line, removed one truss span and replaced it with a through steel-plate girder span. The second, southernmost truss span was replaced by a longer one in 1925. The bridge became part of the Seaboard Coastline system in 1983 and part of the CSXT system in 1986. The through steel-plate girder span, about 140 feet long, rested on three piers and was anchored to the center and north piers with bolts. It rested on a bearing plate on the south pier and, in accordance with the design, was not bolted to that pier. The girder span was designed so that it could be readily modified for use as a swing span, but the machinery was never installed and the bridge remained a fixed bridge. 32 The track structure on the bridge was continuous over the spans. Neither the USACE nor the Coast Guard required bridge protection systems, such as lights, markers, dolphins, and fenders, and none were in place at the time of the accident. CSXT testified that the bridge did not warrant such systems because it is not on a commercially navigable waterway. 33 Postaccident inspection of the bridge revealed no structural deficiencies that would have decreased the load-carrying capacity for which it was designed. The damage found was that caused by the impact from the MAUVILLA and its six barges and by train 2's collision with the structure. The bridge was built according to design and was sufficient to carry the vertical loads and horizontal wind loads for which it had been designed. CSXT informed the Safety Board that it replaced the Big Bayou Canot railroad bridge with a permanent structure following the accident. The 140-foot through-girder span and 60-foot timber approach were replaced with three rolled-steel beam spans (49 feet, 46 feet, and 43.5 feet long, respectively) and one 63.5-foot steel riveted girder span. Supporting the spans are four steel-pipe pile towers and the existing south pier. Replacement began on September 27, 1993, and was completed on October 3, 1993. No permit was required and none was requested. Bridge vulnerability to vessel collision.--Various factors, alone and in combination, make bridges such as the one over the Big Bayou Canot vulnerable to impact from or collision with marine traffic. Vulnerability, by definition, is "a function of the estimated risk and the ability to cope with consequences should they occur. "34 Many vulnerability factors were relevant in this accident. For example, the bridge is over 32A stationary span, that is, one that remains in position and does not move. 33Since the accident, the Coast Guard has instructed CSXT to provide navigation lights on the bridge and has installed dayboards at the entrance to the Big Bayou Canot to alert mariners to the bridge's presence in the bayou. In a recommendation on its Report of Vessel Casualty or Accident (Form CG-2692), W&GN asked the Coast Guard to review the need for additional aids to navigation on the waterway. 34See William D. Rowe, "Risk Assessment Processes for Hazardous Materials Transportation," National Cooperative Highway Research Program, Synthesis ojHighway Practice 103, November 1983, Washington, D.C., p.8. 38

a tidal waterway and has a low vertical clearance, about 7 feet, that is not shown on all river charts. Occasional use of the Big Bayou Canot for barge fleeting was another vulnerability factor. In addition, the bridge had no warning devices, and the bayou had no navigation aids. Fog also sometimes limits visibility in the vicinity, which includes the heavily traveled Mobile River less than 0.7 mile to the east. Until about 1950, the standard inland river dry cargo hopper barge used to transport grain and other dry bulk cargoes was 175 feet long, 26 to 27 feet wide, and about 10 feet deep; it carried about 900 tons of cargo. Today, the standard hopper barge is 195 feet long, 35 feet wide, 11 to 12 feet deep, and has a capacity of 1,400 to 1,500 tons of cargo (about 4 to 5 times the weight of the barge). About 1965, 200-foot hopper barges began to be built. In 1969, the AWO estimated the number of tugs and towboats at 4,300 and the number of barges at 18,400; today, those numbers are about 5,800 and 31,000, respectively. During the past 30 years, waterway traffic has increased significantly between mile 3 and mile 427 on the Mobile, Black Warrior, and Tombigbee Waterways, as these data show. 35 Calendar Year 1960 1970 1980 1990 1992 Statement of Traffic 5,801,107 tons 11,132,650 tons 14,708,012 tons 21,949,000 tons 23,191,000 tons The Mobile District, USACE, Lock Utilization Report for the Demopolis, Alabama, Lock & Dam,36 mile 213.4, Tombigbee River, shows that the number of tows locking north and southbound, averaged 3,624 per year from 1983 through 1987 and 4,064 from 1988 through

1. In 1993, the last year for which figures are available, 4,056 tows used the lock.

The CSXT provided drawings and records that include references to two incidents involving the Big Bayou Canot bridge, one in 1927 and another in 1979. 37 A handwritten note dated January 27, 1927, on one drawing refers to the north pier of the through-plate girder span; it states that the bridge was "hit by boat and concrete cracked" but does not indicate the "boat" type or size. According to the records, concrete on the north pier and pier cap had been damaged; a crack under the east bearing support extended about 5 feet below the pier cap through the full thickness of the cap, which was subsequently repaired. 35Waterborne Commerce of the United States, Part 2, Gulf Coast, Mississippi River System and Antilles. Published annually by the U.S. Army Corps ofEngineers, Navigation Data Center, Waterborne Commerce Statistics Center, New Orleans, Louisiana. The 1992 data was published in January 1994. 36Mobile District, USACE, reports usage on this lock because most of the river traffic on the Black Warrior and Tombigbee Waterways passes through it. 37Neither the FRA nor the Coast Guard has a record of the 1927 or 1979 incidents, and the Coast Guard had not received any complaints about the Big Bayou Canot bridge from mariners. 39

Two repair plans were prepared for the bridge in 1979. The first, dated October 5, 1979, was for repairs to the concrete cap of the south pier on both the east and west ends (upstream and downstream) of the through-plate girder span. The repairs included reconstruction of the top of the south pier cap. A retired Louisville & Nashville Railway (L&N) bridge engineer told the Safety Board that he went to Mobile in 1979 to inspect a bridge at Escambia Bay that had been damaged as a result of Hurricane Frederic. Following that inspection, he traveled, at the local bridge supervisor's request, to the Big Bayou Canot bridge, where the supervisor proposed to repair the concrete on the south pier of the through-plate girder span. The engineer said that these repairs were part of routine maintenance. The second plan, dated November 1, 1979, was for replacement of five steel stiffener angles, five fill plates, and two splice plates and for straightening of the web and two other steel stiffener angles on the north end of the east girder's east (downstream) side. This plan indicated that the span had been "struck" but did not state what had struck it. Two L&N memorandums, one dated October 4, 1979, and one dated November 5, 1979, attribute the damage to the span's north end to barge strikes. The damage did not affect the serviceability of the bridge and did not disrupt rail traffic. NOAA reported that Hurricane Frederic, a category 3 hurricane, came inland near Mobile along the Mississippi-Alabama State line on September 12, 1979. According to the Saf- fir-Simpson hurricane scale, a category 3 hurricane has winds of 111 to 130 mph, a storm surge of 9 to 12 feet above normal, and serious coastal flooding. It blows down large trees and results in floating debris that batters larger structures; terrain lower than 5 feet above sea level may be flooded inland 8 miles or more. Frederic was the most serious hurricane thus far in this century to affect the Mobile, Alabama, and Pascagoula, Mississippi, area. The highest reported wind was a gust of 144 mph on Dauphin Island bridge, about 40 miles south of Big Bayou Canot at the mouth of Mobile Bay. As recently as 1986, commercial vessels navigated in the bayou between the Mobile River and the bridge to fleet (moor barges along a riverbank) and to tie off. 38 If barges were moored in the bayou during Hurricane Frederic, one or more may have broken loose from the mooring and struck the bridge. Large, water-borne debris may also have struck the bridge during this storm. The Safety Board believes that the damage to the north end of the span, which was discussed in the November 1, 1979, repair plans, was probably due to a barge strike that may have occurred as a result of high water and winds generated during Hurricane Frederic. American Railway Engineering Association (AREA) standards recommend that bridges be designed for the combined effects of dead load, live load, impact load, wind load, centrifugal load, other lateral loads, and longitudinal loads. Railroad bridges, like highway bridges, are designed to withstand lateral loads resulting from wind, stream flow, and, depending on the site, 38The USACE has not issued any permits for permanent fleeting facilities in the Big Bayou Canot, and the Coast Guard was unaware of any commercial navigation there until the accident occurred. W&GN applied for a fleeting permit in 1981 but subsequently withdrew the application. 40

ice and drift, but not the extreme lateral loads generated by events such as barge collisions. 39 The Big Bayou Canot bridge was designed in accordance with the standards in effect when it was built, and a recent structural analysis by CSXT showed that it conformed with current AREA standards. However, the bridge was not designed to resist loads from a vessel collision. The mass of the piers provided inherent lateral resistance to lateral loads from the collision. However, the bearing supports of the through-plate girder span provided comparatively little lateral resistance to movement due to a vessel collision, and the span's low vertical clearance made the structure vulnerable to severe damage. Track and bridge alignmentprotection. --Although the collision of the MAUVILLA with the Big Bayou Canot bridge moved the south end of the structure horizontally about 38 inches out of alignment, the rails remained intact. Track wayside signal circuitry is dependent upon the continuity of the rails. Had the rail broken as a result of the collision and subsequent displacement of the bridge and track, the signal at Bayou Sara railroad bridge, about 1.7 miles from the accident site, would have displayed a red or "stop" aspect. Because the rails remained intact and rail continuity was maintained, the signal circuitry was not interrupted. The signal displayed for train 2 on the night of the accident was clear or "proceed," as the assistant conductor confirmed when he said he heard the locomotive crew call the signal over the radio. According to tests performed after the accident, the signal system operated as designed. The Safety Board first addressed the issue of bridge alignment protection after a Union Pacific freight train, traveling westbound at 50 mph, struck a displaced bridge at Devil's Slide, Utah, on November 17, 1979, derailing 5 locomotive units and 56 cars. Damage estimates exceeded $5 million. As a result of its investigation of that accident, the Safety Board issued Safety Recommendation R-80-36, asking the FRA to study "the feasibility of installing a mechanism which can be incorporated in the automatic block system to indicate when bridges are displaced." On May 6, 1981, the FRA responded, noting that the 98,000 route-miles of track currently within block signal territory in the continental United States contain some 85,000 bridges. The cost of installing a mechanism to detect bridge displacement on each of those 85,000 bridges would be about $850 million, according to the FRA, and maintenance costs would total an additional $85 million per year. The FRA also stated that of the 41,627 railroad accidents that occurred between 1976 and 1979, only 20 were caused by displaced bridges or bridges that failed under load. Of those 20, four resulted from misalignments that could have been detected by the recommended mechanism. The FRA weighed the cost against the number of accidents and concluded that projected costs far outweighed the benefits. In its August 1981 reply to the FRA, the Safety Board noted the FRA's comments concerning installation and maintenance costs for such a mechanism. The Safety Board also stated that these costs, an average of $10,000 to install and $1,000 to maintain annually, were excessive and asked for a copy of the FRA's analysis. The FRA did not respond to the Safety 39Railroad bridges are also designed to resist the lateral loads resulting from nosing, which is the horizontal thrust that a wheel flange can deliver to the rail. 41

Board's request. On April 30, 1984, the FRA stated that it had reviewed railroad accident data from 1980 through 1982 and found only six accidents involving bridges, most of which were due to overloading, weakened support systems, or both. None were caused by misalignment that could have been detected by an automatic device. On February 25, 1985, the Safety Board classified Safety Recommendation R-80-36 "Closed--Acceptable Action." The FRA had done the feasibility study that the Safety Board requested. The Safety Board urged the FRA to review periodically the merit of this safety recommendation in light of advances in signal technology, and the FRA agreed to do so. Since January 1982, the FRA has received reports of five other incidents, including the Mobile accident, in which derailments occurred as a result of displaced bridges. Four of the five were caused by trucks, which damaged bridges, displacing the track ahead of a train. According to the FRA, the railroad industry has not adopted a standard system for detection of bridge misalignment. Some carriers have designed site-specific detection devices for bridges vulnerable to damage from impact or rail displacement. The devices comprise commonly available components, combined to meet the unique requirements ofeach structure, and typically transmit an alarm indication through the wayside signal system. In an October 1993 Safety Board telephone survey, five major railroad signal suppliers stated that no mechanisms or devices have been designed to detect bridge misalignment on signal or nonsignal track. They indicated development costs would be high and would require extensive research. The Safety Board has observed demonstration projects of such devices (as yet untested by the railroads), and the results concerning their effectiveness have been inconclusive. Whether such a device is needed and, if so, what level of resources should be devoted to developing one are important questions. The FRA is evaluating the need for bridge alignment protection and assessing the availability of new technology that can be used in this effort. Bridge lighting protection.--Before 1967, the USACE regulated bridges over navigable waterways of the United States. In 1967, these functions were transferred to the Coast Guard. The USACE had not issued a permit for the Big Bayou Canot railroad bridge, and a Coast Guard administrative decision exempted all existing bridges for which a permit had not been issued from having to have one.40 Moreover, the Big Bayou Canot bridge was in the "advance 4°The term "permit" refers to the license that allows construction ofbridges and approaches in or over navigable waters of the United States. Title 33 CFR 114-118, which sets forth the licensing regulations, states: "The decision as to whether a bridge permit. ..regulation will be issued... must rest primarily upon the effect of the proposed action" on "the reasonable needs of navigation after full consideration of the effect of the proposed action on the human environment." The law requires that plans submitted with permit applications show the least clear height of the lowest part of the superstructure over navigation openings; only structural details necessary to illustrate the effect of the proposed structure on navigation have to be provided. Additional factors that must be considered include Federal and State environmental issues, comparison with existing bridges over the waterway, and the attitude of local authorities. 42

approval" construction category and normally would not have to obtain a permit because it spanned a waterway not usually used for commercial navigation. According to Coast Guard testimony: There was never a permit issued to this bridge. Our indication was that it was built in 1909, but it might have been before that based on the testimony we've heard. And there hasn't been one required since that time, because it was grandfathered in when we took the program over. While bridges over waterways in the advance approval category do not require a permit, they are subject to the regulations for lighting and marking. Nonetheless, "the Coast Guard may exempt bridges over waterways with no significant nighttime navigation from lighting and other signal requirements. "41 The owner is responsible for the cost of installing and maintaining such devices. Neither the USACE nor the Coast Guard required that the Big Bayou Canot railroad bridge be lighted, and CSXT did not do so. On March 15, 1994, the Coast Guard Research and Development Center, Groton, Connecticut, analyzed the detection range of bridge hazard lights. According to the Coast Guard's data, if visibility is 200 feet, a hazard light is not detectable until a mariner is 400 feet from it; if visibility is 100 feet, the detection range is 236 feet. At the time of the accident, visibility was about 200 feet. Therefore, the MAUVILLA's pilot, in a pilothouse that was more than 400 feet from the head of the tow, probably would not have detected a hazard light, if one had been installed on the railroad bridge. Had the deckhand been on the head of the tow to guide the pilot, as is the usual practice when approaching an object to tie up to, he might have detected the lights in time to avoid hitting the bridge. However, the MAUVILLA's pilot, concerned about the deckhand's safety in the dense fog, had ordered him back to the towboat. On November 30, 1993, the Coast Guard required CSXT to mark the Big Bayou Canot railroad bridge with permanent lighting by April 30, 1994 (CSXT did so on April 27, 1994), citing the following reasons: The bridge site on Big Bayou Canot is in close proximity to the Mobile River, which has a deep and wide channel heavily utilized by commercial traffic. The bridge crosses Big Bayou Canot, a tributary of the Mobile River, which has a natural channel like the Mobile River. There are few natural landmarks that allow mariners to visually distinguish between this waterway and the Mobile River. 41Commander, Eighth Coast Guard District, New Orleans, Louisiana, letter file 5800, November 17, 1993. An application to construct a bridge includes a description of proposed lighting and other signals. Even if the Coast Guard approves the markings as proposed and requires no modifications or additions, it may alter the requirements for display of lights and other signals after construction when local conditions warrant such changes. 43

There are no obstructions or other hindrances to navigation between the Mobile River Channel and the bridge site, thereby allowing commercial vessels access to the bridge site. The geography of Bayou Sara, Big Bayou Canot, and the Mobile River in the vicinity of the CSX Railroad Bridge is similar enough that in periods of reduced visibility or at nighttime, mariners could become disoriented without additional visual aids. Vessels transiting the Mobile River may enter Big Bayou Canot in error, particularly at nighttime or during periods of limited visibility. WatelWay bridge protection.--The Coast Guard decides what type(s) of navigation aids will be placed in waterways. Through surveys under the Waterways Analysis and Management System (WAMS), the Coast Guard determines whether current aids are sufficient or changes are necessary. The last WAMS on the Black Warrior/Tombigbee/Mobile River System, completed in January 1988, revealed few problems with navigational aids. The Coast Guard also conducts daytime and nighttime patrols of waterways and meets with waterway users every 2 months. Towboat operators are usually the first to call attention to a problem with a navigation aid or lack of one. Neither towboat operators nor companies had complained to the Coast Guard about the Big Bayou Canot bridge before the accident. No warning sign(s), waterway markings, or aids to navigation had been placed in the Big Bayou Canot indicating the presence of a railroad bridge across the waterway before the accident. In November 1993, the Coast Guard installed two standard, all-waterways warning markers, one on each side of the Big Bayou Canot about 700 yards from the bridge, or 350 yards from the Mobile River. 42 The markers' range of visibility is 1 mile in daylight and clear weather, although vessels have to be much closer for observers to read the warning; visibility in fog is a function of the density of the fog and the distance of the observer. The signs were lighted on May 4, 1994, and should therefore be more useful during periods of reduced visibility. The Coast Guard will maintain them. On January 24, 1994, Coast Guard Headquarters initiated a survey of bridges across navigable waters that is being conducted by all Coast Guard districts. 43 The purpose of the survey is to assess the effectiveness of navigation aids in approaches to bridges over navigable waters, as well as the need for additional bridge protection measures, including lighting and fendering systems. The survey extends to those tributaries and waterways used as fleeting areas or sufficiently deep and wide to allow commercial vessels access to a bridge; the approaches to 42The signs, which meet the requirements ofthe Coast Guard's Aids to Navigation Technical Manual, are 3-foot by 3-foot white diamonds, with a 2-inch orange retroreflective border; the word DANGER in 6-inch black letters is in the center, with FIXED above and BRIDGE below in 3-inch black letters. 43Commandant Notice 16590, January 24, 1994, subject: Survey of Bridges Across Navigable Waters of the United States. 44

the Big Bayou Canot railroad bridge are examples of such waterways. In the first 6 months, district personnel will consider various safety issues, including lighting and fendering systems on bridges over waterways used by commercial vessels. Then, district staff will evaluate the need for fendering and lighting on each bridge and follow up with bridge owners to ensure timely and appropriate corrective action. Coast Guard Headquarters will receive and maintain on file reports describing the actions required by the districts and taken by bridge owners. Headquarters did not provide the districts with uniform, objective criteria to use in conducting the survey. The Safety Board is therefore concerned that the district staff evaluations will be subjective, when what is needed is a set of objective criteria against which to evaluate bridges over navigable waterways nationwide. Nonetheless, the Coast Guard survey is long overdue. It should be part of an ongoing process, not a one-time effort. Comprehensive bridge risk assessment.--The Big Bayou Canot railroad bridge, like thousands of other railroad and highway bridges in the United States, is vulnerable to marine vessel collisions. Vessels commonly strike bridges, but because most of these collisions are minor, they go unreported. They generally do not result in damage to the bridge or the vessel and do not meet criteria for reporting an incident to the Coast Guard or the FRA. Nonetheless, the Safety Board has been notified of 21 significant marine vessel collisions with highway and railroad bridges since the accident at Big Bayou Canot occurred. CSXT alone has 11,000 railroad bridges in service (1.7 million linear feet; CSXT classifies as a bridge any span more than 48 inches long). The Safety Board examined CSXT records of bridge strikes for the 4- month period from December 2, 1993, to April 4, 1994, and found that of 48 incidents, only one met the threshold for reporting to the Coast Guard or the FRA. 44 Although no significant commercial traffic uses the Big Bayou Canot, the railroad bridge over the bayou is at some risk because it is adjacent to a commercially navigable waterway. Risk from marine vessel collisions is probably greater to bridges that span such waterways than to those located near them. The Mobile River bridge, for example, about 3 miles north of the Big Bayou Canot railroad bridge, is 1,846 feet long and consists of an 80-foot through-girder span, three 210-foot through trusses, a 340-foot through-truss swing span, and a 796-foot timber trestle. It is equipped with navigation lights and pier fender protection (which meet local Coast Guard standards) only near the swing span, where marine traffic passes through the swing span, and is manned 24 hours a day by a bridge tender whose job is to open and close the swing 44Title 46 CFR 4.05 requires that marine casualties be reported as soon as possible to the nearest Coast Guard Marine Safety or Marine Inspection Office and in writing within 5 days. One reporting criterion is damage to property that exceeds $25,000. On December 10, 1993, the Secretary of Transportation reported that the Coast Guard will initiate rulemaking, expected to be published in midsummer 1994, requiring that casualties be reported immediately and that a notice of a hazardous condition include vessel collisions with a bridge, shore structure, or other stationary object. In addition, the Coast Guard will seek to increase, through legislation, the maximum civil penalty for failing to report a marine casualty from $1,000 to $25,000. Title 49 CFR Part 225 requires that any accident involving a train collision or derailment be reported to the FRA if the damage is $6,300 or more. FRA policy is to investigate accidents resulting in the death of a railroad employee or passenger or in five or more injuries; such accidents must be reported to the agency immediately by telephone. 45

bridge for marine and rail traffic. However, the Mobile River bridge has no lights or pier protection on the approach spans. In reduced visibility, a bridge tender at the swing span could have difficulty detecting a problem on the approach spans. Because of its greater exposure to river traffic, the Mobile River bridge is more likely to be the site of a catastrophic barge collision than the Big Bayou Canot bridge. The former could have sustained an accident similar to the one at the latter, and in fact, barges have hit the Mobile River bridge three times in the 6-month period from December 1993 through May 1994. While bridge strikes are fairly common, comprehensive tracking of their occurrence and systematic evaluation of bridge vulnerability to vessel collision are lacking. Ensuring that appropriate protective measures are provided for bridges such as the one over the Big Bayou Canot is an issue that requires a coordinated national effort. This accident emphasizes the need for such an undertaking to avoid similar mishaps. The actions taken to protect the Big Bayou Canot railroad bridge, however laudable, may not be sufficient to prevent a similar incident, and the degree to which thousands of other bridges are at risk is unknown. Determining which protective method or combination of methods is appropriate depends on the vulnerability of each structure and thus should be preceded by a comprehensive risk analysis, which will make possible a rank ordering of bridges in need of protection. The accident in Mobile occurred only a few months after another serious vessel collision and bridge collapse that the Safety Board investigated. 45 These incidents underscore the urgent need to develop a comprehensive risk assessment methodology for bridges and to ensure that it is uniformly applied to all bridges in the United States. The term "risk," according to a previous Safety Board study, refers to the probability of an event occurring and the consequences of the occurrence. 46 Risk assessment is the process by which risks are identified, quantified, qualified, analyzed, and presented; it combines these variables into a single measure of risk, thereby allowing a comparison and ranking of the factors being analyzed. Risk management uses the results of this analysis to reduce risk to an "accept- able level" and can be applied to any bridge in the Nation, including the one that spans the Big Bayou Canot. The operational factors for each bridge in the United States are unique and should determine the type of protection provided for each structure. Protection from vessel collision can be provided in several ways. New bridges can be built with large vertical and horizontal clearances. In the case of existing bridges that cannot be moved or replaced, other measures are available to minimize risk. They include changes to the channel or aids to navigation such as signs, buoys, retroreflective material on the structure, 45Highway-Marine Accident Report--U.S. Towboat CHRIS Collision with the Judge William Seeber Bridge, New Orleans, Louisiana, May 28, 1993 (NTSB/HAR-94/03). 46Special Study--Protection of Transportation Facilities Against Earthquakes, (NTSB/STS-72/01). 46

bridge lighting, radar reflectors, radar beacons (RACONS),47 and fog signals. 48 Islands, caissons, dolphins, and fenders are also means of affording protection. Manually activated traffic control devices, alignment or movement detection systems, and clear bridge identification to facilitate the notification process are all measures that can reduce loss of life or property in the event of an accident. The Safety Board believes that the DOT should consider the use ofRACONS, radar reflectors, and other devices to make bridges more identifiable on radar. Bridges for which the chance of a catastrophic accident is highest should receive the greatest protection. A railroad bridge that carries numerous passenger trains, hazardous material loads, or both across a waterway merits more attention than a bridge over the same waterway that does not. Similarly, a bridge that spans a waterway with traffic of 200 barges a day is at greater risk than one that spans a waterway carrying 5 barges a day. The location of a bridge is another consideration. A railroad bridge upstream of the Big Bayou Canot bridge, for example, would be exposed to less risk from marine vessel collision because vessels would have to pass under the Big Bayou Canot structure first. Several factors, including the volume of railroad traffic, numbers of passenger and hazardous material trains, proximity to commercial navigation channels, and volume of marine traffic, should be considered when assessing the vulnerability of railroad bridges to collisions from marine vessels. Only when the vulnerability of a bridge has been adequately assessed can an informed decision be made on the appropriate type of protection. The assessment method should allow vulnerability to vessel collision among bridges to be compared so that priorities for protective measures can be assigned. Highway bridges are also at risk from vessel collisions, as the collapse of the Judge William Seeber Bridge in New Orleans, Louisiana, on May 28, 1993, demonstrated. The Safety Board discussed the factors that must be considered in conducting a risk assessment of highway bridges in its report on that accident. Among those factors are daily vehicle traffic over the bridge and the structure's importance to the local economy. The Safety Board reviewed various State and other programs that affect bridge safety through design, construction, inspection, maintenance, and regulatory oversight. Navigation safety, including the granting of bridge permits, is the responsibility of the Coast Guard. The USACE maintains navigation channels. The FHWA and the States oversee regulatory requirements relating to design standards for new highway bridges and vulnerability of highway bridges to vessel collisions. FRA regulations for railroad bridges are limited to protecting personnel who are doing work on bridges. Responsibility for railroad bridges rests with the individual railroads, which use the AREA's Manual ofRecommended Practice for the design, 47When triggered by a vessel's radar signal, RACONS transmit a coded reply display on the vessel's radarscope and provide the approximate range and bearing to the beacon. 48As provided at 33 CFR 118, Coast Guard District Commanders can require such items for bridges. Often they are not required, especially on bridges in the advance approval category, until the maritime industry, having experienced problems with a structure, requests a change in existing protective measures from the Coast Guard. Until an accident occurs, whatever protective measures are in place are considered adequate. 47

construction, inspection, and maintenance of bridges, together with their own specifications, as dictated by the nature of their operations. The following section provides an overview of some initiatives affecting new and existing bridges. The Safety Board is aware of two States that have a risk assessment methodology for bridges to ensure a thorough and systematic analysis of highway bridge vulnerability. The California Transportation Department (CALTRANS) has developed a program to prioritize more than 24,000 highway bridges in the State for seismic retrofit upgrading; CALTRANS adjusted its risk analysis procedure over a 3-year period, as more information became available. 49 New York State bridge engineers developed a "safety assurance" program50 that the Safety Board also examined. Under this program, a review of previous failures, imminent failures, and actual closures provides the basis for identifying probable causes and modes of bridge failures. Using a rating system based on considerations such as site and structural characteristics, engineers categorize and rank structures according to their vulnerability to various failure modes. They also formulate strategies to reduce or eliminate vulnerability over the short and long term. To evaluate vulnerability to vessel collisions, the New York program reviews factors such as barge traffic, accident history, and structural continuity. It also categorizes bridges over waterways according to type--navigable, nonnavigable, and the State canal. Since bridges may be vulnerable to more than one extreme event, vulnerability is analyzed according to a structure's rank in each failure mode. As circumstances change, for example, if waterway traffic increases or corrective action is implemented, each risk is reevaluated. The last phase under the program is implementation of actions recommended to reduce the bridge's vulnerability. In 1991, the American Association of State Highway and Transportation Officials (AASHTO) published a Vessel Collision Guide, and the FHWA has recommended its use for design of highway bridges. The specifications embody new concepts not included in previous design guidelines. They focus on vessel collisions with piers and also cover superstructure above-water clearances and vessel impact potential, albeit by ship masts. To identify bridges that must continue to function after impact from a design vessel,51 the guide recommends classifying bridges as either "critical" or "regular" using social-survival and security-defense requirements as criteria. It also discusses several analytical methods for selecting a design vessel, and it recommends probability-based risk analysis because that method requires the least number of judgment calls by the analyst. Current provisions do not address assessment of the highway 49James E. Roberts, "Practical Lessons From the Lorna Prieta Earthquake-Highway Bridges," paper presented at the American Association of State Highway and Transportation Officials (AASHTO) Bridge Conference, Denver, Colorado, May 1993. 50A.M.Shirole, "Planning for a Comprehensive Bridge Safety Assurance Program," paper presented at the March 1991 Bridge Engineering Conference sponsored by the Transportation Research Board and the FHWA, Denver, Colorado. 5lThe design vessel that has the minimum impact requirement is an empty drifting barge. 48

bridge and surrounding area as a whole to identify factors that make a structure vulnerable to vessel collisions. Although the AREA's Manual for Recommended Practice does not prescribe guidelines for extreme events, such as vessel or vehicle collision, it does recognize the effects on the substructure by allowing for pier protection, additional reinforcement, collision walls, or an increase in mass to provide overturning resistance. Because the AREA manual does not provide guidelines for performing a risk assessment of new or existing railroad bridges, the Safety Board contacted several class 1 railroads concerning their methods of performing a risk assessment on bridges that may be vulnerable to being struck by maritime or surface equipment. 52 Each railroad stated that it maintains the accident history for bridge impacts with the file for that structure. Not all impacts are reported; some are discovered during the inspection process. The railroads indicated that they do not record information for data base-type retrieval. Most bridge engineers recalled only major collisions that required either bridge replacement or substantial repairs. They estimated that fewer than three such incidents occur a year, accounting for less than 1 per cent of total impacts. These events generally involve either movable spans over navigable streams that are struck by a vessel, resulting in major repairs to the structure, or spans that are struck by highway vehicles, resulting in a train derailment due to track misalignment. The railroads stated that annual inspections of the superstructure and periodic underwater inspections are the basis for determining whether changes to a bridge are necessary. None of the carriers said they had a formal risk assessment plan. Those structures that require more than routine maintenance are reviewed by bridge engineers, using their engineering judgment and taking into account railroad traffic projections, economics, increased loading, and estimated remaining life (fatigue evaluation). Extreme events such as floods; slides; and impact from ice, debris, and collision are considered, in accordance with regulations and design standards. Evaluation of each structure is site-specific for location and previous accident history. On April 1, 1994, the AREA adopted new guidelines for seismic design of railway structures. The guidelines were specifically developed to reduce structural damage from earthquakes, and they integrate seismic criteria into railroad bridge design, maintenance, and retrofit for the first time. The AREA stated that the major reason for developing these guidelines was that railroad bridges have historically performed well in seismic events, sustaining little or no damage. The AREA noted three important factors: (1) "the bridges are traversed by a track structure that functions very effectively as a restraint against longitudinal and lateral movements during an earthquake"; (2) "railroad bridges are typically very simple in their design and construction"; and (3) "the types of damages that are permissible for railroad bridges are completely different from highway and other bridges that are used by the public in an environment far less controllable than the movement of trains. " 52The carriers contacted were the Canadian National Railroad, the Atchison, Topeka & Santa Fe Railway Company, the Consolidated Rail Corporation, the Chicago and North Western Railroad, and the Illinois Central Railroad. 49

Lacking a coordinated national bridge risk assessment program, bridge owners have implemented their own risk assessment programs, either formally or informally. In the absence of a comprehensive risk assessment methodology, standards to judge the adequacy of such programs are not available. No single entity is responsible for the safety of the Nation's bridges. Federal, State, and local governments, as well as private industry, share that responsibility, and such fragmentation of authority often leads to a piecemeal, uneven approach to bridge safety. What's more, bridge safety involves several transportation modes, including marine, railroad, and highway; and several Federal agencies, including the Coast Guard, the FRA, the FHWA, and the USACE, have a role in oversight of these modes. The Safety Board concludes that development of a national risk assessment program for determining bridge vulnerability to vessel collision is needed and believes that the DOT modal agencies should develop one. The Safety Board further concludes that the transportation regulatory agencies need a standard methodology for determining the vulnerability of the Nation's highway and railroad bridges to collisions from marine vessels, for formulating a ranking system to identify those bridges at greatest risk, and for providing guidance on the effectiveness and appropriateness of protective measures. The Safety Board believes that the DOT should convene an intermodal task force for this purpose. At a minimum, the methodology should address the highway bridge factors discussed in the Safety Board's report on the collapse of the Judge Seeber Bridge and the railroad bridge factors discussed in this report. It should include a ranking system that will identify bridges at greatest risk so that protective measures can be prioritized. In addition, it should provide guid- ance on the effectiveness and appropriateness of protective measures such as warning signs, lighting, navigation markers, alignment detectors, pier protection, dolphins, caissons, and radar beacons. As the DOT agency that regulates the railroad industry, the FRA should maintain close contact with all railroad companies and with the AAR and the American Short Line Railroad Association (ASLRA), which represent the owners of the majority of the Nation's railroad bridges. The FRA should work with the AAR and the ASLRA on matters pertaining to railroad bridge safety. The Safety Board believes that in the absence of a single entity charged with oversight of all u.S. bridges, the FRA is the appropriate agency to assume responsibility for railroad bridge safety and should require that all railroad bridges be included in a national risk assessment program that employs the comprehensive risk assessment methodology developed by the DOT. While the DOT is developing a national risk assessment methodology, the AAR and the ASLRA should independently initiate certain activities. They should immediately begin to collect data on vessel collisions with railroad bridges from their members. By doing so, the information needed to understand the bridge collision problem and to develop an effective national risk assessment program will be available to the DOT early in its methodology development process. Data on bridge-vessel collisions may also be helpful in identifying the types of bridges that should be included in the risk assessment, as well as those bridges that are especially vulnerable to collisions and thus require immediate protective action by the railroads, the Coast Guard, or other agencies. The Safety Board believes that the AAR and the ASLRA should immediately 50

begin to collect such data from their members and, if appropriate, take steps to increase protection for bridges identified as vulnerable. The railroad industry must also fully cooperate with the DOT to determine the appropriateness of each bridge protection system and the actual level of protection and risk reduction that each protective method provides. The interests of bridge safety are not served by the railroad industry standing by while the DOT devises a national bridge risk assessment methodology. The Safety Board believes that the AAR and the ASLRA should cooperate with the DOT in developing a national risk assessment program for railroad bridges. The Safety Board also believes that the Nation's highway bridges should be included in this process. Since no single entity has oversight of all U.S. bridges, the FHWA is the appropriate agency to assume responsibility for highway bridge safety and should require that all highway bridges be included in a national risk assessment program that employs the methodology developed by the DOT. Emergency Response Several circumstances hampered emergency response efforts. The accident site was remote, accessible only by rail, water, or air; fog in the area was dense, requiring the use of radar to navigate boats; limited modes of transportation were available for bringing in personnel and equipment; and the magnitude of the accident was great. Nonetheless, following a delay while responders identified the location of the accident, emergency response activities were efficient and effective. The Mobile Police Department's 911 operator, who contacted the Mobile Fire Depart- ment about 3:02 a.m., had been told that the accident occurred at the Bayou Sara bridge and the Mobile River instead of the Big Bayou Canot,53 about 1 1/2 miles away. Some 18 minutes elapsed as police and fire departments and CSXT personnel determined the location and jurisdiction of the accident. Units from the Mobile Fire Department, which was prepared to respond regardless of the jurisdiction, were dispatched at 3:20 a.m. After emergency responders arrived at the accident site, they began rescue operations, recovery ofbodies, triage, and firefighting activities. The Coast Guard on-scene commander pro- vided assistance and resources, including planes, helicopters, boats, and manpower, throughout the emergency. The MAUVILLA's crew, SCOTT PRIDE personnel, train crewmembers, and volunteers were all instrumental in rescuing people from the water and evacuating passengers from the train immediately following the accident. Once under way, these activities proceeded smoothly and in a timely manner. The Safety Board concludes that, overall, the emergency response was well-coordinated and effective. S3The Mobile Fire Department's map, which has since been replaced, did not even show the Big Bayou Canot due to an omission during photocopying. 51

However, Amtrak's portable emergency lighting measures, its safety briefing procedures, and its method for compiling passenger lists all need to be improved, as do State emergency drills involving railroad operations. Portable Emergency Lighting According to passengers in coach 34040, which remained on the bridge, darkness prevailed outside the car after the derailment. Battery-powered emergency lighting, available inside the coach, provided some illumination, but only the traincrew had flashlights, which were not part of Amtrak's emergency equipment. A few passengers had penlights to use while walking down the tracks in the dark. The Safety Board concludes that because Amtrak did not equip its passenger cars with portable lighting, passengers were at a disadvantage in evacuating the train. The Safety Board believes train 2 should have been equipped with portable lighting for use by passengers in an emergency. Passengers reported that once cars entered the water, emergency lighting became inoperable, further complicating evacuation from the submerged cars. 54 Without light from a few penlights and from the fire that ensued following the accident, no light would have been available to passengers in these cars. Because emergency lighting was unavailable in the submerged cars, passengers had difficulty locating and moving to exits in the dark. The Safety Board is unable to determine whether emergency lighting, if operable, would have been effective in the muddy water. Safety Briefings Amtrak uses signs and placards, as well as briefings, to inform passengers about the safety features on its trains. This accident casts doubt on the effectiveness of Amtrak's briefing system for communicating such information. Signs in Amtrak cars indicate the location of first-aid kits, fire extinguishers, and emergency windows; signs on the ceilings adjacent to emergency windows are phosphorescent. Each emergency window has signs explaining how to remove it from both the inside and the outside. Signs posted in the car vestibules and elsewhere throughout the cars also give instructions about window removal. 55 Some passengers on train 2 reported having noticed the signs on the emergency windows. 54According to Amtrak, each car had about 15 receptacles, equipped with IS-watt bulbs, in the ceiling, as well as emergency lighting at the ends, the exit signs, and down the stairs. Amtrak noted that possible reasons for the emergency lighting failing in this accident include impact damage to the batteries or cables connecting the batteries to the cars, impact damage to the light fixtures, and water damage to the circuits and fixtures. 55Placards, approximately 17 by 22 inches, at the end of each car read as follows: "Attention Passengers. Emergency Instructions. Each car is equipped with a minimum of 4 marked emergency window exits in addition to the marked emergency door exits. Emergency equipment is also provided." The "Emergency Window Removal" instructions state: "Locate red plastic handle on window. Use red handle to strip away rubber molding. Locate metal handle on window and pull towards you to remove window pane. " 52

Amtrak has provided written guidelines on safety briefings in two employee publications. The General Rules/Manuals of Service Instructions for On Board Service Employees state: All train attendants are responsible for including the following information as part of their routine passenger orientation: o That they have received special training in handling unusual or emergency situations and are prepared to assist in the event of such occurrence. o That passengers should notify their attendant immediately if they become aware of any emergency on the train. o That they are available for passengers' questions about procedures and locations of exit doors, emergency windows in their cars and fire extinguishers. According to the "Guidelines for Effective Announcements" in Amtrak's Manual ofInstruction for Transportation Department Employees, conductors are required to make the following announcement during departures from all stations: Please observe in the seat pocket in front of you or on the bulkhead at each end of your car, an Emergency Exit Instruction Card. Please take a moment to read the procedures for emergency door and window exit instructions. Thus, both OBS personnel and conductors have responsibility for safety briefings on Amtrak trains. Amtrak's written guidelines do not further delineate their duties in this area. Train 2's assistant conductor testified that he usually reinforces the safety briefings provided by the OBS supervisor. The lead service attendant said he believed that he heard a safety briefing over the public address system, and two passengers indicated that because of information provided by the traincrew, they knew the location of emergency exits. Several passengers did not recall hearing a safety briefing by anyone during their trip from Los Angeles to Mobile. If safety briefings were provided in all sections of the train, they were not effective because some passengers reported that they did not receive the information. Moreover, while Amtrak's manuals state that such briefings are to be routinely given at all stations, an Amtrak official testified that the briefings are to be provided at the beginning of a trip and at major stops, noting that a "major stop" has not been defined. He added, "You want to have enough announcements that are informative but not so many that it becomes a burden. . .so it varies by route and type of service." Los Angeles might reasonably be considered a major stop; however, some passengers boarding there said they were not given a safety briefing. They believed that such a briefing would have helped them evacuate the train quickly. 56 56The conductor on train 2 in Los Angeles is no longer employed by Amtrak; despite repeated attempts, investigators were unable to contact him after the accident to ask him whether he had given a safety briefing. 53

After the accident, several passengers said they did not recall hearing a safety briefing when they boarded the train. One passenger provided the following account: My mother-in-law [had] asked us did we know where the emergency exit was. H was at her seat. . .I woke up as the train started derailing...water began rushing in then we went straight to the emergency exit. We only had a few seconds because it was sinking fast. 1don't remember seeing any other passengers besides the three of us and our actions were to escape from the car through the emergency window...only because [my mother-in-law] asked before we left New Orleans. We didn't have time to look...We just knew where it was and without question we were there. Another passenger stated, "The car filled with water so fast it was very dark...1 only wanted to find the door...1 did not know about any emergency exits...No one told me what to do in an emergency. . .1 got on in Los Angeles." A third passenger said he could not swim and that a fellow passenger helped him evacuate through an exit. He added, "Crewmembers must point out the emergency exits when passengers board the train...we boarded at 11 p.m. so even though 1 sat next to an exit, 1 didn't consciously notice it. " One passenger who helped several other passengers testified that this trip was his first one on Amtrak and that he did not recall hearing a safety briefing when he boarded in Los Angeles. A fellow passenger commented: "There needs to be emergency instructions provided by the crew (like the airlines). You don't think something like this will ever happen to you.. .so emergency instructions aren't that important. 1know emergency procedures for a plane from hearing it so many times. " Since most OBS crewmembers were asleep in the dorm-coach and since the train attendants were in the cars on the bridge, passengers in the submerged cars had to make decisions on their own and evacuate without assistance. The fact that at least some apparently had not received safety briefings added to the confusion. Fortunately, a few passengers took control of the situation, located exits, and told others what to do. Safety briefings give passengers confidence that they know what actions to take in the event of an emergency and thus help motivate them to respond appropriately. The Safety Board concludes that some passengers on board train 2 were unaware of safety information and that Amtrak does not have an effective system for apprising passengers of such information. Current written guidelines allow the OBS supervisor and train attendants to determine at which stations they will give briefings about emergency procedures, and the guidelines direct conductors to make an announcement about such procedures during departures from all stations. However, according to an Amtrak official, the conductor's announcement is required at the beginning of the trip, and either the conductor or OBS personnel are to give additional briefings at "major" stops, which have not been defined. The Safety Board believes Amtrak needs to develop and implement a uniform system to effectively apprise passengers of information pertaining to safety features. 54

Adequate Passenger Lists During rescue activities on the day of the accident, an Amtrak representative provided the incident commander with a partial passenger and crew list and told him that about 200 people were on board. A list compiled later the next day showed 207 people. The delay in providing an exact count caused problems because the incident commander had to assign personnel to spend a day counting tickets to help develop a passenger list. In addition, emergency responders did not know when to discontinue rescue operations because the count changed frequently. The railroad was not aware that three infants were on board because they were not ticketed. If . Amtrak had issued nonrevenue tickets for the infants, they would have been included on the passenger list. The Safety Board concludes that emergency responders were at a disadvantage because they were unable to obtain an adequate passenger and crew list from Amtrak until the next day. The Safety Board believes Amtrak needs to improve its passenger and crew count procedures so that accurate passenger lists can be furnished to local authorities with minimum delay. Event Recorder Crashworthiness Each locomotive unit was equipped with an event recorder. The lead locomotive unit (819) had a Pulse Electronics solid-state memory unit, and the two trailing locomotives (262 and 312) had Bach-Simpson paper-strip chart speed recorders. Locomotive 819's solid-state memory unit did not sustain significant damage due to impact, but large amounts of mud and water were found inside its enclosure, which was not watertight. Data for the period from 12:43 a.m. on September 22 until the time of the accident could not be recovered from 819's event recorder because of fluid immersion-induced corrosion, electrolysis of the power pins on some battery- backed memory devices, or both. The paper recording media from locomotives 262 and 312, although slightly damaged by moisture, were legible and provided time, speed, and distance data from New Orleans to the accident site. The data recovered from the paper recording media on the two trailing locomotive units indicated that the Sunset Limited's speed at the time of the derailment was about 72 mph. Because of the water damage to 819's Pulse Electronics unit, important data about the train's operation in the 2 hours preceding the derailment could not be recovered. When functioning properly, such a unit records the following information that is often vital to accident investigation: date and time, drive wheel rotations, traction motor current (load amps), automatic brake pressure, throttle position, horn (on/oft), cab signal acknowledgement (on/oft), pes OPEN (open/closed), independent and dynamic brakes (on/oft), and alerter and brake valve cutouts (on/oft). The Safety Board has investigated other accidents in which event recorder data were lost 55

as a result of fire or water damage. 57 The Safety Board believes that the loss of event recorder data during this accident is further evidence of the need to develop and implement crashworthy locomotive event recorders, and in 1993, the FRA issued a final rule on event recorders that acknowledges this need. 58 As indicated in the rule, because of the time required to develop crashworthy event recorders and equip trains with them, the FRA is seeking first to expeditiously equip locomotives on trains traveling at more than 30 mph with acceptable existing event recorders and then to proceed with crashworthiness and standardization issues. The Safety Board looks forward to helping the FRA and the railroad industry increase the likelihood that recorded data are available to support railroad accident investigations. Disaster Preparedness CSXT notification.--The owner of the Big Bayou Canot bridge, CSXT, did not have an up-to-date telephone listing of local authorities. The number for the Coast Guard in the Mobile telephone directory was incorrect. Consequently, the yardmaster was unsuccessful in his initial attempt to contact the Coast Guard and had to call the operator for assistance. On November 30, 1993, following its investigation of the July 31, 1991, train accident at Lugoff, South Carolina, the Safety Board recommended that CSXT: R-93-20 Maintain an up-to-date emergency response telephone list. On April 15, 1994, CSXT informed the Safety Board that it is preparing emergency contact notebooks that will provide emergency numbers for counties within each of its operating subdivisions. CSXT reported on June 24, 1994, that it has completed notebooks for all 15 of its subdivisions and noted that it is developing a program to computerize the information. Emergency drills. --Although the Mobile County Emergency Management Agency (MCEMA) held drills to simulate transportation accidents before this accident, those drills did not include simulations ofan accident involving railroad operations. In testimony, representatives from Amtrak, CSXT, Mobile County, and the Coast Guard said that they had never discussed the potential for an accident on the CSXT bridge. 57See, for example, Railroad Accident Report--Head-on Collision Between Burlington Northern RailroadFreight Trains 602 and 603 Near Ledger, Montana, on August 30, 1991 (NTSB/RAR-93/01); the Safety Board has also identified this issue in its investigation of the Kelso, Washington, collision between Burlington Northern train 01- 111-10 and Union Pacific train NPSEZ-09 on November 11, 1993 (report forthcoming). 580n July 8, 1993, the FRA published its final rule, which amends 49 CFR 218 and 229, Chapter II, Subtitle B. 56

The MCEMA had most recently conducted a drill, simulating an aircraft accident, on June 17, 1993, in Mobile Bay. The local police and fire departments, Coast Guard, Sheriff's Department, and other agencies involved in the September 22 Amtrak accident participated. Similar drills for accidents involving railroad operations would give participating agencies an opportunity to learn about their responsibilities and jurisdictions and to practice notification procedures, as well as methods of accounting for passengers and crew. The Safety Board concludes that if the MCEMA had held drills to simulate a train accident, the incident commander may have known about Amtrak's procedures for ticketing passengers, and CSXT may have had the correct telephone number for the Coast Guard. The Safety Board therefore recommends that the Federal Emergency Management Agency encourage local authorities to conduct emergency drills that simulate transportation accidents involving railroad operations. MCEMA critique ofemergency response.--In testimony, both the incident commander and the SAR controller discussed the emergency response to this accident. On September 28, 1993, the MCEMA conducted a critique of the emergency response that included representatives from many responding agencies. A synopsis of major suggestions and observations follows: o Because the Civil Air Patrol provided real-time television pictures to the MCEMA, the agency was able to monitor conditions at the accident site. o Agencies and volunteers shared their resources and helped transport equipment to the accident site. o Cellular phones were used to reduce radio communication problems and to limit battery use. o Had smaller boats been available to the Mobile Fire Department, it could have used them to transport personnel and equipment around the accident site. o Amtrak representatives had to show divers the layout of cars that remained on the bridge because they were not familiar with the train equipment. Since the accident, floor plans and a videotape describing Amtrak's emergency procedures have been provided to the Mobile Fire Department. A postaccident critique such as this one, especially when done in conjunction with periodic drills, is a valuable tool for identifying and implementing improvements in emergency response procedures. 57

Bridge Identification Emergency responders were delayed in identifying the location of the accident site because Big Bayou Canot bridge had no waterway mile marker or nameplate, thereby creating confusion and hindering marine response activities. When the captain of the MAUVILLA notified the Coast Guard Group Mobile that an accident had occurred, he was unable to identify the bridge; train 2's crew was unable to do so as well. Marine responders were uncertain which bridge was involved until about an hour after the accident. The MAUVILLA's captain and pilot thought they were near either the Bayou Sara railroad bridge (mile 8.2) or the Fourteen Mile railroad bridge (mile 13.3). At 3:20 a.m., the captain reported to the Group that he was north of Twelve Mile Island and, at 3:25 a.m., that the train had run off the Fourteen Mile bridge. Coast Guard radio traffic shows that the captain and pilot did not know until 3:55 a.m. that they were in the Big Bayou Canot (mile 9.7). Coast Guard, City of Mobile, and other vessels responded to the accident by heading up the Mobile River to the Bayou Sara railroad bridge. Upon arrival there, they realized the accident was at another location, and they continued upriver until they sighted the glow of flames on the Big Bayou Canot. This confusion about the accident location would have been eliminated had the bridge borne a marking that response centers could recognize. Not long after the accident at Mobile, another bridge striking occurred that posed a similar identification problem. At 9:55 a.m. on December 1, 1993, the towboat JENNIE DEHMER and its two-barge tow struck the Norfolk Southern Railroad bridge at mile 647.3, Tennessee River, in Knoxville, Tennessee, displacing the bridge pier 12 to 18 inches and the track 9 inches. The towboat operator on watch reported the accident at 10 a.m. to the Coast Guard Group Ohio Valley radio operator, giving the location as the Louisville and Nashville (L&N) Railroad bridge "just above the 647 point something or other [646.6], here in downtown Knoxville. " About 11:10 a.m., CSXT, which owns the L&N bridge, informed the Coast Guard that the bridge involved was in fact the Norfolk Southern Railroad bridge at mile 647.3. The dispatcher in Knoxville called about 11 :45 a.m. to advise the Coast Guard that someone looking out his office window had seen the accident and immediately called Norfolk Southern Railroad, which was able to prevent a train about 4 miles from the damaged bridge from crossing it. If bridges over waterways had some form of marking visible from both water and land, making identification simple and quick, confusion could be eliminated. Marking a bridge would help mariners and others readily identify it and advise emergency response personnel of the location, thereby facilitating notification of the bridge owner and proper authorities, who could control or stop bridge traffic. As the Mobile and Knoxville accidents demonstrate, prompt bridge identification is critical to ensure efficient movement ofresponse forces to the accident scene and to halt land traffic about to transit damaged structures. The Safety Board concludes that all bridges vulnerable to impact by commercial marine traffic should be required to have appropriate markings so that they can be identified promptly 58

from land and water in the event of an accident or other emergency. The Safety Board believes that the Coast Guard should require such markings and periodically publish a list of them as part of a national bridge register. Such an inventory should be available to emergency response organizations and, following publication, should be included on navigation charts. CONCLUSIONS Findings 1. The traincrew's qualifications and the condition of the track, signals, and train equipment did not contribute to this accident. 2. The Sunset Limited, traveling about 72 mph, derailed after striking a girder that had been displaced about 38 inches when the towboat MAUVILLA, pushing six barges, struck the Big Bayou Canot railroad bridge. 3. Had the pilot used the radar as visibility deteriorated, he could have observed the intersection formed by the Mobile River and the Big Bayou Canot and could have avoided turning his tow and barges into the wrong waterway. 4. The pilot exercised poor decisionmaking under the prevailing conditions by continuing to navigate when he could not find a tree to which to tie up, by continuing his approach to an unidentified object, and by not summoning help from other crewmembers. 5. Warrior & Gulf Navigation Company did not provide adequate radar navigation training to the pilot, nor did it provide him with a compass. 6. Warrior & Gulf Navigation Company's written evaluation form did not fully identify and assess those skills critical to vessel operation, limiting its value as a management tool for ensuring safe vessel operations. 7. The American Waterway Operators, Inc., should encourage member companies to incorporate into towboat operator evaluations a practical method of assessing proficiency in navigation, including the use of radar. 8. Coast Guard standards for inland towing vessel operator licensing are inadequate because they do not address the radar skills that are necessary for safe operation of vessels in restricted visibility. 9. All uninspected towing vessels should be required to carry appropriate navigational devices, including charts, in the wheelhouse; and all such vessels, except those operating in very limited areas, should be required to have a radar installed. 59

Delays in obtaining samples from vessel crewmembers, which prevented conclusive deter- mination of whether alcohol was a factor in this accident, could continue to be a factor in marine accidents because Coast Guard regulations applicable to postaccident alcohol testing do not specify the time limits within which such testing must be conducted. 11. As evidenced by information provided by his employer and a statement from his doctor, the pilot had been able to control his diabetic condition satisfactorily since 1982 and the disease most likely did not preclude him from operating the MAUVILLA safely. 12. Warrior & Gulf Navigation Company should establish procedures that encourage towboat operators to inform management when they are taking medication, determine whether such medication may affect their performance of duties, and arrange for a qualified relief, if necessary. 13. The transportation industry needs to disseminate information and educational materials that stress the relationship between use of medications (over-the-counter and prescription) and an employee's fitness for duty. 14. Damage to the bridge discussed in repair plans issued on November 1, 1979, was probably due to a barge strike that may have occurred as a result of high water and winds generated during Hurricane Frederic. 15. Currently available data pertaining to bridge-vessel collisions are insufficient to allow the U.S. Department of Transportation to develop a bridge risk assessment methodology or to allow the railroads to systematically identify vulnerable bridges and take action to increase protection for them. 16. Development of a national risk assessment program for railroad bridges requires the full cooperation and support of the railroad industry. 17. The U.S. Department of Transportation's development of a national risk assessment program for determining bridge vulnerability to vessel collision is needed. 18. To carry out a national risk assessment program for highway and railroad bridges, the transportation regulatory agencies need a standard methodology so that they can determine the vulnerability of the Nation's highway and railroad bridges to collisions from marine vessels, formulate a ranking system for identifying those bridges at greatest risk, and provide guidance on the effectiveness and appropriateness of protective measures. 19. Bridges vulnerable to impact from commercial marine traffic should bear unique, readily visible markings so that waterway and bridge users are better able to identify bridges involved in accidents when reporting such mishaps to emergency responders; a list of bridge identification markings should be published periodically in a national register of bridges. 20. Considering the remoteness of the accident site, the weather conditions, and the limited modes of transportation available, the emergency response was well-coordinated and effective. 60

Amtrak did not have an effective system of apprising passengers of safety features, and some passengers were unaware of safety information. 22. Because Amtrak did not equip its passenger cars with portable lighting, passengers were at a disadvantage in evacuating the train. 23. Emergency responders were at a disadvantage because they were unable to obtain an adequate passenger and crew list from Amtrak until the next day. 24. If the Mobile County Emergency Management Agency had held drills to simulate a train accident, the incident commander may have known about Amtrak's procedures for accounting for passengers, and CSXT may have had the correct telephone number for the Coast Guard. Probable Cause The National Transportation Safety Board determines that the probable causes of Amtrak train 2's derailment were the displacement of the Big Bayou Canot railroad bridge when it was struck by the MAUVILLA and tow as a result of the MAUVILLA's pilot becoming lost and disoriented in the dense fog because of (1) the pilot's jack of radar navigation competency; (2) Warrior & Gulf Navigation Company's failure to ensure that its pilot was competent to use radar to navigate his tow during periods of reduced visibility; and (3) the U.S. Coast Guard's failure to establish higher standards for inland towing vessel operator licensing. Contributing to the accident was the lack of a national risk assessment program to determine bridge vulnerability to marine vessel collision. 61

RECOMMENDATIONS As a result of its investigation of this accident, the National Transportation Safety Board makes the following recommendations: -- to the U.S. Department of Transportation: Convene an intermodal task force that includes the Coast Guard, the Federal Railroad Administration, the Federal Highway Administration, and the U.S. Army Corps of Engineers to develop a standard methodology for determining the vulnerability of the Nation's highway and railroad bridges to collisions from marine vessels, to formulate a ranking system for identifying bridges at greatest risk, and to provide guidance on the effectiveness and appropriateness of protective measures. (Class II, Priority Action) (1-94-3) Require that the Federal Railroad Administration and the Federal Highway Administration, for their respective modes, use the methodology developed by the intermodal task force to carry out a national risk assessment program for the Nation's railroad and highway bridges. (Class II, Priority Action) (1-94-4) Require the modal operating administrations to develop and disseminate bulletins, notices, circulars, and other documents that call attention to the need for an employee reporting procedure concerning use of medication (over-the-counter and prescription) while on duty and that urge the transportation industry to develop and implement informational and educational programs related to this subject. (Class II, Priority Action) (1-94-5) Consider the use of RACONS, radar reflectors, and other devices to make bridges more identifiable on radar. (Class II, Priority Action) (1-94-6) 62

--to the U.S. Army Corps of Engineers: Cooperate with the U.S. Department of Transportation in developing a standard methodology for determining the vulnerability of the Nation's highway and railroad bridges to collisions from marine vessels, formulating a ranking system to identify bridges at greatest risk, and providing guidance on the effectiveness and appropriateness ofprotective measures. (Class II, Priority Action) (1-94-7) Promote, in cooperation with the U.S. Coast Guard, the development and application of low-cost electronic charting navigation devices for inland rivers. (Class II, Priority Action) (M- 94-30) --to the U.S. Coast Guard: Amend 46 CFR 4 and 16 to specify the time limits, not to exceed 8 hours, within which employers must conduct postaccident alcohol testing. (Class II, Priority Action) (M-94-31) In consultation with the inland towing industry, develop radar training course curricula standards for river towboat operations that emphasize navigational use of radar on rivers and inland waters. (Class II, Priority Action) (M-94-32) Upgrade licensing standards to require that persons licensed as Operators of Uninspected Towing Vessels hold valid river-inland waters radar observer certification if they stand navigation watch on radar-equipped towing vessels and to require that employers provide more specific evidence of training. (Class II, Priority Action) (M-94-33) Require that all uninspected towing vessels carry appropriate navigational devices, including charts, in the wheelhouse. (Class II, Priority Action) (M-94-34) Promote, in cooperation with the U.S. Army Corps of Engineers, the development and application of low-cost electronic charting navigation devices for inland rivers. (Class II, Priority Action) (M- 94-35) 63

64 Require that radar be installed on board all uninspected towing vessels except those that operate within very limited areas. (Class II, Priority Action) (M-94-36) Require that all bridges vulnerable to impact by commercial marine traffic bear unique, readily visible markings so that waterway and bridge users are better able to identify bridges involved in an accident when they report such accidents to emergency responders. (Class II, Priority Action) (M-94-37) Periodically publish a list of bridge identification markings in a national register of bridges. (Class II, Priority Action) (M-94-38) --to the National Railroad Passenger Corporation (Amtrak): Develop and implement a uniform system to effectively apprise passengers of information pertaining to safety features. (Class II, Priority Action) (R-94-6) Develop and implement procedures to provide adequate passenger and crew lists to local authorities with minimum delay in emergencies. (Class II, Priority Action) (R-94-7) Equip cars with portable lighting for use by passengers in an emergency. (Class II, Priority Action) (R-94-8) --to the Federal Emergency Management Agency: Encourage local authorities to conduct emergency drills that simulate transportation accidents involving railroad operations. (Class II, Priority Action) (1-94-8) --to The American Waterways Operators, Inc.: Recommend that member companies equip their tugs and towboats with suitable navigation devices, including charts. (Class II, Priority Action) (M-94-39)

Assist the Coast Guard in developing a curriculum for a training course on river radar navigation. (Class II, Priority Action) (M-94- 40) Recommend that member companies incorporate into towboat operator evaluations a practical method of assessing proficiency in navigation, including the use of radar. (Class II, Priority Action) (M-94-41) --to the Warrior & Gulf Navigation Company: Require that company towboat operators complete a recognized training course on river radar navigation after the curriculum for such a course has been developed. (Class II, Priority Action) (M- 94-42) Establish a trammg protocol that requires company towboat operators to demonstrate proficiency in use of radar, compasses, and charts and incorporate into towboat operator evaluations a practical method of assessing proficiency in river navigation techniques, including use of radar. (Class II, Priority Action) (M- 94-43) Equip all company towboats with a suitable compass, a complete, up-to-date set of navigation charts for the waters over which the vessel is intended to operate, and other appropriate navigational devices. (Class II, Priority Action) (M-94-44) Establish procedures that encourage towboat operators to inform management when they are taking medication, to determine whether such medication may affect performance of their duties, and to arrange for a qualified relief, if necessary. (Class II, Priority Action) (M-94-45) --to the Association of American Railroads: Immediately begin to collect data on vessel collisions with railroad bridges from your members and, if appropriate, take steps to increase protection for bridges identified as vulnerable. (Class II, Priority Action) (R-94-9) 65

Cooperate with the U.S. Department of Transportation in developing a national risk assessment program for railroad bridges. (Class II, Priority Action) (R-94-10) --to the American Short Line Railroad Association: Immediately begin to collect data on vessel collisions with railroad bridges from your members and, if appropriate, take steps to increase protection for bridges identified as vulnerable. (Class II, Priority Action) (R-94-11) Cooperate with the U.S. Department of Transportation in developing a national risk assessment program for railroad bridges. (Class II, Priority Action) (R-94-12) BY THE NATIONAL TRANSPORTATION SAFETY BOARD JAMES E. HALL Acting Chairman JOHN K. LAUBER Member JOHN A. HAMMERSCHMIDT Member CARL W. VOGT Member September 19, 1994 66

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FD07167 ｜ 1995_美国_AAR9505.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1995 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

. NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT RUNWAY COLLISION INVOLVING TRANS WORLD AIRLINES FLIGHT 427 AND SUPERIOR AVIATION CESSNA 441 BRIDGETON, MISSOURI NOVEMBER 22,1994 6519B

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Information about available publications may be obtained by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (202)382-6735 Safety Board publications may be purchased, by individual copy or by subscription, from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (703)487-4600

NTSBIAAR-95105 PB95-9 10405 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT RUNWAY COLLISION INVOLVING TRANS WORLD AIRLINES FLIGHT 427 AND SUPERIOR AVIATION CESSNA 441 BRIDGETON, MISSOURI NOVEMBER 22,1994 Adopted: August 30,1995 Notation 6519B Abstract: This report explains the runway collision of Trans World Airlines flight 427, a McDonnell Douglas DC-9-82, and N441KM, a Cessna 441, at the intersection of runway 30R and taxiway Romeo at the Lambert-St. Louis International Airport in Bridgeton, Missouri. The safety issues discussed in the report include aircraft lighting and conspicuity; airport markings, signs, and lighting; runway 31 designation, utilization, displaced threshold; ATC and pilot phraseology (specifically, the term “back-taxi”); pilot training; runway incursion detection/prevention methods; and ASDE/AMASS development, Safety recommendations concerning some of these issues were made to the Federal Aviation Administration (FAA).

CONTENTS EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. FACTUAL INFORMATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 1.10 1.11 1.12 1.13 1.14 1.15 1.16 H i s t o r y o f t h e F l i g h t s . . 1.5.1 1.5.2 1.5.3 1.5.4 1.5.5 1.5.6 1.5.7 1.5.8 1.6.1 1.6.2 1.10.1 Injuries to Persons . . . . . . . . . . . . . Damage to Airplane . . . . . . . . . . . . Other Damage . . . . . . . . . . . . . . . . Personnel Information . . . . . . . . . . . Trans World Airlines Crewmembers Captain Information . . . . . . . . . . . . First Officer Information . . . . . . . . . Cessna 441 Pilot . . . . . . . . . . . . . . . Cessna 441 Pilot-rated Passenger . . . STL Air Traffic Control Specialists STL Local Controller . . . . . . . . . . . STL Ground Controller . . . . . . . . . . Airplane Information . . . . . . . . . . . . McDonnell Douglas MD-82 . . . . . . . Superior Aviation Cessna 441 . . . . . Meteorological Information . . . . . . . Aids to Navigation . . . . . . . . . . . . . Communications . . . . . . . . . . . . . . . Airport Information . . . . . . . . . . . . Airport Signs, Markings and Lighting . . . . 1.10.2 Runway 3 1 Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.10.3 Postaccident Airport Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.10.4 ATC Tower . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.10.5 Postaccident ATC Scheduling Changes . . . . . . . . . . . . . . . . . . . . Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wreckage and Impact Information . . . . . . . . . . . . . . . . . . . . . . . 1.12.1 Cessna 441 Wreckage Information . . . . . . . . . . . . . . . . . . . . . . . 1.12.2 MD-82 Wreckage Information . . . . . . . . . . . . . . . . . . . . . . . . . . Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . Fire.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.15.1 Evacuation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.15.2 Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.15.3 Emergency Airport Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi 1 1 3 4 4 4 4 4 4 5 5 6 6 6 6 6 6 7 7 7 8 11 11 13 13 14 14 15 15 18 18 20 20 20 20 21 21 111

.................. 47 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Probable Cause. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 4. RECOMMENDATIONS . . . . . 49 iv

• APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

APPENDIX A - INVESTIGATION INFORMATION . . . . . . . . . . . . . . . . APPENDIX B - ATC TRANSCRIPT . . . . . . . . . . . . . . . . . . . . . . . . . . . APPENDIX C - CVR TRANSCRIPT . . . . . . . . . . . . . . . . . . . . . . . . . . . APPENDIX D - FDR DATA PRINTOUT . . . . . . . . . . . . . . . . . . . . . . . . APPENDIX E - RADAR STUDY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . APPENDIX F - MD-82 ACCELERATED STOP DATA . . . . . . . . . . . . . . APPENDIX G - RUNWAY INCURSION/GROUND COLLISION SAFETY RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . APPENDIX H - FEBRUARY 28, 1995, RECOMMENDATIONS . . . . . . . APPENDIX I - AIRPORT CLOSURE RECOMMENDATION . . . . . . . . . . 51 51 53 91 115 121 127 129 145 153 I I ’ EXECUTIVE SUMMARY On November 22, 1994, at 2203 central standard time, Trams World Airlines flight 427, a McDonnell Douglas DC-9-82 (MD-82) N954U, collided with a Cessna 441, N441KM, at the intersection of runway 30R and taxiway Romeo, at the Lambert-St. Louis International Airport (STL) in Bridgeton, Missouri. The MD-82 was operating as a regularly scheduled passenger flight from STL to Denver, Colorado. The flight was conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 12 1. There were 132 passengers, five flight attendants, and three flightcrew members aboard the airplane. The MD-82 sustained substantial damage during the collision. The Cessna 441, operated by Superior Aviation, Inc., as a 14 CFR Part 91 positioning flight, was destroyed. The commercial pilot and the passenger, who was rated as a private pilot, were the sole occupants on board the Cessna and were killed. Of the 140 persons on board the MD-82, eight passengers sustained minor injuries during the evacuation. The National Transportation Safety Board determines that the probable cause of this accident was: the Cessna 441 pilot’s mistaken belief that his assigned departure runway was runway 30R, which resulted in his undetected entrance onto runway 30R, which was being used by the MD-82 for its departure. Contributing to the accident was the lack of Automatic Terminal Information Service and other air traffic control (ATC) information regarding the occasional use of runway 3 1 for departure. The installation and utilization of Airport Surface Detection Equipment (ASDE-3) and particularly ASDE-3 enhanced with the Airport Movement Area Safety System (AMASS), could have prevented this accident. Safety issues discussed in the report include aircraft lighting and conspicuity; airport markings, signs, and lighting; runway 3 1 designation, utilization, displaced threshold; ATC and pilot phraseology (specifically, the term “back-taxi”); pilot training; runway incursion detection/prevention methods; and ASDE/AMASS development. Safety recommendations concerning some of these issues were made to the Federal Aviation Administration (FAA). Also as a result of the investigation of this accident, the Safety Board issued safety recommendations to the FAA on February 28, 1995, concerning the runway incursion issue. vi

NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D. C. 20594 AIRCRAFI’ ACCIDENT REPORT RUNWAY COLLISION INVOLVING TRANS WORLD AIRLINES FLIGHT 427 AND SUPERIOR AVIATION CESSNA 441 BRIDGETON, MISSOURI NOVEMBER 22,1994 1. FACI’UAL INFORMATION 1.1 History of the Flights On November 22, 1994, at 2203 central standard time,’ Trans World Airlines (TWA) flight 427, a McDonnell Douglas DC-9-82 (MD-82), N954U, collided with a Cessna 441, N441KM, at the intersection of runway 30R and taxiway Romeo, at the Lambert-St. Louis International Airport (STL) in Bridgeton, Missouri. The MD-82 was operating as a regularly scheduled passenger flight from STL to Denver, Colorado. The flight was conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 12 1. There were 132 passengers, five flight attendants, and three flightcrew members aboard the airplane. The MD-82 sustained substantial damage during the collision. The Cessna 441, operated by Superior Aviation, Inc., as a 14 CFR Part 91 positioning flight, was destroyed. The commercial pilot and the passenger, who was rated as a private pilot, were the sole occupants on board the Cessna and were killed. Of the 140 persons on board the MD-82, eight passengers sustained minor injuries during the evacuation. The accident occurred on the second day of a 3-day trip sequence for the MD-82 flightcrew. The captain flew the first leg of the second day, from San Jose to STL. The flightcrew had a 2-hour layover before the accident flight. The first officer performed pilot flying duties for the accident leg of the trip sequence. The MD-82 was scheduled to depart STL for Denver at 2134, but there was a short gate delay that the flightcrew attributed to “overbooking.” According to the flightcrew, the airplane was pushed back about 15 minutes late, but otherwise ground operations were routine. They received instructions to taxi to runway 30R for departure. At 2201, as the MD-82 taxied southeastbound on taxiway Papa, the first officer advised local control that they were ready for takeoff on runway 30R. The Cessna 441 was registered to Garrett Aviation, Inc., and operated as a 14 CFR Part 13 5 on-demand charter aircraft by Superior Aviation, Inc., of Iron Mountain, Michigan. On ‘All times herein are central standard time unless otherwise noted

2 the evening of the accident, the Cessna 441 had been scheduled to depart Iron Mountain between 1800 and 1830 with a charter passenger who was to be dropped off at STL. The passenger was late for the proposed departure time because she encountered snowy roads while en route to the airport. She arrived at the airport about 1900, and the flight departed shortly thereafter. The passenger stated that she had flown with the pilot frequently before the night of the accident, but indicated that she did not recognize the passenger who occupied the right seat. She reported that the flight from Iron Mountain to STL went quickly and seemed routine. She did business paperwork during the flight, and did not notice anything out of the ordinary. Upon arrival in the St. Louis area, the pilot made a comment to the local controller about “. this radio .‘I The local controller responded that the pilot’s transmission was loud and clear. Several seconds later, the Cessna 441 pilot transmitted a garbled message, of which “I got you now switch radios here” was discernable. The local controller then issued instructions to land on runway 30R. The Cessna 441 pilot’s response was garbled. The airplane landed on runway 30R uneventfully, and the local controller instructed the pilot to turn right at the intersection of the runway and taxiway November, and then to contact the ground controller. The Cessna 441 pilot reported clearing the runway to the local controller instead of the ground controller. The local controller then reiterated instructions to contact the ground controller. At 2140:24, the pilot of the Cessna 441 contacted the ground controller and reported, ‘I. . clear goin to midwest.” The ground controller stated, “November one Kilo Mike St. Louis ground taxi to Midcoast ramp.” The Cessna 441 pilot replied “(unintelligible) one” and taxied to the Midcoast Aviation ramp. The airplane arrived at Midcoast Aviation to drop off the passenger about 2141. The pilot and the pilot-rated passenger helped the passenger with her bags, paid the landing fee at Midcoast, and prepared to depart for the positioning flight back to Iron Mountain. Midcoast personnel reported that the pilots appeared to be in a pleasant mood, but seemed eager to be on their way home. At 2158, the pilot of the Cessna 441 advised ground control that he was ready to taxi. The ground controller issued taxi instructions to I’. . back-taxi2 into position hold runway three one, let me know this frequency when you’re ready for departure.” The pilot acknowledged by stating “Kilo Mike.” At 2201:23, the local controller cleared the MD-82 for takeoff on runway 30R, with instructions to fly a heading of 335. The first officer confirmed the assigned heading, and the airplane taxied onto runway 30R. At 2202:29, the pilot of the Cessna 441 advised the local controller, ‘I. . . Kilo Mike’s ready to go on the right side.” (See Appendix B for a complete ATC *Although not formally defined, a clearance to “back-taxi” on an active runway generally means to use that runway to taxi in a direction opposite that of departing or landing traffic to reach the takeoff position.

transcript.) As the MD-82 began its takeoff roll, the first officer operated the flight controls, while the captain advanced and set the throttles. As the airplane accelerated on the runway, the captain made the 80-knot callout. About 2 to 3 seconds after the 80-knot call, the additional crewmember (ACM) who occupied the cockpit jumpseat yelled “There’s an airplane!” The captain and first officer reported that they saw the airplane on the runway in front of them at almost the same instant that the ACM alerted them. Both pilots applied the brakes, and the captain applied left rudder in an attempt to steer the airplane left to avoid the Cessna 441. Approximately 2 to 3 seconds after the flightcrew saw the Cessna 441, they felt an impact on the right side of their airplane. The flightcrew members reported that the impact did not adversely affect their ability to maintain directional control of the airplane. They continued to abort the takeoff, and brought the airplane to a stop on the left side of runway 30R near the intersection of taxiway November. Ground scars and physical evidence indicated that the Cessna 441 was located almost directly on the runway centerline, and the MD-82 had veered slightly left of centerline when the collision occurred. The right wing of the MD-82 struck the tail cone and fuselage structure of the Cessna 441, separating the horizontal and vertical stabilizers from the fuselage and shearing the top of the fuselage/cockpit from the airplane. The Cessna 441 came to rest at the right side of runway 30R near taxiway Romeo, with the right engine still running. Airport Rescue and Fire Fighting (ARFF) personnel shut down the engine and secured the airplane. According to the flightcrew members and ACM on board the MD-82, they did not observe the airplane or airplane position lights at any point during their takeoff roll. They stated that they first saw the airplane when it was illuminated by the lights from the MD-82. The pilots reported that, in accordance with normal procedure, the MD-82 had all external lighting on at the time of the accident. They reported that the runway lighting was normal for runway 30R at STL, and included runway edge, centerline, and touchdown zone lighting. (See Section 1.10, Airport Information, for the specific settings of the lighting systems.) The accident occurred at N 38”44”9’, W 90”21”6’, during the hours of darkness. 1.2 Injuries to Persons Injuries Crew Passengers Others Total Fatal 1* 1* 0 2 Serious 0 0 0 0 Minor 0 8*+ 0 8 None A** &I** 9 J3J Total 9 133 0 142

• On board Cessna 441

** On board MD-82

4 1.3 Damage to Airplane The Cessna 441 was destroyed by the impact forces of the collision. The hull loss was approximately $1.2 million. The MD-82 received substantial damage to its right wing, landing gear, lower fuselage, and the right engine. The estimated cost to repair the airplane was $1.7 million. 1.4 Other Damage There was no other damage. 1.5 Penonnel Information 1.5.1 Tmns World Airlines Clewmembers The flight and cabin crews of the MD-82 were qualified in accordance with applicable Federal Aviation Administration (FAA) and company regulations and procedures. The examination of crewmember training records did not reve*l anything remarkable. Further, the investigation of the background of the flightcrew die at reveal anything unusual. All crewmembers indicated that they felt well-rested on the evening of the. accident. 1.5.2 Captain Information The captain of the MD-82, age 57, held Airline Transport Pilot (ATP) Certificate No ;21778 and was type-rated in fixed-wing (B727, B737, B747, DC-9, Learjet, and CE-500) aircraft. He also held a current FAA Class I Medical Certificate, issued in August 1994, with the limitation, “Holder shall wear corrective lenses while exercising the privileges of his airman certificate.” His vision was listed as 20000 in each eye corrected to 20/20 for distant vision, and 20130 in each eye corrected to 20/20 for near vision. He was hired by TWA in October 1965. At the time of the accident, the captain had accumulated approximately 18,651 hours of total flight time, of which 3,178 hours were logged in the DC-9/MD-82 aircraf, He worked in the company training center from 1987 to 1993, and was involved in developing and instructing the crew resource management course. His last proficiency check was accomplished in July 1994, and his last line check was accomplished in November 1994. The captain had accrued about 34 hours of flight time in November, and over 168 hours in the 90 days before the accident. 1.5.3 First Offker Information The first officer of the MD-82, age 38, held ATP Certificate No. 2239191. He also held a current FAA Class I Medical Certificate issued in February 1994 with no limitations or waivers. His vision was listed as 20/20 without correction for both distant and near vision. At the time of the accident, the first officer had logged approximately 10,353 hours total flight time, of which 251 hours were logged as first officer in the DC-9/MD-82 aircraft. His last proficiency check was accomplished in June 1994, and his last line check was accomplished in

E I 5 July 1994. The first officer had accrued about 56 hours of flight time in November, and approximately 153 hours in the 90 days before the accident. 1.5.4 Cessna 441 Pilot The pilot of the Cessna 441 was qualified in accordance with applicable FAA and company regulations and procedures. Investigation of his background did not reveal anything remarkable. The pilot, age 56, held Commercial Pilot Certificate No. 1596566. He possessed a current FAA Class II Medical Certificate, issued in February 1994, with the stated limitation, “Holder will wear corrective lenses while exercising the privilege of his airman certificate.” His vision was listed as 20000 in each eye corrected to 20/20 for distant vision, and 20/20 in each eye without correction for near vision. According to logbook and company records, the pilot had accumulated 7,940 hours of total flight time, including 2,060 hours in the Cessna 441. His last proficiency check was accomplished in the Cessna 441 in November 1994. The pilot had accumulated about 64 hours in the preceding month, and approximately 155 hours in the 90 days before the accident. The Cessna 441 pilot’s flight logbook records indicated that he had flown into STL once before during the preceding 7 years. The previous flight into STL had been a daytime operation and had occurred in January 1994. The Safety Board conducted interviews with the pilot’s wife, Superior Aviation personnel, and the passenger who had chartered the Cessna 441 to STL before the accident flight. These interviews revealed that the Cessna 441 pilot was known as a conscientious, safety- oriented pilot. The passenger stated that the pilot had flown many of the flights that she had chartered. She stated that the pilot habitually held the airport diagrams on his lap for reference during ground operations. She described one charter flight during which the pilot became unsure of his position on an airport; he stopped the airplane, and did not proceed until he was sure where he was. The pilot’s wife stated that the pilot usually arose between 7 and 8 a.m., and went to bed between 10 and 11 p.m. She reported the pilot also frequently took a nap in the early afternoon. The pilot’s work/rest cycle for the 4 days before the accident, as described by his wife, conformed with this schedule. The pilot’s wife reported that on the day of the accident, the pilot had taken a nap early in the afternoon. On the evening of the accident, the pilot was observed to be in good humor, and accomplished his duties in a normal manner. The passenger and Midcoast personnel stated that although the pilot did not seem unduly rushed to leave STL, he mentioned that it was going to snow in Iron Mountain, and they needed to be on their way. 1.5.5 Cessna 441 Pilot-rated Passenger The private pilot-rated passenger on board the Cessna 441, age 43, was a professional accountant with a private pilot certificate, whose wife worked as a receptionist at Superior Aviation. He was riding in the right seat of the Cessna 441 for unofficial familiarization.

6 His presence was not required for the flight. 1.5.6 STL Air Tmffic Control Specialists The air traffic control (ATC) specialists who provided ATC services to the airplanes were qualified in accordance with current procedures.. Examination of their training records revealed nothing remarkable. In addition, the investigation of these controllers’ backgrounds and their activities in the 3 days before the accident did not reveal anything extraordinary. 1.5.7 STL Local Contmller The local controller, age 35, was hired by the FAA in January 1984 as an ATC specialist. She had served previously as an air traffic controller in the U.S. Air Force. Within the FAA, her initial assignment was to the St. Louis Downtown Parks Airport. In July 1990, she was transferred to STL, where she has remained employed as a controller. She achieved Full Performance Level status in May 1991. She held a current FAA Class II Medical Certificate, issued in April 1994, with no limitations or waivers noted. 1.5.8 STL Gmund Contiller The ground controller, age 29, was hired by the FAA in July 1988 as an ATC specialist. He had served previously as an air traffic controller in the U.S. Air Force. Within the FAA, his initial assignment was to the Des Moines International Airport, where he achieved Full Performance Level status in October 1990. He transferred to STL in July 1993, where he achieved Full Performance Level status in April 1994. He held an FAA Class II Medical Certificate issued in June 1994 with no limitations or waivers noted. 1.6 Airplane Information 1.6.1 McDonnell Douglas MD-82 The MD-82, N954U, was certificated for transport-category flight on January 15, 1988, and was configured for two flightcrew members, with seats for five flight attendants and 132 passngers. The airplane was powered by two Pratt and Whitney JT8D turbofan engines. Discrepancies noted in the airplane maintenance logs were either repaired or deferred to Minimum Equipment List/Cabin Discrepancy Listing (MEL/CDL). No noteworthy MEL discrepancies were found in the airplane maintenance log. No windshield deficiencies were noted during the postaccident inspection. l 1.6.2 Superior Aviation Cessna 441 The Cessna 441, N441KM, was certificated for flight on February 12, 1988. The

7 Cessna 441 airplane, which is certificated for single-pilot operations, is a mid-range, light-twin turboprop airplane. Cessna 44 1 s are powered by two Garrett Airesearch TPE-33 1 engines, which are mounted on the wings. The airplane’s maintenance log did not reveal any discrepancies. External lighting on the Cessna 441 consisted of wing-mounted retractable landing lights, a nose gear-mounted taxi light, strobe lights, red and green wing tip-mounted navigation lights, and a white tail cone- mounted navigation light. Superior Aviation procedures required that illumination of the strobe, taxi, and landing lights take place after receipt of a takeoff clearance. 1.7 Meteorological Information The STL surface weather observation taken at 215 1 indicated clear skies, with 25 miles visibility. The temperature was 33 “Fahrenheit (F), and the dew point was 22 “F. Winds were out of 270” at 8 knots, and the barometric pressure was 30.56” Hg. A special weather observation taken after the accident, at 2242, was identical to the 215 1 observation, except the temperature was recorded as 32 “F, and the remarks section stated “ACFT MISHAP.” The STL hourly surface weather observation taken at 2250 indicated that skies were clear, with visibility of 25 miles. The temperature was 32 “F, dew point was ’ 22 “F, and winds were out of 270” at 7 knots. Passengers from the MD-82, ARFF personnel, and pilots who operated in the STL area at the time of the’ accident reported that weather conditions and visibility were good. 1.8 Aids to Navigation No navigational equipment outages or discrepancies were noted in the St. Louis facilities log that would have contributed to this accident. 1.9 Communications Postaccident examination of the ATC very high frequency (VHF) transmitter and receiver equipment found that all equipment was operating within specifications. Ground and local controllers indicated that the workload was moderate at the time of the accident. The night of the accident, the ground controller was working four positions,’ each of which is staffed by a separate controller when the tower is operating at full complement during peak traffic. When working these positions, the controller was monitoring seven different frequencies. These combined positions with multiple frequencies created a situation in which a pilot transmitted and received on a specific frequency, depending on the service required, while ‘The ground controller was working ground control for both the north and south sides of the airport, clearance delivery, and flight data.

3 8 the controller transmitted on all of the frequencies for which he was responsible. Interviews with the MD-82 flightcrew members indicated that the use of combined positions/multiple frequencies occasionally resulted in difficulties. These reported problems included incomplete communications due to pilots’ transmissions being “stepped on” by other pilots, increased controller workload, communication delays and confusion, and potential decreased pilot situational awareness. A review by the Safety Board of I 112 hours of ATC tapes from the evening of the accident revealed several instances of simultaneous transmissions. As the Cessna 441 was inbound to STL, there were several cases of garbled, unintelligible, or partial transmissions between the Cessna 441 and the ATC tower. At one point, the pilot of the Cessna 441 stated I’. . got you now . . . switch radios here . . . .‘I Several subsequent transmissions from the Cessna 441 were also distorted, but most of the Cessna’s outbound transmissions to ATC were clear. Postaccident examination of the Cessna 441 communication radios revealed that they were capable of normal operation. 1.10 Airport Information The STL airport is owned and operated by the City of St. Louis Airport Authority. The airport is located in Bridgeton, Missouri, approximately 12 miles northwest -of St. Louis, and has an airport elevation of 605 feet. (See Figure 1.) STL has five runways, three of which are parallel paved surfaces. Runways 12R/3OL (11 ,019 feet x 200 feet) and 12L/3OR (9,003 feet x 150 feet, the accident runway) are grooved concrete surfaces, with high intensity runway lights (HIRL). Parallel taxiway Foxtrot was converted to a runway (13/3 1) in 1988. Runway 13/3 1 is a 6,289 feet x 75 feet paved surface located northeast of runway 12L/3OR. The first 3,989 feet of Runway 13 is asphalt, and the remaining 2,300 feet is concrete. It has medium intensity runway Iights (MRL), and is restricted to use by aircraft 12,500 pounds or less. Runway 31 is used as a “departure only” runway. However, runway markings indicate a 1,838-foot displaced threshold. The Midcoast Aviation general aviation ramp is located northeast of runway 13/3 1. Taxiway Whiskey is about 150 feet long, and extends perpendicular to runway 31 between the Midcoast Aviation ramp and runway 3 1. Taxiway Romeo is perpendicular to the parallel runways at the approach end of runway 31. The taxiway Romeo centerline is approximately 2,500 feet from the approach end of runway 30R. Taxiway November is also perpendicular to the parallel runways, and its centerline is located approximately 4,500 feet from the approach end of runway 30R, about 2,000 feet from taxiway Romeo. (See Figure 2.) Tower personnel reported no known difficulties with runway and taxiway lighting systems before, or at the time of, the accident. They reported that the runway 30R HIRL, centerline lighting, and the Medium Intensity Approach Lighting System with Runway Alignment Indicator Lights (MALSR) system were illuminated at the Step 3 (of five) intensity level, while the runway 3 1 MIRL were iiluminated at the lower Step 1 (of three) intensity level. The tower

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11 controller stated that at these settings, the runway 30R runway lights were brighter than the runway 31 lights. A review of airport facility maintenance and ATC tower logs found no reported difficulties with the runway/taxiway lighting systems before the accident. A search of the National Aeronautics and Space Administration’s Aviation Safety Reporting System runway incursion reports revealed no pertinent reported events at STL. No significant notices to airmen were issued for the airport during the accident time period. 1.10.1 Airport Signs, Makings and Lighting The Safety Board’s examination of the airfield signs, markings, and lighting near and along the taxi route taken by the Cessna 441 revealed that they conformed to FAA standards. The Safety Board noted that upon exiting the Midcoast ramp area, there were .three signs indicating runway 3 1 on the left side of the entrance to taxiway Whiskey. The furthest sign on the left side of the taxiway was installed in compliance with the FAA’s revised (July 3 1, 1991) signage requirements, but was not yet in full service and was not lit. Behind this sign and slightly to its left was the in-service hold position sign. To the right of the two hold position signs was a wooden sign that read “ACTIVE RUNWAY CONTACT TOWER 121.9.” (See Figure 3.) Airport personnel told Safety Board investigators that the hold position signs for runway 13/3 1 were observed to be not internally illuminated during the hours following the accident: one sign had an inoperative light bulb, and one sign hadn’t been hooked up to power. To simulate the signage conditions that the pilot of the Cessna 441 may have encountered the night of the accident, the Safety Board observed the signs at night, without internal illumination. Investigators noted that the three signs were clearly visible in the ambient light from the Midcoast ramp flood lights. Investigators also noted that all taxiway markings, hold position markings, and displaced threshold markings for runway 3 1 were visible as they traveled from the Midcoast ramp to runway 3 OR, via taxiway Romeo. The yellow hold position markings on taxiways Whiskey and Romeo were highlighted in black to enhance the visibility of the markings. The runway 12L/30R hold position sign at taxiway Romeo had one inoperative light bulb on the right side of the sign. Investigators noted that the sign was clearly visible.’ 1.10.2 Runway 31 Information In 1986, due to increased traffic activity and consequent delays, the STL Airport Authority temporarily established taxiway Foxtrot as runway 13/3 1, to be used for departures only. Despite this landing prohibition, an 1,838-foot displaced threshold was incorporated into the runway 3 1 marking scheme. Runway 13/3 1 was to be used for day, visual flight rules (VFR) operations by commuter and general aviation aircraft.

- t I

I 3 13 The runway 13/3 1 trial program was successful at reducing delays, and in 1988, the STL airport moved to make the conversion permanent, Conversion was completed in 1989, and included the signage, surface markings, and lighting required to identify it as a runway for day and night use. Pavement markings for the displaced threshold remained in place on the runway, and the landing prohibition remained. In 1991, three incidents of air carrier aircraft mistaking runway 13 for runway 12L resulted in a plan to operate the runway 13/31 MIRL at an intensity setting lower than the runway 12L/3OR HIRL. According to the tower supervisor and the local controller, the tower procedure is to turn the runway 13/3 1 lights to a higher intensity when a departing aircraft begins its takeoff roll and to turn the lights back down to the dimmer setting as soon as the aircraft is airborne. The local controller stated that the runway 31 lights were not turned up on the night of the accident. According to STL ATC personnel, the majority of the time runway 13/3 1 is inactive, under the jurisdiction of the ground controller, and is used as a taxiway. This differs from most runways in that runways are usually under the jurisdiction of the local controller. 1.10.3 Postaccident Airport Changes Following the accident, the STL Airport Authority installed taxi-holding position lights (“wig-wag” lights) at taxiway Whiskey to further enhance and delineate the presence of runway 13/31 for aircraft exiting the Midcoast ramp. The STL Airport Authority also petitioned for and received approval to eliminate the 1,838-foot displaced threshold on runway 3 1. The STL Airport Authority anticipates that all displaced threshold runway markings will be removed and that runway 31 will be reopened full length for use by September 1, 1995. 1.10.4 ATC Tower The ATC tower, operated by the FAA, is a tower cab facility, collocated with a Terminal Radar Approach Control (TRACON) facility. FAA statistics rank the STL ATC facility as the 14th busiest in the country. The tower structure is located on the southwest side of the runway complex and terminal buildings, about 1 l/4 miles from the site of the collision (see Figure 1). During interviews, tower personnel stated that the Cessna 441 was visible while it was on the Midcoast ramp. They stated that when the airplane moved from the well-lighted ramp area toward runway 3 1, it was no longer visible. Tower personnel indicated that it was often difficult to see small airplanes operating on the north side of the airport, especially on the far end of runway 3 1, at night. The facility has Airport Surface Detection Equipment (ASDE-3) radar to monitor

14 airplane activity on the ground (also see Section 1.18.3). The ASDE-3 was installed at STL in , September 1994, and was going through its “proving period” before being commissioned. During this proving period, the equipment was occasionally used by controllers for familiarization when it was available. The ASDE-3 equipment was not available on the night of the accident because the computer hard drive had failed. Subsequent to the accident, the ASDE-3 at STL has been commissioned. The ATC tower has 10 positions of operation that may be combined or separated as traffic conditions permit. On the night of the accident, two controllers were in the cab: the local controller (LC) and the ground controller (GC). The ground controller was assuming the duties for positions of flight data clearance delivery as well as ground control for both the north and south sides of the airport. The controller was monitoring the frequencies normally used for these different positions. The supervisory air traffic controller’s scheduled shift ended at 10 p.m. He told investigators that he left the tower cab at 9:45 p.m. and went to a downstairs office to process paperwork. At the time of the accident, he was on his way home. 1.10.5 Postaccident ATC Scheduling Changes At the time of the accident, it was standard staffing practice at STL to have two controllers on duty between 10 p.m. and midnight. ATC personnel stated that this was normally a period with little traffic, except for a “bank” of traffic between 9:45 and 10: 15 p.m. Subsequent to the accident, the STL ATC tower staffing schedule was changed to retain an additional controller until lo:30 p.m. The supervisor’s duty time has also been changed to have him remain in the facility until lo:30 p.m. 1.11 Flight Recorders The Cessna 441 was not equipped with a cockpit voice recorder (CVR) or flight data recorder (FDR), nor was it required to be so equipped under current Federal Aviation Regulations. The MD-82 was equipped with a Fairchild Model A-100 CVR, S/N 3455. Its magnetic tape provided a record of ATC and intracockpit communications. A transcript of the CVR is provided in Appendix C. The MD-82 was also equipped with a Sundstrand Model 573 digital FDR, S/N

1. A printout of selected parameters is provided in Appendix D.

recording: Playback data indicated the following trends moments before the end of the 1. The data were consistent with a normal takeoff roll until 2202:45. Beginning at 2202:45, there were rudder, brake, heading, and vertical and longitudinal acceleration excursions.

a I 15 2. The slat disagree sensor transitioned from “agree” to “disagree” at 2202:47. 3. Peak airspeed value was 114.5 knots, recorded at 2202:50. Both thrust reversers were deployed at 2202:52.

1. The airplane decelerated to a stop at 2203:lO.
2. 12

Wreckage and Impact Information All wreckage was located on runway 30R between taxiways Romeo and November. (See Figures 4 and 5.) The first item in the wreckage path was a 2-foot section of the rudder from the Cessna 441. Approximately 350 feet farther, the main portion of the Cessna 441 was located on the north edge of the runway on a heading of about 320”. Fragments of the upper cabin and empennage were scattered in the vicinity. Approximately 1,450 feet farther, the MD-82 was located on the south edge of the runway on a heading of about 300”. Black rubber skid marks started about 75 feet east of the Romeo intersection and led down the runway to the location of the MD-82. Another set of skid marks began at the intersection and led to the location of the Cessna 441. ’ The physical evidence indicated that the collision occurred on runway 30R at its intersection with taxiway Romeo, approximately 2,500 feet from the approach end. Two pairs of airplane tire scuff marks were on the runway. The between-tire distances for each of the pairs corresponded to the distance between main landing gear on the MD-82 and Cessna 44 1. The geometry of the collision indicated that both airplanes were on the runway heading at impact. 1.12.1 Cessna 441 Wreckage Information The airplane remained on its extended landing gear, with the two main gear tires inflated. The nose gear tire was deflated, and its strut was bent slightly aft. The left engine had pulled forward slightly from its mounts, and rested with its propeller blades and spinner on the pavement. Two of the engine’s propeller blades were bent forward and exhibited severe leading edge damage and chordwise scratches. The right engine remained in its normal position on the wing, and was still running when ARFF personnel arrived at the airplane after the collision. Jagged leading edge damage was evident on all three propeller’blades on the right engine, with two blades bent forward. The upper fuselage was sheared off approximately 2 inches above the bottom of the cabin windows from the tail section to the windscreen, The outboard 7 l/2 feet of the left wing had separated. Separations at the left wing, all window frames, and cabin structure exhibited forward bending. Scrapes and indentations across the upper surface of the left wing, the left engine nacelle, and the instrument panel were angled 14 to 15” from the longitudinal axis of the airplane.

16 I WRECUAQI MAQRU I Figure 4--Wreckage Diagram

I 17 Wreckagr Distribution Diagram :: 3. 4. X: 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.ia. 10. 20. 21. 22. 23. 24. lop of rudder (two foot section) Gray headrest Gear dour section (twatve inch foot by eigM inch section) Number two flap hinge mechanism cover (aft section) Tail se&ion (root faring) Tail cone wtth navigation light Riiht elevator (tive font outkant ssction) Top cabin door s&ion (upper half) ~WwfP Vertical stabilii and rudder Cabin oxygen. outlet box Cabin section (one foot by two foot) LeR hortzontal stabilizer (two foot inboard secb’on) Overhead duct (twalve inch section) Cabin vent outiat Upper cabin section exhibiting adcurdion type budding Left elevator section (aft outboard ssction with Might) Left elevator section (ait inboard SBCfjOn with two foot trim tab setting Cabin door actuator Magnetic compass Number three leading edge slat bft horizontal stabilii sac&n Left outboard wing 8edon (ftactwed 7.5 feet outboard of the number one angina nacalle) found wrapped around rfgM main gear of NO54U Wreckage from N441KM in NOS4U right wing leading edge ;: uppercabtn structum vvlndowfmmes : WTndscfwn~rpostandfmmedons Numbartwoseatsunvizlor 19 Windowautainsecbnns Tail section inspecUon plade Figure 5--Wreckage Distribution Diagram

18 The aft empennage was buckled and bent to the right; the entire empennage showed compression damage from the aft direction. The rudder was separated from the airplane. The vertical and horizontal stabilizers were fractured at their main attach points. During the initial on-scene examination, the two wing-mounted retractable landing lights were found in their stowed positions. The left navigation/strobe clear cover was missing, and the anticollision/strobe light was broken. The right navigation, right anticollision/strobe, tail navigation, and nose gear taxi lights were undamaged. All external lighting cockpit switches were found in their off (down) positions, except the nose gear taxi light, which was found in the on position. ARPF personnel stated that they altered switch positions during their attempt to shut off the right engine. Components of two headsets were in and around the airplane, and the cords were plugged into their respective receptacles. A pair of eyeglass frames were in the pilot’s seat. Several loose pages of Jeppesen approach charts were located in the cockpit area, including the current STL airport diagram (Copyright 1994 Jeppesen Sanderson, Inc.), dated June 3, 1994. (See Figure 6.) 1.12.2 MD-82 Wreckage Information The MD-82 sustained damage to the right wing leading edge devices, flaps, upper surfaces, lower surfaces, and forward spar. The wing damage area included numerous lateral slashes, surface scratches, and red, white, and blue paint smears similar to the color scheme of the Cessna 441. Scratches and smears were parallel to the longitudinal axis of the airplane. Wing damage resulted in approximately 600 gallons of fuel spilled. The right main landing gear, the right lower fuselage, and the number two engine were also damaged. Plexiglass and metal debris from the Cessna was embedded in the MD-82. The largest piece of Cessna debris directly associated with the MD-82 was the outboard section of the left wing, which was wrapped around the right main landing gear strut. 1.13 Medical and Pathological Information The MD-82 flightcrew submitted to toxicological tests in accordance with the FAA’s drug testing regulations and company policy. There was no evidence of alcohol or other major drugs of abuse in either crewmember. The pilot and pilot-rated passenger on board the Cessna 441 died of severe craniocerebral injuries. Blood and urine specimens obtained from the pilot-in-command and the pilot-rated passenger on board the Cessna 441 were examined by the FAA’s Civil Aeromedical Institute for toxicological analysis. All specimens tested negative for alcohol or drugs. Under the FAA drug testing program, the ATC local controller provided a urine sample for testing. No positive results were reported to the NTSB, as required by Federal

I 19 m ST LOUIS, MO 5~1~sc~--lw) 119.5 LAMBERT-ST LOUlS INTL tr.m-dn.~r~ 127.55 crud 121.9 13).7*/9.9 From sn 117.1 NM 44.9 wo90 21.6 rrnlI&h120.05 Mb 1 1 8 . 5 VW OPE EIW 605’ JZPPESEN KSTL 1 I i a Figure 6-- Lambert-StLouis International Airport Diagram (Copyright 1994 Jeppesen Sanderson, Inc.)

20 statutes should positive results be found. The FAA did not perform drug testing on the ground controller. Both controllers declined to provide voluntary blood and urine samples for a more extensive drug screen as requested by the Safety Board. 1.14 Filce Neither airplane was involved in a tire. 1.15 Survival Aspects The headrests on cabin and cockpit seats on the Cessna 441 were separated or bent forward, at the same level that the upper cabin structure was sheared off. This accident was not survivable for the occupants of the Cessna. The MD-82 cockpit and cabin were not damaged, and no occupants of this airplane were injured during the collision. 1.15.1 Evacuation As the MD-82 came to a stop on the south side of runway 30R after the collision, the captain shut down the engines, and advised ATC to, “. . roll the emergency equipment. TWA four hundred and twenty seven hit the other airplane on the uh, runway. Roll the emergency equipment.” The flightcrew stated their evaluation of the situation revealed no fire, or imminent danger of fire, but a substantial amount of fuel was leaking from the right wing. The captain exited the left front (Ll) door to further assess the situation. He noted that due to the slope of the runway, the fuel was running under the fuselage and pooling under the left side of the MD-

1. He instructed the first officer to evacuate the passengers through the right front (RI) door

to minimize passenger contact with the pooling fuel. The right overwing and aft exits were not used due to impact-related structural damage. The flight attendants told Safety Board investigators that during the 2 to 3 minute delay while the flightcrew evaluated the situation, they were able to reassure and calm most passengers, which smoothed the evacuation process. They described the evacuation through the single door as orderly and calm. The average estimate of the duration of the evacuation was 7 minutes. After all’passengers were evacuated, the flight attendants exited, followed by the first officer. 1.15.2 Emergency Response Seconds after the collision, ATC notified ARFF personnel that an accident had occurred on the airport. The first of the airport’s emergency vehicles arrived at the MD-82 within 2 to 3 minutes of the collision. ARFF personnel stated that when they arrived at the MD-82, they evaluated the situation and began applying fire retardant foam to both sides of the airplane and to the pooling fuel on the ground. They estimated that approximately 30 seconds after the

I 21 foam application was initiated, they saw the Rl door open, the emergency evacuation slide deploy, and the passenger evacuation begin. Several firefighters positioned themselves at the bottom of the Rl slide to catch and assist the passengers as they left the airplane. The captain and the ACM were also positioned near the bottom of the Rl slide directing passengers away from the airplane as they evacuated. About 35 minutes after the collision, buses arrived to transport the evacuated passengers back to the terminal area. ARFF personnel located the Cessna 441 about 1 to 2 minutes after their first vehicles arrived at the MD-82. ARFF personnel reported that when they reached the second airplane, the top portion of the airplane was missing, fuel was leaking from the wreckage, and the right engine was still operating. They applied fire retardant foam to the right engine until it shut down, and applied foam to the leaking fuel. They shut off electrical power to the airplane by disconnecting the battery in the nose compartment. One firefighter boarded the Cessna 441 in an effort to assist the occupants. Ten ARFF vehicles responded to the two airplanes. They reported that a large amount of Jet A aviation fuel was spilled on the runway and the grassy area adjacent to it as a result of the collision. They stated that a real fire hazard existed, the evacuation of the MD-82 was necessary, and the evacuation appeared orderly and timely. 1.15.3 Emergency Airport Closulle In the minutes after the ground collision, several taxiing aircraft and numerous emergency rescue vehicles were moving on the airport surface. When the evacuation began, pilots of the taxiing airplanes told the ground controller that they saw passengers wandering in the vicinity of the intersection of runway 30R and taxiway November. These pilots expressed concern that the evacuated passengers might wander into other operating aircraft. About seven minutes after the collision, Federal Express flight 1283 landed on runway 30L without incident. About seventeen minutes after the accident, the ground controller told aircraft on his frequencies that operations at the airport were suspended. The STL Airport Authority, which has jurisdiction over airport operations, did not officially close the airport after the collision. 1.16 Tests and Research Safety Board investigators conducted tests regarding the visibility and conspicuity of the Cessna 441 from the ATC tower and from the approach end of runway 30R. 1.16.1 Night Conspicuity Tests On November 24, 1994, a lighting and conspicuity exercise was conducted to observe the ease or difficulty in visually acquiring a general aviation airplane from the cab of the ATC tower. This exercise took place at approximately the same time in the evening as the accident, under similar weather conditions. Two observers in the ATC tower cab occupied a position near the local control position. To simulate the Cessna 441, a (slightly larger) Beech

22 King Air 200 was towed from the Midcoast Aviation ramp, via runway 31 and taxiway Romeo, to a takeoff position on runway 30R at its intersection with taxiway Romeo. Observations were taken at different points along the route with the airplane using different combinations of lighting. Runway lighting was set at step 1 for runway 31, and step 3 for runway 30R, as it was on the night of the accident, During the airplane conspicuity test, observers noted that the airplane navigation lights were of little use for detection when viewed against other lights in the runway environment. When the airplane was positioned for takeoff, the single red navigation light visible from the tower blended into the other red lights in the environment. Even the taxi lights were only visible during the arc of movement as the airplane turned onto the runway. When the airplane was positioned for takeoff, the taxi light was slightly brighter, but still blended easily into other runway lights. Observers reported that the taxi light was of some value for visibility when the airplane was taxied quickly, but was of little value when the airplane taxied slowly. Only the wing-mounted high-energy anticollision/strobe lights were effective at improving airplane conspicuity. During conspicuity tests, observers noted that the landing lights were effective for visibility in any situation or with any combination of other lights. When the landing lights were turned off, the airplane was often difficult to observe, even to observers who knew its approximate position. 1.16.2 Runway Visibility Tests A runway visibility test was conducted to examine the line-of-sight visibility the MD-82 pilots may have had to the Cessna 441 when both airplanes were positioned for takeoff on runway 30R. To simulate the view of the MD-82 pilots, an airport rescue vehicle with an adjustable platform arm was positioned on runway 30R, with the platform set at the approximate height and runway location of the MD-82 cockpit. A test airplane, similar in size to the Cessna 441, was taxied from the Midcoast general aviation ramp, via back-taxi on runway 3 1 and taxiway Romeo to a takeoff position on the centerline of runway 30R at its intersection with taxiway Romeo. Visual observations were made during afternoon daylight and clear weather conditions. The observations revealed that the test airplane (substituted for the Cessna) was visible from the time it entered the runway 31 environment up to and including the time it was in position on runway 30R. While the test airplane was in takeoff position, it was visible from the point where the tires touched the pavement to the top of the tail. There were no apparent physical obstructions to visibility. Observers noted that the airplane presented a very small target on the runway because of the small cross section when it was oriented for takeoff. 1.16.3 Recorded Radar Data Recorded radar data from the STL radar site was reviewed by the Safety Board.

I 23 These data were used to produce a plot of the Cessna 441’s ground track between 2158: 14 and 2204:43. Secondary data indicated that the Cessna 441’s transponder was turned off at 2143:06, and turned back on at 2156:24. The airplane taxied to the intersection of taxiway Romeo and runway 30R, where it remained for about 3 minutes before the collision. (See Appendix E.) 1.16.4 Lighting Components, Cessna 441 Selected external lighting components were retrieved from the wreckage of the Cessna 44 1 and examined by the Safety Board’s Materials Laboratory. The filaments of the bulbs removed from the left navigation and left landing lights, and the tail light positions were stretched. Brittle fractures were apparent from fragments of filaments from the right navigation and landing light positions. Emergency response personnel reported that the nosewheel taxi light was illuminated when they arrived at the airplane. 1.16.5 Communication Radios, Cessna 441 The two communication radios on the Cessna 441 were examined at the Collins Commercial Avionics facility in Melbourne, Florida. Both radios were operative and functioned within the prescribed limits described in the manufacturer’s production test procedure. Two discrepancies were noted:

1. The number one communication radio transmit light was inoperative.
2. The number two communication radio tune button was missing.

No physical evidence of preimpact discrepancy was found in the remaining components of the Cessna’s communication radio installation. Impact damage precluded additional systems testing. 1.16.6 MD-82 Accelerate-Stop Data Accelerate stop data provided by McDonnell Douglas indicate that the MD-82 could have begun its takeoff roll, accelerated to 114 knots, aborted the takeoff, and come to a complete stop within 4,600 feet. (See Appendix F.) 1.17 Organizational and Management Information 1.17.1 Superior Aviation Superior Aviation began operations as a certificated Part 135 air taxi service on January 30, 1978. The company operation consisted primarily of “on-demand” cargo flights, feeding freight into hub airports for United Parcel Service, Federal Express, etc. These flights were bid and contracted, with schedul.ed route structures. The company also operated occasional on-demand air taxi passenger flights.

24 At the time of the accident, Superior Aviation owned 3 1 airplanes, ranging in size from the Beech 95 to the Swearingen (SA) 226. The company employed 38 pilots, used primarily for single-pilot operations. All of the pilots were qualified to fly as captains in one or more of the airplanes. Pilot turnover was characterized as low during the preceding 2 years. Most of the pilots and airplanes were based at one of the company’s two main bases of operation, in Iron Mountain and Lansing, Michigan. However, the company frequently shifted airplanes and pilots to other temporary duty locations to accommodate cargo contracts and schedules. The company officers included a President/Owner; a General Manager/Director of Operations; a Director of Maintenance; and a Chief Pilot. The company’s training facility and training records were located in Lansing, Michigan, while maintenance operations and documents were located in Iron Mountain. The FAA principal operations inspector (POI) reported that Superior Aviation had a good safety and training record, and reported that the company was responsive to FAA guidance. Superior Aviation required its pilots to either tile an IFR or VFR flight plan, or accomplish flight following by telephone contact with the company. The company provided its pilots with Jeppesen chart subscriptions/updates. 1.18 Additional Information 1.18.1 Automatic Terminal Information Setvice (ATIS) The ATIS is a recorded message repeatedly broadcast to provide noncontrol airport and terminal area information to aircraft. FAA Order 7110.65, “Air Traffic Control,” section 2- 142, enumerates the required contents of the ATIS message. Paragraphs (c) and (d) state: c. Instrument/visual approach/s in use. Specify landing runway/s unless the runway is that to which the instrument approach is made. d. Departure runway/s (to be given only if different from landing runway/s or in the instance of a “departure only” ATIS). Arrival and departure information for STL is contained in a single ATIS. The broadcast in effect for the Cessna 441’s arrival and through the time of the accident was ATIS information “Delta.” No mention was made of the occasional use of runway 3 1 as a departure runway in this ATIS recording. Public hearing testimony from ATC personnel revealed that they did not normally include information about the use of runway 31 on the ATIS, because runway 31 was considered a secondary runway, and it was not active the entire time. The controllers testified that they limited the information included in the ATIS recordings in an attempt to keep the ATIS “brief and concise” as requested by airport user groups (i.e., TWA, ALPA, other air carriers).

25 1.18.2 Air Traffic Handling/Interviews The Cessna 441 landed on runway 30R at approximately 2140. The pilot made a right turn off the runway at taxiway November, and contacted ground control for taxi clearance. The ground controller cleared the pilot to “taxi to Midcoast ramp.” The pilot taxied across taxiway Foxtrot (runway 13/3 1) on the way to the ramp. After dropping off the passenger, the pilot contacted ground control at 2155, requesting clearance to Iron Mountain, and at 2158 he advised ground control that he was ready to taxi. The ground controller responded, “One Kilo Mike, roger, back-taxi into position hold runway three one, let me know this frequency when you’re ready for departure.” The pilot of the Cessna 441 acknowledged the instructions, stating, “Kilo Mike.” Both the ground and local controllers told Safety Board investigators that, although they were unfamiliar with the airplane’s call sign, the pilot of the Cessna 441 seemed to be competent, confident, and familiar with the airport. The ground controller stated that he believed the pilot of the Cessna 441 ‘I. knew where he was going.” Interviews with the ATC personnel revealed that runway 13/31 is used primarily _ ’ for taxi operations and secondarily as a “reliever” runway for general aviation and commuter operations. Because it is the only paved area for aircraft operations on the north side of the airport, runway 13/3 1 is the ground controller’s responsibility until an airplane requires a takeoff clearance. 1.18.3 ASDE3 Information ASDE is a high resolution ground surveillance radar system that displays surface aircraft and vehicle traffic on one or more displays in the ATC tower. This system is designed to augment visual observations to enable ATC tower personnel to detect, locate, and track surface activity, to provide safe and efficient traffic flow. The FAA’s 1995 Runway Incursion Action Plan (RIAP) calls for the latest generation of this equipment, ASDE-3, to be commissioned at 37 domestic airports. STL was originally scheduled to receive ASDE-3 by October 3 1, 1992. Due to multiple delays, including some site-specific difficulties, installation of the ASDE-3 equipment at STL was completed in September 1994. In accordance with FAA procedures, the equipment was subjected to a proving period, during which the equipment was calibrated, functions were verified, and hardware and interface problems were resolved. The ASDE-3 equipment was not available for controller reference on the night of the accident due to a computer hard drive failure. Since the accident, the STL ASDE-3 equipment difficulties have been resolved. The STL ASDE-3 equipment was commissioned in early 1995, and is currently operational and available for controller use 24 hours a day.

26 1.18.4 Airport Movement Area Safety System (AMASS) Information AMASS is a ground-based system that augments ASDE-3 by detecting and alerting controllers to potential collisions on airport surfaces. It uses ground and airborne radar data to predict conflicts, and provides controller alerts via aural warnings and graphic display on the ASDE-3 screen. According to the FAA’s IUAP, each of the 37 airports currently targeted for ASDE-3 installation will receive an AMASS. Although the production contract is still pending, the RIAP indicated that production AMASS units will become available in late 1996, and the 37 currently planned units will be commissioned by mid-1999. 1.18.5 Safety Board Actions -- Runway Incursion Issue The Safety Board’s concern about the hazard of runway incursions dates back to 1972, following an accident at the Chicago O’Hare International Airport. Since that time, the Board has issued 79 safety recommendations relating to runway incursions. These recommendations addressed issues such as procedures, training, pilot and controller communications, and airport signage. Despite these efforts, runway incursion-related incidents and accidents continue to occur. Based on its concerns, the Safety Board included this safety issue when it adopted the “Most Wanted” Transportation Safety Improvements program in 1990. The issue continues to be a part of the “Most Wanted” list. In 1985, the Safety Board conducted a special investigation study of runway incursion incidents. During this special study, the Safety Board investigated 25 runway incursion incidents that were summarized in the special investigation report, which was adopted in May

1. The investigation revealed that runway incursions were typically the result of human

performance issues that involved air traffic controllers and pilots of all levels of experience. The study also concluded that more uniform communication and verification of messages between pilots and controllers could serve to reduce the chance of ambiguous or erroneous commands/actions. The Safety Board’s concern about the runway incursion problem was heightened by three fatal accidents that preceded the STL accident. These accidents were the collision in Atlanta, k.;eorgia, on January 18, 1990;4 the collision in Romulus, Michigan, on December 3, 1990;’ and the collision in Los Angeles, California, on February 1, 1991 .6 These accidents ‘Eastern Airlines flight 111 and Epps Air Service King Air AlOO, Atlanta Hartsfield International Airport, Atlanta, Georgia, January 18, 1990. (NTSB/AAR-91/03.) ‘Northwest Airlines flights 299 and 1482, Detroit Metropolitan Wayne County Airport, Romulus, Michigan, December 3, 1990. (NTSB/AAR-91/05.)

I 27 highlighted the urgent need for improved preventive measures, and redundancy. The Safety Board is aware that, in addition to the more advanced ASDE-3 and AMASS airport surface traffic detection equipment, there are ongoing research and development efforts into alternative, cost- effective airport surface traffic detection systems, such as the ground induction loop. On May 29, 199 1, the Safety Board adopted the Aircraft Accident Report “Runway Collision of Eastern Airlines Boeing 727, Flight 111 and Epps Air Service Beechcraft King Air Al 00, Atlanta Hartsfield International Airport, Atlanta, Georgia, January 18, 1990” (NTSB/AAR- 91/03). That report contained an appendix giving the history of Safety Board recommendation activity on runway incursions. The report also contained two new safety recommendations addressing the runway incursion issue, asking the FAA to: Expedite efforts to fund the development and implementation of an operational system analogous to the airborne conflict alert system to alert controllers to pending runway incursions at all terminal facilities that are scheduled to receive ASDE-3. (A-91-29) Conduct research and development efforts to provide airports that are not scheduled to receive ASDE-3 with an alternate, cost-effective system to bring controller and pilot attention to pending runway incursions in time to prevent ground collisions. (A-9 l-30) Based upon the FAA’s responses to these recommendations, which referred to the AMASS program, research and development activities, and the then-current schedule, the Safety Board classified these recommendations “Open--Acceptable Action” in 1994. As a result of a new recommendation being made in this report, Safety Recommendation A-91-30 is now classified “Closed--Acceptable Action/Superseded.” Since 1991, the Safety Board has issued 28 recommendations concerning the runway incursion issue. Twenty-three of those recommendations and the status of the FAA’s responses are listed in Appendix G. The most recent five recommendations, Safety Recommendations A-95-30 through -34, were issued on February 28, 1995, as a result of concerns discovered during the investigation of this accident (see Appendix H for recommendation letter). The recommendations asked the FAA to: Require, within 45 days of receipt of the recommendation letter, that the Air Traffic Service provide a firm, finalized mission needs and operational requirements document for the AMASS. Also, no further modifications should be implemented until after the first AMASS is commissioned. (A-95-30) %SAir flight 1493 and Skywest Airlines flight 5569, Los Angeles International Airport, Los Angeles, California, February 1, 199 1. (NTSBIAAR-9 l/08.)

28 Provide the Safety Board, within 60 days of receipt of the recommendation letter, with a firm schedule to commission those ASDE-3 radar systems that have been installed and adhere to that schedule. (A-95-31) Require, for those ATC terminal facilities that commission the ASDE-3, that it be operational between sunset and sunrise. When the AMASS is commissioned, require it to be operational 24 hours a day. (A-95-32) Issue an Administrator’s Letter to Airmen that directs pilots to read back, in full, their runway assignment upon receiving taxi clearance when operating at airports that employ more than one runway. Revise the AIM [Airmen’s Information Manual] to reflect this procedure. (A-95-33) Amend FAA Order 7110.65, “Air Traffic Control,” to require that air traffic controllers receive confirmation of runway assignment from pilots after issuing taxi instructions. Require that this procedure be used at those airports that employ more than one runway during operations. (A-95-34) The FAA responded to these recommendations on April 14, 1995, and based on the FAA’s response, the Safety Board classified Safety Recommendations A-95-30, -33, and -34 “Closed--Acceptable Action,” and Safety Recommendations A-95-3 1 and -32, “Open--Acceptable Response,” on August 1, 1995.

29

1. ANALYSIS
2. 1

General The MD-82 flight and cabin crews were certificated, trained, and qualified for their duties. No physiological factors or unusual cockpit distractions existed that would have precluded the flightcrew from seeing the Cessna 441 on the runway. However, environmental factors, such as the darkness and poor conspicuity of the Cessna 441, contributed to the flightcrew’s failure to see the Cessna 441 on runway 30R. The pilot-in-command of the Cessna 441 was certificated, trained, and qualified for the charter flight. The local controller and ground controller were certificated, trained, and qualified for their duties. No physiological disabilities were apparent that would have detracted from their ability to perform at an acceptable level on the evening of the accident. However, the darkness, poor conspicuity of the Cessna 441, and physical distance between the ATC tower cab and the northeast portion of the STL airport contributed to the controller’s failure to see the Cessna 441 on runway 30R. STL airport markings, signs, and lighting near and along the taxi route of the Cessna 441 conformed to FAA standards. Both airplanes were maintained in accordance with the applicable directives, and there was no evidence of any deficiency or malfunction that would have contributed to the collision. Weather conditions were well above the criteria for VFR. In postaccident interviews, neither the flightcrew of the MD-82 nor the air traffic controllers identified environmental factors, other than darkness, as a constraint to the normal performance of their duties. The air traffic volume in the St. Louis area during the time of the accident was moderate, and traffic complexity was routine. However, the ground controller was working seven frequencies at the time of the accident, and several instances of simultaneous transmissions occurred in the 1 l/2 hours before the accident. The ASDE-3 airport surface detection equipment was installed at STL, but had not yet been commissioned and was not operational on the night of the accident. Although the equipment had not yet been commissioned, it would have been available to controllers except that there had been a computer hard drive failure. Had the equipment been operational, it would have displayed the Cessna 441’s position at the intersection of taxiway Romeo and runway 30R for about 3 minutes before the collision.

3 30 The circumstances of this accident indicate that the pilot of the Cessna 441 unintentionally deviated from the taxi clearance he received from the ground controller and taxied onto the active runway being used by the MD-82. The Safety Board’s investigation examined possible reasons why the Cessna pilot might have believed that runway 30R was his departure runway. 2.2 Cessna 441 Pilot Performance The Safety Board believes that several personal factors may have contributed to the Cessna 441 pilot’s deviation from ATC instructions. According to the pilot’s wife, the accident occurred at a time of night when the pilot normally went to sleep, and he may have been tired. Company personnel reported that such late trips were unusual. Although the pilot’s work- rest cycle is not consistent with chronic sleep loss, the fact that he was operating during a period in which he was normally at rest may have had some effect on his performance and level of attentiveness. Additionally, the pilot of the Cessna 441 had commented that it was going to snow in Iron Mountain that night. Midcoast personnel stated that the pilot seemed anxious to go home, a behavior that they considered normal among pilots at that time of night. The combination of the time of day and his desire to return home before the weather deteriorated may have contributed to the mistaken actions of the Cessna 441 pilot, who was generally described in positive terms for his cautious and safe attitude. 2.2.1 Scenario: Pilot Became Lost During Airport Ground Operations The Safety Board considered the possibility that the pilot intended to take off from runway 3 1, as directed, but became lost on the airport and ended up in position to take off on the wrong runway. However, the pilot did not indicate confusion in his radio responses to the taxi clearance, and radar data indicated no hesitation in his taxi route. (See Appendix E.) The passenger who chartered the Cessna 441 to STL before the accident flight reported that on a previous flight when the pilot of the Cessna 441 had become uncertain of his position at an airport, he had stopped taxiing until he determined his location. She also indicated that it was the pilot’s habit to taxi with the airport diagram in front of him. The current STL airport diagram approach chart was located in the cockpit area of the Cessna 441 wreckage. Additionally, the pilot’s flight logbook revealed that he had landed once before at STL. The previous flight was a daytime operation and occurred approximately 10 months before the accident. 2.2.2 Alternate Scenario: Pilot’s Pleconceplion that Runway 30R was his Ihparture Runway The evidence indicates that it was unlikely that the pilot was lost, but rather that he had a preconception that he would be departing on runway 30R and thus did not register the ground controlle.-‘s clearance to runway 3 1. Several situational cues may have reinforcec ‘ie Cessna 441 pilot s preconception that runway 30R was his assigned departure runway. ? he Cessna 441 pilot had landed on runway 30R about 18 minutes before he received the taxi

31 clearance to runway 3 1 for his departure. The “quick turnaround” nature of the flight may have added to the Cessna pilot’s belief that he would be departing on runway 30R. Also, from the time he approached STL for landing until he taxied out for takeoff, all traffic had landed and departed on runways 30R and 30L. The ATIS that was current during the time the pilot operated in the STL area listed runways 30R and 30L as the active runways for arrivals and departures at STL. The STL controllers did not typically list runway 31 as an active runway on the ATIS, as runway 31 was only occasionally used as a departure-only runway. Also, the STL controllers did not typically treat runway 3 1 as if it were an active runway; for example, when the Cessna 44 1 pilot cleared runway 30R on his inbound flight, his taxi clearance to the Midcoast ramp did not include a clearance to cross runway 31. The Safety Board believes that if runway 31 had been referenced as a runway for occasional general aviation departures on the ATIS broadcast, the pilot may have been more attentive to the controller’s taxi clearance and runway assignment. Another situational cue that could have reinforced the Cessna 441 pilot’s notion that runway 30R was his departure runway was the fact that when he began to taxi outbound from the Midcoast ramp on taxiway Whiskey (150 feet long), he almost immediately encountered runway 3 1, unlike the more typical airport layout in which a ramp exit leads to a parallel taxiway en route to the runway. During the on-scene investigation, several local pilots acknowledged that the proximity of runway 31 to the Midcoast ramp created a situation where pilots could inadvertently enter onto runway 3 1 without recognizing that they were on a runway. The Cessna 441 pilot had an airport diagram available in the cockpit, and may have referred to it during his outbound taxi. However, it is also possible that he believed the taxi route to runway 30R was obvious and thus did not pay much attention to the diagram. Even if he had referred to the airport diagram, he may have had difficulty discerning runway 31 on it, due to dim lighting in the cockpit, and the competing tasks that included taxiing the airplane and performing checklists. While runway 3 1 had markings, signage, and lighting consistent with FAA airport certification requirements, had several elements been slightly different, they might have triggered the pilot to question his notion that runway 30R was the assigned departure runway. These elements include runway width, displaced threshold, and runway markings and lighting. Runway 31 is 75 feet wide, which is typical of taxiways at STL. In contrast, runways 30R and 30L are 150 and 200 feet wide, respectively. At the time of the accident, a 1,838-foot displaced threshold was incorporated into the runway 3 1 marking/lighting scheme. The markings on the approximately 800-foot-long portion of runway 3 1 on which the Cessna pilot back-taxied consisted of a series of white arrows pointing toward the numbers. The runway 3 1 numbers were located at the end of the displaced threshold, near the intersection of runway 3 1 and taxiway November. The Cessna pilot’s taxi route did not go past the numbers.

I 32 Along the displaced threshold, the runway lights had split red and white lenses, situated so that the white side of the lens was presented to the Cessna pilot as he back-taxied. This would have been a clue to the pilot that he was on a runway. However, the red side of the lens would have been visible to an airplane on approach for the runway, or to a pilot holding in position on runway 31 for departure. Because of the displaced threshold marking scheme, the Cessna pilot could not have seen the numbers for runway 3 1. Had he seen the numbers, the pilot might have been cued to question the controller as to the controller’s intentions. The Safety Board acknowledges that the runway marking and lighting were in accordance with FAA requirements, and does not consider them to be factors in this accident, except to the extent that they may not have provided the pilot with sufficient cues to cause him to be more attentive to the controller’s clearance. Runways 30R and 30L have complex approach lighting systems, which are especially visible at night. At the time of the accident, the white runway edge lights of runway 31 were operating at a dimmer setting than those of runways 30R and 3OL, which is standard practice at STL. The Safety Board believes that the dimmer lights on runway 31 were not sufficient to distract the pilot from his preconception that runway 30R was his intended departure runway. Finally, as the Cessna 441 pilot proceeded from taxiway Romeo into position on runway 30R, he entered the runway at an intersection 2,500 feet from the threshold. According to the AIM, an intersection clearance can be requested by the pilot or initiated by the controller. The Cessna pilot did not request an intersection takeoff, nor did the ground controller indicate that the pilot should expect an intersection departure, and the pilot should not have entered the runway at an intersection, without specific clearance to do so. While the Cessna 441 pilot’s entry onto the runway at an intersection should have been a final cue that his notion of being cleared to runway 30R was incorrect, the cue was apparently not sufficient to cause him to question his perception that he had been cleared to runway 30R. 2.2.3 Communications Effective radio communications between the Cessna 441 pilot and ATC were critical to establishing a mutual understanding of intentions. The ground controller’s multiple frequencies were congested with almost continuous communication, which resulted in several simultaneous transmissions in the 20 minutes before the accident. Additionally, there was some indication that the Cessna 441 pilot might have experienced communication radio difficulty. Specifically, the pilot complained about his communication radios during the inbound flight to STL, and several subsequent transmissions were garbled. Under these circumstances, it was especially critical for the pilot to ensure that effective communications were taking place. The Safety Board noted that the Cessna pilot did not sta!e the departure runway in any of his clearance readbacks. Although critical item readbacks have always been considered important in airborne operations, until recently, there was no requirement for critical item clearance readbacks for surface operz:ons. This omission was addressed in Safety

33 Recommendations A-95-33 and -34, which were issued, as mentioned in Section 1.18.5 of this report, during this investigation. In response to the recommendations, the FAA stated that it anticipates changing the AIM and Advisory Circulars 61-2 1 A, “Flight Training Handbook,” and 21-23B, “Pilots Handbook of Aeronautical Knowledge,” urging pilots to read back in full their runway assignment when operating at airports with more than one runway. Also, the FAA has developed a change to FAA Order 7110.65, “Air Traffic Control,” to require air traffic controllers to obtain confirmation of runway assignment from pilots after issuing taxi instructions. The Safety Board believes that, had this change been in effect, this accident might not have occurred. The occasionally nonstandard radio communications between the Cessna 441 pilot and the controllers did not serve to effectively clarify intentions or expectations on either side. There is no current FAA requirement for pilots to use standard terminology in their communications with ATC. However, the AIM provides a pilot/controller glossary that presents standard terminology. The Safety Board concludes that airport ground operations, have become sufficiently complicated, that incomplete or colloquial communications are inadequate, and that more rigorous adherence to standard phraseology--by pilots as well as controllers--is essential. 2.3 MD-82 Flightcrew Perfommnce The Safety Board examined the ATC communications and CVR records and concludes that the actions of the MD-82 flightcrew were typical of normal airline operations and did not contribute to the accident. However, the Safety Board was interested in the extent to which the flightcrew might have been aware of the taxi operations of other airplanes. 2.3.1 Airport Traffic Awareness The AIM and other pilot guidance material stress the need for pilots to be alert and vigilant in monitoring air traffic communications during ground operations so that they can detect situations that can lead to conflict with other aircraft or vehicles. However, at STL, as with many other airports, there are multiple ground control and local control frequencies used by different controllers to communicate with aircraft taxiing, landing, or taking off on different parts of the airport. This is necessary during busy traffic periods to distribute controller workload and reduce radio frequency congestion. At STL, there are separate ground control positions in the tower and separate radio frequencies for the north and south operations on the airport. Thus when the tower is fully staffed, air carrier pilots taxiing from the south side of the airport would normally be unable to hear tower communications with, and would thus be unaware of, aircraft taxiing from the general aviation ramp on the north side. During periods when the traffic count permits, it is a common practice to reduce the staffing in the tower cab and assign a single controller the responsibility of multiple operations normally handled by separate controllers. This was the case on the night of the accident when a single controller was staffing both the north and south ground control positions in addition to the clearance delivery and flight data positions. When operating in this position- combined mode, the controller can assign aircraft operating from the north and south sides of the

I 34 airport the same communications frequency, or as on the night of the accident, the controller can monitor different frequencies while transmitting simultaneously on all. Thus, while the pilot of the MD-82 would have been able to hear the ground controller clear the Cessna 441 to taxi, he could not hear the Cessna pilot’s acknowledgement. It is not surprising that the MD-82 flightcrew reported that they were not aware of the Cessna 441 operation from the north side of the airport. In his testimony at the public hearing after the accident, the MD-82 captain reported, “We, as pilots, only hear part of the conversation [two-way ATC dialogue] and don’t know where other aircraft are . . . .That effectively destroys our situational awareness . . . eliminates the double check on . . . safety procedures.” He also testified that he believed that reduction/elimination of multiple frequencies would help pilots’ situational awareness and I’. . . greatly enhance safety . . . .” While the Safety Board agrees that, when controller positions are combined, the use of a common frequency for all aircraft being worked by the controller could enhance the opportunity for pilots to be aware of potential traffic conflicts, it does not consider the use of multiple frequencies to be a factor in this accident. Had the MD-82 flightcrew been attentive to the taxi clearance issued to the Cessna 441, they would have believed that the Cessna was taxiing to runway 31 and it is not likely that they would have considered the Cessna as a potential danger to their operation. Since the Cessna pilot did not read back his runway assignment, the flightcrew of the MD-82 would not have been able to detect the possible mistake in clearance in any event. The Safety Board concludes that the use of combined positions with multiple frequencies was not a factor in this accident. However, the Safety Board does not believe it is in the interest of safety to create a situation in which there can be simultaneous transmissions and potentially decreased pilot awareness. The Safety Board believes that, when positions are combined, ATC personnel should make every effort to use as few frequencies as possible. Those frequencies in use should be broadcast on the ATIS to enable flightcrews to communicate with the controllers. 2.3.2 Conspicuity of Cessna 441 from the Runway 30R dueshold The Safety Board conducted a test to establish the line-of-sight visibility from the MD-82 pilots to the Cessna 441 when both airplanes were positioned for takeoff on runway 30R. The purpose was to establish whether any physical obstruction to the visibility of the Cessna was caused by runway 30R gradation. Visual observations were made during afternoon daylight and clear weather conditions. Under these conditions, the Cessna was visible from the approximate vantage point of the MD-82 flightcrew, but it presented a very small target. During the initial on-scene examination of the Cessna 441, the external lighting cockpit switches were 10~ .ited in their off (down) positions, except the nose gear taxi light, which was found in the on position. Additionally, during the initial examination, the two wing-mounted retractable landing lights were found in their stowed positions. However, based on ARFF

3 35 personnel reports of their activities during the emergency response, the Safety Board does not believe that these positions are necessarily an accurate depiction of switch and light positions at the time of the collision. The Safety Board’s laboratory examination of the light bulbs from the Cessna 441 indicated that filaments were stretched on the left wing tip-mounted navigation, white tail cone- mounted navigation, nose gear-mounted taxi, and the left wing-mounted landing lights. Filament stretch indicates that the filament was hot at the time of impact (an illuminated bulb). The Safety Board believes that the right wing tip-mounted navigation light and the right wing-mounted landing light filaments were not stretched because the right side of the airplane was subject to lesser impact forces. The Safety Board concludes that the Cessna 441 taxied from the Midcoast ramp with the nosewheel taxi, white tail cone-mounted navigation, and red and green wing tip- mounted navigation lights illuminated. Based on Superior Aviation company policy and common pilot practice, the Safety Board believes that the Cessna 441 wing-mounted landing lights were not illuminated until the airplane was in position on runway 30R at its intersection with taxiway Romeo. The Cessna 441 was not equipped with a rotating red anticollision light, which on many other aircraft types is visible from behind the airplane. Wing tip-mounted anticollision/strobe lights satisfied the certification requirement for anticollision lighting. It could not be determined whether the wing tip-mounted anticollision/strobe lights were operating at the time of the collision. Based on the controllers’ inability to maintain visual contact with the Cessna 441, and the common procedure among pilots to delay use of anticollision/strobe lights until takeoff clearance is received (out of consideration for the night vision of other pilots), the Safety Board considers it unlikely that the wing tip-mounted anticollision/strobe lights were operating at the time of the collision. Although the navigational lights on the Cessna met Federal standards, FAA specialists testified that the Federal standards for aircraft external lighting are primarily intended to serve in-flight conspicuity needs rather than conspicuity of aircraft on airport surfaces. External lighting tests had been conducted during the Safety Board’s investigation into the ground collision accident involving a Boeing 737 and an SA-227, in Los Angeles, California, in February, 1991.’ These tests revealed that when the SA-227 was viewed from behind, at night, with navigation lights on, it was difficult to differentiate between an airplane in position on the runway and the lighted runway environment, especially on a runway with centerline lighting. The tests also revealed that airplane conspicuity on an active runway was increased if the airplane used anticollision/strobe lights, and was positioned offset from the runway centerline. The Safety Board issued several safety recommendations to the FAA that addressed aircraft conspicuity as a result of this investigation. Among these recommendations were: ‘NTSB/AAR-91/08.

P 3 36 Redefine the airplane certification coverage compliance standards for anticollision light installations to ensure that the anticollision light(s) of an aircraft in position on a runway are clearly visible to the pilot of another aircraft preparing to land or take off on that runway. (Class II, Priority Action) (A-91-1 11) Evaluate and implement, as appropriate, suitable means for enhancing the conspicuity of aircraft on airport surfaces during night or periods of reduced visibility. Include in this effort, measures such as the displacement of an aircraft away from the runway centerline, where applicable, and the use of conspicuity enhancements, such as high-intensity strobe lighting and logo lighting by aircraft on active runways, and encourage operators of airplanes certificated prior to September 1, 1977, to upgrade their airplanes to the present higher intensity standards for anticollision light installations. (Class II, Priority Action) (A-91-1 12) The current status of Safety Recommendation A-91-1 11 is “Open--Unacceptable Action.” Although the FAA’s initial response in March 1992 indicated that it had reviewed applicable design standards and found them to be adequate, almost 3 years after the recommendation was issued the FAA responded to an NTSB followup letter stating that it was continuing its effort to revise the regulations to comply with the Safety Board’s recommendation, and that it was referring the matter to the Aviation Rulemaking Advisory Committee. The most recent Safety Board correspondence is dated April 27, 1995. The current status of Safety Recommendation A-9 1 - 112 is “Closed--Unacceptable Action,” also dated April 27, 1995. The FAA’s response indicated that it believed that its effort to revise the regulations concerning anticollision light design standards to comply with Safety Recommendation A-91 -111 would completely address the concerns raised in Safety Recommendation A-91 -112. However, the Safety Board received no indication that the FAA evaluated or implemented methods to enhance the conspicuity of aircraft, or encourage operators to upgrade the lighting systems of aircraft certificated before September 1, 1977. The Safety Board believes that the use of strobe lighting and the practice of displacing the airplane off the centerline lighting would significantly enhance the ability of other pilots and air traffic controllers to visually detect traffic conflict situations. Specifically, the Safety Board believes that, had the pilot of the Cessna 441 used anticollision/strobe lights and positioned the airplane so that it was offset from the runway centerline lighting, it would have increased the likelihood that the MD-82 flightcrew would have detected the runway incursion in time to avoid the collision. Although Safety Recommendations A-9 l-1 11 and - 112 address conspicuity issues, they do not address the evaluation of requiring pilots to use anticollision/strobe lights while in position on active runways. Therefore, the Safety Board believes that the FAA should examine the feasibility of requiring pilots to turn on anticollision/strobe lights while holding in position on active runways.

I 3 37 With the wing tip-mounted anticollision/strobe lights turned off, the white tail . cone-mounted navigation light would have been the only light visible to the MD-82 flightcrew. The other navigational lights would have been obscured by the structure of the Cessna. The Safety Board believes that the white tail cone-mounted navigation light would have blended in with the runway centerline lighting system and that it would not be reasonable to expect that the MD-82 flightcrew could have seen the Cessna 441 in time to prevent the accident. 2.4 Role of Air Traffic Contml The Safety Board also evaluated the performance of the ATC personnel involved in this accident. 2.4.1 Issuance of Taxi Cleamnce The ground controller failed to use standard phraseology in his initial taxi clearance transmission. The initial taxi clearance that the Cessna pilot received from the ground controller was, “One Kilo Mike, roger, back-taxi into position hold runway three one, let me know this frequency when you’re ready for departure.” Text in the AIM that was in effect at the time of the accident, section 4-67 , “TAXIING #7,” tells pilots to expect ATC to first specify the runway, then issue taxi instructions, and to state any required hold short instructions. This information is also contained in FAA Order 7110.65, “Air Traffic Control,” which directs controllers to issue clearances in the same manner. An example of a correct clearance would be: “Taxi to runway 3 1. Turn left on runway 1313 1, proceed to the end, position and hold. Let me know this frequency when you’re ready for departure.” In effect, the pilot of the Cessna 441 received a nonstandard clearance, in which the phrase “taxi to,” and the departure runway had been eliminated. Instead, the controller simply issued taxi instructions followed by more detailed instructions regarding a communications frequency. Had the taxi clearance been in accordance with prescribed phraseology, it might have altered the pilot’s preconception of departing on runway 30R. Although the initial taxi clearance included technically improper phraseology, the ground controller gave the Cessna pilot another cue that runway 3 1 was his assigned departure runway when he referenced runway 3 1 in a second transmission. When the Cessna 441 pilot advised the ground controller, ‘I. . . we’re ready to go,” the ground controller replied, I’. . hold on position on runway three one and monitor the tower on one two zero point zero.” The Cessna 441 pilot responded, I’. . understand position and hold, monitor the tower . . . .” The ground controller had no indication that the pilot was not familiar with surface operations at STL. Although the pilot did not read back the departure runway when he acknowledged his taxi clearance, he gave no indication that he was uncertain about the instructions he received from the ground controller. This resulted in an illusion of effective communication, when in fact the pilot misunderstood the ground controller’s intentions. Although there was no requirement at the time of this accident, the controller, could have requested the

38 Cessna 441 pilot to read back the runway assignment. However, the controller’s communication . workload was heavy (as described in Section 2.4.3), and the Safety Board does not fault the controller’s action in this regard. The Safety Board strongly supports the FAA’s change to Order 7110.65, “Air Traffic Control,” requiring that controllers obtain confirmation of runway assignment. Additionally, the Safety Board has noted that the term “back-taxi,” while commonly used, and apparently understood, by pilots and controllers, is not officially defined in either the AIM or FAA Order 7110.65, “Air Traffic Control.” The Safety Board believes that the FAA should officially define the commonly used term “back-taxi” in the Pilot-Controller Glossary, and provide an explanation of the use of the term and application of the procedure in the AIM and FAA Order 7110.65, “Air Traffic Control.” 2.4.2 Visual Detection/Tracking of Cessna 441 The ATC tower structure is located on the southwest side of the runway complex and terminal buildings, about 1 l/4 miles from the site of the collision. ATC tower personnel indicated that it was often difficult to see small airplanes operating on the north side of the airport, especially on the far end of runway 3 1, at night. Given the known difficulty of visually acquiring general aviation airplanes at night in that area of the airport, the ground and local controllers might have heightened their vigilance when they lost visual contact with the Cessna 441. However, based on the pilot’s radio communications, the controllers perceived the pilot of the Cessna 441 to be confident and familiar. Additionally, the ground controller was working the clearance delivery position at the time of the accident, which required that he intermittently have his head down to read and issue clearances. This made it less likely that the ground controller would be able to effectively visually monitor the Cessna 441. Concerning aircraft visibility, the STL ground and local controllers reported that they did not observe any exterior lights illuminated on the Cessna 441. They stated that from the time the Cessna 441 taxied from the well-lighted Midcoast ramp, they were unable to maintain visual contact. ATC personnel acknowledged that it was not unusual to lose visual contact with general aviation airplanes operating on that part of the airport at night. Since ATC personnel did not observe the Cessna 441 in position on runway 30R, they assumed that the airplane did not have its landing lights illuminated. However, postaccident examination of the landing light bulbs indicated that they were illuminated at impact. The Safety Board believes that the Cessna pilot may have turned the landing lights on seconds before impact in anticipation of a takeoff clearance. The Safety Board concludes that, given the Cessna 44 l’s lighting as it departed the Midcoast ramp, the ground and local controllers could not have reasonably been expected to visually .detect the Cessna pilot’s deviation irom the taxi instructions. When it became apparent

39 to the controller that he could not follow or determine the position of the Cessna, he could have requested the pilot to turn on his landing lights and/or anticollision/strobe lights to enhance the airplane’s conspicuity. However, the Safety Board acknowledges that there are no procedures requiring controllers to make such a request and thus cannot fault the controllers for not doing so. Nevertheless, if the Cessna pilot had enhanced the airplane’s conspicuity by using additional lighting, especially during the 3 minutes that the airplane was in position at the intersection of taxiway Romeo and runway 30R, it would have increased the likelihood that the controllers could have detected the airplane’s improper position in time to avoid the collision. The need to enhance conspicuity for controllers as well as other pilots reinforces the Safety Board’s belief that the FAA should revise the Federal Aviation Regulations to require pilots to illuminate all taxi, landing, and logo lights, or otherwise enhance the conspicuity of their aircraft when operating on an active runway (including runway crossing and position-and-hold operations). Further, the Safety Board notes that requiring pilots to turn on aircraft anticollision/strobe lights when holding in position on active runways, as discussed in Section 2.3.2, would assist air traffic controllers, as well as pilots of other aircraft in detecting runway incursions. 2.4.3 ATC Staffing and Wotidoad The Safety Board acknowledges that the efficient use of resources requires FAA facilities to adjust on-duty staffing levels to the traffic flow expected during different times. On the night of the accident, the ground controller was working four positions and monitoring seven radio frequencies. Although the controllers characterized the workload as moderate rather than heavy, the Safety Board believes that the higher-than-normal traffic level, as a result of the Thanksgiving Day holiday, and the continual communication on the clearance delivery and ground control frequencies, may have resulted in the controller being less attentive to the position of the Cessna than he would have been under lesser workload conditions. The Safety Board is particularly concerned that the controller’s communications workload may have been exacerbated by the difficulties of contending with blocked or garbled transmissions as two or more aircraft attempted to communicate on separate radio frequencies. Under such circumstances, the controller may have been less apt to request verbal communication confirmation from the Cessna pilot of the initial runway assignment or his subsequent position on the airport. The Safety Board believes that, considering the workload at the time of the collision, the clearance delivery position should have been manned rather than being combined at the ground control position. The Safety Board also believes that, had the clearance delivery position been staffed, rather than combined at the ground control position, the ground controller would have had more time for other functions, such as tracking the Cessna 44 1. Subsequent to the accident, the STL ATC tower staffing schedule was changed to retain an additional controller and supervisor until lo:30 p.m. The Safety Board believes that this

40 staffing change provides an additional level of safety. The Safety Board is aware of several procedures and services that are being developed and used at airports throughout the country in an attempt to reduce radio frequency congestion. These procedures include standard coded taxi routes (currently in effect only at O’Hare International Airport, in Chicago, Illinois), and automated flight clearance delivery. At the time of this accident, the STL airport had the capability to deliver automated flight clearances, but the MD-82 did not have the onboard equipment to use the service. Since,the accident, TWA has acquired the capability to receive automated flight clearances. Had the automated clearance delivery service been used the night of the accident, the ground controller’s workload would have been significantly reduced. Thus, the Safety Board believes that the FAA should continue to develop, publish, and encourage the implementation of procedures such as automated flight clearances and standard taxi routes to reduce radio frequency congestion during ground operations. 2.5 Airport Factors - Designation of Runway 31 The Safety Board reviewed the significance of runway 1313 1 being designated with a 10” offset instead of being designated as 12L/3OR (with the other two parallel runways redesignated as 12C/3OC and 12R/3OL) as is standard for three parallel runway configurations at other airports. The Safety Board believes that had the runways been designated as 30R, 3OC, and 3OL, the pilot of the Cessna 441 may have discerned the significance of the taxi clearance. However, the Safety Board also acknowledges that such designation could confuse arriving pilots, who would view the two larger parallel runways as a normal right and left configuration. The Safety Board is aware that the FAA is currently studying the feasibility of redesignating these runways. The Safety Board concludes the marking and lighting for runway 13/3 1 was clear, well defined, and in accordance with FAA standards, which the Safety Board believes are adequate. However, the runway 3 1 threshold displacement could have been a source of confusion to pilots if they were unfamiliar and/or inexperienced with displaced threshold marking and lighting. Additionally, since runway 31 was not open to landing traffic, the displacement was, in effect, superfluous. However, as mentioned previously, the STL Airport Authority petitioned for and received FAA approval to eliminate the displaced threshold on runway 3 1; the displaced threshold runway markings will be removed and the runway will appear full length by September 1, 1995. Runway 3 1 will still be restricted to departures only. The Safety Board has noted that following the accident the airport installed taxi- holding position lights (“wig-wag” lights) at taxiway Whiskey to further enhance and delineate the presence of runway 13/3 1 for aircraft exiting from the Midcoast ramp. Although the Safety Board concludes that markings, signs, and lighting in that area were adequate, it also believes that this enhancement is worthwhile and provides an additional safety redundancy.

3 41 2.6 Pllevention of Runway Incursions 2.6.1 Pilot Training in Gnwnd Operations During the Safety Board’s April 19-20, 1995, public hearing on this accident, the Safety Board heard testimony from ATC personnel and air carrier pilots indicating that additional training should be undertaken to ensure that pilots are familiar with airport ground operations, including airfield markings, signs, and lighting. A study/survey of pilots entitled, “Reports by Airline Pilots on Airport Surface Operations”8 indicated a need for pilot training on surface operations. A solution proposed in that study recommends “That the airlines develop and implement training in cockpit procedures and communications for surface operations, emphasizing the timing and integration of all, cockpit tasks and the requirement for structured verbal coordination on surface orientation, and navigation.” Currently, pilot initial and recurrent training programs are directed primarily at airborne operations. However, public hearing testimony indicated that many pilots believed the most difficult part of any trip occurred between the runway turnoff and the gate. This accident reinforced the need for pilot training on surface operations, including airfield markings, signs, and lighting. Although air carrier training was not a factor in this accident, the Safety Board believes that initial and recurrent air carrier pilot training programs should include training in airport surface movement operations and familiarization with airport markings, signs, and lighting. The Safety Board also believes that similar training on airfield surface operations, including airport markings, signs, and lighting should be provided for all general aviation pilots during initial training and biennial flight reviews. As a result of the previously mentioned runway incursion accidents that occurred in Atlanta, Georgia; Romulus, Michigan; and Los Angeles, California;‘. the FAA generated several informational/educational handouts and flyers, which it’ intended to distribute to certificated pilots through a variety of methods (i.e., safety seminars, operations bulletins, etc.). The Safety Board notes that this distribution has not reached its entire intended audience. The Safety Board believes that the FAA should mass-mail all currently certificated pilots FAA publications on reducing runway incursions and airport improvement information, such as airport signage changes. 2.6.2 ASDEIAMASS ASDE-3 was installed at STL in September 1994, and subjected to a proving *Docket No. SA-5 13, Exhibit No. 14B, MITRE Corporation Report on Airport Surface Operations -- May, 1994; pg xxvi, Exhibit Pg. 28. %TSB/AAR-91/03; NTSBJAAR-91105; and NTSBJAAR-91J08, respectively.

42 period, during which the equipment was calibrated, functions were verified, and hardware and interface problems were resolved. During the proving period, controllers had ASDE-3 available periodically, and were encouraged to use the equipment at those times. As mentioned previously, STL controllers reported difficulty visually distinguishing general aviation airplanes operating on the northeast portion of the airport at night. An operational ASDE-3 would supplement visual scan of the airport surface. However, on the night of the accident, the ASDE-3 equipment was not available for controller use, due to the computer hard drive failure. The Safety Board believes that had the ASDE-3 equipment been available for controller use on the night of the accident, the ground and local controllers would have had a higher probability of identifying the Cessna 441 at runway 30R. The Cessna 441’s position at the intersection of taxiway Romeo and runway 30R for 3 minutes before the collision would have allowed ample time for the local controller to have identified the airplane during his routine ASDE-3 scan of the runway before issuing takeoff clearance to the MD-82. The Safety Board is also aware of several advanced concepts in airport surface traffic detection and automation that, when perfected and combined with the correct hardware and location-specific software, could provide automated warnings to preclude accidents of a nature similar to the collision at STL. The Safety Board fully supports the early development and installation of such systems at airports where the volume and complexity of traffic flow warrant their use. AMASS manufacturer Westinghouse-Norden Systems produced a video simulation that portrays how AMASS could have performed at STL during the accident scenario. In this simulation, the AMASS provided controllers with an aural and visual warning about 17 seconds before the collision. Adjustments of the many variables in the AMASS software, typically accomplished when the system is customized for the particular airport installation, can alter this warning time. For AMASS to prevent or reduce the severity of a collision, the system warning must be converted into action by a minimum of two persons. The controller must recognize the warning, comprehend the situation, determine which aircraft and/or vehicles are involved, determine a preventive course of action, and relay appropriate instructions to the subject aircraft and/or vehicles. The aircraft and/or vehicle operator(s) must then comprehend those instructions, and determine and execute an appropriate response. An operational ASDE-3 system could have compensated for the Cessna 441’s poor conspicuity while operating at night on the northeast portion of the STL airport, and an operational AMASS could have provided an automated warning of the impending collision. Thus, the Safety Board believes that the installation and utilization of ASDE-3, and particularly ASDE-3 enhanced with AMASS, could have prevented this accident.

E 43 . 2.6.3 Other Runway Incursion Prcevention Technology Following the runway incursion accident at the Atlanta Hartsfield International Airport on January 18, 1990, the Safety Board recommended that the FAA: Conduct research and development efforts to provide airports that are not scheduled to receive Airport Surface Detection Equipment with an alternate, cost effective system to bring controller and pilot attention to pending runway incursion in time to prevent ground collisions. The Safety Board remained concerned that the problem of runway incursions is not confined to the 37 major airports that are slated to receive the ASDE-3 and its associated AMASS. The Safety Board is aware that during June 1991, the FAA conducted a Broad,Agency Announcement that allowed for the demonstration of alternative technologies for surface movement, These demonstration programs are outlined in the FAA’s 1995 RIAP. A review of the milestones established for the development of a low-cost alternative for runway incursion prevention indicates that an evaluation of these alternatives will continue through 1996. The Safety Board is aware of a draft FAA document entitled, “Operational Concepts for Surface Movement in the 21st Century.” During an FAA-sponsored surface movement technology forum attended by Safety Board staff during March 1995, over 115 participants, comprising a cross-section of users and industry, endorsed this document with only minor changes. This comprehensive document outlines the application of future technologies and operational concepts for operating on airports within the National Airspace System. The Safety Board supports the intent of this type of advance planning and urges the FAA to embrace this document and use it as the blueprint and cornerstone for the development, implementation, and evolution of safer surface operations. 2.6.4 FAA Pmgmm Initiatives/Management The Safety Board was encouraged by many of the FAA’s actions in the aftermath of a series of runway incursion accidents during the early 1990s. These actions included new airport markings, signs, and lighting, coded taxi routes at the O’Hare International Airport, and low visibility operational initiatives at the Seattle/Tacoma International Airport. The Safety Board believes that since 1991, there has been limited action to address the runway incursion issues until the FAA’s 1995 RIAP. Public hearing testimony by MITRE Corporation personnel indicated that the FAA should consider addressing the runway incursion problem in two arenas. One suggested arena was the basic surface system in which human performance issues require corrective action on a near-term basis; the other arena was surface technology, which is more long term. It was also disclosed that MITRE’s “Reports by Airline Pilots on Airport Surface Operations” study contained 40 proposed solutions for the reduction of pilot error during airport surface operations. According to the testimony, most of these solutions were not costly and were “doable”-- for

3 44 example, pilot and controller communications. The Safety Board believes that the FAA, in conjunction with industry, should now develop working groups tasked with developing mechanisms to implement these solutions. The second part of the MITRE report is expected to be completed during September 1995. The Safety Board believes that the FAA should employ an independent source to conduct a survey, similar to that conducted by MITRE, of its terminal ATC staff to determine their concerns and views of the scope and magnitude of the runway incursion problem and their recommendations for the reduction of runway incursions. As a longer-term measure, the Safety Board notes that the FAA has developed a working draft document entitled, “Annotated Regulatory, Procedural, and Recommended Practices for Surface Movement of Aircraft by Pilots and Ground Vehicles by Operators.” This document, prepared by the FAA’s Systems Architecture and Integration Division, is described as “a discussion paper and baseline document to discuss changes in roles and responsibilities on the [airport] surface.” It sets forth procedures for operating aircraft and ground vehicles, emphasizes communications and interactions between the control tower and pilots of aircraft on the ground, and sets forth what might be considered “rules of the road” as a standard applicable to all pilots, both foreign and domestic. The Safety Board believes that the FAA should finalize this document to establish a blueprint for improved operations on the airport surface. The Safety Board believes that there is a lack of accountability and stability in the FAA’s long-term program management process. Statements made by principal witnesses at the public hearing indicated that since the initial development of AMASS, numerous personnel changes occurred in key offices. The Safety Board believes that the process of familiarizing new management personnel with the program may have led to unnecessary revisions in program requirements and priorities that resulted in delays in the AMASS development. The Safety Board understands that past programs have been delayed beyond initial schedule targets because the different organizations involved in establishing and accepting the criteria for equipment performance have been unable to resolve those differences quickly. The Safety Board notes that before the public hearing on the accident, the FAA, in a formal press release, announced that AMASS would be deployed at the San Francisco International Airport in May 1996. Testimony at the public hearing indicated that a “zero bucket” [base-line] AMASS would be installed at San Francisco. The Safety Board notes that the FAA plans a validation phase for the AMASS following the planned May 1996 deployment. The Safety Board hopes that validation of the system will not result in further unnecessary delays. The Safety Board believes that the ATC procedures for the use of AMASS should be reviewed. While acknowledging that AMASS should provide the controller an alert only after other redundancies have failed, the Safety Board does not believe that controllers should be permitted to inhibit targets that would otherwise qualify to generate an alert. In addition, the FAA should assure that the ATC procedures that relate to interface with the ASDE-3 and AMA: .j system are not so demanding that they will divert the controller’s attention away from

45 his/her primary duty of separating aircraft. The Safety Board encourages the FAA to continue the research effort in Airport Surface Traffic Automation (ASTA), which is intended to develop automation tools and more complete automation for controlling the flow of aircraft on the airport surface. In addition to reducing the frequency of runway incursions, design goals of the program should include a reduction in taxiway incursions and improvements in ATC operational efficiency. This automation, including Departure Flow Management (DFM) and Terminal Air Traffic Control Automation (TATCA), is intended to support interactions among the various aircraft on the airport surface and on the approach path. Although the Safety Board fully supports and encourages these efforts, it nevertheless recognizes that these programs are intended for a limited number of high-density air carrier airports, and that the operational benefits will not be available until the late 1990s. The Safety Board encourages the FAA’s efforts to fund, support, and implement an operational system, such as the induction loop in-ground sensor system, analogous to the airborne conflict alert system, to prevent runway incursions at all U.S.-certificated airports. 2.7 Survivability Aspects 2.7.1 Airport Closure/Emergency Operations STL airport management, which has the authority to close the airport after an accident, did not close the airport after this col,lrsion. STL remained open, and aircraft and ground vehicle movement continued near the afcident sites. Several radio transmissions from pilots of taxiing airplanes to the ground controller indicated that the pilots were concerned about the possibility of passengers from the MD-82 wandering in front of their airplanes. Seven minutes after the collision, Federal Express flight 1283 landed on runway 30L. About 17 minutes after the accident, the air traffic controllers temporarily suspended airport operations. The Safety Board believes that, because the airport was not closed immediately following the accident, the evacuated passengers were put in danger of being injured by taxiing aircraft. While the airport authority has jurisdiction over the physical operation of the airport, air traffic controllers still have a responsibility for the safe operation of airplanes on and around the airport. Closing the airport would allow controllers and/or airport authority personnel to assess the situation and to redirect both airborne and surface traffic to areas remote from the accident site. The assessment period could have been brief, and the airport could have been reopened after safe conditions were confirmed by the airport operator. As a result of this unsafe situation, on July 17, 1995, the Safety Board issued Safety Recommendation A-95-78 asking the FAA to: Provide guidance to all 14 CFR Part 139 certificated airports that in the event of an accident or significant incident, the airport be closed immediately by either the

46 airport operator and/or the appropriate FAA air traffic control facilities through letters of agreement with airport operators. Also, specify that the airport, or portions thereof, should not be reopened until the airport operator has ensured that: (1) aircraft operating areas are secure; (2) aircraft movement areas that are to be reopened have been properly inspected; and (3) adequate aircraft rescue and fire fighting protection is available for aircraft operations. The FAA has not yet responded to this recommendation. (The recommendation letter containing this recommendation is in Appendix I.) 2.7.2 Evacuation of the MD-82 The MD-82 flightcrew took an estimated 2 to 3 minutes to evaluate the emergency situation before deciding on the safest method of evacuation. They indicated that the delay afforded the cabin crew some time to calm frightened passengers, and the subsequent evacuation through the single door (Rl) was described as orderly. Estimates as to the duration of the evacuation varied widely, but the average was 7 minutes. The shortest estimate was 4 minutes, the longest was 15 minutes. Several passengers, especially those seated farthest aft in the airplane, complained that the evacuation took too long, because only one exit was used. The FAA certification standard requires that a full airplane must be evacuated within 90 seconds, with half of the exits blocked. The Safety Board believes that the flightcrew’s evacuation decision, based on the large quantity of pooling fuel on the left side of the airplane, and the spilling fuel and impact-related physical damage on the right side of the airplane, was a safe, sound judgment. The Board also believes that the average estimate of evacuation duration was not excessively slow given absence of critical urgency.

47

1. CONCLUSIONS
2. 1

Findings

1. The MD-82 flightcrew and the Cessna 44 1 pilot were properly certificated and

qualified for their respective flights.

1. The air traffic control personnel were properly certificated and qualified for

their duties.

1. Both airplanes were properly certificated and maintained. There is some

evidence the pilot of the Cessna 441 had communication radio difficulties the evening of the accident; however, these difficulties did not contribute to the accident.

1. Airfield markings, signs, and lighting near and along the taxi route of the

Cessna 441 conformed to FAA standards. Although several position signs had inoperative light bulbs, the signs were clearly visible, and therefore were not a factor in this accident. Although the runway 31 displaced threshold was properly marked and lighted, it could have misled the pilot.

1. The ARFF emergency response was timely and effective, and prevented further

serious injuries. Additionally, the MD-82 evacuation was orderly and organized.

1. The pilot of the Cessna 441 acted on an apparently preconceived idea that he

would use his arrival runway, runway 30R, for departure. After receiving taxi clearance to back- taxi into position and hold on runway 3 1, the pilot taxied into position at an intersection on runway 30R, which was the assigned departure runway for the MD-82.

1. The combination of the time of day and his desire to return home before the

weather deteriorated may help explain the mistaken actions of the Cessna 441 pilot.

1. Although the controllers considered their workload moderate, the ground

controller was working seven frequencies with almost constant ,communications. 9. The ATIS current during the time the Cessna 441 pilot operated in the STL area listed runways 30R and 30L as the active runways for arrivals and departures at STL. There was no mention of the occasional use of runway 31.

1. The controller clearly referenced runway 3 1 in two separate transmissions.

In both cases, the pilot acknowledged the clearance, but did not read back the runway assignment. Had the controller used more precise phraseology in the issuance of the initial taxi clearance, the Cessna 441 pilot may have noted the proper departure runway.

1. Had the Cessna 441 pilot volunteered, or had the controller requested,

48 confirmation of the assigned runway, the pilot’s error may have been detected and the accident prevented.

1. Air traffic control personnel were not able to maintain visual contact with the

Cessna 441 after it taxied from the well-lighted ramp area into the runway/taxiway environment of the northeast portion of the STL airport.

1. An operational ASDE-3, particularly ASDE-3 enhanced with AMASS, could

be used to supplement visual scan of the northeast portion of the STL airport surface.

1. The MD-82 flightcrew stated that they did not observe any external lights on

the Cessna 441 before impact. When the Cessna 441 was in position for departure on runway 30R, the most conspicuous exterior lighting was directed forward, and, with the possible exception of wing anticollision/strobe lights, would not have been visible to the MD-82 flightcrew.

1. It is likely that the wing anticollision/strobe lights were not operating when the

collision occurred.

1. Pilot training for surface movement can be improved in both air carrier and

general aviation areas. 3.2 Pm bable Cause The National Transportation Safety Board determines that the probable cause of this accident was: the Cessna 441 pilot’s mistaken belief that his assigned departure runway was runway 30R, which resulted in his undetected entrance onto runway 30R, which was being used by the MD-82 for its departure. Contributing to the accident was the lack of ATIS and other ATC information regarding the occasional use of runway 31 for departure. The utilization of an operational ASDE-3, and particularly ASDE-3 enhanced with AMASS, could have prevented this accident.

49

1. RECOMMENDATIONS

As a result of this investigation, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration: Revise the Federal Aviation Regulations to require pilots to illuminate all taxi, landing, and logo lights, or otherwise enhance the conspicuity of their aircraft when operating on an active runway (including runway crossing and position-and- hold operations). (Class II Priority Action) (A-95-86) Examine the feasibility of requiring pilots to use aircraft anticollision/strobe lights when holding in position on active runways. (Class II Priority Action) (A-95-87) Define the commonly used term “back-taxi” in the Pilot-Controller Glossary, and provide an explanation of the use of the term and application of the procedure in the Airman’s Information Manual and FAA Order 7110.65, “Air Traffic Control.” (Class II Priority Action) (A-95-88) Require air traffic control personnel to make every possible effort to use as few frequencies as possible when positions are combined, and to provide notice of such on the Automatic Terminal Information Service where applicable. (Class II Priority Action) (A-95-89) Continue to develop, publish, and encourage the implementation of procedures such as automated flight clearances and standard taxi routes to reduce radio frequency congestion during ground operations. (Class II Priority Action) (A-95-90) Mass-mail to all currently certificated pilots FAA publications on reducing runway incursions and airport improvement information, such as airport signage changes. (Class II Priority Action)(A-95-91) Require flight instructors to stress airport surface operations, including airport markings, signs, and lighting; situational awareness; clearance readbacks; and proper phraseology during initial training and biennial flight reviews. (Class II Priority Action) (A-95-92) Require that initial and recurrent air carrier pilot training programs include training in airport surface movement operations, and familiarization with airport markings, signs, and lighting. (Class II Priority Action) (A-95-93) Continue research and development efforts to provide airports that are not scheduled to receive Airport Surface Detection Equipment with an alternate, cost-

50 effective system, such as the ground induction loop, to bring controller and pilot attention to pending runway incursions in time to prevent ground collisions. (Class II Priority Action) (A-95-94) Require that Automatic Terminal Information Service broadcasts at Lambert-St. Louis International Airport reference runways that are being used as secondary or occasionally active runways. (Class II Priority Action) (A-95-95) Convene a joint FAA/industry task force on human performance initiatives to produce human performance-related airport surface operation improvements that could be readily implemented, are not cost prohibitive, and would provide additional safety measures during surface operations by mitigating human error. In identifying those initiatives, consider the recommendations contained in the MITRE Corporation study, “Reports by Airline Pilots on Airport Surface Operations.” (Class II Priority Action) (A-95-96) Employ an independent source to conduct a survey of the terminal air traffic control staff, similar to the MITRF Corporation study, “Reports by Airline Pilots on Airport Surface Operations,” to determine from the staffs perspective, their concerns and views of the scope and magnitude of the runway incursion problem and their recommendations toward the reduction of runway incursions with a view toward ultimate implementation of those recommendations. (Class II Priority Action) (A-95-97) BY THE NATIONAL TRANSPORTATION SAFETY BOARD JAMES E. HALL chaimlan ROBERT T. FRANCIS II Vice Chainnan XX-i-N A. HAMMERSCHMIDT Member JOHN J. GOGLIA Member August 30, 1995

51

1. APPENDIXES

APPENDIX A - INVESTIGATION INFORMATION 1. Investigation The Safety Board was initially notified of this accident about 2250 on November 22, 1994, by the FAA. Two investigators from the NTSB’s North Central Regional Office in West Chicago, Illinois, were immediately dispatched to the scene. A Washington-based team departed for the scene the following morning. The team consisted of investigative groups in the areas of Operations, Human Performance, Air Traffic Control, Airports, and Structures. Parties to the investigation were the FAA, TWA, National Air Traffic Controllers Association (NATCA), Air Line Pilots Association (ALPA), Cessna Airplane Company, McDonnell Douglas Aerospace, and Lambert-St. Louis Airport Authority. 2. Public Hearing A public hearing was conducted for this accident on April 19 and 20, 1995. Parties to the public hearing were the FAA, Superior Aviation, TWA, ALPA, NATCA, Lambert- St. Louis Airport Authority, and Airports Council International-North America Region.

Y

53 APPENDIX B - ATC TRANSCRIPT NATIONAL TRANSPORTATION SAFE’f’Y BOARD WASHINGTON, D.C. TRANSCRIPTS REGULAR pages 1-34 INBOUND pages 35-36 ATIS page 37

1 54 Memorandum -: Transcription concerning O,,e Deconber 6,.1994 the accident involving N44lKH Cessna Conquest/441 and TWA427 WcDonnell-Douglas WD-00 on November 23, 1994 at 0403 UTC This transcription covers the St. Louis ATCT Ground Meter, Outbound Ground Control, and North Local Control positions for the time period from November 23, 1994, 0317 UTC to Novesber 23, 1994, 0411 DTC. iusncies nakina St. Louis ATCT, Ground Water St. Louis ATCT, Outbound Ground Control St. Louis ATCT, North Local Control St. Louis Approach Control, Low North Cessna Conquest N441KM Trans World Airlines 427 Air Transport International 837 Federal Express 1250 Federal Express 1283 Northwest Airlines 9864 Northwest Airlines 1048 Omni-Aviacao E Tecnologia 635 Southwest Airlines 327 Southwest Airlines 504 Southwest Airlines 976 Trans World Airlines 23 Trans World Airlines 139 Trans World Airlines 171 Trans World Airlines 175 Trans World Airlines 184 Trans World Airlines 229 Trans World Airlines 233 Trans World Airlines 243 Trans World Airlines 391 Trans World Airlines 397 Trans World Airlines 445 Trans World Airlines 455 Trans World Airlines 458 Trans World Airlines 476 Trans World'Airlines 481 Trans World Airlines 609 Trans World Airlines 703 Trans World Express 13 Trans World Express 80 Tram World Express 130 Trans World Express 450 Trans World Express 459 Trans World Express 464 GO NL LN N441XJl TWA427 ATN8 3 7 FDX1250 FDX1283 NWA9864 NWA1048 OAV635 SWA3 2 7 SWA504 SWA876 TWA2 3 TWA139 TWA171 TWA175 TWA184 TWA229 TWA233 TWA243 TWA391 TWA397 TWA445 TWA455 TWA458 TWA476 TWA481 TWA609 TWA703 LOFl3 LOFBO LOP130 LOP450 LOF459 LOF464

3 55 Zantop International Airlines 432 ZAN432 British Aerospace Jetstream 31 N422AM N422AM British Aerospace Jetstream 31 N434AM N434AM Gates Learjet Learjet 24 N72FP N72FP St. Louis Lambert Emergency Vehicle 42 TRUCK42 St. Louis Lambert Emergency Vehicle 48 TRUCK48 Unknown UNKNOWN I hereby certify that the following is a true transcription of the recorded conversations pertaining to the subject aircraft accident involving N441KM and TWA427: Peter 8. Wilkinson Quality Assurance Specialist December 6, 1994 This portion of the transcription identifies communications at the GM position from 0317 UTC until 0328 UTC. 0317 0318 0318:56 LDF450 And good evening clearance vaterski four fifty with uh . . . delta to champaign 0319:06 GM Waterski four fifty cleared to ch champaign turbo two departure decatur transition as filed maintain three thousand and squawk two one two seven 0319: 15 LOF459 K two one two seven waterski four fifty good night 0319:18 G M 0319:22 TWA23 0319:25 G M Waterski four fifty code correct good night Clearance uh t w a twenty-three to Seattle with delta T w a twenty-three cleared to Seattle Ozark two departure hallsville transition as filed maintain five thousand and squawk one seven four seven

I 56 0319:32 TWA23 0319:34 GM 0319:45 SWA504 0319:48 GM 0319:55 SWA504 0320 0321 0321:28 LOF80 0321:34 GM 0321:45 LCF80 0321:47 GM 0321:56 TWA609 0322:OO G M 0322:lO TWA609 One seven four seven for t w a twenty-three T w a twenty-three code correct Meter southwest five o four taxi Southwest five zero four proceed to spot november and monitor ground control on one two one point six five November point six five southwest uh five o four good day Clearance waterski eighty Springfield illinois delta Waterski eighty saint Iouis clearance delivery cleared to Springfield illinois airport cards three departure capital transition as filed maintain three . thousand n squawk four six seven four Four six seven four waterski eighty Waterski eighty code correct Clearance t w a six zero nine delta des moines T w a six zero nine saint louis clearance delivery cleared to des moines airport Ozark two departure macon transition as filed maintain five thousand and squawk two one one six Two one one six t w a six 0 nine

57 0322:13 0322:23 0322:28 0322:41 0322:44 0322:49 0322:53 0322:57 0323:06 0323:08 0323:lO 0323:ll GM TWA427 GM TWA427 GM TWA427 TWA548 GM TWA548 GM LOF130 N72FP T w a six zero nine code correct Clearance t w a four twenty-seven with delta to denver T w a four twenty-seven saint louis clearance delivery cleared to denver airport Ozark two departure hall huh Ozark two departure hallsville transition as filed maintain five thousand squawk one seven six five Ah i like that one seven six five t w a four twenty-seven thank you sir T w a four twenty-seven code correct getting close to the end of the shift here Us too huh T w a five forty-eight delta to moline T w a five forty-eight saint louis clearance delivery cleared to moline airport cards three departure neens transition as filed maintain uh five thousand and squawk one seven seven five One seven seven five T w a five forty-eight code correct Clearance waterski one (unintelligible) (Unintelligible) two fox papa v f r to spirit two point five we're a lear model twenty-four

58 0323:19 GM Waterski one thirty to Peoria is that correct 0323:22 LOF130 Affirmative 0323:24 GM Waterski one thirty you're cleared to Peoria cards three departure capital transition as filed maintain three thousand and squawk two one six three 0323:31 LOF130 Two one six three waterski one thirty, 0323:34 GM Lear jet v f r to spirit say again your call sign that was the correct code waterski one thirty 0323:39 LOF130 0323:41 N72FP 0323:49 GM 0324:03 N72FP 0324:08 GM 0324:15 N72FP 0324:18 GM See ya later That's lear jet seven two foxtrot papa model twenty-four Lear jet seven two foxtrot papa cleared to depart the class b airspace maintain v f r at or below two thousand one hundred departure frequency will be one one eight point niner five squawk zero two seven four Zero two seven four fox pop uh'we're at sabreliner ready to taxi Lear seven two .foxtrot papa code correct current atis is delta monitor ground control now on one two one point nine Fox pop good night Good night

a a 59 0324:18 TWA243 0324:22’ GM 0324:36 TWA243 0324:38 GM 0324:41 TWA445 0324:45 TWA397 0324:52 GM 0324:58 TWA445 0325:OO GM 0325: 09 TWA445 0325:ll G M 0325:15 TWA397 T w a two forty-three goin to tulsa we have dixie T w a two forty-three you're cleared to the uh tulsa airport lindbergh two departure maples transition as filed maintain five thousand and squawk four seven correction four six seven five Forty-six seventy-five t w a's two forty-three good night T w a two forty-three code correct Clearance t w a four four five down to dallas forth worth delta T w a . . . three ninety-seven delta goin to little rock Goin t to uh tulsa or dulles say it again please little rock stand by Four four five goin to dallas forth worth Four forty-five to d f w cleared to d f w via the lindbergh two departure maples transition as filed maintain five thousand and squawk two one four one Two one four one t w a four four five thank you T w a four forty-five code correct t w a three ninety-seven was it to little rock That's us

0325:16 G M 0325:23 TWA397 0325:26 G M 0325:28 TWA476 0325:31 G M 0325:41 TWA476 0325:43 G M 0325~45 TWA391 0325:47 GM 0325:55 TWA391 0325:58 G M 0326:OO ATN837 60 T w a three ninety-seven cleared to little rock lindbergh two departure little rock transition as filed maintain five thousand and squawk one seven two seven One seven two seven t w a three ninety-seven T w a three ninety-seven code correct A four seventy-six to Washington national T w a four seventy-six cleared to d c a blues one departure louisville transition as filed maintain five thousand departure frequency one one eight point niner five squawk one seven two two Seventeen twenty-two t w a four seventy-six T w a four seventy-six code correct T w a three ninety-one minneapolis delta T w a three ninety-one cleared to minneapolis cards three departure neens transition as filed maintain five thousand and squawk one seven five five Seventeen fifty-five t w a three ninety-one T w a three ninety-one code correct Clearance air transport eight thirty-seven milwaukee with delta

61 0326:03 GM 0326:13 ATN837 0326:15 GM Air transport eight thirty-seven heavy cleared to milwaukee cards three departure capital transition direct Pontiac then as filed maintain five thousand squawk one seven three four Squawk one seven three four eight thirty-seven Air transport eight thirty-seven heavy code correct call uh meter on one two seven point five five when you're ready to taxi out of the cargo ramp 0326:22 ATN837 Twenty-seven fifty-five we'll do 0326:24 TWA229 Hey john t w a two twenty-nine would like to go to albuquerque with the info 0326:27 SWA876 0326:30 GM 0326:38 TWA229 0326:40 GM 0326:45 SWA876 Southwest eight zero six push gate seventy-eight T w a two twenty-nine wish i was goin with ya cleared to albuquerque lindbergh two departure Vichy transition as filed maintain five thousand and squawk two one seven two Twenty-one seventy-two yeah come along T w a two twenty-nine code correct good night calling for uh taxi say again please Southwest eight seventy-six to push seventy-eight

62 0326:47 GM 0326:50 SWA876 0327 0327:Ol LOF464 0327:05 GM 0327:18 SWA327 0327:19 LOF464 0327:23 GM 0327:27 LOF464 0327:30 GM 0327:34 SWA327 0327:36 GM Southwest eight seventy-six push your discretion advise this frequency when you're ready to taxi Seventy-six Clearance waterski four sixty-four delta to water100 Waterski four sixty-four saint louis clearance delivery cleared to Waterloo airport cards three departure neens b transition as filed maintain three thousand squawk two one one three Metering southwest three twenty-seven push at eight six K two one one three waterski four sixty-four Say again the code waterski four sixty-four you were cut out on the other frequency Two one one three waterski four sixty-four That's correct waterski four sixty-four southwest calling is it three twenty-seven That's affirm three twenty-seven push *(eight) six Push your discretion southwest three twenty-seven advise on this frequency when you're ready to taxi

63 0327:41 SWA327 0 k cleared to push call you back for taxi three twenty-seven thanks 0328 This portion of the transcription identifies communications at the GO position from 0350 UTC until 0407 UTC. 0350 0350:05 N422AM Saint louis ground jetstream four ttio two alfa mike 0350:08 GO Jetstream two alfa mike saint-louis ground 035O:ll N422AM Coming out a eighteen would like go sabreliner 0350:13 GO Jetstream two alfa mike roger hold short of runway three zero left taxiway bravo 0350:18 N422AM Three zero left at bravo two alfa mike 0350:23 TWA609 Ground metering t w a six o nine uh abeam seventy-two to taxi 0350:28 GO 0350:36 TWA609 T w a six zero nine saint louis ground meter roger outbound the ramp at november and taxi to runway three zero left via alfa K november to the left side via alfa t w a six 0 nine 0350:40 GO Jetstream two alfa mike cross runway three zero left at bravo and hold short of runway three zero right on taxiway bravo

64 0350:46 N422AM 0351 0352 0352:56 TWA476 0353 0353:Ol GO 0353:15 TWA476 0353:28 ZAN432 0353:31 GO 0353:47 ZAN432 0353:55 OAV635 0354:oo GO 0354:04 OAV635 Cross the left hold short of the right on bravo two alfa mike Ground t w a four seventy-six taxi off fifty-two with uh dixie T w a four seventy-six roger change your departure *(control) correction disregard that uh yeah change your departure control frequency to one one niner point one five runway three zero right hold short of runway three zero left at taxiway hotel Thirty right hold short of the left hotel t w a's uh . . . four seventy-six Saint louis clearance zantop four thirty-two to laredo Zantop four thirty-two saint louis clearance delivery cleared to laredo airport via the lindbergh two departure maples transition then as filed maintain three thousand squawk one one five zero 0 k cleared to laredo via lambert two departure maple transition as filed maintain three and departure is uh squawk one one five zero Saint louis ground omni *(six thirty-five's) clear of the right goin to sabreliner's line to park for u p s Omni six thirty-five saint louis ground taxi to the ramp Six thirty-five

L a 0754:05 GO 0354:12 ZAN432 Roger 0354:13 TWA184 Ground t w a's one eighty-four one eighty-four with uh delta to boston 0354:18 N434AM Saint louis ground jetstream four three four alfa mike 0354:19 TWA703 T w a seven o three to uh kansas city 0354:23 GO T w a seven zero three clearance's on request t w a one eighty-four where'd you say you were at 0354:27 TWA184 Gate sixty-nine with uh delta to boston 0354:33 0354:37 GO T w a seven zero three and t w a one eighty-four clearance's on request jetstream calling ground say again N434AM Yeah it's jetstream four three four alfa mike currently at gate eighteen like to go to sabreliner please 0354:41 G O Jetstream four alfa mike roger 0354:53 GO Jetstream four alfa mike join alfa hold short of runway three zero left at taxiway juliett 0354:58 N434AM 65 Zantop four thirty-two maintain three thousand readback was correct contact me on ground control one two one point niner when you're ready taxi Jetstream four l (alfa) mike hold short of three zero left at iuliett

66 .0355:02 GO 0355:06 TWA476 0355:09 GO 0355:14 N422AM Expedite sabreliner two alfa mike 0355:20 GO Jetstream four alfa ahead now and cross mike go straight .runway three zero left and hold short runway three zero 0355:25 N434AM 0355:37 N441KM 0355:39 TWA427 0355:42 G O 0355:49 TWA397 T w a four seventy-six cross runway three zero left taxi runway three zero right Cross thirty left go to thirty right t w a's four seventy-six Jetstream two alfa mike expedite cross runway three zero right traffic's a mile and a half out right on taxiway bravo Four alfa mike copy on the bravo going across three zero left (Unintelligible) i f r to iron (unintelligible) T w a four twenty-seven your frequency and uh taxi Twin Cessna four four one kilo mike roger clearance on request who else called ground meter or ground control Ground t w a three ninety-seven for gate seventy-two on the alley 0355:53 G O T w a three ninety-seven saint louis ground outbound at november taxi to runway three zero left via alfa 0255:58 TWA397 Alfa to three zero left t w a three ninety-seven

1 67 0356:03 TWA427 0356:13 TWA427 0356:17 GO T w a four twenty-seven taxi with ah juliett at at juliett Ground t w a four twenty-seven at juliett taxi T w a four twenty-seven saint louis ground uh roger and runway three zero right hold short runway three zero left taxiway hotel 0356:23 TWA427 Three zero right hold short of the left at hotel t w a's uh four twenty-seven 0356:27 TWA175 Clearance t w a uh one seventy-five up to cedar rapids delta 0356:28 UNKNOWN 0356:41 UNKNOWN 0356:46 TWA23 0356:50 GO (Unintelligible) (Unintelligible) *(twelve) fifty's clear of the right side +(Meetering) t w a twenty-three's at uh bravo two And uh jetstream four alfa mike traffic'11 hold in position cross runway three zero right proceed to sabreliner ramp 0356:55 N434AM Jetstream four alfa mike crossing three zero right to sabreliner thank you 0356:59 GO 0357:oo UNKNOWN And who else called ground meter (Unintelligible)

68 0357:Ol 0357:04 0357:08 0357:08 0357:12 0357:17 0357‘: 19 0357:21 0357:23 0357:27 0357:31 TWA175 GO TWA455 TWA23 GO TWA455 GO TWA23 GO TWA23 FDX1250 0357:34 GO Uh t w a uh one seventy-five goin to cedar rapids with delta All right whoever's going to cedar rapids uh clearance is on request who needs for ground meter or ground control T w a four fifty-five at gate seventy-two to taxi (Unintelligible) bravo two T w a four fifty-five abeam seventy-two outbound the ramp at taxiway november taxi to runway three zero left Thirty left at november t w a four fifty-five Who else needs ground control It's t t w a twenty-three at bravo two T w a twenty-three saint louis ground runway three zero right hold short runway three zero left at taxiway hotel Thirty left hold short of the tight at hotel t w a's uh twenty-three f(Ex) twelve fifty clear of three zero right T w a four twenty-seven cross runway three zero left taxi runway three zero right

L 69 0357:37 TWA427 Four twenty-seven cross the left to the right 0357340 GO Federal express twelve fifty saint louis ground taxi the ramp 0357:42 FDX1250 *(Ex) twelve fifty 0357:44 0357:49 GO Who else needs ground control GO Who else needs ground control anybody . . . o k twin cesssna four four one kilo mike you're cleared to the uh india mike tango airport via the cards three departure neens transition then as filed maintain three thousand squawk one one zero five 0358:05 N441KM 0358:12 GO 0358:15 N441KM (Unintelligible) o k understand uh three thousand one one zero five uh for one kilo mike One kilo mike readback is correct where you parked at and are you ready to taxi I'm at midcoast and uh yes we are ready to taxi 0358:19 GO One kilo mike roger back taxi into position hold runway three one let me know on this frequency when you're ready for departure 0358:23 N441KM Kilo mike 0358:26 GO Anybody else need clearance delivery 0358:30 TWA175 T w a one seventy-five standing by for clearance

F 70 e 0358:32 GO T w a one seventy-five saint louis clearance delivery you're cleared to the cedar rapids airport via the cards three departure neens transition then as filed maintain five thousand squawk one seven five three 0358:42 TWA175 One seven five three 0358:44 GO T w a one seventy-five code is correct 0358:46 L O F 1 3 Waterski thirteen to *(scuff) with delta 0358:48 GO Waterski thirteen cleared to the Springfield airport via the lindbergh departure Vichy transition then as filed maintain three thousand squawk four seven zero seven 0358:59 LOF13 0359:02 GO 0359:07 LOF13 0359:09 TWA391 0359:lO GO K four seven zero seven and uh is Vichy back on the air Waterski thirteen uh no it's still out of sevice expect radar vectors over Vichy 0 k radar vectors *(eve) Vichy uh. ski thirteen T w a three ninety-one's abeam seventy-two T w a three ninety-one saint louis ground runway three zero right hold short of runway three zero left at taxiway hotel

71 0359:17 TWA391, 0359:24 NWA9864 0359:26 GO 0359: 30 NWA9864 Ninety-eight sixty-four will advise 0359:32 TWA481 Ground t w a uh four eighty-one spot tango taxi 0359:36 GO T w a twenty-three cross runway three zero left taxi to runway three zero right 0359:40 0359:43 0359:45 0359:47 TWA23 0 k uh cross the left taxi the right t w a twenty-three GO Who's at spot tango TWA481 T w a uh four eighty-one GO T w a four eighty-one roger from the tango spot runway three zero right hold short of runway three zero left at taxiway juliett 0359:56 TWA481 o4oo:oo TWA233 Ground t w a two thirty-three juliett Short of thirty left at hotel t w a three ninety-one Saint louis ground northwest ninety-eight sixty-four Northwest ninety-eight sixty-four push off that gate let me know when you're ready to taxi Thirty right hold shor- 21 thirty left at juliett t w a four eighty-one

72

• 0400:02

GO 0400:15 TWA233 0400:24 ZAN432 0400:27 GO 0400:32 ZAN432 0400:34 GO 0400:39 ZAN432 0400:41 UNKNOWN 0400:45 G O T w a two thirty-three saint louis uh ground roger i want you to give way to a company seven twenty-seven that's off the hotel spot then straight ahead taxi runway three zero left via the airline ramp and taxiway delta Give way to the seven two and then uh three zero left via the airline ramp and taxiway delta t w a two thirty-three Ground zantop four thirty-two ready to,go with juliett Zantop four thirty-two saint louis uh ground uh what are you coming off the sabreliner ramp Coming out of zantop Roger zantop four thirty-two you can pull out hold short of runway one three i'll get you moving shortly Hold short of one three zantop four thirty-two Ground t w a (Unintelligible) gate number two Uh northwest for gate two your company just pushed back what i want you to do is turn left on alfa then a right turn at the bravo one spot hold behind the american gates when i get him out of there i'll get you in there

3 73 0400:54 NWA1048 Northwest ten forty-eight understand that 0400:56 TWA243 Ground i know you're busy t w a's two forty-three is number two at seventy-two 0401:Ol GO T w a two forty-three abeam seventy-two's whpt you said 0401:03 TWA243 Yes we're number two behind uh another d c nine 0401:06 GO 0 k who's number one abeam seventy-two 0401:08 0401:09 TWA445 T w a four four five GO T w a four forty-five uh roger i don't have any paperwork on you uh standby...t w a four forty-five outbound the ramp at november taxi runway three zero left via alfa south uh taxiway 0401:23 TWA445 0401:26 GO 0401:30 TWA243 0401:34 GO 0401:38 N441KM Cleared the left via alfa south t w a uh four forty-five T w a two forty-three same for you taxi runway three zero left via alfa south taxiway follow the d c nine ahead Follow the d c nine alfa south t w a's two forty-three And uh one kilo mike you ready for departure One kilo mike yeah we're ready (unintelligible)

74 0401:39 0401:44 0401:49 0401:50 0402:OO NWA9864 0402:Ol N441KM 0402:04 GO 0402:09 0402:ll 0402:16 0402:18 LOF130 GO LOF130 0 k i'm up that frequency right now GO Roger that one kilo mike hold on position on runway three one and monitor the tower on one two zero point zero five WA9864 Join alfa at echo to the charlie pad northwest nine-eight sixty-four GO Northwest ten forty-eight when you see your company go out then you can taxi in to gate two NWA1048 Northwest ten forty-eight copies TWA139 Saint louis ground t w a one thirty-nine's abeam gate seventy-two with delta 0402:20 TWA8 1 Waterski one thirty is an a t r going to bravo two and we have information delta Waterski one thirty roger proceed to bravo two monitor my frequency one two one point niner Saint louis ground northwest ninety-eight *(sixty-four taxi) (Unintelligible) understand position and hold monitor the tower kilo mike Northwest nine-eight sixty-four outbound the ramp join alfa at echo taxi to the charlie pad T w a eighty-one clearance uh to Wichita with delta

a q 75 0402:23 GO 0402:25 TWA391 0402:27 GO 0402:31 TWA481 0402:34 GO 0402:39 LOF130 0402:43 TWA81 0402:44 TWA139 0402:47 GO 0402:Sl LOF130 0402:55 G O 0402:59 TWA139 T w a three ninety-one cross runway three zero left Cross thirty left t w a three ninety-one T w a four eighty-one follow your company traffic to your right cross runway three zero left Follow the company cleared to cross thirty left t w a four eighty-one Waterski one thirty runway three zero right hold short of runway three zero left at taxiway bravo Three zero right hold short of the left at bravo waterski one thirty Saint Louis clearance t w a eighty-one we've got delta T w a one thirty-nine abeam gate seventy-two delta T w waterski one thirty cross runway three zero left there at bravo and taxi runway three zero right 0 k cross the left taxi to the right now waterski one thirty 0 k and uh calling clearance delivery stand by who needs ground meter T w a one thirty-nine abeam seventy-two

0403:Ol GO 0403:07 TWA139 0403:12 UNKNOWN 0403:17 GO 0403:43 GO 0403:51 0404 0404:06 TRUCK42 0404:lO GO 0404:16 TRUCK42 Three zero right at november 0404:18 GO Affirmative runway three zero right at taxiway november 0404:22 TRUCK42 That's clear 0504:23 GO Yeah proceed directly to it and proceed on all the runways 0404:26 TRUCK48 Truck forty-eight clear 76 T w a one thirty-nine outbound the ramp at november runway three zero right hold short of runway three zero left at taxiway november Hold short of three zero uh left at november for three zero right t w a one thirty-nine And ground seven eleven's bravo two for taxi Everybody stand by we've had an aircraft accident on the runway Everybody stand by we've had an airport accident on the runway there's goin ta 0 k you say the lower beacon light's no good Saint louis ground this is truck forty-two do you have a location on this accident Yes it's at the uh intersection 'of runway three zero right and taxiway november we need you to move there now there's been an accident on the airport

3 77 0404:28 GO 0404:33 0404:40 0404:45 GO 0405 0405:28 0405:34 GO 0405:39 TWA175 0405:41 GO 0405:49 TWA175 0406 0406:04 GO 0406:ll ZAN432 TRUCK42 Orty-two's goin to cross at bravo TWA171 T w a one seventy-one's at juliett with uh delta TWA175 0406:21 GO K Truck forty-eight proceed as requested and truck forty-eight comin in from the south side cross runway three zero left Ah everybody callin clearance delivery and ground control just stand by and hold your position (Unintelligible) t w a's one seventy-five's comin up on seventy uh *(three) and we have delta T w a one seventy-five saint louis ground uh say again We're at gate seventy-three and we have delta T w a one seventy-five ss remain hold your position we've had an accident on the airport One seventy-five roger Zantop four thirty-two what can you see from your position where you're at Eh we can't see much just uh looks like the uh t w a’s uh all shut down uh have the uh air stairs open and uh rescue vehicles around em

78 0406:24 0406:26 0406:31 0406:33 0406:36 0406: 39 0406:43 0406:45 0406:47 0406:49 0406:53 0406:55 0406: 58 TWA229 GO NWA9864 GO NWA1048 TWA391 GO TWA391 GO LOF130 GO LOF130 GO Two twenty-nine t w a at b two T w a ninety-eight sixty-four turn left on taxiway alfa and taxi to the Charlie Pad Northwest thirty-eight sixty-four we'll go-to charlie pad Northwest ten forty-eight taxi to the ramp West ten forty-eight taxi to the ramp T w a three ninety-one's just going to hold here by sierra if that's alright with you T w a three ninety-one that'11 be fine Figure that runway's closed now Yes it is Ground waterski one thirty we're at the intersection of papa and bravo Waterski one thirty say again We're at the intersection of papa and bravo Waterski one thirty roger i appreciate that just uh hold your position right there (unintelligible)

79 0407:03 LOF130 Waterski one thirty wilco 0407:06 GO What we're going to do is probably take everybody to the right This portion of the transcription identifies communications at the NL position from 0356 UTC until 0411 UTC. 0356 0356:Ol NL 0356:07 LOF450 0356:33 NL 0356:40 0357 0358 035a:lI FDX1250 Twelve fifty NL Waterski four fifty wind two eight zero at seven runway three zero right turn right heading three five five cleared for takeoff 035a:ia LOF450 Waterski four fifty saint louis tower runway three zero right taxi into position and hold *(Into) position and hold waterski four fifty Fedex twelve fifty turn right . . . and uh contact ground point niner ck Three fifty-five cleared to go waterski four fifty 0358:23 NL 0358:24 LN 0358:25 NL 0358:26 LN We're gonna do an o swap 0 k fine G n Rl

80 0358:34 NL 0358:37 TWA476 0359 0359:01 NL 0359:09 TWA476 0359:15 NL 0359:19 LOF450 0359:22 NL 0359:26 TWA397 0359:54 NL 0359:58 NWAl048 0400 0400:25 NL T w a four seventy-six saint louis tower runway three zero right taxi into position and hold Position hold thirty right t w a four seventy-six T w a four seventy-six the prop ahead'11 be in a right turn northbound wind two eight zero at eight runway three zero right turn right heading three three five cleared for takeoff i Right three three five thirty right cleared for takeoff t w a four seventy-six Waterski four fifty three five five on the heading contact departure good night Three fifty-five we'll see ya waterski four fifty T w a three ninety-seven saint louis tower runway thre zero left taxi into position and hold Position and hold t w a three ninety-seven Northwest ten forty-eight turn left when able and contact ground point nine as you clear the runway good night Northwest ten forty-eight T w a four seventy-six three thirty-five on the heading contact departure good night

r !a 81 0400: 29 TWA476 0400:32 NL 0400:37 TWA397 0400:39 NL 0400:46 TWA455 0400:48 NL 0400:52 TWA455 0400:55 NL 0401 0401:04 NL 04ol:oa TWA455 0401:lO NL 0401:15 TWA455 0401:22 TWA427 0402:24 NL T w a four seventy-six good night T w a three ninety-seven winds two seven zero at seven runway three zero left fly runway heading cleared for takeoff Runway heading cleared to go t w a three ninety-seven T w a four forty-five saint louis tower runway three zero left taxi into position and hold Uh four fifty-five we're not quite ready Yet Uh i don't have any uh paperwork on a four fifty-five where you goin sir Omaha the code is uh two one four four 0 k i've got a four forty-five i don't have a four fifty-five stand by 0 k four fifty-five you're uh number one at three zero left is that correct T w a four fifty-five that's correct Roger change your departure frequency it'll be one one niner point one five and let me know when you're ready to go K stand by one And t w a four twenty-seven's ready T w a four twenty-seven winds two seven zero at seven runway three zero right turn right heading three three five cleared for takeoff

82 0401:30 TWA427 0401:32 NL 0401:36 TWA397 0401:41 'TWA427 0401:47 NL 0401:50 'TWA427 0402 0402:29 N441KM 0402:30 NL 0402:37 N441KIM 0402:38 TWA455 0402:40 N L 0402:43 TWA455 Three thirty five and cleared to go t w a four two seven T w a three ninety-seven runway heading contact departure good night Three ninety-seven good night Confirm uh three twenty-five for t w a's four twenty-seven T w a twenty-seven three three five Three three five thanks And kilo mike's ready to go on the right side Roger i can't roll you simultaneously with the uh traffic departing the right just continue holding in position i'll have something for you in just a second Kilo mike T w a four fifty-five's ready on thirty left T w a four fifty-five runway three zero left taxi into position and hold *(Position) hold-three zero left t w a four fifty-five

a q 83 0402:48 NL 0403:Ol TWA427 0403:15 0403:17 0403:19 0403:41 TWA233 0403:52 NL 0403:58 0404 0404:06 TWA455 Four fifty-five roger TWA427 Tower t w a four twenty-seven 0404:oa NL 0404:lO TWA427 TWA427 Do you hear me do you hear me- NL Yes i do we're rolling the equipment TWA427 Roll the equipment . . . check uh t w a four twenty-seven see if you have uh see if t w a four twenty-seven has any fire Twin Cessna four four one kilo mike winds two eight zero at eight the traffic uh uh use caution for the m d eighty that's uh departing thirty right for possible wake turbulence turn right heading uh three five five . . . continue holding in position T w a four hundred and twenty-seven hit the other airplane on the uh runway roll the emergency equipment And tower t w a two thirty-three is uh with you for the uh three zero left T w a four fifty-five uh continue holding in position i'm going to have you for something for you in just a second T w a four twenty-seven the equipment's rolling right now You see any fire or smoke around da aircraft

P 3 84 0404:14 N L 0404:20 TWA427 (Unintelligible) all that later i just want to make sure everything's safe here 0404:21 0405 0405:02 NL Roger NL T w a four fifty-five we've had an accident on the run on the airport you to go down to the next intersection ahead turn right turn right on papa taxiway and back taxi on papa taxiway back to runway three zero left 0405:16 TWA455 Wilco t w a four fifty 0405:la TWA427 T w a's uh four twenty-seven is evacuating off the left side of the aircraft 0405:23 NL T w a four twenty-seven understand you are evacuating at this time 0405:55 FDX1283 Tower fedex twelve eighty-three is rolling out on the final for the visual three zero left 0406:OO NL Fedex twelve eighty-three saint louis tower runway three zero left cleared to land wind two six zero at seven 0406:05 FDX1283 Cleared to land three zero left fedex twelve eighty-three 0407 0408 0408:04 TWA391 Tower t t w a three ninety-one's uh with ya holding short of sierra No sir i don't . . . he was supposed to be on runway three one i did not see the aircraft on that runway i,need

3 85 . 04oa:oa NL 0408:22 0408:24 0408:27 0408:29 0408:32 0408:35 0408:39 0408:41 0408:43 TWA391 NL Are you number one TWA391 Yeah we're number one on the north side NL Roger TWA391 Give us a warning we got two engines shut down NL Wilco TWA233 Tower t w a two thirty-three NL T w a two thirty-three tower TWA233 Uh yes ma'.am we're sitting here uh number one for three zero left ih is it going to be a while with the accident uh i mean can we shut one down er what 0408:51 NL 0408:59 TWA233 Ve very well thanks T w a three ninety-one uh understand you're holding short of sierra make a right turn there uh you'll plan runway three zero left uh as we uh start getting things started again plan runway three zero left uh and stay on this frequency Hold short of thirty left on sierra t w a three ninety-one No sir runway three zero left is still uh an open runway we will ha we will start departures in just a just a couple of seconds

3 86 0409 0409:02 NL 0409:05 TWA233 And two thirty-three understand you're at the number one position on runway three zero left Uh we're the number one position facing north uh for three zero left 0409:09 NL 0 k four fifty-five who are you behind 0409:ll TWA455 We're behind uh the seven twenty-seven at sierra 0409:16 NL T w a four fifty-five roger 0409:24 NL Express four uh twelve eighty-three turn right and contact ground point niner 0409:28 FDX1283 Fedex twelve eighty-three wilco 0409:34 NL T w a three ninety-one are are you on

the uh o k three ninety-one are which

aircraft are you behind the a t r forty-two 0409:42 TWA391 0409:45 NL 0409:49 TWA391 0409:50 NL No we're number one seven twenty-seven for thirty left on sierra You are the number one aircraft for thirty left on sierra Affirmative 0 k four eighty-one you're the number two aircraft for runway three zero left

87 ” This tnnscfiplion cev& Ihe SI. IAuiS Nmlh Laal Conval md hIbOund Gland Cart& positbnt for the dmt pried fm Nanmkr 23.1994.033S W 0 Howaabet 23.1994. 0341 m. 0335 033m9 NUIJW 033516 NL 033s:u NL a3s:u NL 033546 N44lKM

3 88 mL-ATcT-827 P4e2or2 033S:UI 033s52 033s:s9 E! 0338 0339 %: 16 034&u 0340:37 03uM 1 NUIKM NL NUIICM NL NUIKM NUIKM NL Coqucs~ uh ane kilo mike turn right II dK next intcrsalion uxiw8y nobemkr contact pund amlrol one two one point nincr gaod sight Kilo ntike gu night Grand four four one Lib mike is uh clafin~ One kilo mike catact pud amud poinl nincr goad day 3 ~lonnh8 tranvfiptiam idatifia cammmiations al the GI psi&ion from 0340 UTC 0340 034033 NUIKM Onekibmikeirdear~~oinlomidwest Eat GI NOV80lb8lmtkibf8ikZUiIllbUiigfOUtldl8XitOmidcoWrSlllp 034I:Ob NUIKM Minklligibk) QIC Ed of l-ml* l This Portia) of the rmcdii is not entirely clar. but this rcp1~31~ the bat inkrpretalion puibk wkr lhc circunrrpnar.

a 89 Memorandum UjFORHATTON: Transcription concerning o,,, February 28, 1995 the accident involving N441XM Cessna Conquest/441 and TWA427 McDonnell-Douglas MD-80 on November 23, 1994 at 0403 UTC hoc 10 Ann 01 St. Louis ATCT This transcription covers the St. Louis ATCT Automatic Terminal Information Service broadcasts for the time period from November 23, 1994, 0355 UTC to November 23, 1994, 0402 UTC. Aoencies Makinu Transmissions Abbreviations St. Louis ATCT, Automatic Terminal ATIS Information Service I hereby certify that the following is a true transcription of the recorded Automatic Terminal Information Service broadcast pertaining to the subject aircraft accident involving N441KM and TWA427: Peter B. Wilkinson Quality Assurance Specialist February 28, 1995 0355 0355:02 ATIS *Saint louis lambert airport information delta zero two five zero tulu weather two five thousand thin scattered visibility two five temperature three four dew point two two wind two eight zero at eight altimeter three zero five six simultaneous visual approaches utilizing runway three zero right i 1 s localizer runway three zero left 1 d a d m a localizer notice to airmen Vichy v o r out of service taxiway alfa south is now known as taxiway delta taxiway delta closed from taxiway Charlie to the airline ramp advise on initial contact you have delta End of Transcript *(This broadcast is repeated nine times in full and Once partially by 0402 UTC.)

91 APPENDIX C - CVR TRANSCRJPT

92 NATIONAL TRANSPORTATION SAFETY BOARD Engineering & Computer Services Division Washington, D.C. 20594 SPECIALIST’S FACTUAL REPORT OF INVESTIGATION Cockpit Voice Recorder Albert G. Reitan Transportation Safety Specialist Warning The reader of this report is cautioned that the transcription of a CVR tape is not a precise science but is the best product possible from an NTSB group investigative effort. The transcript, or parts thereof, if taken out of context, could be misleading. The attached CVR transcript should be viewed as an accident investigation tool to be used in conjunction with other evidence gathered during the investigation. Conclusions or interpretations should not be made using the transcript as the sole source of infnrmation.

93 NATIONAL TRANSPORTATION SAFETY BOARD Engineering & Computer Services Division Washington, D.C. 20594 SPECIALIST’S FACTUAL REPORT OF INVESTIGATION Cockpit Voice Recorder CHI 95 MA 044 A/B January 10, 1995 A. ACCIDENT Locat ion: St. Louis International Airport, Missouri Date: November 22, 1994 Time: 2202 Central Standard Time (CST) Aircraft: MD-82 N954U 8. GROUP Chairman: Member: Member: Member: Member: Member: Albert G. Reitan Transportation Safety Specialist (CVR) National Transportation Safety Board Martin H. Potter Aviation Safety Inspector Federal Aviation Administration Capt. Joe Chronic Flight Manager DC9/MD80 Training Trans World Airlines, Inc. Capt. Ernie Hadfield ALPAITVVA Trans World Airlines, Inc David Ryan Air Safety Investigator Cessna Aircraft Company Greg Colclasure Air Safety Investigator National Air Traffic Controllers Association

3 94 C. SUMMARY A Fairchild model A-100 cockpit voice recorder (CVR), s/n 3455, was brought to the audio laboratory of the National Transportation Safety Board on November 23, 1994. The Cockpit Voice Recorder committee convened on November 27, 1994. A transcript was prepared of the last 9:50 minutes the 30:55 minute recording. (attached) D. DETAILS OF INVESTIGATION The exterior of the CVR showed no evidence of structural damage. The interior of the recorder and the tape sustained no apparent heat or impact damage. A Dukane underwater locator beacon (ULB) was installed and when tested in the laboratory, was found to operate satisfactorily. The recording consisted of three channels of good quality audio information. One channel contained the cockpit area microphone audio information. The other two channels contained the Captain and First Officer, audio panel information. The timing on the tape was established using the known time of an air traffic control transmission recorded on a cassette tape provided by the FAA. The transcript started at 2155:lO CST and continued uninterrupted until 2204:58 CST when electrical power was removed from the unit. When the recording started, the flight had just departed the loading gate and received taxi instructions. The recording continued as the crew continued taxiing to the departure runway and started the takeoff roll. The recording ended after the aircraft impacted another aircraft and the crew ordered an evacuation. As part of the Safety Board’s accident investigation process, the cockpit flight crew was invited to review the CVR group’s transcript and suggest corrections or additions. The Captain, First Officer, and the jump seat occupant

95 (a TWA Captain) reviewed the CVR recording and transcript on January 4, 1994 and suggested the following changes. Page 9 2200:31 (26:28) Change CAM-3 to CAM-4 Page 13 2202:38 (28:35} Change to; one ninety four [voice vibrating possibly caused by aircraft nosewheel traveling over rough runway] Page 14 2203:13 (299 0) change CAM-? to CAM-4 Page 17 2204:31 (30:28) change CAM-2 to CAM-3 Page 17 2204:35 {30:32} change CAM-? to CAM-3 Page 17 2204:39 (30336) change to; I’m shuttin’ the right engine down. Albert G. Reitan Transportation Safety Specialist (CVR) Attachment:

96 Transcript of a Fairchild A-100 cockpit voice recorder (CVR), s/n 3455, installed on a McDonnell Douglas MD-82, N954U, which was Involved in a ground collision with another aircraft while departing St. Louis International Airport, on November 22,1994. RDO CAM INT RCT GND TWR PA TW450 TW455 TW183 TW397 JSAM AC-? TW23 FE1250 TW476 441 KM JSAM -1 -2 -3 -4 -6 Radio transmission from accident aircraft Cockpit area microphone voice or sound source Transmissions over aircraft interphone system Radio transmission from TWA ramp control Radio transmission from St. Louis tower Transmission received from St. Louis ground control Transmission made over aircraft Public Address system Radio transmission from TWA flight four fm Radio transmission from TWA flight four fw five Radio transmission from TWA flight one eighty three Radio transmission from TWA flight three ninety seven Radio transmission from aircraft number JSAM Radio transmission from unknown aircraft Radio transmission from TWA flight four twenty three Radio transmission from Federal Express flight twelve fifty Radio transmission from TWA flight four seventy six Radio transmission from aircraft number four four one Kilo Mike Radio transmission from aircraft number WS four f@ Voice identified as Pilot-in-Command (PIC) Voice identified as Co-Pilot Voice identified as ACM captain sitting in observer seat Voice identified as female Flight Attendant Voice identified as aircraft mechanical voice

I !a 97 -? l 0 # % ( 1 1 1 ..a Voice unidentified Unintelligible word Non pertinent word Expletive Break in continuity Questionable insertion Editorial insertion Pause Note: Times are expressed in central standardt time (CST). Times shown in brackets { ) are computer reference times measured from the beginning of the recording.

n INTRA-COCKPIT COMMUNlCATlON AIR-GROUND COMMUNICATION TIME a TIME 6 SOURCE CONTENT SOURCE CONTENT START of TRANSCRIPT 2155:47 (21:44) CAM-l here we are at Juliet ’ 2155:lO RDO-2 2155:12 RCT 2155:16 RDO-2 2155:34 RDO-2 2155:39 RDO-2 2155:43 GND 2155:50 TW397 2155:54 GND (21:07) four twenty seven’s ready to taxi. (21:09) yes sir, they want you to go right to ground, one twenty one nine, right there. we’ll see you later. (21:13) see you later. (21:31) ground, TWA four twenty seven. (21:36) ground, TWA four twenty seven your frequency. and uh, taxi. (21:40) twin Cessna four four one Kilo Mike roger, clearance on request. who else called ground meter or ground con- trol? (21:47) ground, TWA three ninety seven’s abeam seventy two on the alley. (21:51) . TWA three ninety seven St. Louis ground outbound at November, taxi to three zero left via Alpha.

INTRA-COCKPIT COMMUNlCATlON AIR-GROUND COMMUNICATION TIME it TIME 81 SOURCE CONTENT SOURCE CONTENT 2156:26 (22:25) CAM-l hokl short at l-l. 2155:59 TW397 2156:04 RDO-2 2156:14 RDO-2 2156:17 GND 2156:24 RDO-2 2156:29 TW455 2156:41 TW450 2156:46 TW183 2156:50 GND (21:56) Alpha to three zero left, TWA, three ninety seven. (22:Ol) TWA four twenty seven taxi with uh, Juliet, at at Juliet. (22:ll) ground, TWA four twenty seven at Juliet, taxi. (22:14) TWA four twenty seven St. Louis ground uh, roger, and runway three zero right hold short of three zero left taxi- way hotel. (22:21) three zero right, hold short of the lett at Hotel. TWA’s uh, four twenty seven. (22:26) TWA’s four fii five abeam seventy two. g ;☺ l . . , four fit clear of the right side. (22:43) metering, TWA’s one eighty three’s at uh, Bravo two. (22:47) and uh, Jetstream four Alpha Mike, traffii will hold in posi- tion. cross runway three zero right proceed the Saber- l i n e r r a m p . 2156:55 : CAM igu??of horn similar to stabilizer trim-in-motion warning]

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME 8 SOURCE CONTENT TIME 8 SOURCE CONTENT 2156:57 JSBAM (22:54) Jetstream four Alpha Mike, cross three zero right to Sabreliner. thank you. 2156:58 (22:55) CAM-2 full loaded boat. 2156:59 GND 2157:OO TW455 2157:03 GND 2157:08 TW455 2157:ll AC-? 2157:12 GND 2157:17 TW455 2157:19 GND 2157:20 TW23 (22:56) and who else called ground meter? (22:57) four fifty five abeam seventy two. (23:00) alright. whoever’s going to Cedar Rapids uh, clearance is on request. who needs for ground meter or ground con- trot? (23:05) TWA four fii five at gate seventy two to taxi. (23:08) . . . Bravo two. {23:09) TWA four fifty tiie abeam seventy two outbound the ramp at taxiway November, taxi to runway three zero left. (23:14) thirty left at November, TWA four fw five. (23:16) who else needs ground control? (23:17) T, TWA twenty three at Bravo two. ha

TIME 8 SOURCE INTRA-COCKPIT COMMUNlCATlON CONTENT TIME 8 SOURCE AIR-GROUND COMMUNICATION CONTENT 2157:23 GND 2157:28 TW23 2157:31 FE1250 2157:34 GND 2157:37 TW427 2157:39 GND (23:20) TWA twenty three, St. Louis ground. runway three zero right, hold short runway three zero left at taxiway Hotel. (23:25) thirty left, hold short of the right at Hotel, TWA’s uh, twenty three. (23:28) Fed Ex twelve fifty clear of three zero right. (23:31) TWA four twenty seven cross runway three zero left. taxi runway three zero right.

(23:34)

0 four twenty seven, cross the left to the right. (23:36) Federal Express twelve fifty, St. Louis ground, taxi to the ramp. 2157:40 (23:37) CAM-1 cross this thing. 2157144 123:411 CAM-2 ’ ’ he s fa; enough out looks like, it shouldn’t be a problem. 2157:41 FE1250 2157:43 GND (23:38} Fed Ex twelve fifty. (23:40} who else needs ground control? 2157:49 GND (23:46) who else needs ground control, anybody? u

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & SOURCE CONTENT TIME & SOURCE 2157:51 GND CONTENT (23:48) OK, twin Cessna four four one Kilo Mike you’re cleared to the uh, India Mike Tango airport via the Cards three depar- ture, Neens transition, then as filed. maintain three thou- sand. squawk one one zero fiie. 2158:06 (24:03) CAM-1 whenever you get organized, read that taxi check list please. 2158:lO CAM-2 (24:07) alright, taxi check list. 2158:13 GND 2158:18 GND (24:l O} one Kilo Mike, readback is correct. where you parked at and are you ready to taxi? z (24:15) one Kilo Mike roger, back taxi into position and hold run- way three one. let me know on this freq . . . 2158:27 CAM-2 2158:30 CAM-1 2158:31 CAM;2 (24:24) taxi check list says flaps and runway. (24:27) eleven and takeoff thirty right. {24:28) eleven and takeoff thirty right. 2158:33 TWR (24:30) TWA four seventy six l l l three zero right taxi into position and hold. 2158:37 TW476 (24:34) position and hokl thirly right, TWA four, seventy six. 2158:37 CAM-2 [24:34) take off data TRI and airspeed bugs?

INTRA-COCKPIT COMMUNlCATlON AIR-GROUND COMMUNICATION TIME & TIME Lb SOURCE CONTENT SOURCE CONTENT 2158:39 CAM-1 2158:41 CAM-2 2158:42 CAM-l 2158:44 CAM-2 2158:45 CAM-1 2158:46 CAM-2 2158:47 CAM-l 2158:48 CAM-2 2158:49 CAM-1 2158:51 CAM-2 2158:52 CAM-1 2158:54 CAM-2 (24:36) one fifty three big EPRs. set l cross checked. (24:38) stabilizer trim? (24:39) set. (24:41} flight controls? (24:42) checked. (24:43) fuel system? (24:44) that’s checked. (24:45) fuel heat? $:461 (24:48) seat bett and shoulder harness? (24:49) checked. (24:51} taxi check list complete.

TIME a SOURCE INTRA-COCKPIT COMMUNlCATtON CONTENT AIR-GROUND COMMUNICATION TIME b SOURCE CONTENT 2159:oo (24:57) TWR TWA four seventy six, prop ahead ‘II be in a right turn northbound. wind two eight zero at eight, runway three zero right, turn right heading three three five, cleared for takeoff. 2159:09 (25:06) TW476 right three three five, thirty right. cleared for takeoff, TWA four, seventy six. 2159:lO (25:07) CAM-l OK Randy, you can go ahead and start. 2159:ll (25:08) CAM-? all the better, huh? 2159:12 CAM-? ‘h2u5;;7ps) 2159:15 TWR 2159:19 ws450 2159:21 TVVR 2159:42 CAM 2159:52 CAM-? (25:39) sound of chime similar to aircraft generator power transfer l check list. (25:12) Water Ski four fii, three five five on the heading. contact departure, good night. (25:16) three fii fiie, we’ll see ya. Water Ski four fit. (25:18) TWA three ninety seven (St. Louis tower) runway three zero left, taxi into position and hold. 2159:53 CAM-2 (25:50) electrical power?

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME a SOURCE CONTENT TIME s, SOURCE CONTENT 2159:54 TWR (25:51) Northwest, ten forty eight, turn left when able and contact ground point nine as you clear the runway. good night. 2159:55 CAM-1 2159:58 CAM-2 2159:59 CAM-1 22OO:Ol (25:58) CAM-2 fuel system? 2200:02 CAM-1 2200:03 CAM-2 2200:04 CAM-l 2200:05 CAM-2 2200:06 CAM-1 2200:06 CAM-2 2200:07 CAM-1 (25:52} checked. (25:56) checked. (25:59) that’s checked. (26:00) fuel heat? (26:02) engine anti-ice? (26:03) air conditioning? (26:04) auto.

TIME & SOURCE INTRA-COCKPIT COMMUNlCATlON CONTENT TtME a SOURCE AIR-GROUND COMMUNICATION CONTENT 2200:08 CAM-2 22OO:OQ CAM-1 2200:12 CAM-2 2200:16 CAM-4 (26:05) hydraulic systems? (2666) checked and on. (26:09) delayed engine start check list complete. (26:13) ladies and gentlemen we’re l * departure. (cabin attendants) take their seats for takeoff. 2200:31 CAM-4 (26:28) l I’m having trouble with these doors ‘*. that’s why I never work up here. l *** 2200:44 (26:41) CAM-2 (was that) us? 2200:45 CAM-1 (26:42) naw, she said the wrong number. 2200:24 TWR 2200:29 TW476 2200:31 TWR 2200:33 TWR (26:21) TWA four seventy six, three thirty five on the heading. contact departure, good night. (26:26) ‘A four seventy six, good night. (26:28) TWA three ninety seven, winds two seven zero at seven. runway three zero left, fly runway heading. cleared for takeoff. (26:30) TWA four forty five (St. Louis tower) runway three zero left. taxi into position and hotd. Y

TIME & SOURCE INTRA-COCKPIT COMMUNICATION CONTENT TIME & SOURCE AIR-GROUND COMMUNICATION CONTENT 2200:48 TWR 2200:54 TWR 2201:04 TWR 2201:09 TWR 2201:18 (27:15) CAM-l we’re ready (aren’t we)? 2201:35 CAM-2 y;; 2201:21 RDO-2 2201:23 TWR 2201:29 RDO-2 2201:32 TWR (26:45) uh, I don’t have any uh, paperwork on a four fifty fiie. where you going sir? (26:51) OK, I’ve got a four forty fiie. I don’t have a four fii five, stand by. (27:Ol) OK, four fiiy five, you’re uh, number one at three zero left, is that correct? (27:06) roger, change your departure frequency it’ll be one one niner point one five and, let me know when you’re ready to go. (27:18) and TWA four twenty seven’s ready. (27:20) TWA four twenty seven, winds two seven zero at seven. runway three zero right, turn right heading three three five. cleared for takeoff. (27:26) three thirty fiie and cleared to go. TWA four two seven. (27:29) TWA three ninety seven, runway heading. contact depar- ture. good night:

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME a, SOURCE CONTENT TIME 6 SOURCE CONTENT 2201:36 CAM-1 2201:37 CAM-2 2201:39 CAM-1 (27:33) three twenty five, right? (27:34) she said three thirty five? (27:36) I don’t know. ask her. 2201:51 CAM-1 2201:53 CAM-2 220154 CAM-1 2201:55 CAM-2 2201:58 (27:55) CAM-l checked. 2202:03 CAM-? (27:48) three three five. cleared for takeoff. (27:50) cleared for takeoff. (27:51) before takeoff checklist. (27:52) before takeoff checklist says. ice, icing considerations. !;8:00) 2201:40 RDO-2 2201:46 TWR 2201:49 RDO-2 (27:37) confirm uh, three twenty five for TWA’s four twenty seven. {27:43) TWA twenty seven. three three five. (27:46) three three five, thanks. ii

TIME a SOURCE INTRA-COCKPIT COMMUNICATION CONTENT TIME a SOURCE AIR-GROUND COMMUNICATION CONTENT 2202:06 (28:03) CAM-2 (ii’s not) working real good but I think it’s on. 2202:08 CAM (28:05) [unidentified ratcheting sound] 2202:09 CAM-2 (28:06) cabin alert? 2202:09 CAM-l (28:06) checked. 2202:lO CAM-2 (28:07) ignition? 2202:lO CAM-l (28:07) on. 2202:12 CAM-2 (28:09) and, anti-ski? 2202:14 CAM-1 (28:ll) armed. 2202:15 CAM-2 (28:12) and, brake temperature? 2202:16 CAM-1 (28:13) checked. 2202:17 CAM-2 (28:14) transponder. 2202:18 CAM-l (28: 15) on. 2202:20 CAM-1 (28:17) closed. c- 0

TIME b SOURCE INTRA-COCKPIT COMMUNICATION CONTENT TIME LI SOURCE AIR-GROUND COMMUNICATION CONTENT 2202:20 CAM-2 {28:17) pneumatic crossfeed? 2202:22 CAM-1 (28:19) cleared for takeoff, three thirty five, five. 2202:25 (28:22) CAM-2 correct. 2202:27 CAM (28:24) [sound of increasing frequency similar to aircraft accelerating on runway] 2202:38 CAM-1 (28:35) one l four. [voice vibrating possibly caused by aircraft nose- wheel traveling over rough runway] 2202:40 CAM-1 2202:44 CAM-3 (28:37) eighty knots. (28:41) there’s an airplane. 2202:28 441 KM 2202:30 TWR 2202:37 441 KM 2202:40 NVR (28:25) and Kilo Mike’s ready to go on the right side. {28:27) roger, I can’t roll you simultaneously with the uh, traffic departing the right. just continue holding in position. I’% have something for you in just a second. (28:34) Kilo Mike. (28:37) rdAz; fifty fiie runway three zero left, taxi into position

TIME & SOURCE INTRA-COCKPIT COMMUNICATION CONTENT TIME a SOURCE AIR-GROUND COMMUNICATKIN CONTENT 2203:56 CAM-? 2203:57 CAM-l 2203:59 CAM-3 {29:54) we were cleared for takeoff. (29:56) I was not listening, I didn’t have l * you guys confirmed it and, I just saw the guy, I. 2204:06 RDO-1 (30:03) tower, TWA four twenty seven. 2204:08 TWR (30:05) TWA four twenty seven, the equipment’s rolling right now. 2204:lO RDO-1 (30:07) do you see any, fire or smoke around the aircraft? 2204:13 (3O:lO) TVVR no sir, I don’t. 2204:14 RDO-1 2204:16 TWR (3O:ll) IOK. {30:13) he was supposed to be on runway three one. I dii nd see the aircraft o.... 2204:19 RDO-1 (30:16) OK, we’ll handle that later. I just want to make sura avery- thing’s safe here. 2204:22 TWR (30:19) ’ roger.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME S SOURCE CONTENT TIME a SOURCE CONTENT 2202:45 {28:42} CAM-? #. 2202:47 {28:44) CAM [sound of impact] 2202:47 TWR (28:44) twin Cessna four four one Kilo Mike winds two eight zero at eight. the traffii uh, use caution for the MD-80 that’s uh, departing thirty right for possible wake turbulence. turn right heading uh, three five fi... 2202:47 CAM 2202:48 CAM-5 2202:49 CAM 2202:50 CAM-5 2202:53 CAM (2944) [sound of two beeps similar to takeoff warning horn] {28:46) [sound of two beeps similar to takeoff warning horn] I22;71 (28:50) [roaring sound similar to engine reverse thrust lasting six sec- onds] 2202:59 RDO-1 {28:56) roll the emergency equipment. TWA, four hundred and twenty seven hit the other airplane on the uh, runway. roll the emergency equipment. 2203:13 CAM-? (29:lO) head down.

TtME a SOURCE INTRA-COCKPIT COMMUNICATION CONTENT TIME a SOURCE AIR-GROUND COMMUNICATION CONTENT 2204:23 CAM-1 2204:26 CAM-3 2204:31 CAM-2 2204:33 CAM-l 2204:35 CAM-? 2204:38 CAM-4 2204:39 CAM-1 2204:40 CAM-? 2204:42 CAM . 2204:51 CAM-3 2204:52 CAM-? 2204:53 CAM-3 (30:20) OK, go back and see if there’s any damage back there. (30:23) l * let me grab my hat. (30:28) hit somebody with that right wing I guess. (30:30) yeah. I want to see what, see what’s happening out the right wing. (30:35) ladies and gentlemen l everyone seated please, everyone seated, please take your seats. everyone please stay in your seats. we will inform you as soon as possible. (30:36) I’m shuttin’ the right engine l . (30:39) sound of chime similar to aircraft generator power transfer l gasoline rolling under the airplane. {30:49) fuel going all over the left. (30:50) we better get off this thing.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME a SOURCE CONTENT TIME & SOURCE CONTENT 2204:55 (30:52) PA-1 easy victor, easy victor, evacuate the left side. 2204:58 (30:55) PA-4 easy victor, easy victor. 2205:OO {30:57) END of RECORDING END of TRANSCRIPT

juries. The digital flight data recorder (DFDR), a Sundstrand Model 573 (s/n 2432), was removed from the aircraft following the accident. The recorder was sent to the Safety Board’s laboratory in Washington, D.C. for readout and evaluation.

116 The following is a chronology of events as recorded by the fight data recorder. All time references will be local time as established by the cockpit voice recorder: n At 2201:23, air traffic control (ATC) cleared TWA Flight 427 for takeoff on runway 30R. At this time Flight 427 was taxing on a heading of 120” ( the reciprocal of the runway heading 300”). n At 2201:45, the heading values began to decrease, indicating the start of a left turn that continued until reaching 300”, the runway heading. The EPR values increased as the heading value reached 345”, at 2202: 16, and increased sharply 6 seconds later as the heading reached 309”. Runway heading (*lo) was achieved at 2202:26, as the airspeed became active, recording a value of 3 1.75 knots. n At 2202:37, the EPR values for both engines stabilized at approximately 2 as the airspeed reached 75 knots. n The data are consistent with a normal takeoff roll until 2202:45, when the rudder moves to the left 22” in one second as the airspeed increases to 109 knots. This rudder value was held for nearly a second until it changed to 23” right rudder in the following second as the airspeed reaches 111.5 knots, and the Rt. Brake Pedal Position reaches 17” at 2202:47. The longitudinal and lateral acceleration values recorded during this period are consistent with the rudder excursions. A heading change of approximately 7 degrees to the left was coincident with the right rudder input. The slat disagree parameter also switched from “agree” to “disagree” at 2202:47. (Note: The Cockpit Voice Recorder recorded the sound of impact at 2202:47) n The peak airspeed value (114.5 knots) was recorded at 2202:50, 3 seconds after the slat disagree sensor transitioned from “agree” to disagree. The start of thrust reverser transition from stowed to deployed occurred at 2202: 5 1, and both thrust reversers were deployed at 2202:52. n The EPR values for both engines reached their peak values (reverse) of 1.79 (Lt.) and 2.16 (Rt.) 3 seconds after both thrust reversers were deployed. m The remaining heading values are consistent with the airplane being maneuvered first to the right and then to the left until reaching a heading of 293” as the airplane decelerated to a stop at 2203: 10. n The last DFDR data for flight 427 were recorded at 2204:29.

117

1. Descrintion of Data

This model DFDR is designed to accept digital data input information from a remote Flight Data Acquisition Unit (FDAU), and store the data in a crash survivable recording device. The DFDR utilizes coaxial tape reels that hold 820 feet of Vicalloy metal tape, ‘/z mil thick and % inch wide. The 4 track tape moves at 0.43 inches per second while recording on one track at a time in a predetermined bidirectional sequence. The oldest data are erased before recording new data. End-of-tape sensors at both ends of the tape provi,de the signal to reverse the drive motor direction and switch the record electronics to the next track. Recording time for one end-to-end pass of the tape is 6.25 hours, thus the recorder will continuously record and retain the last 25 hours of selected flight data. The FDAU provides a means of gathering, conditioning, and conversion of flight data parameters to digital data. The FDAU provides a serial binary digital data stream to the DFDR at a rate of 768 bit/l ,024 seconds. A binary, or logical one, is represented by a voltage transition between clock transitions. The FDAU input signals are time division multiplexed, with parameter identification established by means of position or time slot addresses in the serial data stream output. This output is continuously repeating every second. The first word contains a unique 12 bit synchronization (sync) word followed by 63 12 bit data words. The data stream is “in sync” when the sync word appears at 64-word intervals. . If the data stream is interrupted, either at the FDAU or the DFDR the sync word will not appear at the proper interval, and the time reference will be lost until the pattern can be reestablished. A loss of data synchronization, or sync loss, can result from either a mechanical or electrical interruption of the data. A mechanical interruption can be caused by foreign matter coming between the tape recording medium and the heads during the record or playback process. Mechanical interruptions can also be caused by DFDR vibration which can introduce wow and flutter to the tape transport, and distort the recorded signal. An interruption of electrical power to the DFDR or FDAU will also interrupt the serial data stream and cause a loss of sync.

1. Examination of Recorder

The flight recorder was examined and found undamaged.

1. Readout and Evaluation

a. Readout The tape recording medium was removed from the DFDR and mounted on the Safety Boards raw tape transport (RTT). The data of interest were then located and transcribed. No modification of the Safety Board’s hardware or software was necessary to recover the data.

a 118 b. Evaluation An examination of the recovered data indicated that the recorder operated normally.

1. DFDR and Cockpit Voice Recorder (CVR) Time Correlation

The correlation of the DFDR and CVR recordings was established by comparing the timing of the VHF radio transmission made by Flight 427. The DFDR records when the airplane’s VHF radio transmitters are keyed and released by setting a single bit (1 “keyed” or 0 “Off”). Therefore, the DFDR check the status of the radio transmissions for only l/768 of a second once every second. As a result, it is possible for the microphone keying status to be off by as much as .9987 seconds or, if keyed less than a second, to not be recorded. The CVR, however, records when the microphone is open but only if there is a sound to record. Therefore, it is expected that a comparison of the DFDR and CVR radio transmission time histories will generally coincide to within f a second. The elapsed time between the last 18 transmissions as recorded by the DFDR and CVR were compared. This comparison revealed that the DFDR did not record 2 transmissions (microphone keying), and that all 14 time intervals between transmissions differed by less than 2 seconds. The two transmissions not recorded by the DFDR were short in duration (less than a seconds), and therefore could have occurred between data samples. In addition, 11 of the 14 time intervals correlated to the second. Therefore, the DFDRKVR time correlation was established over an elapsed time of 8 minutes and 40 seconds, and provided a match to within one second. DFDR times can be converted to CVR (local times) by the following equation: DIBR time in seconds + 78,298 seconds = local time in seconds.

1. Data Printout

A printout of selected parameters is attached. The data covers 3 minutes which includes the turn onto the runway, the takeoff abort, and ends shortly after the aircraft comes to rest.

1. Data Plot

A plot of selected parameters covering a 60 second period commencing at 2202: 14, is attached. This time period covers a portion of the turn on to the runway heading and ends as the airplane decelerated to a stop. Dennis R. Grossi Flight Data Recorder Specialist

TWA FLIGHT 427 ia MD - 82, N954U ST. LCXJIS, LAMBERT FIELD

2

- -a.a ‘7 a -_-____--I. -0.40 ___e--- I3 _--- 1:: --. ---_ 2 P LOCAL TIME kR:MItVSEC~ Accident Date: November 22, j994 Revised August 17. 1995 Flight Recorders / Co!rputers - NTSB Y

is radar site were extracted from the tape for both TWA427 and N441 KM. Primary data (reflection of radar signal which indicate a two dimensional position in space - range/azimuth) from the St. Louis radar site were extracted from the tape.

122 Secondary data between 0358:141 and 0404:43 for N441 KM and TVVA427 and the corresponding Coordinated Universal Time (UTC) are graphically depicted along with runway 31, runway 30R, runway 30L and the St. Louis radar site in Attachment 111-l. Attachment Ill-2 shows, in greater detail, N441 KM’s ground track between 0358: 14 and 0402:43. Secondary and primary data between 0401: 14 and 0404:43 and the corresponding UTC are graphically depicted along with runway 31, runway 30R, runway 30L and the St. Louis radar site in Attachment 111-3. Secondary data indicated N44lKM turned the transponder off at 0343:06 and turned it on 13 minutes and 18 seconds later (0356:24). At 0358: 19, N441 KM taxied to runway 30R and stayed on runway 30R for approximately,3 minutes (0359:42 to 0402:42). The only TWA427 secondary data occurred at 0404:42 and was located approximately 0.36 nautical miles at a bearing of 299 degrees true from the last N441 KM secondary data. D. DETAILS OF STUDY 1. RECORDED RADAR DATA A computer tape containing pertinent recorded radar data was obtained from the FAA’s St. Louis Facility. St. Louis’ Automated Radar Terminal Systems (ARTS) Ill utilizes an Airport Surveillance Radar 9 (ASRS). ARTS is the radar used to track aircraft within the operation area of airports. The St. Louis radar site independently recorded secondary data (time, range, azimuth and altitude) and primary data (reflection of radar signal which indicate a two dimensional position in space - range/azimuth) at approximately 4.6 second intervals. The assigned beacon code for TWA427 was 1765. The assigned beacon codes for N441 KM were 3050 and 1105. The secondary data associated with the beacon code 1150 occurred between the last 3050 beacon code and the first 1105 beacon code and, therefore, assumed to represent N441 KM. The computer tape was read out in the National Transportation Safety Board laboratory and secondary and primary data were extracted from the tape utilizing an ARTS Ill Radar Data Decoding Program. Attachments I-l to l-12 contain pertinent recorded radar data (from the St. Louis radar site) extracted from the computer tape. The data should be assessed using the following generally accepted accuracy limits: ALTITUDE .............. +/- 50 feet RANGE.. ................. +/- 380 feet AZIMUTH................ +I- 1 ACP2 (4096 ACP’s = 360 degrees). I All times are Coordinated Universal Time (UTC) aaxwding to the FAA tape. 2ACP is the FAA Acronym for Azimuth Change Pulse.

123 The altitude and range accuracy limits are usually constant assuming the aircraft transponder was calibrated properly. The azimuth accuracy limit is usually constant at +/- 1 ACP; however, the actual azimuth distance limit increases with range since the arc length of 1 ACP increases linearly with range. Range and azimuth data may exceed the normal limits for single data points. The secondary and primary data from the St. Louis radar site were entered into a computer file named btallrO.ra and primrO.ra, respectively. The secondary and primary data in files btallrO.ra and primrO.ra were processed by the Radar ViewPoint computer program XCDRURF to convert the range/azimuth position data to latitude/longitude data (where the magnetic variation for the St. Louis radar site was 1 degrees east and the location for the St. Louis radar site was 38 degrees 44 minutes 38.18 seconds north and 90 degrees 20 minutes 28.41 seconds west). Files btallrO.urf and primr0.ut-f contain latitude/longitude position data for the secondary and primary data, respectively. 2. Site Position Data Position data in latitude/longitude format were obtained for runway 31, runway 30R, runway 30L and the St. Louis radar site. All data were obtained from the FAA. File sites.lat contains the site position data. Attachment II-1 to II- 13 contain all pertinent data files. 3. Plotted Data Attachments Ill-l to Ill-3 contain various plots of the data discussed in this report. Cassandra Johnson ‘,, Mechanical Engineerw

124 North Range vs. East Range (Secondary data for N441 KM and TWA427 between 0358:14 and 0404:43) 4 W 31 ‘twy 30R Symbol: Aircraft (beacon code) Open X: N441KM (3050) Closed Circle: N441 KM (1150) Diamond: N441 KM (1105) Open Circle: WA427 (1765) 1,242 (0.15nm per inch) Radar ViPoint(tm) by Aimrays Technology, Inc.

r !I 125 North Range vs. East Range (Secondary data for N441 KM between 0358:14 and 0402:43) N441 KM

0358:15x0358:19 _______jj‘\ 0358:47=0358:52 ’ 0358:56 “\ x 0359:Ol x.0359:05‘

\ 0359:10()0359:15 \“ :5() 00359:24 w 31 ‘,00359:33 0‘b359:37 0359:42()QlM&~ 0402:42()0402:tl ‘1 -- .x . . Diamond: N441 KM (1105) I 1:4,713 (0.06nm per inch) Radar VwwPoint(tm) by Airways Tech‘nology, Inc.

126 North Range vs. East Range (Secondary and primary data between 0401:14 and 0404:43) 40403:lo /\0401:56 I04il#t33 Symbol: Aircraft (beacon code) Triangle: Primary data (none) Diamond: N441 KM (1105) Open Circle: TWA427 (1765) 31,242 (O.l!%m per inch) Radar ViPoint(tm) by Aiways Tachnokgy, Inc. 1: ASR9 antenna A0403:09 A 0402338 A0402127 A0403:27 0403:32

127 APPENDIX F - MD-82 ACCELERATED STOP DATA MD-80 JT8D-217 Engines flq Posi!ion = 1 lo Gross Weigti tl45.280 Ibs Field Elevation = 605 ft Engine Bleeds OFF Wind Speed = 0 Runway Slope = 0 am Temp = 0°C DIS & 1.917758! 2000 1. , , ! . , , , ! , , ,I . , , ,I , , , , I, I , , I 1 S’O 90 100 110 lh0 130 l&-GO Rakes ON Speed -- KIAS MD-80 JlBD-217 Engines flap Position = 1 lo aross Weight =145,280 Ibs Field Elevation = 605 ft Engine Bleeds OFF 6000 c $ 5500 ti5 5000 5 ag 4500 co d,5 4000 6 5 l-0 1’5 io is 50 Ambient Tern perature -- “C

129 APPENDIX G Runway IncursionlGmund Collision Safety Recommendations Since 1973, the National Transportation Safety Board has issued 64 safety recommendations regarding the problem of runway incursions/ground collisions of aircraft. Of these, 49 have been classified Closed--Acceptable (or Acceptable Alternate) Action; and nine Closed--Unacceptable Action. Five are being held as Open--Acceptable Response and one as Open--Unacceptable Response. Those classified Closed--Unacceptable Action are the following: A-73-25 A-73-26 A-73-55 A-78-52 A-79-42 A-84-101 A-86-39 A-86-45 Establish and publish taxi routes for arriving and departing aircraft to be used in restricted visibility. Require pilots to obtain controllers approval before crossing a lighted runway during periods of restricted visibility. Require read back of taxi clearances when operating in restricted visibility. Require intersection signs at displaced threshold or taxiways that enter runways at points other than the end of runway. Perform a directed safety study on the runway incursion problem and fix it. Develop and require uniform signs at certificated airports with functional classifications, i.e., size, shape, color to depict different meanings. Include near collisions near surface of airports in near-midair reports. Provide a local control coordinator nosition at O’Hare.

130 A-91-1 12 Evaluate and implement, as appropriate, suitable means for enhancing the conspicuity of aircraft on airport surfaces during night or periods of reduced visibility. Include in this effort measures, such as the displacement of an aircraft away from the runway centerline, where applicable, and the use of conspicuity enhancements, such as high- intensity strobe lighting and logo lighting by aircraft on active runways, and encourage operators of airplanes certificated prior to September 1, 1977, to upgrade their airplanes to the present higher intensity standards for anti-collision light installations. The single Open--Unacceptable Response safety recommendation is the following: A-91-1 11 Redefine the airplane certification coverage compliance standards for anti-collision lights installations to ensure that the anti-collision light(s) of an aircraft in position on a runway are clearly visible to the pilot of another aircraft preparing to land or take off on that runway. The five safety recommendations being held in the Open--Acceptable Response status are the following: A-9 l-29 A-91-30 A-91 -56 A-95-3 1 A-95-32 Expedite efforts to fund the development and implementation of an operational system analogous to the Airborne Conflict alert system to alert controllers to pending runway incursions at all terminal facilities that are scheduled to receive Airport Surface Detection Equipment (ASDE III). Conduct research and development efforts to provide airports that are not scheduled to receive Airport Surface Detection Equipment with an alternate, cost-effective system to bring controller and pilot attention to pending runway incursions in time to prevent ground collisions. Require that CFR 139 certificated airports use reflectorized paint for airport surface markings. Within 60 days of receipt of this letter, provide to the Safety Board a firm schedule to commission those Airport Surface Detection Equipment - three radar systems that have been installed & adhere to t h a t s c h e d u l e . For those traffic control terminal facilities that commission the Airport Surface Detection Equipment - 3, require that it be operational between sunset & sunrise. When the Airport Movement Area Safety All 64 of the safety recommendations are cited on the following pages listing current

131 status assignments and the accidents/incidents from which the safety recommendations were derived. On May 17, 1973, as the result of a ground collision accident at O’Hare’Intemational Airport in Chicago, Illinois, on December 20, 1972, the Safety Board issued six safety recommendations to the FAA. These safety recommendations are listed below with current status assignments: A-73-2 1 A-73-22 A-73- 23 A-73- 24 A-73- 25 Closed--Acceptable Action August 16, 1974 Standardize configuration, alignment techniques, and equipment modifications at the three existing ASDE Brite facilities in an effort to improve the performance of that equipment. Closed--Acceptable Action August 16, 1974 Do not proceed with the scheduled installation of Brite displays at other ASDE- equipped facilities which now use the direct view radar display until satisfactory operation of Brite equipment is achieved at the three facilities where it is now Closed--Acceptable Action August 16, 1974 Contingent upon favorable results of the evaluation of the new model ASDE Brite display currently being conducted by the Transportation Systems Center, install that equipment first at the three locations where Brite equipment is.now used. Closed--Acceptable Action December 3, 1975 Establish standard procedures for the use of ASDE radar, and publish such procedures in appropriate air traffic handbooks. Closed--Unacceptable Action August 16, 1974 Establish and publish taxi routes for arriving and departing aircraft to be used during periods of restricted visibility on the order of 112 mile.

132 A-73- Closed--Unacceptable Action 26 ’ August 16, 1974 Require pilots to obtain the controllers’ approval before crossing a lighted runway during periods of restricted visibility on the order of l/2 mile. On August 10, 1973, the Safety Board issued two runway incursion-related safety recommendations as a result of ongoing investigations of three accidents. These accidents were: United Air Lines Boeing 737 -- Chicago Midway Airport, December 8, 1972; North Central Airlines DC-9 -- Chicago O’Hare Airport, December 20, 1972; and Eastern Airlines Lockheed L-l 0 11 -- Miami, Florida, December 29, 1972. The safety recommendations issued at that time are listed below with the current status assignments. A-73- 54 Closed--Acceptable Action August 14, 1974 Require flight crews to report their aircraft position on the airport when establishing radio communications with controllers, and require the controllers to read back the reported aircraft position when it cannot be verified either visually or by means of radar. A-73- 55 Closed--Unacceptable Action November 16, 1973 Require flight crews to read back taxi clearances when operating in visibilities of less than one-half mile. On August 8, 1978, as a result of a June 3, 1977, accident at the Tucson International Airport, Tucson, Arizona, the Safety Board issued the following safety recommendation to the FAA. The current status assignment is shown. A-78- Closed--Unacceptable Action 52 April 10, 1979 Require that all operators of certificated airports where runway designs feature a displaced threshold and taxiways enter the runway at points other than the runway’s end install an easily visible intersection sign which displays a displaced threshold notation.

133 On June 8, 1979, as a result of the investigation of three separate ground collisions, or nea collisions, the Safety Board issued Safety Recommendations A-79-42 and -43 to the FAA. The acciden involved were: North Central Airlines, DC-9 near-collision with a Cessna Citation at LaGuardia Airport, Flushing, New York on June 21, 1978; Delta Airlines, Boeing 727 near-collision with a Flying Tiger Lines Boeing 747 at Chicago O’Hare Airport on February 15, 1979; and Federal Express Falcon Fan Jet collision with a Beechcraft Model 18 at Memphis International Airport, Memphis, Tennessee on February 24, 1979. The safety recommendations issued are listed below with the current status assignment: A-79-42 Closed--Unacceptable Action/Superseded (by A-86-30 through -44) May 13, 1986 Conduct a directed safety study, on a priority basis, to examine the runway incursion problem and to formulate recommended remedial action to reduce the likelihood of such hazardous conflicts. A-79- Closed--Unacceptable Action 43 May 22, 1984 Alert all controller/pilot personnel that runway incursion mishaps represent a serious safety problem which requires their immediate attention. Special emphasis should be placed on the need for both groups to maintain greater visual surveillance in those taxi operations involving any runway crossing. On April 16, 1984, as a result of a special study of several accidents involving ground cant at airports during times when the runways were contaminated, the Safety Board issued Saf Recommendation A-84-23. This safety recommendation was addressed to the FAA and reads as follol A-84- 23 Closed--Acceptable Alternate Action March 20, 1990 Revise FAA Order 5280.5, Ground Vehicles, to include specific criteria for determining the adequacy of ground vehicle control, such as the number of ground vehicle accidents each year, disciplinary actions taken in accident cases, the number of repeat offenders, and an annual accident rate.

134 On August 23, 1984, as a result of the investigation of a head-on collision between a Korean Air Lines cargo flight and a South Central Air commuter flight at Anchorage International Airport on December 23, 1983, the Safety Board issued five safety recommendations to the FAA related to ground control of aircraft. These five safety recommendations are listed below with their current status assignments. A-84-98 Closed--Acceptable Action March 29, 1990 Require that airports certificated for air carrier operations install signs at all runway and taxiway entrances, exits, and intersections that indicate the identity of the runway or taxiway. A-84-99 Closed--Acceptable Action July 12, 1989 Require that the graphics on taxiway/runway identification signs be standardized and of sufficient size to enable them to be legible to aircraft crewmembers in all meteorological conditions in which air carrier operations are authorized. A-84-l 00 Closed--Acceptable Action April 20, 1990 Require that airport operators inspect and maintain the light illuminating airport . taxiway/runway identification signs as part of the daily airport inspection requirements. A-84- 10 1 Closed--Unacceptable Action August 11, 1986 Require at all airports certificated for air carrier operations that uniform signs be installed which are classified by function (e.g., runway entrance, runway exit, taxiway intersection) with each function having a unique shape, color, and/or size A-84-l 02 Closed--Unacceptable Action September 12, 1985 Require that air carriers incorporate in training o their crewmembers procedures and responsibilities during ground operations in restricted visibility conditions, to enable them to operate safely in such conditions. On February 22, 1985, as a result of the Safety Board’s investigation of the December 19, 1983, co11;,- 1 between a Japan Airlines Boeing 747 and a pickup truck traversing a runway at Anchorage Int. Jnal Airport, Anchorage, Alaska, the Safety Board issued 3 safety recommendations to the FAA reg.. Lg ground control of vehicles. These three safety recommendatidns are listed below with their

135 current status assignments: A-85-15 Closed--Acceptable Action November 4, 1987 Develop a mechanical/aural/visual (or combination thereof) alert device and require its use by local and ground controllers to coordinate their activities when a vehicle has been cleared to operate on the active duty runway for an extended period such as in snow removal operations. A-85-16 Closed--Acceptable Action July 25, 1988 Periodically emphasize in the training of air traffic control personnel providing airport advisory services the proper application of runway usage procedures stressing positive coordination between control positions. A-85-l 7 Closed--Acceptable Action July 25, 1988 Periodically emphasize in the training of air traffic controller personnel the requirements contained in the air traffic control handbook 7110,65D, March 1984, for restricted vehicle and aircraft operations in the ILS critical areas when the ILS is being used for approach/landing guidance and the reported ceiling, visibility or On April 19, 1985, as a result of the investigation of an ATC operational error at Minneapolis-: Paul International Airport on March 3, 1985, the Safety Board issued two safety recommendations to t FAA. These safety recommendations are listed below with the current status assignments: A-85-32 Closed--Acceptable Action January 24, 1986 Issue a General Notice (GENOT) directing the management of all terminal air traffic control facilities to immediately brief all traffic controllers on the importance of complete and accurate coordination between local and ground controllers before taxiing airplanes on or across an active runway.

136 A-85-33 Closed--Acceptable Action February 17, 1987 Develop and implement, on a priority basis, specific procedures and standards, and specify responsibilities to be used during direct face-to-face and/or interphone coordination between local and ground controllers regarding requests and approvals to clear airplanes to taxi across an active runway. On May 13, 1986, the Safety Board issued 14 safety recommendations as a result of a Special Investigation Report, “Runway Incursions at Controlled Airports in the Unite&States.” These safety recommendations are listed below with the current status assignments: A-86- 30 A-86- 31 A-86- 32 A-86- 33 Closed--Acceptable Action November 1, 1991 Revise the current tower training curriculum at the ATC Academy to include more emphasis on practical standardized hands-on tower training using dynamic laboratory and simulation facilities. Closed--Acceptable Action June 30, 1994 Establish a program for improved supervision of tower controller performance in which scanning, coordination, and use of proper phraseology is emphasized and . which includes retraining of controllers who are deficient. Closed--Acceptable Action June 30, 1994 Establish an Ad Hoc task force, including controller and human performance expertise, to develop effective memory aids that would reduce incidents of air traffic controllers forgetting traffic, and to incorporate a description of these memory aids and how they should be used in the ATC Academy controller training syllabus and in the tower facility training program. Closed--Acceptable Action August 16, 1993 Require controllers to obtain a readback for all hold, takeoff, or crossing clearances and for clearances onto an active runway.

c 137 A-86- Closed--Acceptable Action ‘34 October 14, 1987 Emphasize in operational bulletins, the Airman’s Information Manual, general aviation seminars, and pilot training programs, the importance of reading back taxi, hold-short, runway crossing, and takeoff clearances in proper phraseology; the importance of reporting when unable to promptly cross, take off from, or clear a runway when so cleared; and the need to scan properly before entering or crossing a A-86- 35 Closed--Acceptable Action October 14, 1987 Emphasize in operational bulletins, the Airman’s Information Manual, general aviation seminars, and pilot training programs, that a good operating ‘practice for pilots of single-pilot airplanes is to monitor only assigned air traffic control communication frequencies after a clearance onto an active runway for departure, until flight from the airport traffic area is completed, or after receipt of clearance for landing, until the landing and taxi across all active runways is completed. A-86- Closed--Acceptable Action 36 January 13, 1987 Revise controller phraseology for use when issuing takeoff and landing clearances to include the runway number (for example: American 75, Runway 36, Cleared for takeoff ). A-86- Closed--Acceptable Action 37 January 13, 1987 A-86- 38 Issue a general notice directing the management of all terminal air traffic control facilities to brief all controllers on the dangers of attempting to expedite traffic departing or crossing runways in order to accommodate arrival and departure traffic. Closed--Acceptable Alternate Action May 8, 1989 Issue an advisory circular delineating both the pilot and controller roles and responsibilities in the prevention of runway incursion incidents. A-86- Closed--Unacceptable Action 39 August 3, 1987 Revise the near-midair collision reporting and investigating program to clarify the intent that near-collisions on or near the airport surface constitute an occurrence which must be investigated as a near-midair collision,

A-86- 40 A-86- 41 A-86- 42 A-86- 43 138 Closed--Acceptable Action September 22, 1992 Revise and enforce the requirements to report and to investigate operational errors, pilot deviations, and near-midair collisions that involve aircraft on the ground as well as in the air, and develop a combined data base for comprehensive procedural and human performance causal analyses of runway incursion incidents. Closed--Acceptable Action June 23, 1987 Issue an Air Carrier Operations Bulletin to require air carrier inspectors to review air carrier training and operations manuals and pilot training programs to ensure that they contain specific standardized information and guidance to pilots concerning ,, their role in the prevention of runway incursions. Closed--Acceptable Action May 18, 1987 Disseminate copies of the Safety Board’s Special Investigation Report on runway incursions at controlled airports in the United States to all terminal control facilities and to the ATC academy for use in their training programs. Closed--Acceptable Action January 15, 1992 In cooperation with terminal air traffic managers, airport managers, airline representative, and pilot groups, determine the most effective signs, markings, and procedures, from an operational and human performance perspective, to prevent pilot-induced runway incursions and issue an advisory circular to disseminate the information to airport managers and pilot organizations. On May 27, 1986, as a result of the investigation of a May 17, 1986, air traffic control operational error at the Chicago O’Hare International Airport, the Safety Board issued three safety recommendations to the FAA. These safety recommendations are listed below with their current status assignments.

k 139 A-86- Closed--Acceptable Action 44 July 30, 1986 Issue a General Notice (GENOT) to all terminal facilities to require that every controller is briefed on the importance of issuing traffic information to airplanes that have been cleared into position to hold on a runway before takeoff as required by the controller’s handbook 7110.65D, 3-103. A-86- 45 Closed--Unacceptable Action August 3, 1987 Establish on a trial basis, for the north and for the south control operations in the Chicago O’Hare International Airport control tower, local control coordinator positions to monitor and supervise, directly, the local control positions; staff these positions whenever intersecting runways are in concurrent operation. A-86- Closed--Acceptable Action 46 July 10, 1989 Evaluate the need for a local control coordinator position at all major airports that use intersecting runways in concurrent operations and establish the position where the need is evident. On March 16, 1988, as a result of its investigation of another ATC operational error at 1 Chicago O’Hare International Airport (October 29, 1987) the Safety Board issued two saft recommendations to the FAA. These safety recommendations are listed below with the current stal assignments: A-88- Closed--Acceptable Action 47 July 14, 1989 Establish, for the north and for the south control operations in the Chicago O’Hare International Airport control tower, local control coordinator positions to monitor and supervise, directly, the local control positions; staff these positions whenever intersecting runways are in concurrent operation. A-88- Closed--Acceptable Action 48 May 18, 1989 Expand the current Chicago O’Hare tower notice, Order N7110.652, Circling Procedures for Runways 9W4R, dated November 6, 1987, to provide for application to any arriving aircraft whose flightpath will traverse the departure path of another aircraft.

140 On July 17, 1989, as a result of the investigation of a January 10, 1989, accident at the Houston Hobby airport, the Safety Board issued Safety Recommendation A-89-74 to the FAA. The receommendation and its status are described below: A-89- Closed--Acceptable Action 74 December 11, 1990 Assure that the Normal Procedures section of the operations manuals of all air carriers operating under Title 14 Code of Federal Regulations Parts 121 and 135 requires flightcrews to cross-check the heading indicator to the runway heading when the airplane is aligned with the runway for takeoff. On June 12, 1991, as a result of the investigation of a January 1, 1990, accident at the William B. Hartsfield International Airport, Atlanta, Georgia, the Safety Board issued two safety recommendations related to runway incursions to the FAA. These recommendations are described below. A-91-. 29 Open--Acceptable Response Expedite efforts to fund the development and implementation of an operational system analogous to the Airborne Conflict alert system to alert controllers to pending runway incursions at all terminal facilities that are scheduled to receive Airport Surface Detection Equipment (ASDE III). A-91- 30 Open--Acceptable Response Conduct research and development efforts to provide airports that are not scheduled to receive Airport Surface Detection Equipment with an alternate, cost-effective system to bring controller and pilot attention to pending runway incursions in time to prevent ground collisions. On July 23, 1991, as a result of the investigation of the December 3, 1990, ground collision between a Boeing 727 and a DC-9 at the Detroit Metropolitan/Wayne County Airport, Detroit, Michigan, the Safety Board issued seven safety recommendations to the FAA addressing the runway incursion problem. These recommendations and their status are described below: A-91- 54 Closed--Acceptable Action March 15, 1993 Improve standards for airport marking and lighting during low-visibility conditions, such as standards for more conspicuous marking and lighting; evaluation of uni- directional taxi lines for use on acute angle taxiways; and requirements for stop bars or position-hold lights at all taxiways that intersect active runways.

141 A-91- 55 Closed--Acceptable Action August 3 1, 1994 Identify, at all 14 CFR 139 certificated airports, complex intersections where a potential for pilot confusion exists. Where needed, require additional lighting and signs. -. A-91- 56 Open--Acceptable Response Require that CFR 139 certificated airports use reflectorized paint for airport surface markings. A-91- Closed--Acceptable Alternate Action 57 February 16, 1995 Require that CFR 139 certificated airports install semi-flush runway edge lights in accordance with Advisory Circular 150/5340-24. A-91- 61 Closed--Unacceptable Action June 7, 1995 Require that air traffic control tower managers re-emphasize the concept and use of progressive taxi/progressive ground movement instructions during low-.visibility ground operations in local operations position standards handbooks. A-91- 62 Closed--Acceptable Action May 15, 1992 Require that air traffic control tower managers emphasize to local controllers the need for position determination of airplane departures in IFR conditions when direct observations of departing airplanes are not possible. A-91- 66 Closed--Acceptable Action August 30, 1994 Require that the subject of low-visibility taxi problems become a recurring subject in all airline operations manuals and pilot training forums. On December 3, 199 1, as a result of the investigation of the February 1, 1991, accident involl the collision of a landing B-737 with a Fairchild Metroliner waiting for takeoff clearance at the Angeles International Airport, Los Angeles, California, the Safety Board issued eight sa recommendations to the FAA addressing the problem of runway incursion accidents. Tl recommendations are described below.

142 A-9 1 - IO4 Closed--Acceptable Action February 10, 1994 Modify air traffic control procedures at the Los Angeles International Airport to: (a) segregate arrivals and departures to specific runways; (b) provide redundancies as intended in the National Operation Position Standards in the control tower. A-9 l- 105 Closed--Acceptable Action April 8, 1993 Undertake a zero-risk based evaluation of air traffic control procedures at the Los Angeles International Airport, evaluate whether changes are required, and implement necessary changes. The evaluation should consider at least

• the

following issues: (A) runway intersection takeoffs; (B) position-and-hold clearances; (C) displaced runway thresholds; (D) hazards associated with runway crossing traffic; (E) local assist controller; (F) Airport Surface Detection Equipment A-9 1 - 110 Closed--Acceptable Action February 10, 1994 Conduct a one-time examination of the airport lighting at all U.S. tower-controlled airports to eliminate or reduce restrictions to visibility from the control tower to the A-9 1 - 111 runways and other traffic movement areas. Open--Unacceptable Response Redefine the airplane certification coverage compliance standards for anti-collision lights installations to ensure that the anti-collision light(s) of an aircraft in position on a runway are clearly visible to the pilot of another aircraft preparing to land or take off on that runway. A-9 1 - 112 Closed--Unacceptable Action April 12, 1995 Evaluate and implement, as appropriate, suitable means for enhancing the conspicuity of aircraft on airport surfaces during night or periods of reduced visibility. Include in this effort measures, such as the displacement of an aircraft away from the runway centerline, where applicable, and the use of’ conspicuity enhancements, such as high-intensity strobe lighting and logo lighting by aircraft on active runways, and encourage operators of airplanes certificated prior to September 1, 1977, to upgrade their airplanes to the present higher intensity standards for anti-collision light installations.

a 143 A-91-1 13 A-91-1 14 A-91-1 15 Closed--Acceptable Action August 10, 1993 Direct the general aviation community and the airlines to take steps to ensure that pilot training programs, including cockpit resource management training and flight operations procedures, place sufficient emphasis on the need for pilots to maintain vigilance in monitoring air traffic control radio communication frequencies for potential traffic conflicts with their aircraft, especially when on an active runway and/or when conducting a final approach to a landing. Closed--Acceptable Action April 8, 1993 Incorporate into the Airman’s Information Manual language that will alert pilots to the need for vigilance in monitoring air traffic frequencies for traffic conflict situations which may affect the safety of their flight. Closed--Acceptable Action April 16, 1993 Develop for inclusion in the Airman’s Information Manual and the Air Traffic Control Handbook, (7110.65F) specific phraseology to be used by pilots when requesting an intersection departure and specific phraseology to be used by controllers when issuing a position-and-hold clearance for an intersection departure. On February 28, 1995, as a result of the investigation of the November 22, 1994, accidc involving the collision of a McDonnell Douglas MD-82 and a Cessna 441 at the St. Louis/Lamb International Airport, Bridgeton, Missouri, the Safety Board issued five safety recommendations to FAA addressing the problem of runway incursion accidents. These recommendations and their sta are described below: A-95-30 Closed--Acceptable Action August 1, 1995 Within 45 days of receipt of this letter, require that the air traffic service provide a firm, finalized mission needs & operational requirements documents for Airport Movement Area Safety System. No further modifications should be implemented until after the first Airport Movement Area Safety System is commissioned.

, 144 A-95-3 1 Open--Acceptable Response Within 60 days of receipt of this letter, provide to the Safety Board a firm schedule to commission those Airport Surface Detection Equipment -- III radar systems that have been installed & adhere to that schedule. A-95-32 Open--Acceptable Response For those traffic control terminal facilities that commission the Airport Surface Detection Equipment -- III, require that it be operational between sunset & sunrise. When the Airport Movement Area Safety System is commissioned, require that it be operational 24 hours a day. A-91 -33 Closed--Acceptable Action August 1, 1995 Issue an Administrator’s letter to airmen that directs pilots to read back, in full, their runway assignment upon receiving taxi instructions & before receiving their takeoff clearance when operating at airports that employ more than one runway. Also revise the Airman’s Information Manual to reflect this procedure. A-95-34 Closed--Acceptable Action August 1, 1995 Amend FAA Order 7110.65, Air Traffic Control, to require that air traffic controllers receive confirmation of runway assignment from pilots after issuing taxi instructions. Require that this procedure be used at those airports which employ more than one runway during operations.

I 145 APPENDIX H - FEBRUARY 28,1995, RECOMMENDATIONS National Transportation Safety Board Washington, D.C. 20594 safety Recommendation Date: February 28, 1995 In reply refer to: A-95-30 through -34 Honorable David R. Hinson Administrator Federal Aviation Administration Washington, D.C. 20591 Approximately 2202 central standard time on November 22, 1994, a collision occurred at the intersection of taxiway romeo and runway 30R at the St. Louis/Lambert International Airport, St. Louis, Missouri. The St. Louis weather conditions were reported to be clear, with visibility at 25 miles. The accident involved a Cessna 441, N441KM. and a McDonnell Douglas MD-SO, Trans World Airlines flight 427 (TWA427). TWA427 was operating as a scheduled domestic passenger service flight from St. Louis to Denver, Colorado, under the provisions of Title 14 Code of Federal Regulations (CPR) Part 121. N441KM was operating under the provisions of 14 CFR Part 91, under an instrument flight rules clearance to Iron Mountain, Michigan. Both airplanes were in radio communication with the tower local controller at the time of the accident. As a result of the collision, N441KM was destroyed and TWA427 received substantial damage. The pilot and passenger aboard N441KM were fatally injured, and there were eight injuries on TWA427. The Safety Board’s investigation of the accident is continuing. Information obtained to date indicates that N441KM landed on runway 30R at St. Louis and taxied to the ramp at the north side of the airport. After unloading a passenger, the pilot requested and was issued a clearance to Iron Mountain. The ground controller then instructed its pilot to backtaxi on runway 31, which is parallel to runway 30R. The ground controller also instructed the pilot to hold in position on runway 3 I and to advise the controller when he was ready for takeoff. A little more than 3 minutes later, the ground controller inquired if the pilot was ready for takeoff. After receiving an affirmative response, the ground controller instructed the pilot to monitor the tower local control frequency. While the pilot of N441KM was on the ground control frequency, the flightcrew of TWA427 had received their takeoff clearance on runway 30R. About 38 seconds after they acknowledged their takeoff clearance, the pilot of N44lKM advised the local controller, “and kilo mike’s ready to go on the right side.” The local controller advised the pilot that she could not clear him simultaneously, “with the uh traffic departing on the right just continue holding in 6519A

146 position . . . .” About 11 seconds after the pilot of N441KM acknowledged this transmission, the airplane was struck by TWA427 which was on takeoff roll on runway 30R. The Safety Board is focusing on many areas during its investigation and has not concluded that any specific communication was causal to the accident. Notwithstanding, the Safety Board believes that the Federal Aviation Administration (FAA) should take action to make certain that air traffic controllers and pilots clearly understand the intentions and expectations of one another. Also, the Safety Board believes that had previous actions taken by the FAA to reduce the risk of runway collisions received adequate support, this accident could have been prevented. While FAA statistics indicate that the number of runway incursions has decreased yearly since 1991, the Safety Board believes that this accident illustrates that there is no’margin for error for either pilots or controllers and that unresolved errors can lead to catastrophic results. The Safety Board’s concern about the hazards of runway incursions dates back to 1972 following an accident at the Chicago O’Hare International Airport. Since that time, the investigation of other such accidents or incidents has prompted the Safety Board to issue 61 safety recommendations focused on the prevention of runway incursions. At present, this issue is included as a part of the Safety Board’s “Most Wanted” Safety Recommendation Program. Following a runway collision at the Atlanta Hartsfield International Airport that occurred on January 18, 1990, involving an Eastern Airlines Boeing 727 and a King Air AlOO,’ the Safety Board recognized FAA efforts to explore and test several advanced concepts in automated airport surface traffic detection. One of those efforts, the Airport Movement Area Safety System (AMASS) was, at that time, undergoing proof-of-concept testing at the Pittsburgh International Airport. The AMASS system uses data available from the Airport Surface Detection Equipment (ASDE-3) and Automated Radar Terminal System (ARTS) to identify potential incursions and alerts the controller so that timely corrective action can be taken. In testimony before congressional committees on March 6, 1990,’ the FAA stated that it had entered into a contract with Norden Systems, a designer and manufacturer of electronic equipment for the Department of Defense (DOD) and the FAA, for development of AMASS. In testimony, the FAA and Norden acknowledged that while AMASS was conceptual and would require refinements, it would be able to function as a “backstop” to detect, and provide alerts in, at least 29 scenarios during which a runway incursion was most likely to occur (over 90 percent of possible incursion scenarios). FAA testimony noted that because the project had congressional interest, it would be “fast-tracked” and not totally confined to the cumbersome and time- ‘Aircraft Accident Report-Runway Collision of Eastern Airlines Boeing 727, Flight 111 and Epps Air Service Beechcraft King Air Al 00, Atlanta Hartsfield International Airport, Atlanta, Georgia, January 18, 1990 (NTSWAAR-91/03). ‘Statement of FAA’s Executive Director for System Development before the House Committee on Science, Space, and Technology, subcommittee on Transportation, Aviation and Materials, concerning runway incursions.

I 147 consuming acquisition hurdles of most projects, and as a result, it was anticipated that the project would be onerational by 1992. Following a preliminary design review during July 1991, work began on a pre-production prototype. This required input from staff from the FAA’s Air Traffic Requirements Office, which provides operational requirements for new equipment. During October 1992, a “Demonstration/Validation” of the safety logic required for detecting the 29 situations during which a runway incursion could occur was provided to the air traffic requirements team. At that time, the system was capable of tracking 128 targets, but could be expanded to track 256 targets. During December 1992, live traffic testing began at the San Francisco International Airport. Concurrent with the decision for live traffic testing, the FAA’s AMASS technical officer received a letter dated December 7, 1992, from the FAA’s Director of Air Traffic Requirements. The letter outlined 30 modifications to AMASS hardware and software, 15 of which required substantial and additional funding, and would expand the time frame for the completion of the project. This letter also stated that additional requirement modifications would be forthcoming. Because a date for validation during April 1993 had been established, some changes that could be done quickly were accomplished. Ironically, most of the modifications were not associated with issues of increasing safety, but rather had to do with human [controller] interface. Some requirement changes went against the basic objective of the AMASS program; for example, one requirement called for the program to be able to inhibit specific targets from generating any type of alert, even though the target would normally qualify in an intrusion scenario. While it was envisioned initially that AMASS would be a virtual hands-off system for controllers, these, and other later modifications have created an AMASS system that may now be labor intensive, and could compromise its potential safety benefits. During a December 1993 meeting which involved senior FAA staff associated with the AMASS project, the AMASS technical officer informed attendees that, of the new requirements submitted, eight could be accomplished with existing research and development (R&D) funds. The new requirements were accomplished and demonstrated at the Boston Logan International Airport, which had since received its ASDE-3 radar system. It’was also noted that, of the eight new requirements, only one was safety related, and only one was applicable to those operations conducted at the Boston airport, During February 1994, the AMASS project then transitioned from R&D funding to facilities and equipment (F&E) funding, which permitted the initiation of the formal specification review and formal a.cquisition process. This process dictated that the Air Traffic Requirements program manager submit a revalidated mission needs statement and operational requirements document, which enabled the AMASS program manager to set up the AMASS program for production. The mission needs and operational requirements document has not been received, and as a result, the AMASS program remains stalled. Over $20 million has been spent so far on the AMASS project. At present, no AMASS systems are operational in the National Airspace System (NAS) at those airports envisioned to have the program before 1996. The Safety Board is concerned that progress of this important

c a 148 project has been effectively paralyzed as a result of a succession of changes in operational specifications imposed from within the FAA’s Air Traffic Service. Despite the involvement of staff from the Air Traffic Req:.;.em&ts office in every stage of the development and acq; tuition process, there appears to have been reluctance to establish firm and realistic requirements that would have kept the project on schedule. While the Safety Board recognizes that the input from the Air Traffic Requirements office is prudent and necessary, it would appear that factions within it are attempting to require that AMASS become something it was never intended to be. The Safety Board also believes that had this program continued, unencumbered by repeated requirement changes, AMASS would have been available for operational consideration during

1. The Safety Board notes that AMASS hardware production continues, in anticipation of

eventual installation. The Safety Board believes that the AMASS project should move ahead immediately. Safety Board staff has observed the AMASS system in operation and is satisfied that it works. Of more concern is that the accident at St. Louis may have been prevented had AMASS been in use at that airport. On November 29, 1993, the FAA’s National Runway Incursion Manager and members of his staff provided a briefing to Safety Board staff concerning the status of major FAA runway incursion initiatives. During this briefing, the FAA advised that while some problems had been encountered and some “slippage” had occurred, for the most part, all projects were on track and on target. The Safety Board is deeply concerned to learn that this has not been the case. The Safety Board also believes that the Air Traffic Service should provide a firm, finalized operational requirements document to the AMASS technical officer within 45 days from receipt of this letter. No further modifications should be implemented until after the first AMASS system is certified by the FAA as being ready for operation (commissioned). The ASDE-3 and AMASS are interconnected. AMASS is not capable of being a stand- alone system. During the investigation of the accident at St. Louis, Safety Board investigators learned that the hard drive on the ASDE-3 system had failed, but because it had not been commissioned it did not receive priority for logistical support to implement timely repair. During September.1 989, the ASDE-3 was installed at the Pittsburgh International Airport, Pittsburgh, Pennsylvania, to become the first system in the NAS. Since that time, 23 sites, including St. Louis, have received the ASDE-3. The Safety Board is aware that the ASDE-3 has experienced some problems since it was first introduced. One of the earlier problems, which has since been resolved, was delamination of the antenna. Another problem was site specific where it was learned that the pedestal on which the antenna is mounted was improperly installed. Another problem that has been encountered, primarily at the Atlanta Hartsfield International Airport, has been a phenomenon called “multi-path,” which is the generation of false targets from intense reflectivity from buildings or other natural obstructions on the surface of the airport. When augmented with AMASS, the generation of false targets could trigger false alerts in specific areas of the airport. However, this problem has been mitigated through the use of icons superimposed over the radar target of known aircraft. Almost all problems have either been corrected or resolved in some manner, although it is acknowledged that the system is not perfect.

a 149 At the time of this accident, the Safety Board learned that of those sites that have the ASDE-3, only one airport, the Seattle/Tacoma International Airport, in Seattle, Washington, had a commissioned system. This airport was selected by &3 FAA to be the premier facility for low visibility operations. Since this accident, Safety Board staff has learned that six other airports with the ASDE-3 system have been commissioned. For the controller workforce, probably the most contentious issue surrounding the ASDE3 system has been the design of the zoom feature on the ASDE-3 display, in which the target of the airplane may appear as several targets when magnified. It is analogous to looking at printed letters with the naked eye, in which the letters will appear to be a solid line, but when magnified, the print is broken into pixels (dots). This is not a design flaw, but rather a natural feature of high resolution radar such as the ASDE3. While this impasse is not delaying the installation of ASDE-3 at those airports slated to get the system, the controversy over this issue has possibly served as the impetus for not commissioning those systems. However, it must be recognized that for those facilities that currently have the system in place, those controllers must operate with a substandard ground-based radar system or without the benefit of any surface detection system because commissioning has not occurred. The Safety Board believes that unless there are compelling reasons not to commission those currently installed ASDE-3 radars, the FAA should do so immediately. Safety Board’ investigators note that the weather conditions that prevailed at St. Louis would not have, under current procedures, required that the ASDE-3 be operational; however, had it been, it is conceivable that the local controller would have been able to confirm the position of N441KM when advised, “ready to go on the right side.” As stated earlier, had the ASDE-3 been augmented with AMASS processing, an alert would have been generated. The Safety Board believes that the FAA should require that the ASDE-3 be operational between sunset and sunrise, regardless of weather, and once AMASS processing is commissioned, it should operate 24 hours a day. With regard to the St. Louis accident, the Safety Board notes that, after receiving his clearance to taxi, the pilot of N441KM did not read back his runway assignment during any subsequent transmissions, nor was he required to. When the pilot of N441KM advised the local controller that he was, “ready to go on the right side,” it seems that this transmission should have prompted the local controller concern, since her next transmission also referred to, “on the right.” This was the first indication to the local controller that the pilot of N441KM was in position on the wrong runway; however, at that moment, it is doubtful that there was time to clear runway 30R. Her failure to perceive the significance of his initial transmission may have been a result of her being advised by the ground controller that the pilot of N441KM had been instructed to expect to take off on runway 3 1 and her resultant expectation that the pilot was in position on the adjacent, parallel runway. In addition, the pilot, after being advised by the local controller, “I can’t roll you simultaneously with the uh traffic departing on the right,“ did not realize that he had taxied into position on the wrong runway.

150 The intersection at which the pilot of N441KM entered runway 30R is about 2,000 feet from thf: departure end of runway 3OR, where the flightcrew of TWA427 was initiating their i;keoff roll. The communication from the pilot of N441f:&I to the local controller that he was, “ready to go on the right,” may have been perceived by the flightcrew of TWA427 as a routine communication in that another pilot was advising the tower that he WAS ready to depart, in sequence, on runway 30R. At present, voice communication is the primary interface between the controller and pilots, and common human performance failures make it one of the most vulnerable to error. Under the circumstances of this accident, it cannot be determined what the pilot of N44lKM heard or understood. As a result of its 1986 study of airport runway incursionsP the Safety Board issued Safety Recommendation A-86-33, which asked the FAA to “require controllers to obtain a read back for all hold, takeoff, or crossing clearances and for clearances onto an active runway.” The FAA reluctantly agreed to amend the ATC Handbook to require that controllers receive a readback of all runway hold short clearances. The FAA‘s primary concern was that this change would create additional frequency congestion during peak traffic periods. In 1993, the FAA informed the Board that during low visibility conditions, controllers would be required to obtain a readback from pilots to confirm an airplane’s.movement to cross or take off from an active runway. Based on this action, the Board classified Safety Recommendation A-86-33 “Closed-- Acceptable Action.” The Safety Board maintains that this change is responsible, in part, for the decrease in runway incursion incidents. However, this most recent accident demonstrates that additional measures are required. At many airports in the United States, multiple runway configurations are used for arriving and departing aircraft. The Safety Board believes that for those airports that employ multiple runway configurations, to alleviate any misunderstandings or miscommunications, pilots should confirm their runway assignment when initially issued, by stating fully the runway assignment and any other instruction that requires the pilot to taxi on, near, or to a runway. Following any subsequent frequency changes, this procedure should again be employed until the flight is airborne. The Safety Board believes that the benefit of receiving an explicit confirmation of runway assignment from the pilot before receiving takeoff clearance will provide an extra measure of safety in that this procedure will allow the controller to eliminate those errors where a pilot has misunderstood his runway assignment and will enhance situational awareness on the part of other flightcrews that are landing or are to take off on that specific runway. The FAA has two primary tools through which pilots can quickly be provided with fundamental flight information and air traffic control procedures. These are the Airman’s Information Manual (AIM) and an Administrator’s Letter to Airmen. Because clear and concise communications are the backbone to safety during ground operations, the Safety Board believes that the FAA should issue an Administrator’s Letter to Airmen and should amend the AIM to ‘National Transportation Safety Board, Runway Incursions at Controlled Airports in the United States, NTSB/SIR-86/01.

151 encourage pilots to read back their runway assignment during ground operations until receiving their clearance for takeoff. The rationale for this ‘procedure should be provided, in conjunction with specific examples 0; appropriate phraseology. For air traffic controllers, FAA Order 7110.65, “Air Traffic Control,” should be amended to require that controllers receive full acknowledgement of runway assignment and any clearance associated with the runway assignment when multiple runway configurations are employed. Under current procedures, the possibility that miscommunication may occur is greater because there is no requirement for the pilot to fully acknowledge such clearances. The Safety Board believes that during busy traffic periods, it is imperative that the controller receive confirmation that his instructions have been clearly understood. In addition, by having specific confirmation of the runway assignment and the pilot’s actions stated on the radio frequency, the information becomes available to other flightcrews to enhance their situational awareness in a manner not otherwise available under current procedures. Therefore, the National Transportation Safety Board recommends that the Federal Aviation Administration: ’ Within 45 days of receipt of this letter, require that the Air Traffic Service provide a firm, finalized mission needs and operational requirements document for the Airport Movement Area Safety System. No further modifications should be implemented until after the first Airport Movement Area Safety System is . commissioned. (Class II, Priority Action)(A-95-30) Within 60 days of receipt of this letter, provide to the Safety Board a firm schedule to commission those Airport Surface Detection Equipment-3 radar systems that have been installed and adhere to that schedule. (Class II, Priority Action)(A-95-3 1) For those air traffic control terminal facilities that commission the Airport Surface Detection Equipment-3, require that it be operational between sunset and sunrise. When the Airport Movement Area Safety System is commissioned, require that it be operational 24 hours a day. (Class II, Priority Action)(A-95-32) Issue an Administrator’s Letter to Airmen that directs pilots to read back, in full, their runway assignment upon receiving taxi instructions and before receiving their takeoff clearance when operating at airports that employ more than one runway. Also, revise the Airman’s Information Manual to reflect this procedure. (Class II, Priority Action)(A-95-33) Amend FAA Order 7110.65, “Air TrafTic Control,” to require that air traffic controllers receive confirmation of runway assignment from pilots after issuing

152 taxi instructions. Require that this procedure be used at those airports which employ more than one runway during operations.’ (Class II, Priority Action)(A-95- 34) Chairman HALL, Vice Chairman FRANCIS, and Member HAMMERSCHMIDT concurred in these recommendations. By: Chairman

153 APPENDIX I - AIRPORT CLOSURE RECOMMENDATION National Transportation Safety Board Washington, D.C. 20594 Safety Recommendation Date: July 17, 1995 In reply refer to: A-95-77 and -78 Honorable David R. Hiion Administrator Federal Aviation Administration Washington, D.C. 20591 On July 2, 1994, about 1843 eastern daylight time, a Douglas DC-9-31, N954VJ, operated by USAir, Inc., as tlight 1016, collided with trees and a private residence near the Charlotte/Douglas Intemational Airport (CLT), Charlotte, North Carolina, shortly after the flightcrew executed a missed approach from tk instrument landing system approach to runway 18R The captain, first officer, one flight attendax& and one passenger received minor injuries. ‘Iwo flight attendants and 14 passengers sustained serious injuries. The mmaining 37 passengers received fatal injuries. The airplane was destroyed by impact forces and a postcrash fire. Instrument meteorological conditions prevailed at the time of the accident, and an instrument flight rules (IFR) fight plan had been Ned. FIight 1016 was being conducted under 14 Code of Federal Regulations (CFR) Part 121 as a regularly scheduled passenger flight from Columbia, South Carolina, to Charlotte.* The National Transportation Safety Board has determined that the probable causes of the accident were: 1) the flightcrew’s decision to continue an approach into severe convective activity that was conducive to a microburs~ 2) the flightcrew’s failure to recognixe a windshear situation in a timely manner; 3) the flightcrew’s failure to establish and maintain the proper airplane attitude and thrust setting necessary to escape the windshear and 4) the lack of real-time adverse weather and windshear hazard information dissemination from air traffic control ‘Far more detailed information. read Aim& Aazicbt Rqat - “Flight Into Twain During M&scxJ @roach. USAir Flight 1016. X-9-31. N9S4VJ. Charlottd&& Manational Airpm CharIottc. North Carob July 2,194W (NW3/AA.C9S/o3) 6573

154 (ATC), ail of which led to an encounter with and failure to escape from a microbur. I: induced windshear that was produced by ? rapidly developing thunderstorm located at the approach end of runway 18R. Contributing to the accident were: 1) the lack of ATC procedures that would have required the controller to display and issue airport surveillance radar (ASR-9) weather information to the pilots of flight 1016; 2) the Charlotte tower supervisor’s failure to properly advise and ensure that all controllers were aware of and reporting the reduction in visibility and the runway visual range value information, and the low level windshear alerts that had occurred in multiple quadrants; 3) the inadequate remedial actions by USAir to ensure adherence to standard operating procedu’&s; and 4) the inadequate software logic in the airplane’s windshear warning system that did not provide an alert upon entry into the windshear. About 1845, the CLT ATC tower activated the “crash phone” linked to the airport fire station (Station 17) and indicated that “we lost a plane on radar - 5 - 5 SOB [Souls on Board].” Eight fm fighters responded with three aircraft rescue and fm fighting (ARFFJ trucks (Blaze 1, 2, and 7), and one quick response and command truck (Blaze 5) from the fire station located near the base of the ATC tower. Several fire fighters stated that at the time the equipment was dispatched “it was raining very hard.” The initial notification to the fire station by the ATC tower did not identify any particular location of the downed aircraft because of the restricted visibility; thus, the fire equipment traversed the airport, via taxiway A, searching for evidence of an accident. At 1846:09, the ATC ground controller notified the crew in Blaze 5 “we have a large area of smoke visible from the tower, now it appears to .be approximately a quarter mile north of the old hangar that CCAir is using....” Simultaneous to the ground controller’s transmission, the crew of Blaze 5 heard a transmission from the City alarm room indicating that there was a “possible plane crash in the vicinity of Wallace Neel and Old Dowd.” The ATC ground controller contacted the crew of Blaze 5 and stated that there were “five zero souls, plus five crew on board.” The fm equipment vehicles crossed the airport, and two of the vehicles exited the airport property through a security gate (gate 36) operated by a magnetic key card. The two remaining vehicles were delayed because of difficulties opening gate 36; in fact, they “crashed” through the gate and proceeded to the accident site.

155 About 4 minutes after the Cha.rlr\t+e AFWF units arrived on scene, the Charlotte Fire Department units arrived ac the accident site. The fiFe fighting efforts proceeded for approximately 5 minutes, using water and aqueous film- forming foam as the extinguishing agents. The Safety Board is concerned that the response of the ARFF units was delayed because of difficulties experienced in opening airport security gate 36. The Airport Authority later determined that the gate had been functioning properly but had failed to open because the ARFF personnel had passed their magnetic cards through the card readers too quickly. While the solution to this problem would be for emergency response personnel to pass the gate cards through the card reader more slowly, the ARFF Incident Commander testified at the Safety Board’s public hearing that when the gate did open, it did so very slowly. The Safety Board believes that passing a gate card through a card reader too quickly by emergency response personnel, who would normally be anxious and hurried while responding to a disaster, is understandable. However, response time is critical in fighting fires, especially aircraft fires. The time lost in repeatedly trying to open a gate, and then waiting for the gate to retract to the open position, could jeopardize lives. ‘Ihe Safety Board acknowledges that fences and restricted gate access are required for security at airports; however, devices used to provide this security should not interfere with an expeditious response by emrgency personnel. Themfore, the Safety Board believes that the Federal Aviation Administration (FAA) should require that all airports certificated under 14 CFR Part 139 identify gates that ARFF personnel and their equipment might need to access while responding to emrgencies. Further, the FAA should require the necessary changes to ensure that ARFF personnel and their equipment can pass through these gates without hesitation or delay. Additionally, the gates that are identified and the procedures required to access them should be included ‘in the Airport Emergency Plan The Safety Board is also concerned that CLT remained open and that air carrier operations continued for about 30 minutes after ARFF personnel and equipment were involved in fm fighting and rescue activities at the accident site. Although ARFP units were in close proximity to the airport and could have responded immediately to another emergency, the Safety Board found that all the available ARFF units and personnel were involved in the fire fighting and extrication efforts of USAir flight 1016. As a result, fire extinguishing materials were significantly diminished. The Safety Board believes that if another aircraft

156

• emergency had occuned at the airport, it would have been extremely difficult for

AKIT units to respond in a timely and effective manor. About 2203, on November 22, 1994, Trans World Airlines flight 427, providing scheduled 14 CFR Part 121 service between St. Louis, Missouri, and Denver, Colorado, collided with a Cessna 441, N441KM, at the intersection of runway 30R and taxiway R, at the Lambert&. Louis International Airport, Bridgeton, Missouri. Plight 427, a McDonnell Douglas DC-9-82, N954U, sustained substantial damage during the collision. The 2 flight crewmembers, an additional crewmember in the cockpit jumpseat, 5 flight attendants, and 124 of the 132 passengers on board evacuated the airplane without injury. The Cess& 441, operated by Superior Aviation Inc., was destroyed, and the commercial pilot and the passenger, who was a rated private pilot, received fatal injuries. The accident occurred during the hours of darkness, and visual meteorological conditions prevailed. Both flights were operating on IPR flight plans. The Cessna was holding in position awaiting takeoff clearance for an intended 14 CPR Part 91 positioning flight to Iron Mountain, Michigan. I Although the accident is still under investigation, the Safety Board found that Lambert-St. Louis International Airport nznained open after the accident, and that aircraft movement continued near the accident site. Several radio transmissions to the ATC ground controller from pilots of taxiing airplanes revealed that they were concerned about the possibility of passengers from the accident flight wandering into the paths of taxiing airplanes. After receiving these transmissions, the ground controller stopped aircraft movement in the area. Shortly thereafter, all ground movement on the airport was halted. The Safety Board believes that because the airport was not closed immediately following the accident, the potential for injury to the evacuated passengers by taxiing airplanes was high. Closing the airport would have allowed controllers to assess the situation and to redirect both airborne and taxiing traffic to areas of the airport that were remote from the accident site. The assessment period could have been brief, and the airport could have been reopened after safe conditions were confnned by the airport operator. Therefore, the Safety Board believes that the FAA should provide guidance to all airports certificated under 14 CFR Part 139 that in the event of an accident or significant incident, the airport be closed immediately by either the airport operator and/or the appropriate FAA air trafTic facilities thmugb let&xx of agreement with airport operators. In addition, airports, or portions thereof, should not be reopened until the airport

157 operator has en?lvred that: (1) aircraft operating areas are secum; (2) aircraft movenxxrt areas that axe to be reopened have been properly inspected; and (‘; adequate ARFF protection is available for aircraft operations. Therefore, as a result of its investigation of these accidents, the National Transportation Safety Board recommends that the Federal Aviation Administration: Require that aII 14 CFR 139 certificated airports identify gates that aircraft rescue and fire fighting personnel and their equiprznt might need to access whiIe responding to emergencies, and make the necessary changes to ensure that enxxgency personnel a&their equipment can pass through these gates without hesitation or delay. Additionally, the gates that axe identified and the procedures required to access them should be incIuded in the Airport Emergency PIan (Class II, Priority Action) (A-95-77) Provide guidance to aII 14 CFR 139 certificated airports that in the event of an accident or significant incident, the airport be closed irnnxzdiately by either the airport operator and/or the appropriate FAA air traffic facilities through letters of agreenxnt with airport operators. Also, specify that the airport, or portions thereof, should not be reopened unt.iI the airport operator has ensured that: (1) aircraft operating areas are secure; (2) aircraft movementareas that are to be reopened have been properly inspected; and (3) adequate aircral? rescue and fire fighting protection is available for aircraft operations. (Class II, Priority Action) (A-95-78) Chairman KALL, Vice chailmaxl FRANCIS, and Member HAMMERSCHMIDT concurred in these recommendations. By: l U.S. COVE-T PRINTING OFFICE: ‘555-~05-700/230~~

FD07168 ｜ 1995_美国_NTSB_HZB9801_Tank_Car_Failure_and_Release_of_Poisonous_and_Corrosive_Vapo.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1995 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

National Transportation Safety Board Washington, D.C. 20594

Hazardous Materials Accident Brief Accident No.: DCA-96-MZ-001 Transportation Mode: Rail Type of Accident: Tank car failure and release of poisonous and corrosive vapors Location: Gaylord Chemical Corporation, Bogalusa, Louisiana Date and Time: October 23, 1995, about 4:45 p.m. Shipper: Vicksburg Chemical Company Tank Car Specification: DOT 105A500W Tank Car Manufacturer: Union Tank Car Company Injured: 4,710 people were treated at area hospitals, of whom 81 were admitted Evacuated: Approximately 3,000 people Material Released: Nitrogen tetroxide, a poisonous material (oxidizer) Type of Failure: Corrosion Accident Narrative At 3:55 p.m. on October 23, 1995, at the Gaylord Chemical Corporation plant in Bogalusa, Louisiana, yellow-brown vapors began leaking from the dome of the DOT class 105A railroad tank car UTLX 82329 that contained a mixture of nitrogen tetroxide, which is a liquefied poisonous gas and oxidizer, and water. The vapors initially formed a plume between 10 and 15 feet in diameter. Plant personnel notified emergency response agencies and used two plant fire hoses to spray water into the plume to suppress the vapors. About 4:30 p.m. Bogalusa fire personnel arrived at the plant and set up fire hoses to help-suppress the vapors. The head on the B-end of the tank car failed about 4:45 p.m., resulting in one end of the tank car jacket being torn away and thrown about 350 feet. The tank car was then propelled 35 feet down the track and derailed at a track bumping block. A large reddish-brown vapor cloud was released from the tank car. Vapors continued to be released from the opening in the tank car for another 36 hours until the chemical reaction that had occurred within the tank was brought under control through neutralization and dilution. Some 3,000 people were evacuated from the area as a result of the vapor cloud. Of 4,710 people who were treated at local hospitals, 81 people were admitted. Events Preceding the Accident On September 14, 1995, nitrogen tetroxide vapors had leaked at a valve on the tank car while it was at the Gaylord plant. A mechanic sprayed water to suppress the vapors and then directed the water stream onto the valve stem as the tank car was unloaded. When the water

was turned off could not be determined. Another mechanic stated that the water was no longer being applied over the valve on September 22, when employees of the Union Tank Car Company (manufacturer and owner of the tank car) arrived at the plant to replace the valve; they replaced four valves. Postaccident examination of those valves removed from the tank car disclosed that one valve stem had significant wear. The tank car was moved to the Vicksburg Chemical Company in Vicksburg, Mississippi, on September 26, for another load of nitrogen tetroxide. On October 5, the chemical company recorded that the tare weight of this tank car was 9,500 pounds over the marked weight for the tank car. A Vicksburg employee noticed the new valves on the tank car and assumed that the car had been rebuilt and that the tank car’s trucks had been replaced, thus changing the weight. He did not, however, verify these assumptions. The tank car was then filled with approximately 10,000 gallons (110,000 pounds) of nitrogen tetroxide. A quality check had been conducted on the nitrogen tetroxide before it was transferred to the tank car, and it was found to meet the specifications of the Gaylord Chemical Corporation. No quality check was performed on the material after it was loaded into the tank car. The loaded tank car was returned to Gaylord. On October 12, Gaylord mechanics began transferring nitrogen tetroxide from the tank car to a storage tank. While this transfer was taking place, the material in the storage tank was simultaneously being transferred into the plant. At 9 a.m., the process safety interlocks shut down the chemical reactor. Gaylord’s investigation into the cause of the chemical reactor shutdown revealed that the nitrogen tetroxide had been contaminated with water. To prevent corrosion damage from nitric acid, which results when water reacts with nitrogen tetroxide, Gaylord decided to transfer the contaminated material from the tank car and storage tank into stainless steel highway cargo tank trailers. A meter was used to measure the amount of product transferred from the tanks. A pressure gauge with a maximum calibrated pressure of 100 psig was used to monitor the internal pressure of the tank car. Overnight, between October 12 and 13, the meter indicated that 10,100 gallons of product were transferred from the tank car into two cargo tanks. No other check was made on the tank car or the cargo tanks before the accident to determine how much material had been transferred. When the transfer operation was stopped, a material sample was taken from the transfer system; the sample contained a small amount of green liquid with foam. At 4 a.m. on October 13, Gaylord employees believed the tank car was empty, except for a small amount of residual material that could not be pushed up through one of the eduction pipes, and water was added to the tank car to dilute this residual material. Postaccident weighing of the material loaded into the two cargo tanks revealed that only 491 gallons (6,080 pounds) had been transferred. Postaccident examination of the tank car showed that the carbon steel eduction pipes had corroded and that only a small section of each, near the top of the tank, remained. No work was performed on the tank car for several days while Gaylord employees were cleaning, testing, and inspecting the plant storage tank. On October 16, Gaylord determined that the vapors coming from the tank car were excessive, indicating that the material in the tank car was not dilute enough to permit discharge of the residual material into the plant sewer system. Plans were made to transfer the residual material into another cargo tank, but these plans were changed when vapors started leaking from the manway of another cargo tank

that had been filled with material from the storage tank. Gaylord determined that several cargo tanks had gaskets and valves that were not appropriate for nitrogen tetroxide and fuming nitric acid and between October 17 and 20 replaced these gaskets and valves.

On October 19, material samples obtained from the tank car and the three cargo tanks were taken to the Vicksburg Chemical Company for chemical analysis. Gaylord employees began the transfer of the material remaining in the tank car on October 20, and by 6 p.m. that day, the meter indicated that 6,700 gallons of material had been transferred from the tank car to a cargo tank. At the conclusion of the transfer, a material sample taken from the transfer system was observed to contain foam and a very small amount of green liquid. Postaccident weighing of the material loaded into this cargo tank revealed that only about 850 gallons (10,520 pounds) of material had been transferred. Water was added to the tank car using a fire hose to purge and clean it; the addition of water was discontinued when the internal pressure of the tank car rose to between 60 and 65 psig. Gaylord employees vented the vapors from the tank car through the plant scrubber to lower the pressure in the tank car. Later on the evening of October 20, Gaylord employees began emptying the material from the tank car into the plant sewer system; after 2 or 3 minutes, a large vapor cloud was released, and the unloading was stopped. On October 21, a Gaylord employee twice added water to dilute the material in the tank car and vented the vapors through the scrubber. The internal pressure of the tank car increased each time the water was added. On October 23, the gauge on the tank car indicated that the internal pressure was 18 psig. Plans were made to complete the emptying and the cleaning of the tank car. At 12:54 p.m., Gaylord received the results of the chemical analysis of the material sample obtained from the tank car on October 19. The results indicated that the material was wet nitrogen tetroxide. These results were unexpected because Gaylord believed that on October 13 the nitrogen tetroxide had been unloaded from the tank car and that the residue had been diluted with water. After discussing the apparent discrepancy with the Vicksburg laboratory specialist who had tested the sample, Gaylord personnel decided the sample may not have been representative of the material in the tank car. Between 1:30 and 1:45 p.m. on October 23, Gaylord employees put more water into the tank car, and the internal pressure rose from 18 to 80 psig in 4 to 5 minutes, at which point the water was turned off. About 2 p.m., the pressure reached 92 psig and then slowly began to decline. The plant scrubber was still being used to vent the vapors from the tank car, and an additional hose was run from one of the tank car valves to a water-filled drum for additional venting. The internal tank car pressure was 55 psig by 2:30 p.m. When Gaylord employees reopened the fire hose, the pressure rose to 100 psig, which is the maximum calibrated pressure on the gauge. The water was turned off, and the vapors were again vented. At 3 p.m., the pressure appeared to be falling, but at 3:30 p.m., it was still above the measurement limit of the gauge and appeared to be rising. At 3:55 p.m., a yellow-brown vapor was observed leaking from the dome of the tank car. The head on the B-end of the tank car failed about 4:45 p.m. releasing a huge reddish-brown vapor cloud.

Postaccident examination of the safety relief mechanism mounted in the dome revealed that it had recently activated. (Activation pressure is about 375 psig.) The examination also revealed an 8-inch-high by 66-inch-wide corroded opening in the B-end head of the tank car near the top. In addition, at least three distinctive horizontal bands of corrosion were found near the top of the interior tank wall; one band was at the same level as the opening in the tank head. Postaccident Actions Gaylord Chemical Corporation has discontinued the use of tank cars to transport nitrogen tetroxide and now uses smaller tanks that hold only 3 percent of the volume capacity of the tank car involved in the accident. Cargo purity assurance procedures, including the testing of cargo before and after loading, have been implemented to prevent the transport of contaminated cargo. The plant has additionally installed equipment to warn residents of any accidental release and, in coordination with the city of Bogalusa, has developed emergency procedures and conducted training. The tank car destroyed in this accident was the last carbon steel tank car in use that had been approved by the US Department of Transportation for transporting nitrogen tetroxide. Probable Cause The National Transportation Safety Board determines that the probable cause of the accident was the lack of adequate procedures on the part of the Gaylord Chemical Corporation and the Vicksburg Chemical Company to prevent or detect the contamination of nitrogen tetroxide with water, resulting in the formation of an extremely corrosive product and the subsequent failure of the tank car. Contributing to the severity of the accident were the Gaylord Chemical Corporation’s inadequate procedures for emergency transfer of contaminated cargo from the tank car. Recommendations – None Adopted 1/27/98

FD07169 ｜ 1995_美国_NTSB_MAR9601_Fire_On_Board_the_US_Fishing_Vessel_Alaska_Spirit.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1995 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

/ PB96-916401 NTSB/MAR-96/01 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 MARINE ACCIDENT REPORT FIRE ON BOARD THE U.S. FISH PROCESSING VESSEL ALASKA SPIRIT, SEWARD, ALASKA, MAY 27, 1995 6594A

Abstract: About 0200 on May 27, 1995, the U.S. fish processing vessel ALASKA SPIRIT caught fire and burned while moored alongside a dock at the Seward Marine Industrial Center, Seward, Alaska. Firefighters extinguished the fire at 1100. The master of the vessel died, and damage to the vessel was estimated at $3 million. The safety issues addressed in the following report are: adequacy of noncombustible construction standards for uninspected commercial fishing industry vessels; adequacy of fire detection and fire suppression equipment; drills and readiness of on-board firefighting hoses; and existing vessel fire safety standards. As a result of its investigation, the National Transportation Safety Board made safety recommendations to the U.S. Coast Guard, The Fishing Company of Alaska, Incorporated, the Commercial Fishing Industry Vessel Safety Advisory Committee, and the National Fire Protection Association. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Information about available publications may be obtained by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 L’Enfant Plaza East, S.W. Washington, D.C. 20594 (202) 382-6735 Safety Board publications may be purchased, by individual copy or by subscription, from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (703) 487-4600

FIRE ON BOARD THE U.S. FISH PROCESSING VESSEL ALASKA SPIRIT, SEWARD, ALASKA, MAY 27, 1995 MARINE ACCIDENT REPORT Adopted: June 11, 1996 Notation 6594A National Transportation Safety Board Washington, DC 20594

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iii CONTENTS ACRONYMS ....................................................................................................................vi EXECUTIVE SUMMARY.............................................................................................vii INVESTIGATION ............................................................................................................ 1 Accident .............................................................................................................................. 1 Fire .......................................................................................................................... 5 Emergency Response and Fire Extinguishing....................................................... 11 Injuries............................................................................................................................... 14 Vessel Damage.................................................................................................................. 14 Crew Information .............................................................................................................. 15 Staffing.................................................................................................................. 15 Master.................................................................................................................... 15 Chief Engineer....................................................................................................... 15 Assistant Engineer................................................................................................. 15 Cook ...................................................................................................................... 15 Processor-deckhands ............................................................................................. 16 Watchman.............................................................................................................. 16 Vessel Information ............................................................................................................ 16 Firefighting Equipment ......................................................................................... 17 Survival Equipment............................................................................................... 17 The FCA................................................................................................................ 18 Waterway Information....................................................................................................... 18 Meteorological Information .............................................................................................. 18 Postaccident Vessel Examination...................................................................................... 19 Hull Structure and Construction............................................................................ 19 Wreckage............................................................................................................... 20 Medical, Pathological, and Toxicological Information..................................................... 24 Drills.................................................................................................................................. 25 Tests and Research............................................................................................................ 26 Possible Ignition Sources ...................................................................................... 26 Battery Charger Examination.................................................................... 26 Cook Pot Examination .............................................................................. 26 Heat Detector Testing............................................................................................ 27 Other Information.............................................................................................................. 28 Coast Guard Regulations....................................................................................... 28 Standards Applicable to Industrial Vessels........................................................... 30 Building Codes...................................................................................................... 31

iv Life Safety Code.................................................................................................... 31 U.S. Fishing Fleet.................................................................................................. 32 Accident Statistics................................................................................................. 33 Coast Guard Oversight of Fish Processing Vessels .............................................. 33 Survival Factors................................................................................................................. 34 Fire Control Efforts ............................................................................................... 34 Notification Procedures......................................................................................... 34 Local Contingency Planning ............................................................................................. 34 City of Seward....................................................................................................... 34 Western Alaska Marine Firefighting Contingency Plan........................................ 35 ANALYSIS....................................................................................................................... 38 General .............................................................................................................................. 38 Source of Ignition.............................................................................................................. 38 Fire Safety Standards......................................................................................................... 41 Construction .......................................................................................................... 41 Fire Detection Equipment ..................................................................................... 43 Fire Suppression Equipment ................................................................................. 44 Existing Standards................................................................................................. 45 Fire Hose ............................................................................................................... 46 Survival Factors................................................................................................................. 47 Reporting of Fire ................................................................................................... 47 Drills...................................................................................................................... 47 Significance of the ALASKA SPIRIT Investigation......................................................... 48 Toxicological Test Results................................................................................................ 48 Carboxyhemoglobin (COHb)................................................................................ 49 Alcohol.................................................................................................................. 49 CONCLUSIONS ............................................................................................................. 50 PROBABLE CAUSE ...................................................................................................... 51 RECOMMENDATIONS................................................................................................ 51

v APPENDIXES Appendix A -- Safety Board Investigation........................................................................ 55 Appendix B -- Crew Licensing Information .................................................................... 57 Appendix C -- Battery Charger Examination.................................................................... 59 Appendix D -- Global Fire and Safety, Inc., Heat Detector Test Report ......................... 61 Appendix E -- Building Codes.......................................................................................... 69 Appendix F -- Conditions Reported by the SVFD Fire Chief that Affected ALASKA SPIRIT Firefighting................................................................................... 71 Appendix G -- Toxic Effects of Carboxyhemoglobin Saturation ..................................... 73 Appendix H -- Master’s Blood Alcohol Level.................................................................. 75 FIGURES AND TABLES Figure 1 -----Port side view of the ALASKA SPIRIT while moored at Seward, Alaska... 2 Figure 2 -----Accident site .................................................................................................. 3 Figure 3 -----Plan of the ALASKA SPIRIT........................................................................ 6 Figure 4 -----Plan of the ALASKA SPIRIT (continued) .................................................... 7 Figure 5 -----Enlarged plan view of the 02 deck................................................................. 8 Figure 6 -----View of the deckhouse from the trawl deck .................................................. 9 Figure 7 -----Forward bulkhead of 02 deck ...................................................................... 19 Figure 8 -----The ALASKA SPIRIT’s fire-damaged wheelhouse.................................... 21 Figure 9 -----02 deck fire damage..................................................................................... 21 Figure 10----Chase in wheelhouse.................................................................................... 22 Figure 11----Fire pattern around cook pot........................................................................ 23 Table 1 ------Comparison of various fire safety regulations............................................. 36

vi ABS --------------American Bureau of Shipping ASTM ------------American Society for Testing Materials BAC -------------- blood alcohol concentration BOCA ------------ Building Officials and Code Administrators International CFR -------------- Code of Federal Regulations CHT -------------- Center for Human Toxicology CO ---------------- carbon monoxide COHb ------------ carboxyhemoglobin COTP ------------ Coast Guard Captain of the Port DNV -------------- Det Norske Veritas EPIRB ----------- Emergency Position Indicating Radio Beacon FCA -------------- Fishing Company of Alaska, Inc. ICBO ------------- International Conference of Building Officials LSC -------------- Life Safety Code NBC -------------- National Building Code NFPA ------------ National Fire Prevention Association NVIC ------------- Navigation and Vessel Inspection Circular RPU -------------- rigid polyurethane SBC -------------- Standard Building Code SBCCI ----------- Southern Building Code Congress International, Inc. SCBA------------- self-contained breathing apparatus SECC ------------ Seward Emergency Communications Center SMIC ------------ Seward Marine Industrial Center SVFD ------------ Seward Volunteer Fire Department UBC -------------- Uniform Building Code USC -------------- United States Code USCG ------------ United States Coast Guard USSG ------------ United States Standard Gauge ACRONYMS

vii EXECUTIVE SUMMARY About 0200 on May 27, 1995, the U.S. fish processing vessel ALASKA SPIRIT caught fire and burned while moored alongside a dock at the Seward Marine Industrial Center, Seward, Alaska. Firefighters extinguished the fire at 1100. The master of the vessel died, and damage to the vessel was estimated at $3 million. The National Transportation Safety Board determined that the probable cause of the fire aboard the ALASKA SPIRIT was the failure of The Fishing Company of Alaska, Incorporated, to address the inadequate fire safety conditions and practices on the vessel. Contributing to the severity of the damage and the loss of life was the lack of fire safety standards for commercial fishing industry vessels. The safety issues discussed in this report are: • Adequacy of noncombustible construction standards for uninspected commercial fishing industry vessels. • Adequacy of fire detection and fire suppression equipment. • Drills and readiness of on-board firefighting hoses. • Existing vessel fire safety standards. As a result of this accident, the National Transportation Safety Board makes safety recommendations to the U.S. Coast Guard, The Fishing Company of Alaska, Incorporated, the Commercial Fishing Industry Vessel Safety Advisory Committee, and the National Fire Protection Association.

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Accident Following a fishing voyage, the U.S. fish processing vessel1 ALASKA SPIRIT (see figure 1) arrived in Dutch Harbor, Unalaska Island, Alaska, on May 19, 1995. Prior to the vessel’s departure, 35 crewmembers and a U.S. National Marine Fishery Service observer debarked, reducing the vessel complement (including the master) to 11 persons. According to the engineroom log, the vessel departed from Dutch Harbor about 11002 on May 21. It arrived at the Seward Marine Industrial Center (SMIC) docks (also known as the Fourth of July docks), located north of the Fourth of July Creek and across Resurrection Bay from downtown Seward (see figure 2), at 1130 on May 24. At Seward, 3 crewmembers debarked, reducing the crew to 8 persons: the master, chief engineer,

1A fish processing vessel is defined under Title 46 United States Code (USC) 2101 (11b) as “a vessel that commercially prepares fish or fish products other than by gutting, decapitating, gilling, skinning, shucking, icing, freezing, or brine chilling.” Processing activities can include mincing, filleting, preparation of fish meal, boiling (crab), or a combination of these which prepares the seafood for direct marketing and often includes packaging the product. This type of fish processing vessel also catches fish with a trawl net and is also known as a “factory- trawler.” The term “factory” refers to the fish processing operation, while “trawler” refers to the method of fishing it uses. A trawler catches fish in a net (which can be compared to a funnel) towed astern. 2All times noted herein are given in Alaska daylight time. assistant engineer, cook, and 4 processor-deckhands (deckhands). The remaining crew stayed on board to repair, maintain, and prepare the vessel for the next fishing voyage, which was scheduled for about July 1. No deck or engineering watches were stood during this period, but work in various parts of the vessel was carried out during the day. Some engineroom equipment remained operating to provide vessel hotel services. A company-hired night watchman (watchman) testified that he made rounds about every hour from 1900 to 0700 to check on the safety and security of the ALASKA SPIRIT and the ALASKA RANGER.3 The watchman said he would meet with the ships’ master or mate and chief engineer or assistant engineer each evening. These officers would advise the watchman about specific items to check on that night and tell him who he should notify if he found something out of the ordinary. He would routinely adjust mooring lines as necessary, check operating engines, and look for indications of flooding and any other factors that could adversely affect the vessels’ safety.

3The ALASKA RANGER was a trawler-fish processing vessel operated by The Fishing Company of Alaska, Inc., that was moored at an adjacent dock, preparing for its next fishing voyage. INVESTIGATION

2

/

0 1 4 * S W 149-20w Figure 2 — Accident site 3

4 After completing his security check on the ALASKA RANGER, the watchman would board the ALASKA SPIRIT to conduct a similar security check of that vessel. A complete security check would include a walk through the engineroom, factory deck, accessible accommodation spaces, and the wheelhouse. He would also check mooring lines and the gangway. Each round on a vessel took about 10-15 minutes. The watchman reported that, after completing rounds on both vessels, he would station himself in the wheelhouse of the ALASKA RANGER. From there, he would observe the gangways of both vessels and stop unauthorized persons from boarding. According to the ALASKA SPIRIT’s cook, on May 26 he first spoke with the vessel’s master about 0800, when the master came to the galley for coffee. The cook next saw the master when he went to the wheelhouse around 1100 or 1130 to chat. At that time, however, the master was on the telephone to his wife, so the cook returned below. The cook said that he went back upstairs about 1210 to take the master his lunch. The cook testified that the master went to town after lunch and returned about

1. The cook’s last conversation with

the master took place in the galley sometime between 1700 and 1730. The cook told the master that he would like to go to Anchorage that evening, to which the master replied, “Okay, James. See you later.” The cook left the vessel about 1810. The chief engineer had several conversations with the master on the day before the accident. He stated that he spoke with the master about 1000, when he went to the wheelhouse to borrow a tool, and again at 1100 when he returned the tool to the master. After completing work sometime after 1900, the chief engineer and the master met on the bridge deck, where they talked about sport fishing. The chief engineer last saw the master about 2000, when he went to the master’s room to borrow a videocassette. According to the chief engineer, the master said that he intended either to read a book or watch a movie before going to bed. The chief engineer said that after leaving the master he watched a movie, played an electronic game, and went into the engineroom about midnight to check the engineroom and operating equipment. He found nothing out of the ordinary. He checked the power board (switchboard) and found no indication of any electrical short circuits. He then went to the galley for a snack, picked up an audiocassette from the factory deck, and returned to his room. He listened to some music, played some more electronic games, and went to sleep. The assistant engineer testified that, after finishing his day’s work about 1700, he went to bed and read in his room—located forward of the galley in the athwartships (cross) corridor. About midnight, he went to the engine control room and looked through some manuals. About 0130-0145, he went to his room and read. At no time during this entire period did he see, hear, or smell anything out of the ordinary.

5 About 2130 on May 26, the four deckhands were in the port-forward crewroom on the 02 deck (see figures 3, 4, and 5) discussing their off-duty plans for the evening. Three of the four deckhands decided to go into town. They departed the vessel about 2200. The remaining deckhand left the crewroom, stopped briefly in the galley, and went to his room (a four-person room on the forward starboard side of the 01 deck) to sleep. About 0100 on May 27, one of the three deckhands who had gone into Seward returned to the vessel and signed in on a chalkboard in the galley. He retired to his room on the 01 deck port side aft (at the foot of the inside stairwell to the 02 deck) and apparently went to sleep. Fire -- Shortly before 0200, after completing his round on the ALASKA RANGER, the watchman walked to the ALASKA SPIRIT, about 500 feet away. When asked by investigators about his previous round that evening on the ALASKA SPIRIT, he stated that It just seemed like there was nothing unusual or anything to make me cause any attention. It just seemed like everything was OK that night. He also testified that he did not notice anything unusual as he made his way to the ALASKA SPIRIT and commenced his round in the engineroom. After checking the engineroom wearing ear protection, he went up to the starboard side of the factory deck and took his ear plugs out. At this time, he heard the fire alarm. He went up to the net retrieval area (trawl deck) and walked toward the chief engineer’s room on the port side aft on the 01 deck accommodation area. He saw the door to the chief engineer’s room ajar, indicating to him that the chief engineer was awake. The watchman then went out to the trawl deck and saw the cook. The cook testified that he returned by car from Anchorage at 02044 on May 27 and parked near the ALASKA SPIRIT’s gangway. He was walking towards the ALASKA SPIRIT’s gangway when he noticed flames and smoke on the 02 deck aft port door and in the wheelhouse (see figure 1). As the cook headed toward the 01 deck, he met the watchman, who had just exited the engineroom stairwell on the trawl deck. He climbed the outside stairwell from the 01 deck and looked into the 02 deck aft doors (see figure 6). The cook saw flames on the port side corridor in the overhead, and heavy smoke about a third of the way down from the overhead. He saw flames in the toilet to the left and inside the port door. The flames extended along the overhead of the port corridor down to the toilet to the right of the door. The stairwell to the wheelhouse was filled with thick smoke. On the starboard side corridor, he noticed a little smoke along the overhead but no fire. The watchman left the vessel and ran to the ALASKA RANGER, where he telephoned the Seward Emergency Communications Center (SECC) to notify them of the fire. The call was logged in about 0213.

4The cook noted the time from a clock in his car. A Seward fire investigator later checked the clock and verified that it was accurate to within 30 seconds of the dispatch clock.

~ ‘-””-”””””””] a . . . . v L 1.:[ I 1 i “[”” .-. -U (~: !-E I I \— ,/ ,;E , 0 !0 ,, a , -. -.. . ----- n 1 ! ~“i J I 41 . . . . . . t i 642 B......-. . .

1. . . . . . . . . . . . .‘&

‘(;’? 7

02 Deck Toilet P I%dlr7 ,Fan 3-Crew (cooks) n D ) . . . & oom 4-Crew Room Figure 5 — Enlarged plan view of the 02 deck

Figure 6 — View of the deckhouse from the trawl deck, looking forward (courtesy NFPA, Quincy, Massachusetts) 9

10 The watchman only asked if SECC knew about the fire. After receiving an affirmative reply, the watchman hung up. He provided no further information, nor did the SECC operator request that he provide any or identify himself. While on the ALASKA RANGER, the watchman woke the vessel’s two engineers, who returned with him to the ALASKA SPIRIT to assist in the firefighting activities. The chief engineer testified that the fire alarm woke him. He dressed and left his room. He saw the assistant engineer and a deckhand in the corridor outside his room on the port side aft on the 01 deck. (The assistant engineer testified that he had been reading in his room when he heard the alarm at 0200 and got up to investigate.) The chief engineer attempted to go up the inside stairwell on the port side to the 02 deck where he noticed “smoke, fumes, and felt the heat, and saw the glow through the smoke of fire.” He retreated and told the assistant engineer that “we were in trouble, we were on fire.” The assistant went to the engineroom and started the fire pump. The deckhand who had not visited Seward that evening said he was asleep in the four-person room forward on the starboard side of the 01 deck when the vessel’s fire alarm woke him. He dressed, went into the corridor, and followed the assistant engineer aft on the 01 deck. On the way, he checked the door to the five-person room on the port side by the stairwell to the 02 deck and found it locked. He smelled smoke and remarked to the assistant engineer that the door of the room was locked, and he thought a deckhand was inside. The assistant engineer kicked the door open, removed the sleeping deckhandand carried him to the trawl deck. The deckhand who had been awakened by the alarm attempted to go up the inside stairwell to the 02 deck. He said that he “wanted to have a look” because he thought that the other two deckhands might be sleeping in their room on the port side forward. He went up far enough to peer through the doorway on the 02 deck. From there he saw something burning on the deck to the left of the doorway. He testified that “I said burning floor, but now that I think about it, it was probably boots, ‘cause I’d seen them in the hallway.” He also saw a single row of flames in the overhead of the 02 deck corridor. He stated that “…there was black stuff dripping5 out of the ceiling (overhead in the stairwell)” and “there was a lot of heat.” The smoke was not thick or heavy. He further stated that “soon as I saw flames on top (overhead), I forgot about going up there (onto the 02 deck).” He retreated down the stairwell and exited aft on the port side of the 01 deck. He assisted the cook in putting water on the fire until the shoreside firefighters arrived. He then assisted them as requested. The chief engineer attempted to survey the fire from the exterior decks.

5Thermoplastics (such as polystyrene and polyurethane foam insulation) will melt and drip in a fiery environment. Also, the thin coating on the bulkhead paneling was a plastic type of material that, when heated, could have resulted in a black liquid.

11 As he was climbing the exterior stairway and approaching the 02 deck port door, the door window blew out. He returned to the 01 deck and attempted to survey the fire from the trawl deck. He also had the crew lay out (unroll) fire hoses from the port and starboard midships fire stations. The ALASKA SPIRIT was equipped with two different types of fire hose — a 1 ½-inch standard hose and a nonstandard Armtex hose. The hose6 that the cook selected for use on the port fire station hydrant was an Armtex hose, which has a nonstandard coupler, smaller in diameter than the vessel’s hydrant hose connection. To attach Armtex hoses to such hydrants required an adapter hose coupling. Recognizing this incompatible situation, the chief engineer immediately returned to his room on the 01 deck and retrieved an adapter to mate the 1 ½-inch hydrant hose connection to the smaller Armtex coupling. The vessel carried at least three such adapters, which were kept in the chief engineer’s room. The chief engineer handed the cook a fire hose and told him to spray water onto the 02 deck outside port door. The cook stated that the fire intensified within the first 5 minutes of this spraying. About 5-10 minutes later, he saw flashing lights from a police car; about 5 minutes after that, he heard a fire truck siren, signaling the arrival of shoreside firefighters at 0220. The cook assisted the shoreside firefighters until the fire was extinguished.

6“Hose” refers to one or more sections of hosing that may be connected to form a single hose unit. After handing the hose to the cook, the chief engineer went to the engineroom and aligned the ship’s general service and seawater service pumps to operate with the fire pump. The two engineers from the ALASKA RANGER arrived and assisted in laying out hose and spraying water inside the port 01 deck inside stairwell to prevent fire from “walking down” from the 02 deck. In the first 20 minutes after the fire erupted and as land-based firefighters responded, the crew of the ALASKA SPIRIT and two engineers from the ALASKA RANGER conducted the firefighting operations. Guided by the ALASKA SPIRIT’s chief and assistant engineers, the crew attempted to spray water into the interior stairwell between the 01 and 02 decks using two 1 ½-inch hose lines. The crew fought the intensifying fire at the 02 deck port side door and at the 01 deck interior stairwell. The chief engineer also had the two deckhands move about 30-40 cans of oil-based paint from the aft 01 deck corridor to the trawl deck. Emergency Response and Fire Extinguishing -- About 0209, while listening to a CB scanner, a Seward taxi driver overheard persons aboard two unidentified vessels discussing a fire that they could see. According to them, the fire appeared to be aboard a vessel at the SMIC docks. The taxi driver phoned the information to the SECC. At 0211, the Seward Volunteer Fire Department (SVFD) dispatched a fire pump truck and a medical rescue vehicle

12 from the main fire station in Seward, approximately 7-8 miles from the dock. Additionally, the deputy fire chief and four firefighters responded to the SMIC area, where a fire pump truck and a medical rescue vehicle were already pre- positioned at a fire station within several hundred yards of the moored ALASKA SPIRIT. Fire response personnel drove these units directly to the dock. At 0217, the SVFD fire chief told the SECC dispatcher to request mutual aid from the Bear Creek7 Volunteer Fire Department. Eventually, 30 firefighters from the two volunteer fire departments were involved in the firefighting effort. About 0220, the deputy fire chief of the SVFD arrived on-scene at the ALASKA SPIRIT dock. He observed brownish-gray smoke coming from the upper deck of the vessel, but no flames. Shortly afterwards, the SVFD fire chief arrived on-scene and saw heavy smoke and flames coming from the 02 deck and wheelhouse access. As the incident commander, the fire chief boarded the vessel to assess on-board conditions and met with the ALASKA SPIRIT’s chief engineer. He established a command post, manned by the deputy fire chief, at the fire pump truck, which was positioned at the shoreside hydrant. The chief engineer said three crewmembers were unaccounted for (the master and two deckhands), and he thought they were trapped on the 02 deck. Additionally, the chief engineer showed the hull arrangement plan

7A community to the north of Seward and about 9 miles from the fire. entitled “safety plan” to the fire chief. He advised the fire chief that the crew had searched all of the lower decks, but fire kept them from searching the accommodation area on the 02 deck. (Later that morning, during the shoreside firefighting operation, the two deckhands who had been in Seward arrived at the vessel.) The crew continued to fight the fire by spraying water onto the interior port side 01 deck stairway and onto the exterior port side 02 deck door. Following his survey of the accident scene, the fire chief decided: • To use all land-based fire suppression equipment rather than the equipment on the ALASKA SPIRIT, because he did not know if the fire suppression equipment on the ship was reliable. In addition, the land-based firefighters wore self-contained breathing apparatus (SCBAs) and were more familiar with their own equipment than the shipboard apparatus. (The assistant engineer later stated that, although there were two SCBAs on the ALASKA SPIRIT, the crew had had no time to don them.) • To attack the fire at the port side door on the 02 deck in an attempt to rescue the master. • To continue the hose attack at the interior stairwell to prevent the fire from walking down the stairs to the 01 deck. While the fire chief was making his survey, the deputy chief pulled hoses from the fire engines and laid a supply

13 line between the engine and the closest fire hydrant, which was several hundred feet away.8 The hoses were laid from the engine to the gangway area to the trawl deck. The 1 ¾-inch hose attack lines were used rather than larger hose lines because they allowed firefighters greater mobility within the narrow corridors on the vessel. About 0230, firefighters preparing for entry into the port door on the 02 deck found the corridor filled with a “thick, dark-black, gritty smoke” extending from the overhead to the deck. As the firefighters crawled into the port side corridor, they heard crackling noises coming from all sides, but no flames were visible due to the heavy smoke. About 2 feet from the assistant fish master’s room door, the firefighters adjusted their nozzle to provide a semi- fog pattern, but they could not endure the intense heat in this area and returned to the open deck. The firefighters attempted two or three more attacks using various water streams through the port door on the 02 deck, but they could not reach the master’s room (which was across the corridor from the assistant fish master’s room). The fire continued to burn out of control. The fire chief later stated that, because intense heat forced the firefighters off the 02 deck and the firefighters on the 01 deck could not go up the inside stairwell due to heat, they could not reach the ship’s master at that

8Engine 4 laid a 5-inch supply line from the hydrant to the pier where the vessel was moored. The deputy chief had two 2 ½-inch hose lines laid to the deck of the vessel and connected four 1 ¾-inch hose lines. time. He focused tactical efforts on fire control. As evidenced by the heat-caused breaking of the wheelhouse windows, the fire intensified in the wheelhouse and on the 02 deck at about this time. The fire chief decided that he could not attack the fire in the wheelhouse because it was being fed by the flames coming from the 02 deck. Firefighters in the starboard corridor saw that the steel bulkhead on the starboard side of the assistant fish master’s room was glowing red. They realized that there was an intense fire in the room. Eventually, the vessel’s fire pump failed, as the fire consumed the wheelhouse and the circuitry for the fire pump. Because responding firefighters had already charged their hose lines from shore, fire suppression efforts were not interrupted. Crewmembers reported that, with both the general service and seawater pumps on-line, there was no noticeable interruption in flow rate when the vessel’s fire pump failed. They directed hose streams on the vessel’s fuel tank vents on the 02 deck near the deckhouse to dissipate heat and disperse fuel oil vapors to prevent fuel tank ignition. At 0326, the fire chief had the SECC operator notify the U.S. Coast Guard (USCG) Cutter MUSTANG, in port at Seward, of the ALASKA SPIRIT fire situation. He did not request Coast Guard assistance. The cutter duty officer in turn notified the USCG Marine Safety Office in Anchorage, in accordance with the Western Alaska Marine Firefighting Plan. This plan was developed and

14 promulgated in 1987 by the Coast Guard Captain of the Port (COTP)9 of Western Alaska to coordinate firefighting activities for marine disasters posing a risk to vessels, facilities, or harbors in the COTP’s zone. The fire chief felt that during the first 6 hours of the effort to get the fire under control, the unfamiliar and confined configuration of the ALASKA SPIRIT’s accommodation area created an environment that taxed firefighting resources. Of the 30 firefighters at the scene, approximately 20 were involved in suppression operations. The other 10 firefighters were advisory and support personnel who performed such tasks as refilling an estimated 100 air bottles with the cascade air resupply system. About 0900, the fire chief established an arbitrary target time of 0945 for fire control. If the team had not gained control by that time, he planned to remove the firefighters from the fire area to a distance from which they could work to suppress the fire with minimum risk to themselves. About 0930, firefighters controlled the fire. They continued their suppression activities, focusing on hot spots, for another 30 to 40 minutes. About 1100, the fire chief declared the fire out. At 1123, the master’s body was found lying face-down inside the door to the hospital adjacent to his quarters. He was dressed in his underwear. About 1330,

9The Coast Guard officer (under the command of a District Commander) so designated by the Commandant to give immediate direction to Coast Guard law enforcement activities within an assigned area. the fire department completed overhaul10 of fire debris. The fire chief set a reflash watch on the vessel, and all units departed the scene at 1356. (See appendix A for Safety Board investigation information.) Injuries Injuries Vessel Complement Fatal 1 Serious 0 Minor 0 None 7 Total Crew 8 Vessel Damage The Fishing Company of Alaska, Inc. (FCA), owner of the ALASKA SPIRIT, reported that damage to the vessel from this accident was estimated at $3 million. Before the fire, the vessel had been valued at $6 million. Replacement cost was estimated at $14 million. In September 1995, the vessel was towed to Japan for repair. It returned to service on January 18, 1996. A company spokesman told the Safety Board that portable heaters were not reinstalled in crewrooms, combustible insulation was replaced with fiberglass insulation, and a Coast Guard-approved marine smoke detection system was installed on the vessel.

10The process of moving and separating burned material to locate any hot or smoldering debris and to cool it or wet it down to prevent reflash of the fire.

15 Crew Information Staffing -- At sea, the ALASKA SPIRIT carried a maximum crew of 48 persons—a National Marine Fisheries Service observer and about 47 crewmembers. Of these crewmembers, typically about 12 were in the deck department, 2 were in the engineering department, 31 were in the processing department, and 2 were in the galley (the cook and cook’s assistant). Staffing information is approximate, as no fixed staffing regulations are in effect for such vessels. Only the master, mate, chief engineer, and assistant engineer must be licensed by the Coast Guard on fishing vessels over 200 gross tons. No licensed persons were required to be on board during the in-port period. The ALASKA SPIRIT’s master and its two engineers were, however, properly licensed by the Coast Guard for operating this vessel (see appendix B for crew licensing information). Personnel information for the six crewmembers who made up the vessel’s complement at the time of the fire and the watchman follows. Master -- The master, age 44, began his maritime career in 1972 as an unlicensed seaman. He sailed in that capacity aboard various fishing vessels for the next 9 years. In June 1981, he received his first license as a mate of uninspected motor fishing vessels. He increased the grade and scope of his license over the next several years before joining the FCA in May 1989. He was initially assigned as mate to the trawler ALASKA I. He was reassigned to the ALASKA SPIRIT in November 1991 and served as its master until the accident. The National Driver Registry has no record of suspensions or revocations against his driver’s license. Chief Engineer -- The chief engineer, age 33, had held that position aboard the ALASKA SPIRIT since joining the FCA in March 1992. His testimony to Safety Board investigators described a variety of previous engineering work that he had performed, dating to 1982. This experience included about 1 ½ years of serving on offshore supply vessels in construction diving support, over 4 years of operations and maintenance on vessels with multiple moorings (anchors), and another 4 years on diving support vessels. Assistant Engineer -- The assistant engineer, age 46, stated that he began sailing about 1970, first on fishing vessels out of Kodiak and then on tankers operated by the Military Sealift Command. From October 1976 to December 1983, he worked as an engineer aboard offshore supply vessels operating in domestic and foreign waters. He then worked about 7 years with a towing company out of Dutch Harbor, before joining the FCA in March

1. He initially worked as chief

engineer on the ALASKA RANGER for about 2 ½ years, and then conducted shipyard maintenance work and ship- board relief work for the company. Sometime prior to the fire, he had relieved the regular chief engineer on the ALASKA SPIRIT. At the time of the accident, he was relieving the regular assistant engineer. Cook -- The cook, age 46, began to work as a cook aboard FCA vessels in May 1990. After working for 6 months

16 on the ALASKA PIONEER, he transferred to the ALASKA SPIRIT, where he remained until the fire.

Processor-deckhands

The two processor-deckhands on board at the time of the fire, aged 26 and 25, joined the FCA in January and March 1992, respectively. They worked in that capacity for about 200 days each year until the accident. The older deckhand had no other seagoing work experience, but the younger had in 1989 served for 5 months as a processor-deckhand aboard a fish processing vessel owned by another company. Watchman -- The watchman, age 38, had worked for the FCA intermittently since 1988, mostly as a processor- deckhand. He learned to perform his rounds through on-the-job training. He was taught that if he found anything unusual, he should notify the chief engineer, and that if he needed assistance in adjusting mooring lines, he was to notify the mate or the master. Vessel Information The ALASKA SPIRIT was originally built in March 1974, at Lockport, Louisiana, as a 166.4-foot-long offshore supply vessel for the oil industry. The vessel was named the GULF FLEET NO. 10. The American Bureau of Shipping (ABS) certified that the supply vessel had been built in accordance with ABS rules. In 1987, the vessel was taken out of service. It was sold to the Palmco Pacific Corporation on January 5, 1988, converted into a trawler-fish processing vessel (also known as a factory-trawler), at Ishinomaki, Japan, and renamed the NORTHERN HERO in February 1990. During the conversion, the vessel was lengthened by 37.3 feet to a total length of 202.7 feet. The vessel was not required to be inspected by the Coast Guard to operate as a fish processing vessel. (See section on Coast Guard Regulations.) It was not required to meet international Safety of Life at Sea convention regulations (structural fire protection, etc.) because it was not engaged in international voyages,11 although it fished in international waters. On November 25, 1991, the FCA purchased the vessel and renamed it the ALASKA SPIRIT. Because the vessel was engaged in domestic voyages by sea, it was required to have a load line.12 The Det Norske Veritas (DNV) classification society issued a certificate for the ALASKA SPIRIT on December 26, 1992, attesting that the vessel complied with the International Convention on Load Lines of 1966. The principal characteristics of the ALASKA SPIRIT were: Length Overall 202.7 feet Breadth 38.0 feet Depth 21.6 feet Gross Tonnage 1,418 Net Tonnage 425 Horsepower 3,600

11Voyages between U.S. and foreign ports. 12Lines marked on the sides of a vessel that show the maximum depths to which the vessel may be safely loaded, as determined by the rules of the International Convention on Load Lines.

17 From the keel up, the ALASKA SPIRIT had five decks: the hold deck (two freezer holds forward and engineroom13 area aft); the factory deck (processing area); the main or 01 deck (galley and crew accommodations (for 28) were forward, and the trawl deck was aft); the 02 deck (crew accommodations for 20); and the bridge deck.14 The only exterior openings in the 01 and 02 decks were two weathertight doors (one on the port and one on the starboard side) at the aft end of each deck. These decks had no portholes or other hull openings. Firefighting Equipment -- A fire pump, a general service pump, and a seawater service pump could be connected at a manifold that could distribute water to fire stations throughout the vessel. A remote control located in the wheelhouse could start the fire pump and pressurize the fire main.15 The fire pump and fire stations were not required by regulation. Seventeen portable fire extinguishers

13It had a 20-cylinder diesel engine driving a single propeller shaft with a controllable pitch propeller. The vessel was also equipped with a bow thruster. 14The navigation and communication equipment in the wheelhouse included satellite communication equipment, direction finders, fish finders, echo sounders and recorders, a gyro- compass, a magnetic compass, radars, radio telephones, electronic position fixing devices, including global positioning system (satellite) equipment, other electronic equipment used for fishing or fish processing operations, and a public address system. A console in the wheelhouse controlled the main engine, the propeller pitch, and the bow thruster. The console had audio and visual alarms. 15A seawater pipeline that provides an adequate water supply for vessel fire hydrants and hoses. were distributed throughout the vessel. A fixed carbon dioxide (CO2) firefighting system, consisting of 14 100-pound compressed CO2 cylinders, was piped into the engineroom spaces. A fire detection alarm control panel, with audio and visual alarms, was also located in the wheelhouse on the starboard side aft. The detection system consisted of 27 heat detectors located in the overhead throughout the vessel (1 in each of the 17 crewrooms, 4 in the galley-mess room, 1 in the processing area, 1 in the wheelhouse, and 4 in the engineering spaces), and 3 smoke detectors in the freezer holds. The fire detection system was not required by regulation. The heat detectors activated when the heat in the vicinity exceeded 70 oC (158 oF). The circuit would remain closed until the heat lessened to about 60 oC (140 oF), at which time the detector would open and reset. It would then be ready for reactivation if the heat rose above the preset temperature. Aural fire alarm warning buzzers were located on the bulkhead in the starboard corridor on the 02 deck outside the assistant fish master’s room, on the bulkhead in the port corridor on the 01 deck adjacent to the port inside stairwell across from the galley, and in the engineroom. A fire alarm from an activated sensor could be heard outside as well as inside the wheelhouse. Survival Equipment -- The ALASKA SPIRIT was fully equipped with all of

18 the routinely necessary survival equipment.16 The FCA -- The FCA formed in 1985. It purchased 1 vessel in 1986 and 10 others through 1992. At the time of this accident, the company operated 10 vessels, including the ALASKA SPIRIT. An 11th FCA vessel was not in service. The company’s main office is in Seattle, Washington, and the FCA has field offices in Anchorage, Dutch Harbor, and Seward, Alaska. On an annual basis, the company employs about 2,000 people. It has 12 employees on its management staff and 20 in support functions. Coast Guard records show that during the period from 1992 through 1994, the ALASKA SPIRIT had one reportable personnel injury, one equipment failure, and one pollution incident. The records also show that between 1986 and 1994, the 10 other vessels owned by the FCA experienced 4 personnel injuries and 6 vessel accidents. Of the 6 accidents, 1 was a loss of engine propulsion from equipment failure, 1 was a steering gear equipment failure, 1 was a collision with another vessel, and 3 were engine reduction gear failures. The FCA director of operations described the operation of the ALASKA SPIRIT in the following manner: “The master is in charge of all operational decisions regarding the vessel at sea and

16The ALASKA SPIRIT carried flares, an emergency position indicating radio beacon (EPIRB), 4 ring life buoys with lights, 4 other ring buoys, 2 inflatable liferafts (which could accommodate 50 persons each), an 18-foot-long inflatable rescue boat with a 30-horsepower engine, 48 life preservers, and 50 immersion suits. in port. The fish master on the vessel is in charge of the fishing operation…”. The director further stated that the FCA had no operating or safety manuals and that the vessel was not routinely visited by company managers. The company provided the Safety Board with a copy of its 1995 Human Resources and Claims Guide.17 Waterway Information The fire aboard the ALASKA SPIRIT occurred while the vessel was moored at SMIC, Seward, Alaska, at latitude 60o05.4’ N, longitude 149o21.8’ W. The dock is situated on Resurrection Bay, about 2.2 miles east-southeast of mid- town Seward. By road, the dock is 7-8 miles from mid-town Seward. The bay is a deep waterway extending south from Seward for about 16 miles to the Gulf of Alaska. Meteorological Information From 0800 on May 26 to about 1400 on May 27, skies were mostly cloudy in the accident locale. Visibility varied from 5 to 20 miles and was generally 5

17The guide contained sections for a sample emergency station bill; guidelines for reporting injuries and illnesses; guidelines for completing Coast Guard marine accident, injury, or death reports; guidelines for completing crew departure forms; FCA policies against harassment; guidelines for completing crew evaluation forms; guidelines for completing payroll disbursement requests; work rules and duties; employment contracts for new employees; a copy of 46 CFR 28; and University of Alaska marine advisory program bulletin 27 on tendinitis and related afflictions affecting fishermen and processing workers.

20 Sheets of polystyrene insulation (Styrofoam) appeared to have been used in some overhead and bulkhead locations. In other areas, the bulkhead had fiberglass insulation in the spaces between the paneling and in the overhead. The foam insulation was not covered with noncombustible material.18 The furnishings in each room consisted of wood cabinetry, wood paneling, wood bunks, and wood lockers. Rooms were not centrally heated; instead, each room had an electric resistance-type heater. Investigators found the heaters in some of the rooms, but none was found plugged into an electrical source. An air ventilation ducting system provided outside air to each room. Wreckage -- The ALASKA SPIRIT’s entire wheelhouse, including all of its electronic and navigation equipment, was destroyed in the fire (see figure 8). The hull and steel deck plating in the area of the wheelhouse and 02 deck were buckled and distorted, and showed discoloration consistent with intense heat. Masts and associated rigging in the area of the fire sustained heat damage. The rooms on the port, forward center, and forward starboard sides of the 02 deck were gutted (see figure 9). The RPU foam insulation and woodwork in the 02 deck were burned and, in most areas, completely destroyed. The fish master’s room in the starboard corridor aft was significantly burned, but not as

18Materials that neither burn nor produce flammable vapor in sufficient quantity for self- ignition when heated to 1350 oF or above.. extensively as rooms on the port side. The crew shower/toilet on the starboard side sustained only heat and smoke damage. The fire damage in the starboard side corridor decreased from forward to the aft doorway exit. The inside stairwell to the wheelhouse (on the port side) from the 02 deck was burned extensively and partially collapsed. A door at the top of this stairwell separated it from the wheelhouse. This was not a fire door, and crewmembers reported that it stood open most of the time. The door appeared to have been open during the fire, although most of it was destroyed by the fire. The upper bulkheads of the inside stairwell between the 02 deck and the 01 deck (port side) were destroyed, but the stairwell suffered only heat and smoke damage and remained intact and usable. The 01 deck accommodation area near the inside stairwell to the 02 deck (port side) sustained limited damage, mainly caused by heat and smoke. Some interior finish vinyl veneer on the paneling was melted and had dripped. The galley sustained smoke damage from the fire and some water damage from the firefighting operations. The assistant fish master’s room (center aft on the 02 deck) had steel bulkheads and a wood door with a louvered vent in its bottom section. The door was completely destroyed in the fire. A small ventilation fan (8- by 8-inch opening) was located about 6 feet above the deck aft of the door in the port aft part of the bulkhead to the corridor (the door to the master’s room was across the corridor). A 6- by 16-inch

24 but investigators found no evidence of electrical arcing. Power cords from several other pieces of electrical equipment in the accommodation space were plugged into the multiple-plug receptacle just inside the door. The stairwells between the 01 and 02 decks, and between the 02 deck and the wheelhouse, were constructed of wood risers, treads, and stringers. Both stairwells were finished on the interior with plywood paneling. The stairwell between the 02 deck and the wheelhouse was extensively burned and partially collapsed. The stairwell between the 01 and 02 decks exhibited heat and smoke damage but was still intact and usable. The corridor that led into the stairwell between the 01 and 02 decks had heat and smoke damage. Some of the interior finish vinyl veneer that had been installed over the plywood paneling was melted and hanging down. Medical, Pathological, and Toxicological Information The master lost his life in the course of the accident. The SVFD reported that the master’s body was located on May 27 at 1123 and removed from the vessel at 1247. The body was found in the hospital room just inside the closed door from the 02 deck port corridor. The SVFD deputy fire chief said that, from the position of the body, it looked as if the master had been headed back into the hospital room when he collapsed. The hospital room adjoined the master’s room through an interior door (see figure 5). Directly opposite the corridor door to the master’s room was a ventilation fan opening in the assistant fish master’s room at a height of about 6 feet above the floor. Just forward of the fan opening was the door to the assistant fish master’s room. The deputy fire chief reported that he asked a crewmember what the master’s standard response would have been if he had heard the alarm. The crewmember replied that the master would normally go to the wheelhouse. The deputy fire chief surmised that: Assuming that he (the master) was in his stateroom, he would go out his stateroom door, turn to the right and go up the stairway to the wheelhouse; where he would go ahead to the alarm panel and determine where the alarm was coming from. The deputy fire chief also told Safety Board investigators that: My assumption is that if he (the master) heard the alarm or was woken up by smoke, he opened up his door to go see toward the wheelhouse, and it had a whole bunch of smoke. He said, ‘no, that’s not the way to go.’ (He) closed his door, because the door was closed. (He) went back through the medical area and... came up and got another blast of air right in that passageway. (He) turned and fell down. On May 30, 1995, the deputy chief medical examiner, Office of the Alaska State Medical Examiner, autopsied the master’s body. The autopsy report stated that the cause of death had been smoke inhalation. The deputy chief medical examiner also collected a fluid blood

25 sample for toxicological analysis. The deputy fire marshal, who attended the autopsy, told investigators that the blood sample had been difficult to obtain due to coagulation. He said that neither urine nor vitreous humor was available for sampling. Analysis of the blood sample found a blood alcohol concentration of 0.353 gm/dL21 and a carboxyhemoglobin (COHb) saturation of 90.6 percent. At the request of the Safety Board, the Office of the Alaska State Medical Examiner sent a portion of the master’s blood sample to the Center for Human Toxicology (CHT), University of Utah, for further toxicological analysis. The CHT findings were: blood alcohol concentration, 0.36 gm/dL; COHb, 84 percent saturation; hemoglobin, 6.8 gm/dL; cyanide, negative; and phenethylamine, detected as a decomposition product. The CHT detected no other common drugs. The cook said that he had known the master for 3½ years and considered him a very disciplined person who never overreacted. He also considered the master physically fit. The chief engineer noted that the master would often work out on an exercise machine or jog in place before beginning his day (frequently well before 0600) in the wheelhouse. In summary, the chief engineer said that the master “took care of himself.” Safety Board investigators also talked with the master’s wife about his lifestyle. She said that he was physically fit and that at home he only drank socially. She also reported that her

21Grams per deciliter. husband did not drink on the vessel and that he did not permit alcohol on board. Drills According to U.S. Coast Guard requirements (see 46 Code of Federal Regulations (CFR) 28.270), fishing vessels must hold drills monthly. The regulations list 10 contingencies that must be covered in such drills, including “abandon ship” and firefighting. They also state that drills are to be conducted as if an actual emergency exists, with the breaking out and using of emergency equipment. Further, they state that fire drills should be held in different parts of the vessel. An ALASKA SPIRIT deckhand stated that the drills on that vessel consisted of mustering on the bridge deck when the general alarm bell sounded. The drills were held whenever the vessel entered port and the crew changed. (This took place about every 7- 10 days.) Fire drills were conducted without laying out or charging the fire hose lines from the hydrants, donning SCBAs, or putting on firefighting equipment. During abandon ship drills, the crew did not don survival suits. According to the chief engineer, each time the ALASKA SPIRIT deployed for a fishing trip, the ship’s officers held a meeting, primarily to familiarize the new personnel (such as the fish processors) with topics such as: routine rules and practices; general company and ship rules regarding smoking, running, riding conveyor belts, fighting, etc.; training and drill procedures for fire, abandon ship, man overboard, and flooding drills; and the general alarm warning sound.

26 They also used the meetings to conduct safety equipment familiarization sessions, such as demonstrating survival suit-wearing procedures and liferaft use; to identify muster station locations; and to allot emergency squad assignments and responsibilities during firefighting and chemical responses. According to the engineroom log, the last fire drill on the ALASKA SPIRIT had been held on May 5, 1995. Tests and Research Possible Ignition Sources -- The Safety Board investigated various possible ignition sources for this fire. The sources considered included portable electric space heaters found in crewrooms, a boot warmer found outside the port forward 02 deck crewroom, (lighted) smoking materials, battery chargers, and the cook pot found in the assistant fish master’s room. The space heaters on the vessel were rated at 5,000 watts at 220 volts. None was found plugged into an outlet. Investigators examined the remains of a boot warmer found outside the four- person crewroom on the forward port side on the 02 deck. No evidence of electric arcing was noted. The bottom of the boot warmer was found on the deck and unburned, while the top of the appliance had been burned or melted away. According to crewmembers, smoking had been permitted in the vessel’s accommodation spaces. The four-person crewroom forward on the port side of the 02 deck was considered a likely area for fire origin, because a deckhand had seen the deck near this room on fire shortly after the fire alarm sounded. The room had been occupied by smokers on the night of the fire. Battery Charger

Examination

Investigators found that Nippon Denchi was the manufacturer of the chargers removed for examination from the ALASKA SPIRIT’s sister vessel, the ALASKA VICTORY. These chargers appeared to be identical to the heavily fire-damaged chargers found on the ALASKA SPIRIT. Electrical diagrams for the chargers were not available. The chief engineer testified that the chargers, which he called “converters,” had been used to convert 105 volts AC to either 12 or 24 volts DC for wheelhouse radios. According to the chief engineer, the chargers were permanently mounted. During the fire investigation, it appeared that the chargers on the ALASKA SPIRIT had been hard-wired or permanently wired to the radios in the wheelhouse. On August 29, 1995, the fire-damaged battery chargers were examined (see appendix C), photographed, and disassembled. No evidence of electrical arcing was found. Cook Pot

Examination

An inventory of the contents of the assistant fish master’s room provided to the Safety Board listed an object described as a “boiler.” This appliance was a round cylindrical object found sitting on the deck in this room; it was essentially a cook pot that had been used to heat water. The cook pot was constructed of two concentric metal cans approximately 9 inches tall and 7 inches in diameter. When asked if crewmembers had cooked food in their rooms, the cook said he had not been aware of anyone doing so.

27 The cook pot was found next to the built-in bunk bed. A darkened burn pattern around it trailed over to the corner of the left battery charger. A power cord extended from the bottom of the cook pot forward to the center of the forward bulkhead. The insulation on the exposed cord and plug had been destroyed. Because of the damage to the room, investigators could not determine whether the plug had been connected to an electrical receptacle. Investigators removed the cook pot, along with a piece of carpeting to which it was attached. The cook pot and the remains of a small can next to it (stuck to the same piece of carpeting) were sent to the Safety Board for further analysis. Investigators found many small tube- type fuses made of glass and screws stuck together on the can bottom. The can appeared to have been a receptacle for these spare parts. The carpeting under the cook pot was intact and gave some evidence of heating but none of burning. A broken glass tube ran up the side of the cook pot between the two concentric cans. The tube appeared to have been used as a sight glass to determine the water level in the cook pot. The power cord to the cook pot was about 5 feet long. Part of the power cord (about 12 inches) was coiled beneath the cook pot. This portion of the cord was still intact and evidenced no fire or heat damage. The rest of the cord consisted of two bare wires. All the electrical insulation on this part of the cord was missing. The plug that held the prongs was completely destroyed, and the prongs held the electrical leads attached with screws. No evidence of electrical arcing was noted on the power cord. The bottom of the cook pot was covered by a metal plate attached with three screws. This plate appeared to have been a heat reflector. About ½ inch of a powdery material that easily crumbled away was found on top of this plate. Above this material were electrical wiring and support hardware (consistent with Bakelite22) for attaching the electrical leads to a heating element in the bottom of the innermost can. The insulation on these wires was fiberglass and it appeared to be undamaged. The wire attachment hardware, however, was soft and powdery. A small switch was fastened to a recessed hole in the center of the inner can. This switch came apart during the disassembly, and investigators could not determine whether it had been functional before the fire. It appeared to have been an over-temperature switch, but this could not be verified, since the cook pot manufacturer could not be identified. Heat Detector Testing -- The detectors on the ALASKA SPIRIT were automatic restorable detectors23 and were not required equipment for this vessel. Following the accident, a heat detector from the ALASKA SPIRIT’s galley was removed and tested by an independent laboratory (see appendix D for results).

22Trademark for any group of thermosetting plastics having high chemical and electrical resistance used in a variety of manufactured articles. 23A device of which the sensing element is not ordinarily destroyed by the process of detecting a fire. Restoration of the device to a detection mode may be manual or automatic.

28 The detector was found in acceptable operating order. The detector was set to be activated at about 70 oC (158 oF) and to reset at about 60 oC (140 oF). Coast Guard regulations for heat detectors (see 46 CFR 76.27) allow a range setting from “135 oF (57.2 oC) to 165 oF (73.8 oC)” for activating heat detectors. International regulations (Safety of Life at Sea, Chapter II-2, Part A, Regulation 13, Paragraph 3.3) allow a range from 54 oC (129.2 oF) to 78 oC (172.4 oF). Other Information Coast Guard

Regulations

The requirements for uninspected commercial fishing industry vessels are at 46 CFR Subchapter C (Uninspected Vessels), which includes Part 28, “Requirements for Commercial Fishing Industry Vessels.”24 Subpart 28.100 requires that each commercial fishing industry vessel meet the requirements of Parts 24 (General Provisions), 25 (Equipment

Requirements

Life Preservers, Fire Extinguishers, and EPIRBs) and 26 (Operations) of Subchapter C, in addition to the requirements of Part 28. Fish processing vessels “of not more than 5,000 gross tons” are exempt from Coast Guard inspection by law.25 The ALASKA SPIRIT was 1,418 gross tons

24The regulations went into effect on September 15, 1991, and were the result of The Commercial Fishing Industry Vessel Safety Act of 1988, Public Law 100-424 (Title 46 USC Chapter 45). 25Title 46 USC 3302(c)(1). and was, therefore, exempt from inspection. Section 28.710(a) also requires that, every 2 years, fish processing vessels not subject to inspection be examined for compliance with Subchapter C. Compliance must be certified in writing by the ABS, a similarly qualified organization such as the DNV, or a surveyor of an accepted organization.26 A DNV surveyor examined the ALASKA SPIRIT on January 16, 1994, and found it to be in compliance with the appropriate regulations. The surveyor issued the vessel a Certificate of Compliance (valid until January 16, 1996) that certified that the vessel complied: With the applicable requirements of U.S. Regulations 46 CFR Chapter C Uninspected Vessels Part 28 as required by 46 CFR 28.710 (Lifesaving, Firefighting, Navigation, and Other Safety Equipment). Coast Guard regulations require that those vessels built or converted on or after September 15, 1991 (the effective date of the regulations for commercial fishing industry vessels), “must be constructed so as to minimize fire hazards insofar as is reasonable and practical.” Insulation must be noncombustible except when used for certain engineering applications, in cargo holds, and in refrigerated spaces.

26An organization that meets the requirements of 46 CFR 28.73 and is designated by the Coast Guard for the purpose of examining commercial fishing industry vessels.

29 Further, on vessels operating with more than 49 persons, the regulations at 46 CFR Part 28, Subpart D, require that superstructures and deckhouses be constructed of noncombustible materials. Because the ALASKA SPIRIT was converted in 1990 and carried fewer than 49 persons, it was not required to meet any of these fire safety requirements. However, the vessel’s superstructure, deckhouse, and assistant fish master’s room were constructed of steel (which is noncombustible). Regulations require that vessels carrying 16 or more persons have an independent modular smoke detector or a smoke-actuated fire detecting unit in each accommodation space. The ALASKA SPIRIT was not required to have smoke detectors because it was converted before September 15, 1991, the effective date of the regulations. The regulations do not require commercial fishing industry vessels to have sprinkler systems in their accommodation areas. Regulations for existing fishing industry vessels (those built or converted prior to the effective date of the regulations - September 15, 1991) do not require a fire pump or that the pump be connected to fixed piping (fire main).27 Only those vessels built or converted on or after September 15, 1991, that are 36 feet or more in length and carry more than 16 persons must be so equipped. The ALASKA SPIRIT, although not

27Regulations require that vessels with a power-driven fire pump have a fire main system, including fire main, hydrants, hose, and hose nozzles. required to have a fire pump or fire main piping/hydrants installed, had this equipment. On April 29, 1980, the Coast Guard issued Navigation and Vessel Inspection Circular (NVIC)28 8-80 (Fire Hazard of Polyurethane and Other Organic Foams) “to alert vessel inspectors, designers, builders, and operators of the potential fire hazard of polyurethane and other organic foam materials” because of “serious fires” on “several ships.” These guidelines are intended to apply to all vessels. The NVIC states: When organic foams (including those described as self- extinguishing, non-burning, fire resistant, flame resistant, and similar terms) are exposed to fire or heat, they may ignite and burn with rapid flame spread, high temperatures, toxic gases, and voluminous quantities of smoke. The NVIC further states that: Whenever polyurethane or other organic foam materials are installed in cargo holds or other spaces, it is recommended that a covering of 22 United States Standard Gauge (USSG) steel (about 0.03 inches or about 1/32- inch thick) or other suitable noncombustible material, with at least a 15-minute fire rating, be installed over the foam insulation.

28Published by Coast Guard Headquarters to disseminate recommended policy, requirements, procedures, or guidance for Coast Guard marine safety personnel and the marine industry.

30 The ALASKA SPIRIT had RPU foam insulation on the steel hull in the crew accommodation areas on the 01 and 02 decks. It was not covered with a noncombustible material, nor was it required to be. Polystyrene blocks and fiberglass insulation were also used between the wooden framing and bulkhead covering, and (apparently randomly) in the overheads of the accommodation spaces. On August 18, 1986, the Coast Guard issued NVIC 5-86 (Voluntary Standards for U.S. Uninspected Commercial Fishing Vessels) “In response to the poor safety record of uninspected commercial fishing vessels...”. NVIC 5-86 (page 3-9) refers to NVIC 8-80 for further information on foam insulation in refrigerated compartments and fishholds. NVIC 5-86 (page 3-2) recommends that: (a) noncombustible materials should be used for bulkheads, decks, and other structures, in accommodations, service areas, and control spaces; (b) smoke or fire detection systems should be installed to indicate the presence and location of fire or smoke in galleys, other high risk spaces, and accommodations, further stating that an Underwriters Laboratory- approved house-type smoke detector is usually adequate for accommodations and galleys (page 3-5); and (c) combustible materials be limited to reduce the amount of fuel available for a fire. The NVIC also states that insulating foams and plastics produce extremely toxic products when burning and “should not be used or at least be reduced in quantity wherever possible” (page 3-3), and that “insulating materials in accommodations, service areas, control spaces, and machinery spaces should be noncombustible (Mineral wool, etc.)” (page 3-11). Three Worcester Polytechnic Institute students, with the U.S. Coast Guard Headquarters Marine Technical and Hazardous Materials Division, prepared a report29 for the Coast Guard which examined safety factors on fish processing vessels. Among other findings, the report concluded that polyurethane foam “has been shown to consistently contribute to fires aboard fish processing vessels.” The report recommended that a substitute be found for polyurethane foam insulation. Standards Applicable to Industrial Vessels -- Coast Guard structural fire protection regulations for Cargo and Miscellaneous Vessels are found at 46 CFR 92.07 and apply to industrial vessels30 of 300 and over gross tons but less than 4,000 gross tons contracted for on or before July 1, 1968, which carry in excess of 12 “industrial persons.”31 The

29Unclassed Fish Processing Vessel Study, October 12, 1990. 30A vessel which, by reason of its special outfit, purpose, design, or function, engages in certain industrial ventures. Included are such vessels as drill rigs, missile range ships, dredges, cable layers, derrick barges, pipe laying barges, and construction and wrecking barges. Excluded are vessels that carry freight for hire or are engaged in oceanography, limnology, or the fishing industry. (46 CFR 90.10-16) 31Any person carried on board an industrial vessel for the sole purpose of carrying out the industrial business or functions of the vessel. Examples are laborers, such as wreckers and mechanics, technicians, drilling persons, and divers. Industrial persons and fish processing persons are similar in training and experience with respect to responding to emergencies aboard vessels.

31 regulations in part require that, within accommodation and service areas, corridor bulkheads shall be of “A”32 or “B”33 class construction; all other bulkheads shall be of “A,” “B,” or “C”34 class construction. Trunks35 shall be of “A” class construction; ceilings, linings, and all insulation shall be noncombustible. An approved interior finish may be used in corridors. An approved interior finish, as defined by the Coast Guard, is one that is subjected to American Society for Testing Materials (ASTM) E8436 and develops a flame spread of less than 20 and has smoke development of less than 10.

32“A” class bulkheads or decks shall be composed of steel or equivalent metal construction. In a standard fire test, they would be capable of preventing the passage of flame and smoke for 1 hour. A standard fire test is one which develops in the test furnace a series of time to temperature relationships as follows: 5 minutes— 1,000 oF; 10 minutes—1,300 oF; 30 minutes— 1,550 oF; and 60 minutes—1,700 oF. 33“B” class bulkheads shall be constructed with approved noncombustible materials. In a standard fire test, they would be capable of preventing the passage of flame for ½ hour. 34“C” class bulkheads must be constructed of approved noncombustible materials but are not required to meet requirements for the passage of flame. 35A passage extending through one or more decks to provide access or ventilation to a space. 36E84 is a standard test method developed by the ASTM. The method exposes a 24-foot by 20- inch specimen to fire and measures the rates of flame spread and smoke development. The material rating (flame spread index) and smoke number are obtained from a comparison with the flame spread rate and smoke development of red oak. The flame spread rates for shredded wood fiberboard (treated with flame retardant), gypsum board (with paper surface on both sides), and red oak (untreated) are -20 to 25, -10 to 25, and - 100, respectively. These requirements were in the regulations when the structural fire regulations were being developed for commercial fishing industry vessels, but they could not, by law, be incorporated into the regulations for existing fishing vessels. (See section on Coast Guard Oversight of Fish Processing Vessels.) They were only partially incorporated for fishing vessels that operate with more than 49 persons and were built or converted after September 15, 1991. Building Codes -- See appendix E for building codes for shoreside structures. Life Safety Code -- The National Fire Prevention Association (NFPA)37 developed and published NFPA 101 “Code for Safety to Life from Fire in Buildings and Structures,” known as the Life Safety Code (LSC).38 The purpose of the LSC, stated in Section 1.2, is: To provide minimum requirements, with due regard to function, for the design, operation, and maintenance of buildings and structures for safety to life from fire and similar emergencies.

37The nonprofit NFPA advances the development and dispersion of fire safety standards, many of which are adopted into Federal, State, and municipal fire codes. Association volunteers are in such professions as fire service, health care, business, insurance, government, education, and industry. 38NFPA Life Safety Code, Chapter 6: “Existing Hotels and Dormitories,” Section 6-5, Interior Finishes. National Fire Protection Association, Quincy, Massachusetts, 1994.

32 The LSC mainly addresses safe egress from shoreside buildings. It also establishes certain flammability requirements for building structure and interior design. For example, the LSC requires that smoke detectors be placed in sleeping quarters for hotels (with more than 16 sleeping accommodations) and dormitories (for more than 16 persons). In addition, the LSC limits the flammability of the interior finishes on walls and overheads of exit enclosures to Class A or Class B materials.39 Plywood of ¼-inch thickness has a flame spread rating of 120-196, depending on the exact type of plywood and finish.40 The flame spread rating of the ¼-inch plywood used as interior finish on the 02 and 01 decks on the ALASKA SPIRIT was not available or determined by testing. It is, however, likely that the rating was greater than 120, based on the flame spread ratings for plywood of ¼-inch thickness. If an approved automatic sprinkler system is in place in a location, the LSC states that Class C interior wall and overhead finish materials shall be permitted wherever Class B materials would normally be required. Class B interior wall and overhead finish

39The LSC defines three classes of finish materials, dependent on flame spread and smoke development, as follows: Class A — Flame spread of 0-25 and smoke development of 0-450, Class B — Flame spread of 26-75 and smoke development of 0-450, and Class C — Flame spread of 76-200 and smoke development of 0-450. 40Flame Spread Performance of Wood Products, National Forest Products Association, Washington, D.C., 1992. materials shall be permitted anywhere Class A would normally be required. U.S. Fishing Fleet -- The U.S. fishing fleet numbers approximately 130,000 vessels, of which about 250 are fish processors or combination fishing-fish processor-type vessels. Approximately 50 fish processing and 76 combination fishing-fish processing vessels are more than 79 feet long.41 Only one U.S. fish processing vessel, the 17,845-gross ton OCEAN PHOENIX (635.5 feet long), is required, because of its size, to be inspected by the Coast Guard. Approximately 1,400 U.S. fishing industry vessels are over 79 feet long. Crew size varies greatly for vessels over 79 feet, “from 4 to 5 for fishing vessels, to 20 to 30 for large catcher-processors, to well over 100 for the largest floating processor.”42 The Coast Guard does not maintain records of crew size for uninspected vessels, so it does not know how many vessels are more than 79 feet long and carry more than 16 (or 49) persons. Between January 1992 and December 1995, a total of 1,167 fishing industry vessels were newly registered with the Coast Guard. Of these, 1,105 were less than 79 feet long, 60 were between 79 and 100 feet long, 1 was 112.8 feet long, and 1 was 201.2 feet long. The last vessel is similar in size to the ALASKA SPIRIT.

41Fishing Vessels of the United States 79' and Over, Nautilus Publishing Co., Seattle, Washington, 1994. 42Fishing Vessel Safety, National Research Council, National Academy Press, Washington, D.C., 1991, p. 41.

33 Accident Statistics -- According to Coast Guard records, from January 1, 1992, through March 15, 1994, a total of 2,214 fishing vessel accidents43 were reported and investigated. Of these, 228 (10.3 percent) involved fires, of which 105 either were classed as uncontrollable or burned themselves out. The dollar loss of $24.8 million caused by the fires was 29.5 percent of the total for fishing vessel accident losses ($84.2 million) during this period. For the period March 16, 1994, through 1995, records are incomplete because of open investigations and computer file loading in progress. One fire on a fish processing vessel that was not included in the statistics was the fire on board the fish processing vessel ALL ALASKAN in July 1994.44 The Safety Board investigated this fire, in which one person died and the 379.5-foot-long vessel sustained damage in the range of $24.3-30 million.

43Coast Guard regulations at 46 CFR 4.05 define accidents/casualty as: a grounding; loss of main propulsion or primary steering or any associated component or control system; an occurrence that adversely affects the vessel such as fire, flooding, failure of fixed fire extinguishing systems, life saving equipment, auxiliary generating equipment, or bilge pumping systems; loss of life; injury which requires professional medical treatment beyond first aid, or a person is unfit to perform routine vessel duties, an occurrence not meeting the above that results in damage to property in excess of $25,000. (Note: Over the years, the damage amount has been gradually increased to its present amount.) 44Marine Accident Report -- Fire On Board the U.S. Fish Processing Vessel ALL ALASKAN, Near Unimak Island, Alaska, Bering Sea, July 24, 1994 (NTSB/MAR-95/02). Coast Guard Oversight of Fish Processing Vessels -- Uninspected vessels that must be examined by a qualified organization (ABS, DNV, etc.) for compliance with regulations are not normally examined by Coast Guard personnel. The ALASKA SPIRIT was in this category and was required to be examined by the DNV biannually. If, however, the Coast Guard had boarded the vessel at sea, an examination could have been carried out. The Coast Guard’s at-sea program of boarding fishing industry vessels operates in conjunction with search and rescue, fisheries management, and law enforcement boarding. The Coast Guard does not conduct planned patrols for the sole purpose of safety equipment enforcement. Title 46 United States Code (USC) Chapter 45 is the codified law affecting uninspected commercial fishing industry vessels. In prescribing regulations under this chapter, the Secretary (of Transportation) “may not require the alteration of a vessel or associated equipment that was constructed or manufactured before the effective date of the regulation.”45 Thus, vessels are exempt from new regulations and the owner or operator cannot be required to upgrade equipment or meet construction requirements for vessels built or converted before the regulation’s effective date. Fire and electrical regulations or requirements (at 46 CFR Part 28, Subpart D), and stability requirements (at 46 CFR Part 28, Subpart E) are effective only for new vessels or vessels that complete a major

45Title 46 USC 4502(e)(2).

34 conversion46 on or after September 15,

1. (See table 1 on pages 36-37 for

fire regulation summary and comparison information.) Survival Factors Fire Control Efforts -- Conditions reported by the SVFD fire chief that affected the ALASKA SPIRIT firefighting efforts appear in appendix F. Notification Procedures -- Seward’s emergency operators normally receive 6 weeks on-the-job training under a supervisor. During the program, they are instructed in gathering basic information from callers on the nature and location of the complaint. Seward’s emergency operators are also trained to question callers to determine if fire or hazardous chemicals are involved in the complaint. Additionally, the city of Seward has prepared a Vessel in Distress Procedure Manual (revised March 1995) that identifies information that emergency operators should gather to address a general emergency involving a vessel at sea (i.e., the name of the vessel, its radio type, coordinates, survival equipment, the number of people involved, etc.). Among the resources available to local planners is the Western Alaska Marine Firefighting Contingency Plan (see Local Contingency Planning section

46Defined at Title 46 USC 2101 (14a) as “a conversion of a vessel that: (A) substantially changes the dimensions or carrying capacity of the vessel; (B) changes the type of the vessel; (C) substantially prolongs the life of the vessel; or (D) otherwise so changes the vessel that it is essentially a new vessel, as decided by the Secretary [of Transportation - U.S. Coast Guard].” below). The plan provides the following checklist for information gathering: • What is the name and telephone number of the person reporting? • What is the nature of the emergency and extent of fire? • What is the location of the incident? • What is the exact location of the fire, by compartment and deck? • Is anyone trapped or injured? • What is burning? (Details regarding class of fire) • Is any hazardous cargo in or near the fire? • What, if any, firefighting efforts are in progress? • What is the vessel’s capability to maneuver? • What is the amount and type of “bunker” (fuel for ship’s engines)? While the Seward emergency operators were not specifically familiar with the plan, they were trained to obtain basic information on the nature and location of the fire from the initial caller. Local Contingency Planning City of Seward -- The Alaska Division of Emergency Services approved the Kenai Borough Emergency Plan, which addresses natural disasters and hazardous materials releases. The plan establishes an emergency operations center and command levels for operations and support personnel. It also

35 lists other support agencies and resources in the State. The last training drill or “table-top exercise” conducted by the Kenai Peninsula Borough prior to the accident took place on December 8, 1994. The scenario addressed was the involvement of an above-ground propane storage tank in a fire. The last previous marine firefighting training session for the SVFD occurred on May 21, 1995. Between 1984 and June 1995, the SVFD responded to 25 marine incidents that took place on vessels ranging in length from 14 to 218 feet. In summer, Seward-Anchorage is the terminus for many of the world’s largest cruise ships, which visit western Alaska from the West Coast of the United States and Canada, making approximately 185 port calls (about 125 in Seward). SVFD personnel board all cruise ships visiting Seward to conduct a familiarization tour of each vessel. This is not part of the Kenai Borough Emergency Plan. Other than the borough emergency plan, the SVFD does not have a local contingency plan for dealing with shipboard fires. Western Alaska Marine Firefighting Contingency Plan -- According to the Coast Guard’s Marine Safety Manual,47 each COTP must maintain a marine firefighting contingency plan for dealing with shipboard and waterfront fires within their geographic area of responsibility. Marine Safety Office

47The manual presents the authority, background, policy, and rationale for various programs associated with marine safety for the information, use, and guidance of Coast Guard personnel assigned to carry out marine safety duties. Anchorage’s area is western Alaska. The Western Alaska Marine Firefighting Contingency Plan (dated September 18, 1987) was distributed to the harbor masters and fire departments within the Western Alaska Zone, namely Anchorage, Homer, Whittier, Seward, Kodiak, and Dutch Harbor. The plan recommends that local fire chiefs take charge of firefighting operations within their jurisdictions and that vessel masters or senior officers serve as liaisons between the fire chief and the vessel crew. It lists key steps that should be taken before firefighters arrive. The steps include sounding the crew alarm, making an announcement on the public address system, and notifying the local fire department with specific information (such as location by deck and compartment, firefighting efforts in progress, and personnel involved). Under a Section 20, Fire Department Contingency Plan recommendation: Each fire department which is responsible for the fighting of shipboard fires should establish a training program within their unit, dealing with shipboard fires. Fire departments should establish local contingency plans to cover such emergencies. A copy of this plan is to be submitted to the COTP. While Seward has not specifically developed a firefighting contingency plan to deal with shipboard fires, many of the key steps in its firefighting strategies and assigned individual responsibilities are identical to those in the Coast Guard’s Western Alaska Marine Firefighting Contingency Plan.

Table 1 – Comparison of fire safety regulations and guidelines (all information has been revised and condensed for table inclusion) Commercial Fishing Industry Vessels Built or Converted Before September 15, 1991 46 CFR Part 28, Subparts C&D Commercial Fishing Industry Vessels Built or Converted On or After September 15, 1991 46 CFR Part 28, Subparts C&D Industrial Vessels 300 Gross Tons (GT) and Less than 4,000 GT 46 CFR Subparts 92, 95, & 97 U.S. Coast Guard Voluntary Standards NVIC 5-86 Chapter 3 - Fire Safety Persons on Board 16 or fewer More than 16 More than 49 16 or fewer More than 16 More than 49 In excess of 12 industrial persons Any number Fire Detection Systems NOT REQUIRED NOT REQUIRED NOT REQUIRED NOT REQUIRED Each accommodation space must be equipped with an independent modular smoke detector or a smoke-actuated fire detecting unit. Not required, except that each compartment containing explosives or enclosed spaces suited for vehicles shall be provided with a smoke-detecting or other suitable type of fire- detecting system. However, if a smoke-detecting system is installed, it shall meet the requirements of 46 CFR 76.33. An approved house-type smoke detector is usually adequate for accommodations and galleys. Machinery spaces should have fire or smoke detectors with an audible and visual alarm in the pilothouse and on deck. Detectors should indicate the presence and location of fire or smoke in high risk areas. Fire Suppression Equipment NOT REQUIRED NOT REQUIRED NOT REQUIRED NOT REQUIRED A fixed gas (i.e. CO2) fire extinguishing system is required for all vessels 79’ long or over in a space containing an internal combustion engine of more than 50 horsepower (HP), an oil-fired boiler, or a gasoline storage tank. Required in cargo compartments and tanks for combustible cargoes, paint lockers, engine spaces on vessels of 1,000 GT and over containing oil-fired boilers, or their fuel oil units, and with engine power of 1,000 BHP or greater. When a cargo compartment is to be working or living quarters, a water sprinkling system may be required. Machinery spaces containing oil- fired boilers, fuel oil units, or internal combustion engines should have a fixed fire extinguishing system. Fire Hose NOT REQUIRED NOT REQUIRED NOT REQUIRED NOT REQUIRED Hoses must be connected to hydrants whenever the vessel is operating. Fire hose shall be connected to the outlets at all times. However, on the open decks where no protection is afforded to the hose in heavy weather, or where the hose may be damaged from the handling of cargo, the hose may be temporarily removed from the hydrant and stowed in an accessible nearby location.

Fire Main NOT REQUIRED NOT REQUIRED NOT REQUIRED NOT REQUIRED Vessels 36’ or more in length must have a fire pump connected to fixed piping (fire main). One to two fire pumps, depending on the GT of the vessel, piping and pumping requirements delineated. Fire pumps and hydrants should be provided for all vessels in accordance with 46 CFR 95.10-5 to 15. Structural Fire Protection NOT REQUIRED NOT REQUIRED NOT REQUIRED NOT REQUIRED Each vessel must be constructed so as to minimize the fire hazards as far as it is reasonable and practical. Insulation must be noncombustible, except for machinery space pipe and machinery lagging and cargo holds. In addition, for more than 49 persons, the vessel’s hull, structural bulkheads, columns and stanchions must be made of steel. Deckhouse must be constructed of noncombustible material. Ceilings, linings, and insulation, including pipe and duct coverings, shall be of incombustible materials. Any sheathing, furring, or holding pieces for securing any bulkhead (BH), ceiling, lining, or insulation shall be of incombustible materials. BHs, linings, and ceilings may have a combustible veneer within a room not to exceed 1/14” in thickness. Combustible veneer shall not be used in corridors. Corridors and BHs in accommodations shall be of “A” or “B” class construction. Stairtowers shall be of “A” class construction. The hull, superstructure, structural BHs, decks, and deckhouses shall be constructed of steel. Noncombustible materials should be used for BHs, decks, and other structures and furniture in accommodations. Combustible materials and insulating foams should not be used or should be reduced in quantity wherever possible. For foam insulation use, consult NVIC 8-80. Insulating materials in accommodations should be noncombustible. Fire Drills Not required unless vessel operates beyond the Boundary lines. Required once a month. Hold in different locations on the vessel. Drills to be conducted as if an actual emergency exists. All on board must participate, using emergency equipment. Same as vessels built or converted before September 15, 1991. Drills at least once every week and conducted as if an actual emergency exists. Fire pumps started and a sufficient number of outlets used to determine that the system is in proper working order. Fire drills should be realistic and deal with an assumed outbreak of fire in some specified part of the vessel. Hoses should be laid out and tested. Drills should be held at intervals of not more than one month.

38 ANALYSIS General The weather conditions at the time of the accident were good and did not hamper the detection of the fire or the firefighting efforts. The engineroom equipment functioned properly before and during the fire. The Safety Board therefore concludes that the weather conditions and the vessel mechanical systems were not factors in this accident. Source of Ignition Early eyewitnesses reported almost simultaneous observations of fire in the wheelhouse and on the 02 deck. If the fire had started in the wheelhouse, it would have taken some time for it to progress downward to the 02 deck, so witnesses could not have seen fire simultaneously in the wheelhouse and the 02 deck in the early stages of the accident. In other words, had the fire begun in wheelhouse, the wheelhouse should have been seen to have greater fire involvement than the 02 deck, which is not what witnesses reported. On this basis, investigation for an ignition source was directed to the 02 deck. On the 02 deck, the cook observed heavy smoke and fire in the port corridor 2 to 3 feet down from the overhead, and he could see only 10 to 15 feet into the port corridor. He observed only light smoke for the length of the starboard corridor. If the fire had started in the forward port corridor or the forward port crewroom, the fire spread by smoke or heat down the corridor should have occurred in the athwartships (cross) corridor and the starboard corridor, as well as down the port corridor. Fire damage on the 02 deck was more extensive on the port than on the starboard side. This pattern was most evident in the port and starboard corridors and living spaces along the outer perimeters of these two corridors. The final burn pattern was much deeper in the port corridor and cross corridor. Although firefighting efforts were initiated at the 02 deck port aft door, the intensity of the fire forced firefighters to retreat. At this time, the port aft corridor was already fully involved in fire. Consequently, firefighters entered the starboard aft door to fight the fire. Early in the firefighting efforts, firefighters noted that the starboard bulkhead in the assistant fish master’s room glowed red as viewed from the starboard corridor. Since crewmembers had been socializing in the port forward four- person crewroom on the 02 deck on the evening prior to the fire, investigators considered the possibility that discarded smoking materials in this location might have ignited the fire. The duration and intensity of the fire would have ensured that any remaining residue from discarded smoking material was destroyed. However, discarded smoking materials do not appear to have caused ignition, given the ultimate burn pattern and eyewitness accounts of the fire.

39 Investigation revealed numerous other possible ignition sources on the 02 deck. They included: a boot warmer found outside the port forward crewroom, space heaters in crewrooms, battery chargers found in the assistant fish master’s room, and a cook pot found in the assistant fish master’s room. The location of the ignition source must be consistent with the following factors: (1) the pattern of fire damage on the 02 deck, (2) the early and almost simultaneous appearance of fire in the wheelhouse and 02 deck, and (3) the observation of fire in the 02 deck port corridor, but smoke only in the starboard corridor, early in the fire progression. The deckhand who had been awakened by the fire alarm stated that he went about halfway up the stairwell to the 02 deck before the firefighters arrived and saw fire in the overhead and on the deck of the forward port corridor. He believed that he saw burning boots on the deck. Investigation of a boot warmer found outside the port forward crewroom uncovered no problems with the wiring that led over the door’s metal threshold. Further, the boot warmer appeared to have melted or burned from the top down, with no indication of ignition from the lower part of the warmer. These observations are consistent with radiant heat from the fire in the overhead having caused the boot warmer’s melting. The investigation could not confirm what materials the deckhand might have seen burning on the deck. Each accommodation space on the ALASKA SPIRIT appeared to have contained an electric space heater, since no other heat was available in the rooms. None of the heaters located by investigators was powered or plugged into an electrical source. A fire starting in the assistant fish master’s room could easily have spread (via the chase in the overhead above the bed) into the wheelhouse early in the course of the fire. Because the chase would have acted as a chimney going directly into the wheelhouse, fire-spread into the wheelhouse could have occurred before the smoke and hot gases escaped into the corridor via the room’s light wooden door and vent fan opening. RPU foam lined the inside of the chase on the ALASKA SPIRIT’s sister vessel and remnants of RPU foam were found in the chase on the ALASKA SPIRIT after the fire. Such a flammable lining would have increased the rapidity with which the fire would have spread into the wheelhouse by this route. A fire initiating in the assistant fish master’s room also could have spread to the wheelhouse by a second route. The burn pattern in the 02 deck corridor is consistent with fire exiting from this room into the port corridor. Smoke, hot gases, and fire would have exited into the port corridor via the fan vent opening and the light, hollow-core wooden door of the assistant fish master’s room. The wooden, non-fire-rated door at the top of the stairway to the wheelhouse was destroyed and, according to testimony, was probably open at the time of the fire. This testimony is consistent with damaged conditions found after the fire. The wooden stair treads and wooden paneling in the stairwell between the 02 deck and the wheelhouse were

40 extensively damaged by the fire. Consequently, both the chase and the stairwell were major means by which the heat, smoke, and fire could have traveled from the 02 deck into the wheelhouse. The assistant fish master’s room was of fire-resistive construction, as it had steel bulkheads. However, the steel bulkheads were covered, interior and exterior, with light wooden construction materials. The extensive destruction of the materials in the assistant fish master’s room indicates there was an intense fire in this room. The red glow that firefighters observed in the starboard corridor on the steel bulkhead of the assistant fish master’s room is consistent with the burning of a high fuel load48 (bedding, clothing, wood construction and framing material along this bulkhead). Based on the foregoing evidence, the Safety Board concludes that the fire originated in the assistant fish master’s room. The burn pattern under and beside the left battery charger found in the assistant fish master’s room indicates that this damage occurred early in the course of the fire. That is, the fire burned the wooden shelf that supported the chargers before the materials (debris) fell onto and buried this charger. Further, the differential heat and fire damage noted in the left battery charger, as compared to the right charger adjacent to it, shows that the left charger was considerably hotter both inside and outside the charger case. The aluminum diode (rectifier) heat sink plates of the left charger were melted, and some of the

48Pounds of combustibles per square foot of deck area. molten aluminum was found under the shelf. The insulation on the transformer wires was completely burned away, but no electrical faults or arcing could be found in this charger. In addition, the charger contained little fuel that could have produced heat sufficient to melt aluminum heat sink plates. Another possible ignition source in the assistant fish master’s room was the cook pot found sitting on the deck next to the bunk-type bed and just forward of the battery chargers. Heat damage to the wire tie-downs and the internal potting material is consistent with excessively high temperatures inside the appliance due to overheating. Fire starting exterior to the cook pot and then spreading to it would have first destroyed the carpet and power cord that was coiled beneath the cook pot before causing internal heat damage to the cook pot. The fact that the carpet and power cord beneath the pot were unburned supports the conclusion that the fire did not start exterior to the cook pot. The location of this cook pot next to the bed also made it a prime candidate as the ignition source. In this location, overheating of this appliance could have ignited bedding materials. The room had not been occupied for about 6 days. The room contained a heat detector but no smoke detector. Ignition of the bedding could have occurred sometime during the 6 days that the room had been vacant, and a smoldering combustion might have gone undetected for some time. The presence of water in the cook pot would have delayed overheating until the water evaporated.

41 From this ignition source, the fire could have spread to the wheelhouse via two routes. First, the cook pot was in close proximity to the bed. Once flames erupted, the high fuel load in the assistant fish master’s room would have facilitated rapid fire growth and spread into the chase directly above the bed. The fire would have spread through the chase into the wheelhouse. Second, the combustible gases and smoke that normally accumulate in the ceiling area of a room of origin would have quickly burned through the light wooden door of the assistant fish master’s room, creating another path by which fire might have spread. Once the top of this door was burned, the smoke, heat, and combustible gases would have rapidly spread into the corridor and up the open stairwell to the wheelhouse. This scenario fits the report of the first eyewitness (the cook) that he saw flames in the wheelhouse and 02 deck port door. Since the door to the assistant fish master’s room and the fan vent opening are almost opposite the door to the master’s room and the hospital room, this fire propagation scenario is consistent with the master being unable to escape the fire. He appears to have been overcome by the products of combustion (principally carbon monoxide) that would have moved directly across the narrow corridor to the doorways of these two rooms. Based on the foregoing evidence, the Safety Board concludes that the most likely ignition source was the cook pot in the assistant fish master’s room. When crewmembers leave their vessel after a voyage, they often do not check their accommodation rooms to verify that all electrical items have been turned off and secured, and that smoking materials have been removed. After occupants vacate a room, if it is likely to be vacant for a period of time, the room should be checked for fire hazards. Good marine practice calls for a responsible measure of “good housekeeping” on board vessels to lessen the danger of fire or other hazards occurring unexpectedly. Regular checking of rooms for fire hazards is one of the best possible safeguards against fire ignition. While such routine checks cannot guarantee vessel safety, they can increase the likelihood that accidents will be prevented. The Safety Board therefore concludes that, had the FCA provided written guidance to vessel masters to check on the fire safety condition of vacant crewrooms and had such a review procedure been implemented, the fire might have been avoided. Consequently, the Safety Board believes that the FCA should develop written guidance for its vessel masters to use to review the fire safety condition of all crewrooms when the occupants disembark from the vessel and the room will be vacant, and should implement a procedure whereby the conduct of such reviews may be documented. Fire Safety Standards Construction -- The extensive use of combustible wood construction materials, the use of unprotected, highly flammable RPU and polystyrene insulations, and the high concentration of combustible bedding and furnishings on the ALASKA SPIRIT contributed to

42 a very rapidly spreading fire that was difficult to extinguish until much of the combustible fuel had been consumed. The fuel load was very high on the 02 deck because of the wood construction and the volume of bedding, clothing, and wood furniture in the small rooms. All of the partition bulkheads were constructed of wood with a vinyl veneer that had a Class C flame spread rating. The assistant fish master’s room had steel bulkheads, but they were covered with highly combustible wooden structures. Further, all of the interior hull and deck surfaces, the exteriors of which were exposed to the elements, were covered with RPU foam insulation. In some areas, sheets of polystyrene insulation were installed behind the wooden bulkheads and overhead. These combustible materials all contributed to fuel a rapidly spreading fire. Because of the extensive use of ¼- inch plywood over light wooden supports in the escape corridors, the ALASKA SPIRIT would not have met the requirements of the Coast Guard structural fire protection regulations for cargo and miscellaneous vessels or the NFPA shoreside LSC. The Safety Board therefore concludes that the rapid fire growth and spread were due to the high fuel load and lack of noncombustible construction. The Coast Guard had established cargo and miscellaneous vessel structural fire regulations and later developed the guidelines for fishing industry vessels in the NVIC 5-86 (which refer to the cargo and miscellaneous vessel regulations (46 CFR Subchapter I) for structural fire protection). Most of these regulations and guidelines were not incorporated into commercial fishing industry vessel regulations. Had structural fire protection guidelines been adopted into the regulations for fishing industry vessels, the FCA would still not have been required to implement them. The ALASKA SPIRIT was exempted from the regulations because: (1) it carried 49 or fewer persons, and (2) it had been operating as a fishing industry vessel before the effective date of the regulations. The previous owner of the ALASKA SPIRIT apparently did not use the information in the NVIC’s voluntary guidelines for fire protection when converting it into a fishing industry vessel. Current Coast Guard regulations for new vessels carrying more than 16 persons require that vessels “minimize fire hazards insofar as is reasonable and practicable” and that “insulation be noncombustible.” Except for NVIC 5- 86, there is no other national standard for fishing industry vessels. This accident highlights the need to establish structural fire protection regulations for fishing industry vessels that carry more than 16 persons (the same figure is used in the LSC for shoreside buildings when more than 16 sleeping accommodations are available in the structure). NFPA does not have a life safety code for vessels, but it is working with the Coast Guard to develop such a document. Following its 1994 investigation of the fire in the cargo spaces on the fish

43 processing vessel ALL ALASKAN,49 the Safety Board recommended that the Coast Guard: M-95-16 Establish, in cooperation with the National Fire Protection Association, a national marine safety standard on the safe use of rigid polyurethane foam and other organic combustible material insulations on vessels. The Coast Guard replied to this recommendation that it is working with the NFPA to develop such a standard. The Safety Board classified this recommendation “Open -- Acceptable Response” on February 6, 1996. After the same accident, the Board recommended that the NFPA: M-95-25 Establish, in cooperation with the U.S. Coast Guard, a national marine safety standard on the safe use of rigid polyurethane foam and other organic combustible material insulations on vessels. The NFPA replied that it is working with the Coast Guard to develop such a standard to address fire protection and life safety aboard merchant vessels. The new standard will be designated NFPA

1. Pending the publication of NFPA

301, the Safety Board classified the recommendation “Open -- Acceptable Response” on October 26, 1995.

49Marine Accident Report -- NTSB/MAR- 95/02. Seeking changes to regulations takes time. In the interests of safety, the Coast Guard could, in the interim, develop a national marine fire safety standard with the NFPA. A national marine fire safety standard for commercial fishing industry vessels, containing structural fire protection standards, would improve the level of fire safety on commercial fishing industry vessels by reducing the amount of highly combustible materials in vessel living spaces and corridors. Fire Detection Equipment -- While the ALASKA SPIRIT’s previous owner had installed the fire protection equipment used on the vessel, the responsibility for reviewing the adequacy of that equipment to ensure the fire safety of the vessel and the crew lay with the current owner, the FCA. Such a review would have revealed the need for smoke rather than heat detectors in the vessel’s living quarters. When the fire ignited on the ALASKA SPIRIT, by the time that the (properly operating) heat detectors activated, the fire had advanced to a point that the master could not escape and shoreside firefighters could only contain it to the 02 deck and wheelhouse. The Safety Board therefore concludes that, because heat rather than smoke detectors were used on the ALASKA SPIRIT, the crew was not provided with sufficient early warning of the fire, which led to the death of the master and allowed the fire to go out of control. An operating smoke detector in the rooms, and especially in the room of origin, would have given warning of the fire while it was still in the smoldering stage. Smoldering fires can produce smoke without significantly increasing

44 room temperature. Openings (wire chase, wooden door with ventilation opening, and the opening in the bulkhead for a fan) in the room of fire origin allowed smoke and combustible and poisonous gases to spread quickly into other spaces in the vessel. Smoke-actuated fire-detecting units or independent modular smoke detectors, however, are only required in the accommodation spaces of those commercial fishing industry vessels built or converted after September 15, 1991, that carry more than 16 persons. The minimal cost of these household-type battery-operated smoke detectors, and their ease of installation, strongly suggests the use of this safety device on existing vessels. The Safety Board recognizes that the FCA has installed a smoke detection system on the repaired ALASKA SPIRIT and believes that the FCA should install smoke detectors in accommodation spaces on all its vessels, regardless of whether heat detectors are installed. Fire Suppression Equipment -- By the time the fire was discovered, it was well established and beyond the crew’s capability to contain it. The crew and shoreside firefighters prevented the fire from burning back down the port inside stairwell to the 01 deck, and shoreside firefighters put enough water on the 02 deck to prevent heat and flames from propagating down to the 01 deck. Using shoreside equipment, firefighters working in narrow corridors and high heat virtually controlled the fire until it burned itself out. The regulations for new fishing industry vessels that are 36 feet and over in length that carry more than 16 persons require a power-driven fire pump and fire main system, but no fire suppression system in the accommodation area. The ALASKA SPIRIT had a power-driven pump and fire main system, which were not required by the regulations for this existing fishing vessel, but did not have a sprinkler system. Although automatic fire-extinguishing sprinkler systems are not required in accommodation spaces, the management of the vessel is responsible for ensuring that fire suppression equipment is adequate to safeguard the crew and the vessel in case of fire. To provide effective fire protection to the crew and the vessel, fire suppression equipment should be part of the power-driven fire pump and fire main system. The Coast Guard should consider requiring automatic fire-extinguishing sprinkler systems on fish processing vessels with accommodations that are not of noncombustible construction. Such vessels often carry large numbers of people not trained as firefighters. They also operate in areas remote from professional firefighting assistance, in weather and sea conditions that could prevent help from being rendered even if available. Sprinklers also reduce the dependency on vessel personnel for responding to and extinguishing a fire, which is especially important when a reduced crew is staffing the vessel. The Safety Board therefore concludes that an installed sprinkler (suppression) system would probably have extinguished the fire in its early stages of development, impeded the spread of fire in the accommodation spaces, and possibly prevented the loss of life.

45 Therefore, in view of the fire danger posed by the combustible materials used in the construction of the ALASKA SPIRIT and ALASKA VICTORY, the Safety Board believes that the FCA should install automatic fire suppression systems in all its vessel accommodation spaces that are constructed of combustible materials. Existing Standards -- The ALASKA SPIRIT investigation has shown that fire safety standards for commercial fishing industry vessels are inadequate. In particular, it highlighted deficiencies in the areas of structural fire protection, fire detection systems, and fire suppression systems. The Safety Board therefore concludes that the development and use of a national marine fire safety standard for commercial fishing industry vessels that includes structural fire protection standards and fire detection and suppression systems would improve the level of fire safety on board these vessels. Thus, the Safety Board believes that the Coast Guard should develop, in cooperation with the NFPA, a national marine fire safety standard for commercial fishing industry vessels, which should include structural fire protection standards and fire detection and suppression systems in accommodation areas, and adopt it into the regulations. The Coast Guard reports that, since January 1992, a total of 62 new fishing vessels over 79 feet long have entered the industry. Only two of these vessels were over 100 feet long, and only one of the two was over 200 feet long. It is probable that only these 2 vessels, out of the 62 entering the industry, will carry more than 16 persons and so be required to meet some of the new fire safety regulations. Even the larger vessel will likely not carry more than 49 persons and so will not be required to meet the structural fire regulations at 46 CFR 28.385. A combination of reduced fishing quotas, over-capitalization, and owners’ wishes to avoid costly implementation of the safety features required by regulations on new vessels perpetuates the use of older, less fire-protected vessels. These older vessels continue to operate without safety improvements, such as smoke detectors and the reduced use of combustible construction materials. By exempting these older vessels from safety regulations, two widely differing standards of safety for the fishing industry are effectively sanctioned. But all fishermen and fish processors are exposed to the same rigors on their jobs and should be afforded the same level of workplace safety. As the result of Safety Board recommendations, passenger vessel safety has been improved internationally in recent years, with the phasing in of higher fire protection levels on vessels built before the introduction of more stringent fire safety regulations. The older, less fire-protected passenger vessels are no longer permanently excused from meeting the higher fire prevention standards for new vessels. The same procedure could be used to improve the fire safety of fishing vessels. Under current law, existing fishing industry vessels built before the effective date of the regulations are permanently

46 exempted from meeting the new regulations. Because of the prevalence of fires that occur on fishing vessels and their great human and economic costs, the Coast Guard should seek legislation that would require the phasing in of fire safety regulations for all fishing vessels, regardless of age. Owners of existing fishing vessels could gradually upgrade their vessels, in a planned cost procedure, or defer upgrading until their vessel is no longer permitted to operate and then replace it with a new vessel that would meet the higher regulatory standards. Such action would remove from operation those vessels currently exempted from the safety regulations and set a single safety standard for the fishing industry. The Safety Board therefore concludes that a procedure is needed to improve fire safety on existing fishing industry vessels by phasing in the fire safety regulations currently applicable only to new vessels to all vessels, regardless of age. Consequently, the Safety Board believes that the Coast Guard should promptly seek to change the law to require the phasing in of fire safety regulations to apply to all existing fishing industry vessels that carry more than 16 persons. The process of making the same regulations applicable to all such vessels should be completed by the year 2010. Fire Hose -- Because some Armtex hoses were used on the ALASKA SPIRIT, a special adapter was required to connect the vessel’s hydrant outlets with the nonstandard fitting of this hose. The Safety Board therefore concludes that because the ALASKA SPIRIT had some fire hoses that were incompatible with its hydrants, the crew was initially delayed in its firefighting efforts. (Given their limited resources and the rapidity of the fire growth, however, it is doubtful whether the ALASKA SPIRIT’s crew could have saved the master even had the hoses been attached to the hydrants.) The Safety Board is deeply concerned about the operation of a vessel with fire hose equipment that was not only incompatible but which had critical components (i.e. adapter coupling) stowed far away from the hydrants. It seems evident that if adapters are necessary, they should be installed. The responsibility for ensuring the adequacy of vessel fire hose systems and their practical hookup lies with the vessel’s management, in this case the FCA. The Safety Board believes, therefore, that the FCA should direct the masters of all its vessels to check all fire stations on their vessels to ensure that fire hose thread couplers are compatible with vessel fire hydrants and to replace incompatible equipment as appropriate. Coast Guard regulation 46 CFR 28.315(b)(2), requires that fire hoses be connected to each hydrant at all times that the vessel is operating. This regulation, however, applies only to commercial fishing industry vessels that had their keels laid or were converted after September 15, 1991, and that operate with more than 16 individuals on board. Coast Guard regulation 46 CFR 95.10-10, which applies to cargo and miscellaneous vessels, was also not applicable to the ALASKA SPIRIT. This regulation requires that all fire station hydrants have fire hose coupling threads of 1 ½-inch and 2 ½-inch sizes. NVIC 5-

47 86 refers to the above regulation as a voluntary standard for uninspected commercial fishing vessels. As part of the regulatory efforts of the Coast Guard to ensure that fish processing vessels meet the regulations, every 2 years qualified organizations must examine and certify that vessels meet the requirements of 46 CFR Subchapter C. To improve the level of fire safety on board uninspected commercial fishing industry vessels, examiners should ensure that firefighting hoses are attached to and fit fire hydrants at fire stations. Survival Factors Reporting of Fire -- After the fire erupted, reports of it were quickly communicated to the SECC, via the 911 telephone number. Despite being alone, the emergency operator performed her duties well, not only in handling the incoming calls but also in dispatching police, fire, and medical units. Nevertheless, more efficient communication might have been beneficial. Had the watchman identified himself, the 911 operator could have questioned him for additional details. The watchman might have been a source of specific information, such as the exact location of the fire on the vessel and whether individuals might have been trapped or injured. The FCA did not train night watch personnel in procedures for notifying response centers of an emergency. The Safety Board therefore concludes that security night watch personnel on FCA vessels should have a checklist of initial notification procedures to ensure that requisite information is provided to emergency response communicators. At a minimum, the initial notification procedures should address: the emergency’s nature, location, and extent; details as to personnel trapped or injured; and efforts in process to minimize the damage. Drills -- The ALASKA SPIRIT’s master last conducted a fire drill on the previous fishing trip when the vessel was at Dutch Harbor. However, the fire drill was conducted without the crew’s laying out or charging the ship’s fire hose lines from any of the hydrants or donning the SCBAs or firefighting gear. As a result, the firefighting system was not tested and the crew was not completely familiar with the equipment. This accident demonstrates the importance of holding realistic fire training drills, designed to improve the crew’s familiarity with the equipment and to test the equipment’s effectiveness. The Safety Board therefore concludes that the lack of realistic fire drills compromised the vessel’s firefighting system. Coast Guard regulation at 46 CFR 28.270, applicable to the ALASKA SPIRIT and all documented fishing vessels with more than 16 individuals on board,50 requires that drills be carried out as if:

50On documented vessels with 16 or fewer persons, the rule applies if the vessel operates beyond the Boundary lines as listed in 46 CFR Part 7. Generally, the lines are seaward of the shorelines and cross entrances to small bays, inlets, and rivers.

48 There were an actual emergency and must include participation by all individuals on board, breaking out and using emergency equipment, testing of all alarm and detection systems, donning protective clothing... . Therefore, given the evidence that drills on board the ALASKA SPIRIT were not conducted as if an actual emergency existed, the Safety Board believes that the FCA should develop fire contingency plans that improve the readiness of its vessel personnel and equipment to respond to a fire emergency, and include provisions concerning the duties of security watch personnel and the training of crew in firefighting techniques by the implementation of realistic fire drill procedures. To be realistic, the drills should require that each crewmember know where all fire and lifesaving equipment is stowed and how to use it. Significance of the ALASKA SPIRIT Investigation The issues raised by the investigation of the fire on board the ALASKA SPIRIT are applicable to the entire fishing industry. Thus, to ensure that all of the recommendations developed as a result of the ALASKA SPIRIT investigation receive wide dissemination within the industry, the Safety Board believes that the Commercial Fishing Industry Vessel Safety Advisory Committee (CFIVSAC)51 should inform

51Established under the authority of Title 46 USC 4508, the 17-member CFIVSAC advises the Coast Guard Commandant, the Secretary of Transportation, and Congress on safety issues related to commercial fishing industry vessels. fishing industry vessel owners of this accident and advise them to: install on their vessels smoke detectors in accommodation spaces; install automatic fire suppression systems in accommodation spaces that are constructed of combustible materials; develop written guidance for vessel masters to review the fire safety condition of all crewrooms when the occupants disembark from the vessel and the room will be vacant; direct vessel masters to check fire stations to ensure that fire hose couplers are compatible with vessel fire hydrants; and develop fire contingency plans that improve the readiness of vessel personnel and equipment, including provisions addressing the duties of security watch personnel and procedures for realistic fire drills. Toxicological Test Results The CHT tested the master’s blood sample for the presence of drugs and found phenethylamine as a decomposition product but detected no other common drugs. The Safety Board therefore concludes that drug use was not a factor in this accident. Independent toxicological tests conducted by the Alaska State Medical Examiner’s Office and the CHT both found high levels of COHb and alcohol in the sample.

Committee members include crewmembers or processors on uninspected fish processing vessels, naval architects or marine surveyors, manufacturers of industry equipment, industry educators or trainers, insurance underwriters for fishing vessels, and the general public.

49 Carboxyhemoglobin (COHb) -- The Alaska State Medical Examiner’s Office found that the master’s death was caused by smoke inhalation. The results of the CHT test for cyanide, a toxicant sometimes found in smoke, were negative. Another toxicant, carbon monoxide (CO), was a component of the smoke, as evidenced by the high levels of COHb found in the master’s blood sample. The Alaska Medical Examiner’s Office and the CHT reported COHb saturation levels of 90.6 percent and 84 percent, respectively. According to Hill,52 the master would have become incapacitated and lost consciousness at 40-50 percent COHb saturation, before succumbing at the reported level of 84-90.6 percent COHb saturation. The site where the master’s body was found—inside the hospital room door— indicates that he had been awakened by the fire alarm. By the time the alarm sounded, air containing CO had probably already circulated through the common ventilation system and the louvered doors on the 02 deck. Although the concentrations of CO in the master’s room and hospital room when the alarm sounded cannot be

52Hill, I.R., Aviation, Space, and Environmental Medicine, “An Analysis of Factors Impeding Passenger Escape from Aircraft Fires,” March 1990, pp. 261-265. determined with certainty, at 1-2 percent concentration of CO in the air, an exposed person would have had about 120 seconds before becoming incapacitated at the level of 40-50 percent COHb saturation; at 5-10 percent concentration in the air, incapacitation would take about 30 seconds. In either case, the master would have had perilously little time for escape. (See appendix G for more information concerning the toxic effects of COHb saturation.)

Alcohol

The blood alcohol concentration (BAC) of the master’s blood sample was reported as 0.353 gm/dL by the Alaska Medical Examiner’s Office and as 0.360 gm/dL by the CHT. While this is a high BAC, the Safety Board found that the preponderance of evidence, both with regard to the master’s lifestyle and the circumstances of his death, indicates that the high BAC was caused by postmortem generation rather than ingestion. (See appendix H for additional information regarding the master’s BAC.) The Safety Board thus concludes that the high alcohol content in the master’s blood sample was likely due to postmortem generation rather than ingestion.

50 CONCLUSIONS 1. The weather conditions and the vessel mechanical systems were not factors in this accident. 2. The fire originated in the assistant fish master’s room. 3. The most likely ignition source was the cook pot in the assistant fish master’s room. 4. Had the FCA provided written guidance to vessel masters to check on the fire safety condition of vacant crewrooms and had such a review procedure been implemented, the fire might have been avoided. 5. The rapid fire growth and spread were due to the high fuel load and lack of noncombustible construction. 6. Because heat rather than smoke detectors were used on the ALASKA SPIRIT, the crew was not provided with sufficient early warning of the fire, which led to the death of the master and allowed the fire to go out of control. 7. An installed sprinkler (suppression) system would probably have extinguished the fire in its early stages of development, impeded the spread of fire in the accommodation spaces, and possibly prevented the loss of life. 8. The development and use of a national marine fire safety standard for commercial fishing industry vessels that includes structural fire protection standards and fire detection and suppression systems would improve the level of fire safety on board these vessels. 9. A procedure is needed to improve fire safety on existing fishing industry vessels by phasing in the fire safety regulations currently applicable only to new vessels to all vessels, regardless of age. 10. Because the ALASKA SPIRIT had some fire hoses that were incompatible with its hydrants, the crew was initially delayed in its firefighting efforts.

51 11. Security night watch personnel on FCA vessels should have a checklist of initial notification procedures to ensure that requisite information is provided to emergency response communicators. 12. The lack of realistic fire drills compromised the vessel’s firefighting system. 13. Drug use was not a factor in this accident. 14. The high alcohol content in the master’s blood sample was likely due to postmortem generation rather than ingestion. PROBABLE CAUSE The National Transportation Safety Board determines that the probable cause of the fire aboard the ALASKA SPIRIT was the failure of The Fishing Company of Alaska, Incorporated, to address the inadequate fire safety conditions and practices on the vessel. Contributing to the severity of the damage and the loss of life was the lack of fire safety standards for commercial fishing industry vessels. RECOMMENDATIONS -- to the U.S. Coast Guard: Develop, in cooperation with the National Fire Protection Association, a national marine fire safety standard for commercial fishing industry vessels, which should include structural fire protection standards and fire detection and suppression systems in accommodation areas, and adopt it into the regulations. (Class II, Priority Action) (M-96-1) Promptly seek to change the law to require the phasing in of fire safety regulations to apply to all existing fishing industry vessels that carry more than 16 persons. (Class II, Priority Action) (M-96-2) Publicize the circumstances of this fire to the fishing industry. (Class II, Priority Action) (M-96-3)

52 -- to The Fishing Company of Alaska, Incorporated: Develop written guidance for your vessel masters to use to review the fire safety condition of all crewrooms when the occupants disembark from the vessel and the room will be vacant, and implement a procedure whereby the conduct of such reviews may be documented. (Class II, Priority Action) (M-96-4) Install smoke detectors in accommodation spaces on all your vessels, regardless of whether heat detectors are installed. (Class II, Priority Action) (M-96-5) Install automatic fire suppression systems in all your vessel accommodation spaces that are constructed of combustible materials. (Class II, Priority Action) (M-96-6) Direct the masters of all your vessels to check all fire stations on their vessels to ensure that fire hose thread couplers are compatible with vessel fire hydrants and to replace incompatible equipment as appropriate. (Class II, Priority Action) (M-96-7) Develop fire contingency plans that improve the readiness of your vessel personnel and equipment to respond to a fire emergency, and include provisions concerning the duties of security watch personnel and the training of crew in firefighting techniques by the implementation of realistic fire drill procedures. (Class II, Priority Action) (M-96-8) -- to the Commercial Fishing Industry Vessel Safety Advisory Committee: Inform fishing industry vessel owners of this accident and advise them to: install on their vessels smoke detectors in accommodation spaces; install automatic fire suppression systems in accommodation spaces that are constructed of combustible materials; develop written guidance for vessel masters to review the fire safety condition of all crewrooms when the occupants disembark from the vessel and the room will be vacant; direct vessel masters to check fire stations to ensure that fire hose couplers are compatible with vessel fire hydrants; and develop fire contingency plans that improve the readiness of vessel personnel and equipment, including provisions addressing the duties of security watch personnel and procedures for realistic fire drills. (Class II, Priority Action) (M-96-9)

53 -- to the National Fire Protection Association: Develop, in cooperation with the U.S. Coast Guard, a national marine fire safety standard for commercial fishing industry vessels, which should include structural fire protection standards and fire detection and suppression systems in accommodation areas. (Class II, Priority Action) (M-96-10) BY THE NATIONAL TRANSPORTATION SAFETY BOARD JAMES E. HALL Chairman ROBERT T. FRANCIS II Vice Chairman JOHN A. HAMMERSCHMIDT Member JOHN J. GOGLIA Member GEORGE W. BLACK, JR. Member June 11, 1996

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55 APPENDIX A Safety Board Investigation Investigation The U.S. Coast Guard notified the National Transportation Safety Board of this accident on May 30, 1995. Four investigators from the Safety Board's Washington, D.C., headquarters were dispatched immediately to Seward, Alaska. They began investigation of the accident on June 1, 1995. The Safety Board invited the National Fire Protection Association (NFPA) to assist in the investigation, and the NFPA sent one investigator to Seward. The Safety Board investigated this accident independently, under the authority of Section 304(a)(1)(F) of the Independent Safety Board Act of 1974. The report is based on the factual information developed as a result of the investigation and additional analyses made by the Safety Board. The Safety Board considered all facts in the investigative record that are pertinent to its statutory responsibility to determine the cause or probable cause of the accident and to make recommendations. The Fishing Company of Alaska, Inc., the U.S. Coast Guard, and the Seward Volunteer Fire Department participated as parties to the investigation. Hearing and Deposition Sworn testimony regarding this accident was taken on June 2, 1995, in Seward, Alaska, and on June 5, 1995, in Seattle, Washington. On August 28-29, 1995, two Safety Board investigators went to San Francisco, California, to witness the testing of a heat detector that had been removed from the ALASKA SPIRIT and to examine the battery chargers removed from the ALASKA SPIRIT. On October 29, 1995, two investigators went to Seattle, Washington, to visit the ALASKA SPIRIT’s sister vessel, the ALASKA VICTORY, and to examine undamaged battery chargers taken from that vessel. APPENDIXES

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57 APPENDIX B Crew Licensing Information Master ALASKA SPIRIT Master Todd M. Eggers received the original issue of his master's license on April 3, 1989, as Master of Near Coastal Uninspected Fishing Industry Vessels of not more than 1600 gross tons; also, Master of Near Coastal Steam or Motor Vessels of not more than 200 gross tons. On November 19, 1990, his license was amended to include Master of Ocean Uninspected Fishing Industry Vessels of not more than 2,000 gross tons. He renewed the license on February 23, 1994. The license included an endorsement as a Radar Observer (Unlimited) and had an expiration date of January 6, 1998. Chief Engineer Richard D. Lewis, Sr., was on his third issue of a license to serve as Chief Engineer of Limited Oceans Motor Vessels of not more than 5,000 horsepower. The license was issued on October 19, 1994, by the U.S. Coast Guard Officer-in-Charge of Marine Inspection (OCMI), New Orleans, Louisiana. Assistant Engineer Frank P. Lemacks, Jr., held a license to serve as Chief Engineer of Limited Oceans Motor Vessels of any horsepower, as well as Second Assistant Engineer of Motor Vessels of any horsepower. His license was issued for the fourth time on February 23, 1995, by the OCMI, New Orleans, Louisiana.

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59 APPENDIX C Battery Charger Examination On August 29, 1995, the two battery chargers found on the ALASKA SPIRIT were examined, photographed, and disassembled at Fire Cause and Analysis,1 in Berkeley, California. (The charger found on the left side in the assistant fish master’s room corresponded to model SP1-35-20B; the charger from the right side corresponded to model SP1-35-30B.) The less damaged battery charger, which had been found on the right side in the assistant fish master's room, was examined first. Aside from the burned and melted condition of its meters, circuit breaker switches, and other plastic-type electrical devices, the battery charger did not show significant signs of damage. This charger had no melted metal parts. The two aluminum heat sink plates for the rectifiers (diodes) on this charger were intact, and the diodes were attached. The electrical insulation on the transformers in the charger was intact, although the transformers had experienced extensive fire damage. The investigators next examined the other (left) battery charger taken from the assistant fish master's room. The plastic-type electrical devices on this charger were burned more extensively than the right charger's devices. The investigators separately removed the two transformers of the left charger from the chassis, took them apart (removed laminated plates from the transformer coils), and examined them. All electrical insulation had been burned from the transformers. There was no apparent arcing between primary and secondary coils on either of the two transformers in this charger. Two aluminum heat sink plates, on which the diodes had been mounted, had melted. The exterior meter, switches, and connectors on the left charger were completely destroyed by the fire. Interior fire damage was extensive. All electrical insulation on the transformers in the left charger was destroyed. Investigators found no evidence of electrical arcing on the transformers.

1An independent company hired by the FCA to perform the analysis.

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69 APPENDIX E Building Codes The three major groups — the International Conference of Building Officials (ICBO), the Southern Building Code Congress International, Inc. (SBCCI), and the Building Officials and Code Administrators International (BOCA) — have developed national model building codes. The BOCA, the SBCCI, and the ICBO publish the National Building Code (NBC), the Standard Building Code (SBC), and the Uniform Building Code (UBC), respectively. Each code group is a consensus of building officials with a degree of uniformity among their model codes, although different regional and geographic needs are met by the different code groups. Because of the high flammability of plastic foam insulation, the U.S. model building codes (shoreside) were modified in 1976 to limit the use of cellular plastic materials. The NBC, SBC, and UBC require that foam plastic insulation have a flame spread index of not more than 75 and a smoke development rating of not more than 450, when tested in accordance with ASTM E84. In addition, when used on room side surfaces, they either must be protected (covered) by a thermal barrier equal in fire resistance to ½-inch gypsum board, or they may be used only in buildings that have sprinkler systems.1 Both requirements apply to foam more than 4 inches thick. The high flame spread rate of RPU foam is attributed to its relatively low decomposition temperature (about 325 oF) and high smoke emission rate (combustible gases). In the 1960s and early 1970s, spray-on RPUs were advertised as self- extinguishing and nonflammable and were used extensively as thermal insulation in shoreside structures. In some instances, RPU foams were involved in fires during the construction phase.2 RPU foam flammability and its associated hazards are best demonstrated by the full-scale room studies conducted by various investigators. In a 1973 report by W.F. Marconi,3 a room was completely lined with 1 ½-inch- thick RPU foam with a flame spread index of 200, when tested in accordance with ASTM E84. The wall and overhead lining were ignited from a source in the corner. The fire spread rates in this experiment exceeded the response capability of the automatic

1Model code provisions pertaining to foam plastics insulation. The Society of Plastics Industry, Inc., 1990. 2Paul, George H., Clougherty, Edward V., and Lathrop, James K., Fire Journal, “Federal Reserve Bank - Fire in Exposed Urethane Insulation in Building Under Construction,” Boston, Massachusetts, July 1977, pp. 33-55. 3Marconi, W.F., Fire Journal, “Large-Scale Fire Tests of Rigid Cellular Plastic Wall and Roof Insulation,” Boston, Massachusetts, November 1973, pp. 24-26.

APPENDIX E 70 sprinkler system. In a 1986 Swedish study,4 a room was covered with various materials, including RPU foam, and ignition was initiated in the corner. The flash over5 delay was measured, and the process took 6 seconds when the room was lined with RPU foam, compared with 157 seconds when lined with wood particle board.

4Sundstrom, B., Full-Scale Fire Testing of Surface Materials, Technical Report SP-RAPP 1986:45, Swedish National Testing Institute, Boras, 1986. 5Transition from a small fire to full-room involvement.

71 APPENDIX F Conditions Reported by the SVFD Fire Chief that Affected ALASKA SPIRIT Firefighting Absence of Forward Access Doors on the 02 Deck The absence of such doors to accommodation areas limited the firefighters’ ability to approach one side of the fire. Deeply seated fires in the master’s room and the forward part of the 02 deck were not accessible during most of the incident due to intense heat. Lack of Natural Ventilation in Accommodation Areas In response to the high heat levels and volume of smoke, firefighters used blowers to exhaust heat and smoke from the 02 deck. Also, due to the limited firefighting access to the 02 deck, firefighters used power saws and sledge hammers to make holes in the steel bridge deck and forward bulkhead of the 02 deck. These openings immediately began releasing heat and smoke, which allowed the firefighters to introduce water down onto the fire from the bridge deck and permitted firefighter entry into the confined space. Necessity of Frequent Firefighter Rotation The fire chief rotated his crews to provide them respite from the intense heat and allow them to change SCBA bottles. Due to the narrowness of the corridor, the fire chief felt it was too hazardous to have two crews of firefighters in the accommodations area simultaneously. During the firefighting lull while crews rotated, the fire would advance down the corridor to the point of entry. Consequently, each crew had to rebattle the fire back to the point where the other had left it.

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73 APPENDIX G Toxic Effects of Carboxyhemoglobin Saturation The blood component hemoglobin normally carries oxygen from the lungs to the tissues. Hemoglobin, however, has a much greater affinity for carbon monoxide (CO) than for oxygen. When a person inhales air containing CO, the compound carboxyhemoglobin (COHb) is formed in the blood as CO occupies the positions on the hemoglobin molecule normally filled by oxygen. As indicated in table 1 (below), as the level of COHb saturation increases, the toxic effects become increasingly severe. Table 1 — Toxic effects of Carboxyhemoglobin saturation %COHb Saturation Effect 10 Psychomotor and judgment inefficiencies 10-20 Exertional dyspnoea (shortness of breath) 20-30 Headaches 30-40 Nausea, dizziness, and muscular weakness 40-50 Syncope (loss of consciousness, fainting) 50-60 Convulsions 60-70 Coma 80 Rapid death The time required for an exposed person to reach an incapacitating level of COHb saturation depends on the concentration of CO in the air. Fire-produced concentrations of CO in the air can range as high as 10 percent. Lower concentrations generally occur in well-ventilated fires. Higher concentrations occur in poorly ventilated fires, such as was the case during the early stages of the smoldering combustion in the assistant fish master’s room. Hill’s report1 tabulated COHb levels as functions of CO concentration in the air and exposure time. The length of time it would have taken for the master to reach an incapacitating level of COHb saturation cannot be precisely calculated, but a range can be derived (see table 2).

1Hill, I.R., Aviation, Space, and Environmental Medicine, “An Analysis of Factors Impeding Passenger Escape from Aircraft Fires,” March 1990, pp. 261-265.

APPENDIX G 74 Table 2 — Carboxyhemoglobin saturation as a function of exposure time and percentage of carbon monoxide in the air % of CO % COHb Saturation in the air 10 SECONDS 30 SECONDS 60 SECONDS 120 SECONDS 0.1 0.2 0.6 1.3 2.5 1 2.5 7.5 15.0 30.0 2 5.0 15.0 30.0 60.0 5 12.5 38.0 75.0 — 10 25.0 75.0 — —

75 APPENDIX H Master’s Blood Alcohol Level The blood alcohol concentration (BAC) of the master’s blood sample was reported as 0.353 gm/dL by the Alaska Medical Examiner’s Office and 0.360 gm/dL by the Center for Human Toxicology (CHT). The average can be expressed equivalently as 0.36 percent of alcohol by weight/volume. If the BAC was caused by ingested alcohol, the physiological effects in an individual who had not developed a tolerance for alcohol would have been “stupor, marked incoordination, and possibly coma.”1 Upon receipt of the master’s blood sample, the CHT staff observed that it did not appear to be whole blood and that the sample had hemolyzed due to decomposition. The CHT test found the sample’s blood hemoglobin concentration to be 6.8 gm/dL, which is about 42 percent of that normally found in whole blood. Literature on blood alcohol, forensic tests, and Government regulations on BAC levels all refer to concentrations in whole blood. Specimens from live individuals present no problem, but postmortem samples may have undergone extensive clotting. When some blood solids are absent because of clotting and sedimentation, the remaining fluid blood specimen will have a higher-than-normal water content. Since testing detects alcohol in proportion to water content, the amount of alcohol found is also greater than it would be in a sample of whole blood. Such was likely the case with the master’s blood sample, since the deputy fire marshal attending the autopsy noted difficulties in obtaining a fluid sample due to coagulation. Scientific literature2 indicates that, in these circumstances, a whole blood sample’s BAC might have been 10- 20 percent lower than in the hemolyzed specimen. Nevertheless, even if the master’s whole blood BAC had been 10-20 percent lower than the detected value, the physiological effects of that level of ingested alcohol would still have been incapacitating. Consequently, the key question to consider is the origin of the alcohol. Was it ingested or was it a consequence of postmortem generation? Investigators found no evidence that the master had ingested alcohol on the day or evening before the fire, although that possibility cannot be conclusively discounted. Investigators also considered the likelihood of postmortem alcohol generation — that is, alcohol generated by microbial action within the body after death. Confirmed

1Freimuth, H.C., Medicolegal Investigation of Death, 3rd ed., W.U. Spitz (Ed.), “Forensic Aspects of Alcohol,” Springfield, Illinois, 1993, pp. 767-775. 2Garriott, J., (Ed.), Medicolegal Aspects of Alcohol Determination, PSG Publishing, Littleton, Massachusetts, 1988.

APPENDIX H 76 postmortem alcohol levels in excess of 0.30 percent have been reported3 and the condition can best be inferred by a positive finding of alcohol in blood, coupled with the absence of alcohol in urine and/or vitreous humor. Neither urine nor vitreous humor was available from the master’s autopsy for cross-validation of the blood sample. Postmortem generation of alcohol is likely to occur when a body has been exposed to elevated temperatures and time elapses between death and the collection of a test specimen. Such conditions were present in this case. Before being removed from the vessel, the deceased had been exposed to heightened temperatures (because of the fire) for more than 10 hours. Further, the hemolyzed condition of the blood sample noted by the CHT and the autopsy report’s description of the body are both indicative of decomposition. In summary, the conditions were highly favorable for postmortem generation of alcohol.

3Canfield, D.V., Kupiec, T., and Huffine, E., Journal of Forensic Sciences, 38(4),“Postmortem Alcohol Production in Fatal Aircraft Accidents,” 1993, pp. 914-917.

FD07170 ｜ 1996_美国_AAR9603.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1996 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

PB96-910403 NTSB/AAR-96/03 . I NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 I AIRCRAFT ACCIDENT REPORT UNCONTAINED ENGINE FAILURE/FIRE VALUJET AIRLINES FLIGHT 597 DOUGLAS DC-9-32, N908VJ ATLANTA, GEORGIA JUNE 8, 1995 I I 6579A I

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Information about available publications may be obtained by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (202)382-6735 (800)877-6799 Safety Board publications may be purchased, by individual copy or by subscription, from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (703)487-4600

NTSB/AAR-96/03 PB96-910403 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT UNCONTAINED ENGINE FAILURE/FIRE VALUJET AIRLINES FLIGHT 597 DOUGLAS DC-9-32, N908VJ ATLANTA, GEORGIA JUNE 8,1995 Adopted: July 30, 1996 Notation 6579A Abstract: This report explains the uncontained engine failure/fire on ValuJet Airlines flight 597, a Douglas DC-9-32, N908VJ, at Atlanta, Georgia, on June 8, 1995. The safety issues discussed in the report include the clarity of operations specifications for repair stations, recordkeeping requirements for foreign repair stations, regulatory guidance concerning maintenance documentation, intent of “serviceable tags,” independently powered public address systems on all transport-category airplanes, flight attendant training programs and manuals, enforcement of occupant restraint requirements, notification of flightcrew of cabin fire, cabin material/fire safety standards, flight attendant attire, and quality of cockpit voice recordings. Safety recommendations concerning these issues were made to the Federal Aviation Administration (FAA).

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iii CONTENTS EXECUTIVE SUMMARY............................................................................................................vi

1. FACTUAL INFORMATION..................................................................................................... 1
2. 1 History of the Flight .............................................................................................................. 1
3. 2 Injuries to Persons ................................................................................................................. 3
4. 3 Damage to Aircraft................................................................................................................ 3
5. 4 Other Damage........................................................................................................................ 3
6. 5 Personnel Information........................................................................................................... 3
7. 5.1 The Captain .................................................................................................................... 3
8. 5.2 The First Officer............................................................................................................. 4
9. 5.3 Flight Attendants............................................................................................................ 4
10. 6 Aircraft Information .............................................................................................................. 4
11. 6.1 Aircraft Origin and Configuration.................................................................................. 4
12. 6.2 Emergency Lighting and Power ..................................................................................... 5
13. 7 Meteorological Information .................................................................................................. 7
14. 8 Aids to Navigation ................................................................................................................ 7
15. 9 Communications ................................................................................................................... 7
16. 10 Airport Information............................................................................................................. 8
17. 11 Flight Recorders .................................................................................................................. 8
18. 12 Wreckage and Impact Information...................................................................................... 9
19. 12.1 Right Engine................................................................................................................. 9
20. 12.2 Left Engine................................................................................................................. 11
21. 12.3 Fuselage...................................................................................................................... 11
22. 13 Medical and Pathological Information.............................................................................. 12

iv 1.14 Fire .................................................................................................................................... 14 1.14.1 Emergency Response.................................................................................................. 14 1.15 Survival Aspects................................................................................................................ 14 1.16 Tests and Research............................................................................................................ 16 1.16.1 Metallurgical Examinations ....................................................................................... 16 1.16.2 Burn Tests of Cabin Furnishings................................................................................ 20 1.17 Additional Information...................................................................................................... 21 1.17.1 ValuJet’s Purchase of Turk Hava Yollari (THY) Aircraft, Engines, and Spare Parts21 1.17.1.1 Pre-delivery Activities in Turkey............................................................................ 21 1.17.1.2 Post-delivery Activities in the United States........................................................... 25 1.17.2 1991 Overhaul/Inspection of 7th Stage HPC Disk by THY........................................ 26 1.17.3 Pratt & Whitney Guidance on Engine Overhaul/Inspection ...................................... 28 1.17.4 FAA Regulations Regarding the Return to Service of the Spare Engines ................. 30 1.17.5 THY Repair Station.................................................................................................... 32 1.17.5.1 Pratt & Whitney Engine Shop Maintenance Review .............................................. 34 1.17.5.2 FAA Inspections of THY Repair Station ................................................................ 35 1.17.6 ValuJet’s Flight Attendant Training Program............................................................ 37 1.17.7 Safety Board Recommendations Subsequent to the Accident ................................... 38

1. ANALYSIS .............................................................................................................................. 41
2. 1 General ................................................................................................................................ 41
3. 2 Uncontained Engine Failure................................................................................................ 41
4. 3 Overhaul Procedures by THY ............................................................................................. 42
5. 4 Adequacy of FAA Recordkeeping Requirements. .............................................................. 45

v 2.5 Maintenance Release and “Serviceable” Tags for Aircraft Components............................ 47 2.6 THY’s Authority to Overhaul JT8D Engines...................................................................... 47 2.7 Emergency Lighting and Public Address System ............................................................... 48 2.8 ValuJet’s Flight Attendant Training Program..................................................................... 50 2.9 In-Lap Children over 2 Years Old....................................................................................... 51 2.10 Notification of Flightcrew of Cabin Fire........................................................................... 52 2.11 Fire Retardant Cabin Furnishings...................................................................................... 53 2.12 ValuJet Flight Attendant Uniforms................................................................................... 55 2.13 Quality of CVR Recording................................................................................................ 55

1. CONCLUSIONS...................................................................................................................... 57
2. 1 Findings............................................................................................................................... 57
3. 2 Probable Cause.................................................................................................................... 59
4. RECOMMENDATIONS ......................................................................................................... 60
5. APPENDIXES ......................................................................................................................... 63

APPENDIX A - Investigation And Hearing.................................................................................. 63 APPENDIX B - CVR Transcript................................................................................................... 65 APPENDIX C - Example of a “Process Sheet” ............................................................................ 91 APPENDIX D - Pratt &Whitney Plating Requirements for #7 HPC Disk................................. 102 APPENDIX E - Examples of THY Repair Station Operations Specifications........................... 118 APPENDIX F - Examples of ValuJet’s Flight Attendant Manual Emergency Equipment—Before and After Revision in November 11, 1995 ................................................................................. 126 APPENDIX G - Comparison of Requirements for Domestic and Foreign Repair Stations Certificated Under FAR Part 145................................................................................................ 128

vi EXECUTIVE SUMMARY On June 8, 1995, a Douglas DC-9-32, N908VJ, was being operated by ValuJet Airlines as a scheduled, domestic passenger flight under the provisions of Title 14 Code of Federal Regulations (CFR) Part 121. Flight 597, destined for Miami, Florida, departed gate C25 at the William B. Hartsfield Atlanta International Airport, Atlanta, Georgia, at 1855, and was cleared for takeoff on runway 27R at 1908. Five crewmembers and 57 passengers were on board. As flight 597 began its takeoff roll, a "loud bang" was heard by the airplane occupants and air traffic control personnel. The right engine fire warning light illuminated, the flightcrew of a following airplane reported to the ValuJet crew that the right engine was on fire, and the takeoff was rejected. Shrapnel from the right engine penetrated the fuselage and the right engine main fuel line, and a cabin fire erupted. The airplane was stopped on the runway, and the captain ordered the evacuation of the airplane. The flight attendant seated in the aft flight attendant jumpseat received serious puncture wounds from shrapnel and thermal injuries. Another flight attendant and five passengers received minor injuries. The pilots, the third flight attendant, and 52 passengers were not injured. The airplane’s fuselage was destroyed. The National Transportation Safety Board determines that the probable cause of this accident was the failure of Turk Hava Yollari maintenance and inspection personnel to perform a proper inspection of a 7th stage high compressor disk, thus allowing the detectable crack to grow to a length at which the disk ruptured, under normal operating conditions, propelling engine fragments into the fuselage; the fragments severed the right engine main fuel line, which resulted in a fire that rapidly engulfed the cabin area. The lack of an adequate recordkeeping system and the failure to use “process sheets” to document the step-by-step overhaul/inspection procedures contributed to the failure to detect the crack and, thus, to the accident. The safety issues in this report include the clarity of operations specifications for repair stations, recordkeeping requirements for foreign repair stations, regulatory guidance concerning maintenance documentation, intent of “serviceable tags,” independently powered public address systems on all transport-category airplanes, flight attendant training programs and manuals, enforcement of occupant restraint requirements, and cabin material/fire safety standards. Safety recommendations concerning these issues were addressed to the Federal Aviation Administration.

UNCONTAINED ENGINE FAILURE/FIRE VALUJET AIRLINES FLIGHT 597 DOUGLAS DC-9-32, N908VJ ATLANTA, GEORGIA JUNE 8, 1995

1. FACTUAL INFORMATION
2. 1

History of the Flight On June 8, 1995, a Douglas DC-9-32, N908VJ, was being operated by ValuJet Airlines as a scheduled, domestic passenger flight under the provisions of Title 14 Code of Federal Regulations (CFR) Part 121. Flight 597, destined for Miami, Florida, departed gate C25 at the William B. Hartsfield Atlanta International Airport, Atlanta, Georgia, at 1855,1 and was cleared for takeoff on runway 27R at 1908. Five crewmembers and 57 passengers were on board. As flight 597 began its takeoff roll, a "loud bang" was heard by the airplane occupants and air traffic control personnel. The right engine fire warning light illuminated, the flightcrew of a following airplane reported to the ValuJet crew that the right engine was on fire, and the takeoff was rejected. Shrapnel from the right engine penetrated the fuselage and the right engine main fuel line, and a cabin fire erupted. The airplane was stopped on the runway, and the captain ordered the evacuation of the airplane. After the airplane came to a stop, the forward flight attendants opened the forward passenger boarding door and the service door exits, and the airplane was evacuated. The flight attendant at the service door exit stated that when the door was opened, the cabin filled with smoke from about waist level up to the ceiling. The flight attendant seated in the aft flight attendant jumpseat received serious puncture wounds from shrapnel and thermal injuries and evacuated herself from the airplane through an overwing exit. Another flight attendant and five passengers received minor injuries. The pilots, the third flight attendant, and 52 passengers were not injured. The airplane’s fuselage was destroyed. The accident occurred at dusk. The airplane came to a stop about 1,500 feet down runway 27R, before taxiway M18, approximately 33° 38’04” North latitude and 84° 24’50” West longitude (see figure 1).

1 Unless otherwise indicated, all times are eastern standard time, based on a 24-hour clock.

2 . . . . . . - .- — .,- IJ ULZ . . . 1 -— lUUL -nr fll lL lflL nnH Ju , I u 9R -.

—

..- --. . . .. 1. i . . i . Figure l—Location of flight 597 at Hartsfield Atlanta

3 1.2 Injuries to Persons Injuries Cockpit crew Flight attendants Passengers Other Total Fatal 0 0 0 0 0 Serious 0 1 0 0 1 Minor 0 1 5 0 6 None 2 1 52 0 55 Total 2 3 57 0 62 1.3 Damage to Aircraft The fuselage was destroyed by fire, which gutted the interior, burned through the roof of the forward cabin area of the airplane, and consumed most of the cabin overhead. There was substantial exterior damage with circumferential outward tearing of the right engine cowl and engine case in the plane of rotation of the right engine 7th stage high pressure compressor (HPC) disk. There was also shrapnel damage to the fuselage and left engine cowl. 1.4 Other Damage No other property damage resulted from this accident. 1.5 Personnel Information The flightcrew consisted of the captain and the first officer. Three flight attendants were aboard the airplane. 1.5.1 The Captain The captain, age 45, was hired by ValuJet Airlines on November 25, 1993, as a captain on DC-9 airplanes. He held an airline transport pilot (ATP) certificate, with an airplane multiengine land rating, and DC-9, Boeing 737, and Lear Jet type ratings. He had commercial pilot privileges for airplane single-engine land. He was a certified flight instructor with airplane multiengine and instrument airplane ratings. The captain’s first-class medical certificate was issued on March 21, 1995, with no restrictions or limitations. The captain was a designated pilot examiner for Boeing 737 airplane type ratings. His last proficiency check was completed on May 7, 1995, in the DC-9 airplane. According to company records, the captain had accumulated about 9,500 total flight hours, with about 3,500 hours in the DC-9, and 2,500 hours as a DC-9 captain. The captain had about 11 years previous experience with Eastern Airlines as a DC-9 captain and first officer, a Boeing 727 first officer, and a Lockheed L-1011 second officer.

4 The captain reported for duty on the day of the accident at 1332, following 3 days off duty. 1.5.2 The First Officer The first officer, age 43, was hired by ValuJet Airlines on October 28, 1994, as a first officer on the DC-9 airplane. He held an ATP certificate with airplane single-engine and multiengine land ratings. His first-class medical certificate was issued on September 14, 1994, with no restrictions or limitations. The first officer’s last proficiency check was completed on May 29, 1995, in the DC-9 airplane. According to company records, he had accumulated about 3,800 total flight hours with 552 hours in the DC-9, all as first officer. The first officer had previous flight experience in a Lockheed P-32 with the United States Navy, between 1982 and 1991. The first officer reported for duty on the day of the accident at 1328, following 2 days off duty. 1.5.3 Flight Attendants Two flight attendants occupied the aft-facing double-occupancy jumpseat in the forward cabin at the time of the accident. One of the flight attendants had completed her initial ValuJet training on November 15, 1994. She had been previously employed as a flight attendant with Eastern Airlines for 7½ years and with Private Jet for 1½ years. She was scheduled for her first recurrent training in November 1995. The other flight attendant in the forward section of the cabin had completed her initial training on December 15, 1994. She had no prior flight attendant experience. She was scheduled for her first recurrent training in December 1995. The flight attendant who occupied the jumpseat in the rear cabin had completed her initial training on December 23, 1993. She had no prior flight attendant experience. Her most recent recurrent training before the accident was completed in November 1994. 1.6 Aircraft Information 1.6.1 Aircraft Origin and Configuration N908VJ, a Douglas DC-9-32, serial number (SN) 47321, was registered to ValuJet Airlines. The airplane was purchased from the Douglas Aircraft Company and was put into service as part of ValuJet’s fleet on February 4, 1994. It had previously been operated by Delta Air Lines. The airplane was powered by two Pratt & Whitney (P&W) JT8D-9A turbofan engines.

2 The Lockheed P-3 is a Navy antisubmarine patrol plane equipped with four turbopropeller engines.

5 The right engine, SN 666966, was installed on the airplane in March 1995. It had been obtained by ValuJet from Turk Hava Yollari (THY) A.O., Turkish Airlines, in a large equipment purchase on October 3, 1994, that included a total of 23 engines.3 THY is a Turkish domestic and international airline that also operates an airframe and engine repair station. At the time of the accident, flight 597 had a basic operating weight of 61,564 pounds and a takeoff weight of 96,374 pounds; maximum takeoff weight for this DC-9-32 was 102,900 pounds. The center of gravity was at 23 percent mean aerodynamic chord, which was within limits. During the pre-departure preparations, the flightcrew noted that the traffic collision and avoidance system (TCAS) fail light remained illuminated. The minimum equipment list for the accident aircraft indicated that the TCAS was not required for flight, and at the time of the accident, this discrepancy could be left uncorrected for up to 10 days. The airplane was configured with 108 passenger seats. Supplemental oxygen for both the flightcrew and the passengers was provided by compressed oxygen-filled bottles. Two floor-level exits were located in the forward cabin, four overwing exits were located at rows 14 and 16, and a tailcone exit was located at the rear of the cabin. (See figure 2.) Two cockpit windows could be used as emergency exits. 1.6.2 Emergency Lighting and Power The airplane was equipped with a cabin floor path emergency lighting system, which, along with other emergency lights, provides illumination in the main cabin when the normal electrical power is interrupted. The emergency lighting system was installed in accordance with a supplemental type certificate.4 The emergency lighting system is powered by either the Emergency direct current (DC) Bus or dedicated rechargeable battery packs and is controlled by a three-position emergency lighting switch with positions “ON,” “OFF,” and “ARMED” located in the cockpit overhead panel. The Emergency DC Bus is normally powered by engine-driven generators. It can also be activated by manually selecting emergency electrical power. Placing the emergency lighting switch to “ON” illuminates the emergency lights when the Emergency DC Bus is powered. The “ARMED” position is the normal flight position, which turns off the emergency lights and causes the battery packs to be charged. The “OFF” position extinguishes the lights and discontinues the charging of the batteries. If electrical power to the Emergency DC Bus is interrupted, the emergency lights automatically illuminate (if the emergency lighting switch is in the “ARMED” position), with the electrical power provided by the battery packs. The manual selection of emergency electrical

3 See section 1.17.1 discussed later in this report. 4 An emergency floor path proximity lighting system was not required when the DC-9 was introduced into service. Subsequently, Federal regulations required transport-category airplanes in commercial passenger service to be so equipped. Therefore, emergency lighting systems were installed in accordance with supplemental type certificates that were approved by the Federal Aviation Administration (FAA).

6 A i I =E -= = =7 u Figure 2—DC9-32 cabin configuration

7 power restores power to the Emergency DC Bus from the aircraft’s batteries; however, unless the emergency light switch is first moved from the “ARMED” to the “ON” position, this action will also extinguish the emergency lights and resume charging of the battery packs. Placing the cabin emergency lighting switch to the “ON” position was the fourth item on the ValuJet Emergency Evacuation Checklist.5 The airplane was equipped with a public address (PA) system that enabled the flightcrew and flight attendants to address occupants through loudspeakers located throughout the cabin. The PA system is also powered by the Emergency DC Bus. An interruption of electrical power to the Emergency DC Bus disables the PA system. Manual selection of emergency electrical power restores power to the PA system. 1.7 Meteorological Information Visual meteorological conditions prevailed at the time of the accident. The Hartsfield Atlanta International Airport hourly weather observation at 1850 was: sky—scattered clouds, ceiling at 5,500 feet; visibility—12 miles; temperature—93 °F; dew point—71 °F; wind—290° at 8 knots; and altimeter setting—29.99. The weather was essentially the same at the next hourly observation. 1.8 Aids to Navigation There were no known difficulties with aids to navigation. 1.9 Communications There were no known external communication difficulties involving the airplane. The flightcrew of Delta flight 846, which had been cleared to “position and hold” behind flight 597, advised the ValuJet crew of a fire in the right engine, prompting the captain to reject the takeoff and stop the airplane on the runway. After the captain stopped the airplane and the engines were shut down, he attempted to communicate to the passengers using the PA system but was unable to do so. After the captain selected emergency electrical power, the power was restored to the PA system, and the captain successfully communicated the evacuation order. One of the flight attendants in the forward section of the cabin saw flames around the flight attendant in the aft jumpseat and tried to notify the flightcrew of the fire by opening the cockpit door. As required by FAA regulations, the cockpit door was locked. While one of the forward flight attendants reached for the cockpit door key, which had been stored in the galley per

5 The first three items on the checklist are (1) setting the parking brakes, (2) retracting the spoilers, and (3) lowering the flap handle.

8 ValuJet procedures, the other flight attendant successfully opened the cockpit door with her own key and informed the flightcrew of the fire. The captain then ordered an evacuation through the forward exits. According to ValuJet’s flight attendant manual in effect at the time of the accident: If life threatening conditions exist inside the cabin, the first crewmember aware of the situation shall notify the pilots via the interphone using the emergency signal (six chimes).6 If no response, unlock the cockpit door and evaluate conditions. If able, the captain will evaluate the situation and, if necessary, initiate an evacuation with the PA announcement of Evacuate, Evacuate, Evacuate. The flight attendant manual further provides that “If a life threatening situation exists inside the cabin, and you are unable to contact the cockpit, begin shouting the appropriate commands. Once the aircraft comes to a complete stop, initiate the evacuation. Note: An evacuation should not be initiated until the aircraft has come to a complete stop.” 1.10 Airport Information The William B. Hartsfield Atlanta International Airport is located 6 miles south of Atlanta, Georgia. It is served by four parallel runways oriented east/west. The terminal building and passenger loading concourses are situated between the two innermost parallel runways. Runway 27R, used by ValuJet flight 597, is the runway closest to the terminal on the south side of the terminal/concourse area. Departure operations are normally conducted from the inner runways, with landing operations normally conducted on the outer runways. Runway 27R is 11,889 feet long and 150 feet wide. The approach threshold elevation is 978 feet mean sea level. Hartsfield International Airport is fully certificated under 14 CFR Part 139 and is an Index E Aircraft Rescue and Fire Fighting (ARFF) facility.7 1.11 Flight Recorders Digital flight data (DFDR) and cockpit voice (CVR) recorders were installed in the airplane. The DFDR was a Fairchild Model F800, SN 05466, with an 11-parameter recorder, with two channels that were not recording properly. The CVR was a Fairchild Model A-100A, SN

1. Both recorders were removed from the airplane and sent to the Safety Board’s laboratory

in Washington, D.C., for readout.

6 No chimes were recorded on the CVR. A review of available information, including the CVR transcript and maintenance records, provided no evidence that the interphone was inoperative. 7 Title 14 CFR Part 139 requires, for scheduled air carrier service with aircraft at least 200 feet in length, that at a minimum the airport be equipped with at least three ARFF vehicles with at least 6,000 gallons of water for foam production.

9 The cases of both recorders were intact and covered with a light sooting. An excellent recording was obtained from the DFDR, and a recording of fair quality8 was obtained from the CVR. There was no apparent interior heat or impact damage to the CVR. Data from the DFDR indicated that the engine pressure ratio (EPR) on both engines began increasing shortly after flight 597 was cleared for takeoff. The airplane accelerated for about 14 seconds, reaching an indicated airspeed of about 31 knots when the right engine EPR decreased from about 1.57 to about 0.91 within 1 second. The CVR recording consisted of three channels: the cockpit area microphone, the pilot audio panel, and the interphone/PA system. The cockpit area microphone channel recording contained background noise that nearly obliterated the pilots’ voices and made them difficult to understand. A transcript was prepared of the entire 31-minute, 16-second recording. The transcript of the CVR is contained in appendix B of this report. The CVR recording started at 1838:03, with the airplane at the gate being prepared for departure. It continued through the flightcrew’s preparations for departure, taxi, and takeoff. The recording ended after engine shutdown with the airplane stopped on the departure runway. 1.12 Wreckage and Impact Information The airplane stopped on the centerline of runway 27R, about 1,500 feet west of the approach end of the runway. Debris from the right engine was found on the runway, from about 100 feet west of the runway threshold to the stopped airplane. Additional engine debris was found in the grass areas on either side of the runway. The overwing exit hatch from the right side of passenger seat row 14 was found on the runway, about 1,200 feet west of the runway threshold. 1.12.1 Right Engine The right engine, SN 666966, remained attached to the pylon structure. The nacelle doors were closed, and all four latches were locked. A circumferential tear of the engine nacelle encompassed the upper and lower nacelle doors from approximately the 9 o’clock position clockwise to the 6 o’clock position.9 The circumferential opening was approximately 14 inches wide and about 67 inches aft of the engine inlet flange. The circumferential tear of the right engine nacelle was aligned with the rotational plane of the 7th stage HPC disk. The torn edges

8 The Safety Board generally uses the following criteria to assess the quality of a CVR recording: a “poor” recording is one in which a transcription is nearly impossible given that a large portion of the recording is unintelligible; a “fair” recording is one in which a transcription is possible, but the recording is difficult to understand; a “good” recording is one in which few words are unintelligible; and an “excellent” recording is very clear and easily transcribed. 9 All clock references to the engine or the airplane are as viewed from aft, looking forward.

10 were ragged and curled outboard, away from the center of the engine. The forward edges of the hole were burned, with the paint blistered and charred. The nacelle was heat damaged from about the 1 to 6 o’clock position, to about 15 inches forward of the circumferential opening. The nacelle lower half was covered with soot aft of the circumferential opening. The fan discharge outer rear duct and the compressor case were also circumferentially ripped open through 360° and about 8 inches wide, directly behind the intermediate case (G flange). A 1-inch-wide strip of fan duct skin remained at the 6 o’clock position. All of the 1st stage fan blades were in place in the fan disk with varying degrees of hard body impact damage to the airfoil leading and trailing edges, outboard of the midspan shrouds. The airfoil trailing edge tips were bent forward. Only two pieces of the fractured 7th stage HPC disk, SN G78851, were recovered.10 One piece, about half of the disk, was found resting on the accessory gearbox, visible through the circumferential tear in the cowling. The section of disk, which previously formed the bore for the missing half of disk, was straight and extended tangentially from the inner diameter of the disk. The straightened section of disk bore protruded radially out through the circumferential opening in the compressor case and nacelle at the 5 o’clock position. The 7th stage compressor blades retained in the disk were bent opposite the direction of rotation. The 6th stage airseal was separated from the 7th stage disk. The airseal was bent and fragmented. About 60 percent of the airseal was recovered. The largest fragment, comprising about 150° of arc, was found lodged in the nacelle, against the pylon. Additional pieces were recovered from the accident runway and adjacent area. The 8th stage compressor disk and hub were visible through the circumferential opening in the fan duct and compressor case. Several 8th stage compressor blades were missing from their respective blade slots. The remaining blades had hard body damage on the leading edges. All of the compressor tierods were fractured at the 8th stage disk. Most of the tierod fractured ends protruded out of the 8th stage disk and were bent radially outward from their respective holes. The thrust reverser and turbine exhaust case appeared undamaged by the event. The turbine exhaust case had metal fragments lying on the bottom of the case. The forward, upper portion of the gearbox case, behind the fuel pump and control mount pad, was fractured, exposing the internal drive gears. The gearbox mounting lugs were fractured, and the gearbox was below the running position. The radial driveshaft from the gearbox to the intermediate case was disengaged. Oil and fuel lines to the gearbox and its associated accessories were intact. The hydraulic pump housing and main fuel pump separated from their respective gearbox mount pads.

10 A substantial portion of the disk was not recovered.

11 The two pylon vibration absorbers and their respective attachment bolts, aft of “G” flange, were fractured. The pylon vibration absorbers are in the plane of rotation of the 7th stage disk. Thirty-three 7th stage compressor blades were retained in the larger piece of the 7th stage disk, which was found inside the engine. An arc of 8 and an arc of 11 adjacent blades were bent opposite the direction of rotation. An arc of 14 blades was transversely fractured, adjacent to the blade platform. The smaller piece of the 7th stage disk was recovered from runway 27R, left of the centerline. The smaller piece of the 7th stage disk had six blades retained in the rim. The blades were transversely fractured adjacent to the blade platforms. The two pieces of the 7th stage HPC disk were shipped to the Safety Board’s materials laboratory in Washington, D.C., for examination. (See section 1.16.1 of this report for details of the disk examination.) 1.12.2 Left Engine The left engine (SN 666055) nacelle had a dent and a ¼-inch-diameter puncture at about the 4 o’clock position in line with a series of holes through the fuselage. Inspection of the engine inlet, inlet guide vanes, fan, and 4th stage blades did not reveal any damage. There was no fire damage. The examination of the left engine and data from the DFDR provided no evidence of problems with the left engine. The left engine was not disassembled or tested. 1.12.3 Fuselage Several punctures were observed in the fuselage above and below the right engine pylon. The largest puncture was adjacent to the right engine main fuel line. A 6-inch section of the fuel line was severed where it passed through the aft lavatory sidewall, about 1 foot above the cabin floor. The lavatory door had an approximate 1-foot-diameter puncture hole adjacent to the forward door frame. The galley’s forward frame had a piece of the corner post missing with the metal smeared to the left side of the airplane. The galley cooler box11 had grooves across its front side. The left side of the fuselage under the engine pylon had a puncture hole with outward bent edges, consistent with a projectile penetrating the left side of the fuselage from inside to outside. A rope was used to establish that the hole in the right side of the fuselage, the hole in the lavatory door, damage to the galley cooler and frame, the exit hole in the left side of the fuselage, and the dent in the left engine cowling were all aligned. Fire damage inside the aft lavatory was less severe than the fire damage elsewhere in the passenger cabin. The cabin floor support beam at the forward edge of the lavatory, which

11 The cooler box, which is a cube-shaped metal container that has an insulated plastic liner, holds canned beverages in ice cubes. It is located on the forward side of the galley at floor level.

12 extended from sidewall to sidewall, was nearly burned through at the center. The section of cabin floor surrounding the beam was partially melted and burned. The cargo bay liner beneath the aft lavatory was charred on the top and sides. Wire bundles and conduits between the cabin floor and the cargo bay liner in the same area as the damaged floor beam were more severely burned than in adjacent areas. The injured flight attendant’s jumpseat was immediately aft of the center aisle section that was nearly burned through. The jumpseat was also just aft of the path made by the rope used to establish the relationship between the right side fuselage hole and the dent in the left engine cowling. The top of the cabin, above the cabin windows, was consumed by fire from the 2nd window rearward to about the 15th window. There was severe interior fire damage to the entire passenger cabin, with sooting and blackening of the interior of the cockpit. The seat fabric, carpet, and cabin interior material were nearly consumed by the fire. The evacuation slides at both forward floor-level exits were found deployed and inflated. All overwing exit hatches were absent. One overwing exit hatch was found on the runway along the debris trail. The passenger seated in 14E stated that he opened the right overwing exit hatch located by his seat and threw it from the airplane. His companion seated in 14C confirmed that account. The passenger seated in 20C stated that when he moved to the right side overwing exits, another passenger removed one of the exit hatches and handed it to him, and he laid it in the adjacent seat. A third hatch was found adjacent to the aft window frame forward of row 16, on the left side of the airplane. It was not determined how the left overwing exit hatches were removed. Soot trails on the exterior of the aircraft extended up and aft from the overwing exits and the forward doors. Photographs taken by a passenger and provided to the Safety Board showed flames visible at the overwing exit and smoke at the forward and overwing exits. (See figure 3.) The tailcone, aft of the rear pressure bulkhead, was in place and not burned. In the cockpit, the emergency power switch was found in the “ON” position, and the emergency lighting switch was in the “ARMED” position. The left and right engine fire handles were in the aft, or activated position.12 Both fuel shutoff valves were in the closed position and both fire suppression bottles had been discharged into the right engine. 1.13 Medical and Pathological Information Five passengers sustained minor lacerations and contusions during the evacuation. They were treated at the scene, transported to local medical facilities for hyperventilation and smoke inhalation, and released the same day. The aft flight attendant sustained second degree burns on her legs, and two puncture wounds above and below the inside of her left knee. She was wearing shorts and a short-sleeved polo shirt—ValuJet’s flight attendant manual in effect at the time listed standard uniform items for ValuJet flight attendants as trousers, shorts (optional), polo

12 Activation of the engine fire handles will silence the fire warning bell, secure fluid supply valves to the engines, and select the fire suppression bottles. Subsequently turning the handles either clockwise or counterclockwise will discharge the respective bottles.

14 shirt (short or long sleeve), sweater (optional), a jacket, white socks, and white shoes. Unidentified pieces of the airplane debris were removed from the flight attendant’s leg by medical personnel. In accordance with ValuJet’s FAA-approved program, the flightcrew provided postaccident toxicological samples for analysis. The samples were analyzed and found to be negative for ethanol and other drugs of abuse. In addition, samples were requested from and provided by the two flight attendants who were not injured. These were likewise negative. Although a sample was requested from the flight attendant who had been injured, the request was received after she had been hospitalized and treated for her injuries. Consequently, no toxicological sample was obtained. 1.14 Fire According to passenger statements, within seconds after the takeoff roll began, a sound was heard that was described as a loud bang or explosion. Passengers reported looking rearward in the direction of the sound and observing flames and fuel around the aft flight attendant. The flight attendant seated in the forward jumpseat stated that within a few seconds after the takeoff began, she heard a loud bang, saw flashes, and could clearly see smoke and flames around the feet of the flight attendant seated in the aft cabin. The fire that began in the aft fuselage rapidly spread through the airplane and consumed the fuselage. 1.14.1 Emergency Response At 1908, the local control supervisor in the Atlanta Air Traffic Control Tower notified the Atlanta Fire Department at the airport of the ValuJet emergency. Battalion 7 of the Atlanta Fire Department was dispatched and arrived at the scene at 1911. Additional firefighting units arrived on the scene at 1913. When the Atlanta Fire Department units arrived, all occupants had evacuated the airplane. The two flight attendants in the forward section of the airplane and the first officer reported that shortly after they exited the airplane following the passengers, the firefighting vehicles arrived on scene. According to the Atlanta Fire Department report, arriving units could see fire near the No. 2 (right) engine and heavy smoke emanating from all exits. Firefighting personnel reported that the fire was spreading rapidly through the airplane from rear to front. An interior attack was initiated on the cabin fire. According to firefighting personnel, after noting the rapid progress of the fire along the overhead area and because the evacuation had been completed, the firefighters retreated and continued fire suppression efforts from outside the airplane. The fire was brought under control about 1922 and extinguished about 1925. 1.15 Survival Aspects The cockpit was configured conventionally with two flight crewmember seats and an observer jumpseat. No one occupied the observer jumpseat. The two flight attendants in the forward section were seated on an aft-facing double-occupancy jumpseat attached to the cockpit bulkhead, adjacent to the forward entry door. The flight attendant in the aft cabin was seated in a forward-facing jumpseat attached to the aft cabin exit door.

15 About ½ of the available cabin seats were occupied. The ValuJet passenger manifest listed one lap child. That lap child (a female) was older than 24 months old. Title 14 CFR Part 121.311(b) requires that all passengers more than 24 months of age be restrained during takeoff and landing. According to passenger interviews, the child was seated on the lap of a female adult in the 21-E window seat. During the evacuation, the adult handed the child to a male passenger who carried the child through the right overwing emergency exit to another passenger who carried the child across the wing and, holding the child, jumped off the trailing edge of the wing to the runway without injury. All exits and evacuation slides, except the tailcone exit (which was blocked by the aft cabin fire), were unobstructed and were used during the evacuation. Some passengers who saw the fire in the aft section of the cabin released their seat belts and moved toward exits before the airplane came to a stop. The captain reported that as he and the first officer were accomplishing the evacuation checklist, the smoke in the cockpit became thick, black, and acrid, and was lowering rapidly. The first officer reported that he was reading the evacuation checklist and had verified that the brakes were set and that the spoilers were retracted, had lowered the flap handle, and had pulled the No. 1 engine fire handle (the captain had pulled the No. 2 handle), after which he could hardly breathe. The first officer stated that he then yelled to the captain that “we’ve got to get out of here,” before they were able to place the emergency light switch (the fourth, and next, item in the evacuation checklist) in the “ON” position. The captain reported that as the first officer stood up, he could not see him from the chest up. According to the first officer, when he exited the cockpit into the cabin, he could feel people walking past him but could see them only from the waist down. He stated that when he no longer felt anyone passing by, he exited through the front left door of the airplane. The captain stated that when he exited the cockpit, he dropped to the floor and could see “some distance down the aisle, but only within about 3 to 4 inches of the floor.” According to passengers, the fire spread rapidly and fully engulfed the cabin area within about 3 minutes after the engine failure. Passengers reported that during the evacuation, the emergency floor track lighting illuminated briefly but then extinguished. Also, as mentioned previously, the captain reported that his initial attempt to broadcast the evacuation announcement over the PA system had not been successful; he then moved the emergency power switch to the “ON” position (which caused the emergency lights to turn off) and repeated the announcement. One passenger reported that the injured flight attendant in the aft jumpseat was struggling to release her seat belt and that as he moved aft to assist her, she released the belt and moved forward to escape through a left overwing exit. Several passengers described difficulty with visibility because of the smoke.

16 1.16 Tests and Research 1.16.1 Metallurgical Examinations The Safety Board disassembled the failed engine at the AeroThrust Corporation in Miami, Florida.13 Following the disassembly, parts, including the recovered portions of the failed 7th stage HPC disk, SN G78851, were taken to the Safety Board’s materials laboratory for further examination. Maintenance records for the engine indicated that the disk had accumulated 24,101 hours and 16,340 cycles. It had a life limit of 30,000 hours or 18,932 cycles.14 The larger piece of the recovered disk was fractured circumferentially (see arrows “c,” figure 4), which is typical of overstress. About ¼ of the disk outward (toward the rim) of the bore was separated and not recovered. There was a radial fracture of the disk bore at the position shown by arrows “h1” and “h2” in figure 4. Examination of these fractures showed that they were matching overstress separations and therefore accounted for the complete separation of the bore section of the disk. Twenty-four evenly spaced holes are machined in the web area of the disk. Twelve of these holes are known as stress redistribution (SR) holes,15 also referred to as shielding holes in the engine manual. Alternating with these SR holes are 12 slightly larger holes known as tierod holes, through which the tierods are put to clamp the disk to the mating disks and spacers in the complete engine assembly. Figure 5 shows the aft face of the two recovered pieces situated relative to each other by fracture matching. The SR holes are shown by arrows “1” through “9” and arrow “12” in figure 5. The SR hole numbering was arbitrarily begun at the radial fracture plane indicated by arrows “A1” and “A2” in figure 5 and progressed sequentially counterclockwise looking forward around the disk (as shown in figure 5). The missing section of web would have contained SR holes “10” and “11” in the above numbering sequence, and three tierod holes. Scanning electron microscope (SEM) examination established that fatigue cracking originated from numerous pits in the hole wall and progressed radially inboard (toward the center of the disk) from SR hole “1,” approximately 6.9 millimeters (mm) (0.27 inch). SEM examination also showed evidence of fatigue cracking outboard (toward the rim) from SR hole “1” that measured 22.25 mm (0.88 inch). Figure 6 shows the fracture surface containing the primary fatigue crack.

13 AeroThrust Corporation is an FAA-certificated repair station, and was one of the vendors used by ValuJet at that time for the repair and overhaul of JT8D engines. Air New Zealand, (located in New Zealand) also an FAA- certificated repair station, was another vendor used by ValuJet for engine repair and overhaul of its JT8D engines. 14 The cycle life limit for the 7th stage disk SN G78851 was prorated from 20,000 cycles to 18,932 cycles, per P&W procedures, because it had been previously operated in a higher-rated JT8D-15 engine. 15 Holes placed midway between the tierod holes to redistribute the stress in the web area between the tierod holes.

19 Energy dispersive x-ray analysis of the pits on the hole wall revealed cadmium-rich deposits16 with some nickel. Cadmium-rich deposits were also found on the fracture surface adjacent to the pits and hole wall. Visual and SEM examinations of the outboard fracture surface from SR hole “1” showed extensive post-fracture smearing that obliterated most of the microscopic fracture features on the fracture surface. However, some undamaged fracture areas were found that indicated an origin area at the outboard wall of SR hole “1.” Features outside of the smeared region up to a distance of about 3 mm (0.12 inch) showed a granular appearance with no evidence of striation development. At this point, fatigue striation development was noted that continued outboard approximately 22.25 mm (0.88 inch) from SR hole “1.” Striation spacing measurements of the fracture surface of SR hole "1" were attempted but hampered by the smearing in the fracture surface. The striation spacing in the granular type fracture regions near the origin were possibly unresolvable or nonexistent. Striation spacings outside of the granular fracture regions and smearing for the outboard fatigue crack from SR hole “1” averaged about 2 microns (0.002 mm) from about 3 mm to the terminus at 22.25 mm. This indicated that at least 9,500 striations (19 mm/0.002 mm per striation) were present along this fatigue region. Fatigue cracking was also evident radiating outboard from other SR holes, indicated by arrows “4,” “6,” “8,” “9,” and “12” in figure 5. The largest of these fatigue cracks was 5 mm (0.20 inch) outboard from its respective hole. Most of the secondary cracks appeared to initiate at well- defined corrosion pits in the hole wall with the largest and deepest pit measuring 0.01-inch wide at the hole wall and being about 0.003-inch deep. Magnified examination of the cross section of the crack disclosed a surface deposit on the pit cavity wall and hole wall surfaces indicative of the nickel-cadmium plating. Fatigue striations with a fairly uniform striation density of approximately 2.5 microns were clearly apparent near the terminus of the crack from SR hole “4” as well as near the termini of the fatigue cracks from SR hole “1.” A P&W metallurgist indicated that spacings between 10 and 100 microinches (0.254 to 2.54 microns) are realistic spacings expected for low-cycle fatigue cracking in the disk. Low-cycle fatigue cracking propagates from engine operation stresses that occur in flight between each engine start and shutdown (flight cycle), and one striation is created by one flight cycle. The 0.88-inch fatigue crack outboard from SR hole “1” was the longest fatigue region at any of the SR holes. The crack lengths from each side of the hole combined with the diameter of the SR hole (0.410 inch) gave a calculated overall crack length of 1.56 inch for SR hole “1” at the time of disk separation.

16 The disk is plated with a nickel cadmium (Ni-Cad) coating for corrosion protection during original manufacture. It is also required to be chemically stripped and re-plated during certain inspections and repairs.

20 The only evidence of fatigue cracking inboard from an SR hole on the recovered pieces of the 7th stage disk was that at SR hole “1.” The 12th stage HPC disk from the accident engine (which was not damaged in the accident) was examined at the P&W Metallurgical Laboratory in East Hartford, Connecticut, by P&W and Safety Board metallurgists. Several tierod holes in that disk were found with corrosion pits. Examination of a cross section through the pits confirmed that nickel and cadmium had been plated onto the pitted surfaces of these tierod holes. Two additional engines previously owned by THY and sold to ValuJet were available for disassembly and examination of their 7th stage HPC disks by the Safety Board. Both 7th stage HPC disks appeared in serviceable condition with no plating over pitting noted. Three other engines also previously owned by THY and sold to ValuJet had been sent by ValuJet to Air New Zealand for repair. The 7th stage HPC disks on these engines were examined by Air New Zealand engineering for the Safety Board under the supervision and control of the Civil Aviation Authority (CAA), New Zealand, and later at the P&W Metallurgical Laboratory. Each of these disks had been retired because the total time and cycles were near the hour and cycle life limit, and it would have been uneconomical to reinstall the disks and operate them for the remaining hours or cycles before they had to be removed from service. Nickel and cadmium plating over corrosion pitting in tierod and SR holes was confirmed on two of the disks, and not found on the third. No failures of the 7th stage HPC disk on any P&W JT8D engine have been reported since 1975; however, on August 30, 1985, one failure was reported in Cameroon during taxi to takeoff. The cause was never determined because the disk fragments could not be recovered. 1.16.2 Burn Tests of Cabin Furnishings The need for fire retardant cabin furnishings on transport-category aircraft was first addressed by the FAA in 1947. By 1972, FAA regulations required carpets, seats, and interior panels to undergo Bunsen burner flammability tests. Subsequently, the FAA conducted additional research and proposed upgrading these standards by adding toxicity, smoke, and improved flammability criteria. By 1977, there were still no full-scale burn tests to support the proposed rule and standards, and the proposed rule was withdrawn. As a result, the FAA formed the Committee on Special Aviation Fire and Explosion Reduction (SAFER), which conducted full-scale tests and research and made recommendations for fire safety improvements. The technical information developed as a result of these tests provided a standardized method of evaluating the suitability of cabin materials. On April 16, 1985, the FAA issued a notice of proposed rulemaking (NPRM) entitled “Improved Flammability Standards for Materials Used in the Interiors of Transport Category Airplane Cabins,” which became a final rule in 1985. The regulation established new fire test

21 criteria for type certification, required that the cabin interiors of airplanes manufactured after 1985 and used in air carrier service comply with these new criteria, and required that cabin interiors of all other airplanes type certified after January 1, 1958, and used in air carrier service, comply with these new criteria upon the first “general retrofit” of the cabin interior. The accident DC-9 was manufactured before the effective date of the 1985 regulation and therefore any retrofit of fire retardant cabin furnishings was required only in the event of a "general retrofit" by the carrier. Piecemeal replacements of cabin furnishings, except for fire-blocked seat covers, are not required to meet the new flammability standards. The FAA stated that this was based on the adverse economic effect on the airline industry if the industry had to comply with the new standard. Thus, it is reasonable to expect that if an air carrier applied this regulation, as written, an airplane in service for 20 or more years might never be subjected to a “general retrofit.” On August 15, 1995, burn tests of selected pieces of cabin furnishings from the accident airplane were conducted at the Fire Safety Branch of the FAA’s Technical Center in Atlantic City, New Jersey. A relatively undamaged carpet sample, sidewall panel sample, and a seat cover that were collected from the rear of the accident airplane were tested. Testing was conducted in accordance with the standard in effect before 1985, which required the Bunsen burner flammability test. All of the components were directly exposed to the FAA’s Bunsen burner test flame of 1,650 °F (1,500 °F is the minimum requirement) for 60 seconds. No ignition of the materials occurred. Thus, all of the samples met the applicable (pre-1985) FAA test requirements for flammability. 1.17 Additional Information 1.17.1 ValuJet’s Purchase of Turk Hava Yollari (THY) Aircraft, Engines, and Spare Parts 1.17.1.1 Pre-delivery Activities in Turkey In July 1994, ValuJet Airlines became aware that THY had several DC-9-32 aircraft and engines for sale. ValuJet contracted with two independent consultants, who went to Turkey to evaluate the aircraft and related equipment and their records, and to provide information that would assist ValuJet in deciding whether to purchase the aircraft. After receiving input from the consultants, ValuJet decided to execute the purchase. In September 1994, ValuJet contracted with Avionics and Aircraft Systems Engineering Services, Inc. (AAS), to provide aircraft and maintenance engineering assistance, on-site management of the aircraft delivery program, and technical publication services in connection with the acquisition and refurbishment of the THY aircraft. One of the original consultants, who was a vice president at AAS, became the primary manager of the purchase and importation

22 process.17 On October 3, 1994, a formal sales agreement was executed between ValuJet Airlines and THY for the purchase of nine aircraft, five spare engines (including the accident engine, SN 666966), and 4,400 spare parts. Before ValuJet’s acceptance of any engine or aircraft, each was subjected to a ground inspection that included the following: • verification that all records and manuals were being delivered, and that they were complete and current, • a borescope inspection of all mounted and spare engines, • verification that any structural damage had been repaired in full compliance with the Aircraft DC-9 Structural Repair Manual or approved McDonnell Douglas data, • verification of aircraft airworthiness, and currency of U.S. FAA airworthiness directives (ADs) on all aircraft, • verification that cabin configuration changes requested by ValuJet were accomplished by THY before removing aircraft from service by Turkish Airlines, • verification that all mounted engines were “serviceable” in accordance with P&W engine manuals, • verification that P&W Service Bulletins 4127 (noise attenuation) and 2141 (oil dampened No.1 bearing) had been complied with on certain engines, • verification that the aircraft had been on a program in which the fuel tank area was inspected for corrosion and microbiological contamination, and • inspection of the cabin for excessive wear or lack of cleanliness.

17 The consultant who became the primary manager had worked either as an employee or consultant for several operators in the past. While working for these operators, he had at different times been responsible for writing FAA- approved maintenance programs, developing/managing a Part 121 aircraft acceptance program, directing a passenger- to-freighter aircraft configuration conversion program, directing a cockpit/avionics standardization program, developing several large aircraft FAA-approved supplemental type certificates, and developing the guidelines for the DC-9 Structural Inspection Document program for the Douglas Aircraft Company.

23 In addition, each aircraft and the engines mounted on them for their ferry flight to the United States were subjected to a regimented flight test program. According to the consultant, the test flights, which were conducted by a ValuJet-contracted pilot, the AAS representative, and a THY employee, were performed in accordance with the Douglas DC-9-32 Used Production Flight Procedures Manual.18 The sales agreement between ValuJet and THY called for five of the airplanes to be delivered with specific engines installed in specified positions. The remaining four airplanes could be delivered with any of the remaining 13 engines installed in any location. Five of the engines would then be delivered as spares. The borescope inspection, which was conducted as part of the pre-sales agreement discussed above, found that three of the spare engines and one mounted engine needed either turbine blade or guide vane repair before they would be accepted by ValuJet. These four engines were repaired and then tested. Because a test cell was not available, some of the engines in service were removed from operating airplanes so that the repaired engines could be tested on an airplane. Thus, engine SN 666966, which was being operated in line service at the time the consultant arrived in Turkey, was removed from an airplane and became one of the five “spare” engines. According to the AAS representative, the five spare engines were subsequently preserved by THY in accordance with the P&W JT8D engine manual requirements.19 According to the sales agreement between ValuJet and THY, all spare engines were to be certified as serviceable by an FAA-certificated Part 145 repair station before acceptance by ValuJet. ValuJet and THY agreed that the spare engines would be certified as serviceable by the THY repair station and then shipped to the United States with “serviceable tags.”20 According to the consultant, the repair station prepared one of these tags for each spare engine. Entries on the tag for engine SN 666966 describing the work done indicated that it had been removed from an aircraft so that another engine could be installed and that it had been preserved for up to 90 days. The consultant stated that as part of the preshipping process, he cross-checked the SN of each spare engine with its associated tag. According to the technical control director of THY’s repair station engine shop, THY intended that the statement of serviceability and release for return to service on the “serviceable tag” apply to more than just the work listed on the tag (in the case of engine SN 666966, removed from aircraft and preserved), and represented a “full” statement of serviceability. He stated that in

18 This manual provides guidance on performing flight tests in a manner to demonstrate that the aircraft are airworthy and that their systems are fully operational in accordance with their intended use. 19 This preservation process included purging the fuel system with mineral oil, installing desiccant and humidity indicators inside the engine, and covering the intake, exhaust, and exhaust breather outlet with appropriate covers. 20 “Serviceable tags” are a commonly used method for repair stations to attach a written maintenance release containing the information specified in FAR 43.9 to an aviation product to show that it is approved for return to service.

24 his opinion, engine SN 666966 was able to be installed by ValuJet with no further inspections needed, except for a depreservation inspection and any in-house inspections required by ValuJet. According to THY’s technical control director, the tags that had been prepared for all five spare engines were placed into a single large brown envelope and shipped to ValuJet along with the remainder of the aircraft and engine records. The inspector stated that no tags were attached to the engines for fear that they would be lost during shipment. The spare engines were then air shipped to the United States and trucked to ValuJet’s facilities in Atlanta. The AAS consultant stated that because the aircraft had been operated by a foreign carrier, he evaluated the THY maintenance scheduling and recordkeeping system to confirm the validity of the aircraft records and conformity with FAA requirements.21 As part of this process, AAS reviewed all entries in the Aircraft Maintenance Log of each airplane for the last 2 years, or since the last “D” check, whichever came last. AAS also reviewed the records of all mounted engines, spare engines, and major components for the last 2 years, or since the last overhaul. During this review, any entries that could not be accurately determined were translated into English. In addition, other applicable records, such as FAA Forms 337 (Major Repair or Alteration), AD and engine disk status records, and certain shop records associated with the repair of spare parts, were translated into English. According to the AAS representative, during this process, he reviewed the records to verify a history of compliance, and compared compliance statements recorded in the maintenance records to process documents executed at the time of the compliance action. As part of this process, and in accordance with the guidance provided in FAA Order 8300.10, the accuracy of AD compliance records was verified by spot checks of the aircraft. According to the AAS representative, all requested documentation was provided, and he determined that the recordkeeping system was valid. The consultant also confirmed that the THY aircraft had been maintained in accordance with the following documents/programs: McDonnell Douglas Aircraft Maintenance Planning Document, DC-9/MD-80 Corrosion Prevention and Control Document, DC-9/MD-80 Aging Aircraft Service Requirements Documents, and DC-9/MD-80 Life Limited Parts Document. At the time of the purchase, these documents/programs were being used to maintain DC-9 aircraft already operating in the ValuJet Airlines fleet; and these documents/programs became the basis for phasing the THY aircraft into the ValuJet maintenance program. When all pre-acceptance inspections were completed on an aircraft, it was deregistered in Turkey22 and issued a “Certificate of Airworthiness For Export” by the Republic of Turkey

21FAA Order 8300.10 (Airworthiness Inspector’s Handbook), Bulletin A-92-04 (Current FAA Policy Regarding Aircraft Records), dated 7/17/92, states that if an aircraft is being transferred from a foreign airline, it may be necessary to evaluate the foreign operator’s maintenance and recordkeeping system to ensure the source validity of the records. The bulletin provides a number of recommendations for determining the validity of the records, which then become the basis for confidence in the current status of life-limited parts and AD compliance. 22 Deregistration is required by FAR 47.37. See also FAA Order 8130.2C, Chapter 6, Section 2.

25 Ministry of Transport and Communications. Each aircraft was then issued an FAA Temporary Registration and an FAA Ferry/Environmental Permit by the ValuJet FAA principal maintenance inspector (PMI). Each of the nine aircraft was then flown to Lake City Municipal Airport, Lake City, Florida, where Aero Corporation began the process necessary for the aircraft’s return to service in the United States. 1.17.1.2 Post-delivery Activities in the United States A designated airworthiness representative (DAR) was contracted by ValuJet’s consultant to issue the U.S. Standard Airworthiness Certificate for the nine aircraft. The DAR had no involvement with the inspection, acceptance, delivery, or return to service of the five spare engines and the approximately 4,400 spare parts purchased by ValuJet.23 While at ValuJet’s facility in Atlanta, engine SN 666966 was stored inside but did not undergo humidity inspections at 30-day intervals as required by the P&W engine manual. According to ValuJet’s Manager of Engineering, the inspections were not performed because ValuJet’s general maintenance manual at the time did not include specific instructions for conducting humidity inspections of stored engines. Since this accident, stored-engine inspection procedures, consistent with P&W’s instructions, have been incorporated into ValuJet’s powerplant and maintenance specifications. Engine SN 666966 was subsequently shipped to the AeroThrust Corporation in Miami, Florida, where P&W Service Bulletin 4127 (installation of noise attenuation equipment) was complied with on January 21, 1995. The engine was then shipped to the Dee Howard Corporation in San Antonio, Texas, on January 27, 1995, for installation on an aircraft. According to the receiving and tagging instructions contained in ValuJet’s general maintenance manual, when a serial-numbered component is received by ValuJet, the component is to be tagged with the company’s equipment transfer record (ETR). Applicable information regarding the item’s serviceability from the vendor’s tag or manufacturer’s certification is transferred to the ETR, and copies of the ETR, along with the original vendor’s tag, are forwarded to ValuJet’s Aircraft Records Department. One copy of the ETR remains attached to the component, and installation and removal data are entered on this record when the component is installed on an aircraft. According to ValuJet’s general maintenance manual, Dee Howard’s inspection procedures manual, and the aircraft maintenance agreement between ValuJet and Dee Howard, engine SN 666966 should have been shipped to Dee Howard with a partially executed ETR attached. The serviceable component tag would remain in ValuJet’s Aircraft Records Department. The engine could then be installed by Dee Howard based upon the certification of airworthiness inherent in the signature in block #10 of the ETR. However, according to Dee Howard’s manager

23 Title 14 CFR Part 21.175 requires airworthiness certificates for aircraft. An airworthiness certificate is not required for unmounted engines or spare parts.

26 of quality assurance, engine SN 666966 arrived at Dee Howard without a ValuJet ETR or a vendor’s tag from THY. The only document that arrived with the engine was the “Partial Repair Item” tag executed by AeroThrust Corporation during the completion of P&W Service Bulletin 4127 (installation of noise attenuation equipment). According to the manager of Dee Howard’s quality assurance, because the engine arrived without documentation of its serviceability, Dee Howard requested that the on-site ValuJet quality control inspector provide certification for the engine. Dee Howard was informed by this inspector that a serviceable component tag had been issued by an FAA Part 145 foreign repair station. The ValuJet quality control inspector on site (at Dee Howard) then executed ETR #14419 certifying the airworthiness of the engine. The investigation revealed that he did not review engine records or a serviceable tag before doing so. On February 9, 1995, after 106 days in preservation, engine SN 666966 was removed from preservation to be installed in the No. 2 (right) position on N908VJ, the accident airplane, on March 5, 1995. The engine and airplane were subsequently operated by ValuJet until the accident on June 8, 1995. 1.17.2 1991 Overhaul/Inspection of 7th Stage HPC Disk by THY Maintenance records obtained from ValuJet indicated that the 7th stage HPC disk had been overhauled by THY during the time period from March 1991 to August 1991, and that the disk had accumulated 18,477 hours and 11,907 cycles at that time. The records obtained from ValuJet pertaining to the 1991 overhaul were limited to build records24 and logbooks documenting the times and cycles of the engine, including the accident disk. However, no records were found documenting each step of the overhaul of each individual disk, including what kind of an inspection was performed on the 7th stage disk.25 (See appendix C for an example of this sort of documentation, typically used in the industry.) THY personnel stated that all of the records that pertained to the airplanes and engines purchased by ValuJet were transferred to ValuJet. The Director of THY’s overhaul shop26 stated in a meeting with Safety Board staff that the repair facility had performed a magnetic particle inspection (MPI)27 on the disk but during that

24 Build records are documents specific to each engine in which all component part numbers, SNs, certain measurements, fits, and clearances or other special requirements are recorded in order of assembly. 25 Such documents, typically known as “shop travelers” or “process sheets,” break down the overhaul and inspection process of a component into individual tasks, which include excerpts or references to the appropriate manual, service bulletin, or job instruction card and a signature block for the technician or inspector performing the task. (Hereinafter referred to as “process sheets” or similar documentation.) 26 The Director of THY’s overhaul shop was contacted by the Safety Board after the Safety Board obtained information that P&W had conducted an engine shop maintenance review of THY in December 1991. See Section 1.17.5.1 later in this report for more details regarding that review 27 Magnetic particle inspection (MPI) is a nondestructive method of detecting cracks and other defects in ferromagnetic materials such as iron or steel. The inspection consists of magnetizing the part with high amperage DC electricity thus creating magnetic lines of flux, then applying or immersing the part in a liquid containing

27 time had only inspected the tierod holes, not the SR holes, because the P&W engine manual only required the tierod holes to be inspected. (See section 1.17.3 for more discussion on this.) In response to the Safety Board’s inquiry about whether THY’s repair facility had documented each step of the inspection and overhaul process, the Director of THY’s overhaul shop provided the Safety Board, as a sample, a small card (slightly larger than a 3" by 5" card) that had been used during the overhaul of a disk in 1995. The card had part identification and operation data on one side, and handwritten notes about the repairs that had been done on the other side. The card listed repairs for removing and replacing the nickel cadmium plating; however, it did not list fluorescent magnetic particle inspection (FMPI),28 which is a required inspection during disk overhaul, according to the P&W JT8D engine manual (see next section of this report). The type of card displayed by the Director of THY’s overhaul shop was not found in any engine record package for the failed engine. In a letter to Safety Board staff dated June 18, 1996, the Director of THY’s overhaul shop stated that an FMPI inspection had been used in July 1991 to inspect the 7th stage HPC disks in JT8D engines. He stated that Turkish Airlines has had FMPI capability since the early 1970s and improved the capability in 1978 and 1985. He further stated that per Turkish Airlines’ procedures in 1991, nickel cadmium plating would not have been removed from a JT8D HPC disk if there were 0.003-inch (or less) deep corrosion pits on the surface of the disk, provided such pits were not located in the tierod/pin holes, the bore area, and/or snap diameters. He further stated that it was necessary, in July 1991, to inspect for and remove surface corrosion pits from within the SR holes only if their depth was over 0.003 inch, based on the fact that the P&W engine manual did not list SR holes as a critical inspection area and “it did not even show them in Figures 801 and 802 of the referenced section, until subject section of the Manual was revised after June 1995.”

ferromagnetic particles in suspension. The ferromagnetic particles align themselves with the magnetic lines of flux on the surface of the part forming a pattern. If a discontinuity is present in the material on or near the surface, opposing magnetic poles form on either side of the discontinuity and the pattern is disrupted, forming an “indication.” The indication assumes the approximate shape of the surface projection of the discontinuity; however, indications are more visible when the defects are approximately perpendicular to the magnetic lines of flux. As a result, it may be necessary to magnetize in more than one direction to reveal defects aligned parallel to the magnetic lines of flux. The effectiveness of the MPI also depends on the flux density or field strength at the surface of the part when the indicating medium is applied. As the flux density is increased, the sensitivity increased. However, excessively high flux densities may form non-relevant indications. 28 FMPI is similar to an MPI except the ferromagnetic particles held in suspension are fluorescent such that surface flaw indications luminesce under black light inspection.

28 1.17.3 Pratt & Whitney Guidance on Engine Overhaul/Inspection The 7th stage compressor disk inspection instructions from the P&W JT8D Engine Manual, Section 72-36-41, revision dated February 1, 1991, state that the following disk features must be inspected very carefully: bore, tierod holes, snap diameter (front and rear) fillet radius, pin holes, areas on the rim that touch blades, and for very early disks, balance flanges and balance flange rivet holes. Graphic illustrations in the instructions (listed as figure 801 in the P&W instructions) show the various features of the disk that were named in the text. (See figure 7.) The P&W engine manual specifies that for area 7 of the P&W figure 802 (see appendix D), which is depicted as a tierod hole, no unrepaired damage can be allowed in any hole, or within 0.125 inch of the edge of the hole on adjacent surfaces, and that damage can be repaired to a depth of 0.005 inch by blending. The instructions further indicate that damage up to 0.003 inch is acceptable in the web area of the disk without blending. The cross-section of the 7th stage disk in P&W figure 802 depicts the tierod holes, but does not have the hidden lines,29 which would depict the smaller diameter SR holes behind the tierod holes, or a separate cross-section of the disk, just through the SR holes. P&W JT8D Engine Manual Section 72-36-41, lists steps for overhauling the 7th stage HPC disk (see appendix D) (steps that are incorporated onto “process sheets” or similar documentation provided by airlines and Part 145 repair stations). The following summarizes the overhaul steps:

1. Measure and record front and rear snap diameters, tierod hole

centerline in relation to rear snap diameter, and web thickness in area contacted by spacers.

1. Strip existing nickel-cadmium plate.
2. Remove any residual rust after stripping nickel-cadmium.
3. Dimensionally inspect after removing old nickel-cadmium plate and

any previous plating repairs, measure front and rear snap diameters and tierod holes.

1. Visually inspect all areas of each disk for pitting, galling, and other

defects.

1. Magnetic particle inspect per Task 72-36-00-24-000, Section 72-36-

00, Inspection 02. [This section and inspection refers to

29 Hidden lines, which depict the edges of a smaller feature located behind the larger feature, are shown on orthographic projections as dashed lines.

29 TIEROD HOLES ~i.pws,91.E,,T.i:.- Pratt & Whitney JT8D ENGINE (PN 481672 - RESTRUCTURED) COMPRESSOR DISK, STAGE 7 - INSPECTION-01 EXAMINE THE AREAS THAT TOUCH THE BLADE FOR GALLING P T T R 2 R R 1’ RIM AREA ADJACENT TO PIN HOLES PIN HOLES / RIM FILLET RADIUS R\ FILLET RADIUS ‘

BORE L–H0206 1. 0.125 Inch Maximum. 2. Electrical Contact Permissible Only In This Area. No Burning, Pitting, or Selective Attack Permitted. Important Inspection And Electrical Contact Areas Figure 801 (Task 72-36-41-22-000) 72-36-41 INSP-01 Page 803 EFF : -ALL FEB 1/93 000 Figure 7—P&W JT8D Engine Manual -- Compressor disk, stage 7-Inspection 01

30 fluorescent magnetic particle inspection.] Note: Inspection is necessary after stripping even though disk may have been inspected previously.

1. Make all necessary blending and machining repairs prior to plating.
2. Mask areas not to be plated leaving areas exposed that require

restoration or new plating.

1. Nickel plate areas not masked.
2. Machine nickel plated areas as required.
3. Nickel-cadmium plate entire disk.
4. 17.4

FAA Regulations Regarding the Return to Service of the Spare Engines Federal regulations require that the following specific information be entered in the maintenance record of any item on which work has been performed: a description of the work performed; the date the work was completed; the name of the person who performed the work; and the signature, certificate number, and kind of certificate held by the person who approved the work. The signature constitutes the approval for return to service only for the work performed, and this maintenance record entry must be made before any person can return an engine to service. The regulations further state that the holder of a repair station certificate may approve an aircraft, airframe, engine…for return to service.30 The regulations also provide that before an engine can be returned to service it must have been inspected by a qualified inspector and that the maintenance facility must certify in the maintenance record that it is airworthy with respect to the maintenance performed. The qualified inspector must be an individual who has shown by experience as a journeyman that he or she understands the inspection methods, techniques, and equipment used in determining the airworthiness of the article concerned.31 Common industry practice is to include the following statement, or words to this effect, on the serviceable tag:32

30 See 14 CFR Section 43.5 (Approval for return to service after maintenance, preventative maintenance, rebuilding, or alteration.); Section 43.9 (Content, form, and disposition of maintenance, preventative maintenance rebuilding, and alteration records.); and Section 43.7 (Persons authorized to approve aircraft, airframes, aircraft engines, propellers, appliances, or component parts for return to service after maintenance, preventative maintenance, rebuilding, or alteration.); and Section 145.51 (Privileges of repair station certificate.). 31 Title 14 CFR Part 145.59 (a) and (b) (Inspection of work performed.). 32 This language is required in maintenance entries for major repairs or alterations. (See Appendix B to FAR Part 43, Par. (b)(4).) Not all serviceable tags document major repairs or alterations.

31 The aircraft, airframe, aircraft engine, propeller, or appliance identified above was repaired and inspected in accordance with current FAA regulations, and is approved for return to service. Pertinent details of the repair are on file at this repair station under Order No.____. FAA Advisory Circular 145-3 (Guide for Developing and Evaluating Repair Station Inspection Procedure Manuals (IPMs)) Appendix F, Figure 34 (Final Inspection and Release to Service) provides this sample language for a repair station IPM: “Aircraft components, appliances, and other items, other than complete aircraft, repaired or overhauled as authorized by the repair station specifications, will be returned to service through the use of a maintenance release preprinted on the serviceable parts tag described by this section of the manual.” With respect to the scope of work authorized by foreign repair stations, the regulations state that a certified repair station may, with respect to U.S.-registered aircraft, maintain or alter aircraft, airframes, powerplants, propellers, or component parts. The regulations further state that after major repair or alteration, a certified repair station (domestic or foreign) can return to service only articles that have been worked on according to technical data approved by the FAA Administrator.33 Federal regulations require that domestic repair stations keep records of work performed for at least 2 years; foreign repair stations are exempt from these recordkeeping requirements.34 However, foreign repair stations are required to keep records of maintenance performed on U.S.- registered aircraft containing basic details and whatever additional information the FAA Administrator finds necessary regarding U.S.-registered aircraft.35 The regulations do not specify how long such records must be kept. However, the FAA generally specifies a time period in the repair station’s inspection procedures manual. FAA Order 8130.2C (Airworthiness certification of aircraft and related products) Section 3 (aircraft engines, propellers, materials, parts and appliances), paragraph 220, states that the person who returns an imported product to service (in accordance with 14 CFR Part 43.5) must ensure that the product: • has not been modified, changed, or damaged subsequent to the time of export certification; • complies with all FAA ADs;

33 Title 14 CFR Part 145.73 (Foreign repair stations—scope of work authorized.) and Part 145.51 (Privileges of certificates.). 34 Title 14 CFR Part 145, Subpart B and C. 35 Title 14 CFR Section 145.79.

32 • is installed in accordance with FAA-approved design data; • is found to be in condition for safe operation; and • is accompanied by the necessary maintenance documentation. 1.17.5 THY Repair Station THY operates a repair station that is certified by both the FAA and the Director General of Civil Aviation (DGCA) in Turkey. The repair station maintains and overhauls airplanes that are part of the Turkish Airlines fleet as well as airplanes and engines operated by foreign and domestic operators. Authority granted by the Turkish DGCA allows the repair station to overhaul JT8D engines for the THY fleet. THY receives its authority to overhaul JT8D engines for U.S.- registered airlines from the FAA. According to its FAA Air Agency Certificate, first issued in 1974, and its Repair Station Operations Specifications, which are periodically reissued and revised by the FAA, THY has been an FAA-certificated 14 CFR Part 145 Subpart C repair station since March 8, 1974, with the following ratings: airframe, powerplant, instrument, accessory, radio, and limited specialized service. Before 1986, its operations specification limitations listed Airframe Class 4 (all-metal large aircraft) and Powerplant Class 3 (turbine engines), without further limitation to specific airframes or engines. The revised operations specification issued on November 21, 1986,36 listed “Limited Ratings”37 for Airframe to include: Airbus Industries A300 and A310 series, Boeing B707/720, and B727 series, Fokker F28 series, McDonnell Douglas DC-9 and DC-10 series, and other airplanes; and for Powerplant to include: General Electric CF6 series, P&W JT3D, JT8D, JT9D, and PT6A series, and various Rolls Royce engines. A note under the powerplant limited ratings stated the following: LINE MAINTENANCE FOR OTHER ENGINES IN THE CLASS 3 CATEGORY. AUTHORIZATION IS LIMITED TO MINOR INSPECTIONS, REMOVAL/ INSTALLATION OF ACCESSORIES AND COMPONENTS, ADJUSTMENTS, MINOR REPAIRS, MINOR ALTERATIONS ONLY. WORK TO BE ACCOMPLISHED IN ACCORDANCE WITH THE MANUFACTURER’S TECHNICAL DATA OR OTHER PROCEDURES ACCEPTABLE TO THE [FAA] ADMINISTRATOR.

36 See appendix E for examples of THY’s repair station operations specifications. 37 Limited ratings are ratings issued to repair stations for the performance of maintenance on particular makes and models of airframes, powerplants, propellers, radios, instruments, accessories, and/or parts. (8300.10 (Chapter 161, Section 1, paragraph (8) FAR 145.33.))

33 The Safety Board was unable to obtain the THY Repair Station Operations Specifications that were applicable between November 1989 and October 1991. The Board did examine the operations specifications in force for the period ending November 23, 1989, and the period beginning October 29, 1991. Both of those operations specifications included limited ratings for P&W JT8D and other engines and contained the same note, quoted above: “Line maintenance for other engines in the Class 3 category. Authorization is limited to minor inspections….” The statement addressing line maintenance of other engines in the Class 3 category remained unchanged until August 4, 1994, when the entire note under powerplant limited ratings was revised to read: POWERPLANT AUTHORIZATION FOR THE AFOREMENTIONED ENGINES INCLUDES MAINTENANCE AT ALL LEVELS UP TO AND INCLUDING OVERHAUL IN ACCORDANCE WITH CURRENT MANUFACTURER’S MAINTENANCE MANUALS OR OTHER FAA APPROVED DATA. MAINTENANCE (EXCLUDING OVERHAUL) IS LIMITED TO ENGINES INSTALLED ON AIRCRAFT LISTED IN THE AIRFRAME RATINGS AND FURTHER LIMITED TO THOSE MAINTENANCE FUNCTIONS AS AUTHORIZED BY THE CURRENT MANUFACTURER’S MAINTENANCE OR FAA APPROVED DATA. Under “Specialized Service,” the October 29, 1991, Repair Station Operations Specifications listed the following nondestructive testing methods: ultrasonic; magnetic particle per MIL-I-25135 and MIL-SAD-6868, as revised; eddy current per MIL-SAD-1537A, as revised; penetrant-visible dye and fluorescent dye per MIL-SAD-6866, as revised; and radiographic x-ray per MIL-SAD-453C, as revised. THY maintains that it was authorized by the Turkish DGCA to operate a turbine-engine repair station and to overhaul P&W JT8D and other engines. However, THY maintained that it “…clearly understood from operations specifications of Turkish Airlines that THY [was] authorized to make any kind of repair and overhaul of JT8D engines. Turkish Airlines repair/overhaul certification for JT8D engines has never been discontinued between 1974 and 1996.” Following the accident, by memorandum dated November 16, 1995, the Safety Board was advised by the FAA’s Director of Flight Standards Service (AFS-1) that the THY repair station had not been decertified at any time since the 1974 issuance of its original repair station certificate. However, he reported that THY’s Class 3 powerplant rating had been changed to limited powerplant, excluding overhaul, on November 21, 1986, and that the FAA’s “files do not contain any information relative to this change other than the certificates themselves.” AFS-1 reported that THY was again authorized to overhaul JT8D engines on August 4, 1994. The PMI who was assigned surveillance responsibilities at THY from 1992 to 1995 stated that although THY retained the capability to conduct JT8D overhauls after 1986, THY had no need for FAA-granted overhaul authority from the FAA until 1994, because of inactivity involving U.S.-registered airplanes. Reauthorization of foreign operations specifications was, at that time, dependent on annual activity in support of U.S.-registered airplanes. He stated that he

34 was confident that THY understood its 1986-1994 limitation because he received a phone call from THY in 1994 requesting that THY’s FAA repair station authority be expanded to include overhauls on various engines. According to the PMI, the PMI, along with a three-man team, subsequently conducted a 3-day inspection that resulted in the amended THY repair station operations specifications dated August 4, 1994, which authorized overhauls of CF6, JT3D, JT8D, JT9D, and PT6A series engines. The amended operations specifications also added D-check authorizations for Airbus Industries A310, A340, Boeing 707/720, 727, 737, Fokker F28, McDonnell Douglas DC-9 and DC-10, and other airplanes. THY maintains that the FAA never informed it of any change to its authority to overhaul JT8D or other engines and that THY has never requested such a change to its operations specifications. THY reported to the Safety Board that it has always maintained and overhauled P&W engines in accordance with manufacturer maintenance and overhaul manuals and standards and that this is also a requirement for certification as a repair station by the Turkish DGCA. 1.17.5.1 Pratt & Whitney Engine Shop Maintenance Review During the investigation, the Safety Board discovered that P&W engineering personnel had conducted a Turkish Airlines JT8D Engine Shop Maintenance Review in December 1991. THY provided a copy of the review to the Safety Board. The report noted that the THY shop had been set up to handle a maximum of 50 JT8D shop visits per year and that it was averaging approximately 35 shop visits per year. The P&W review contained conclusions/ recommendations, including the following: • Conclusion: Turkish Airlines’ shop personnel are experienced and know the procedures for cleaning, stripping, plating, and other repairs; however, new personnel sometimes enter the shop, and procedures are sometimes revised. Because the Engine Manual is written in English and presents a generic view of each procedure, Turkish Airlines should prepare process sheets that 1) describe the specific processes and repair procedures in Turkish, 2) describe actual shop equipment used at Turkish Airlines, and 3) require shop personnel to sign each significant step of the procedure as that procedure is completed. Process sheets will help avoid many repair problems and will confirm that the complete, up-to-date procedure has been accomplished. These sheets can also be used in a computerized parts tracking system. • Recommendation: Prepare specific, Turkish-language process sheets for parts sent into the shop. • Conclusion: Many of the parts racks are dirty. Clean parts can become dirty enroute to the FPI [fluorescent particle

35 inspection]/FMPI area, which can lead to contamination of the expensive FPI penetrants. • Recommendation: Periodically steam clean the parts racks. • Conclusion: The job card that routes the parts through FPI and FMPI does not specify the process or have a sign-off line for the inspectors to see that the work has been done. The only indication that the parts have been FPI inspected is a green wire attached to the parts. Several parts were found with green wires attached without any evidence of background fluorescence that is typical of parts that have been processed through the FPI line. • Recommendation: Specify the FPI or FMPI SPOP on the work order with a sign-off line for the inspector to permit the inspection process to be verified and the inspector for that part to be identified. 1.17.5.2 FAA Inspections of THY Repair Station The Safety Board staff reviewed FAA Program Tracking and Reporting System (PTRS) records and correspondence between the FAA and THY to determine the frequency and level of FAA oversight of the THY repair station. The PTRS records, which were only available from June 1993 to the present, typically reflected one to three visits per year with mostly favorable but some adverse comments that required corrective action. These records were not as detailed as the 1991 P&W JT8D Engine Shop Maintenance Review, but included checklists and indicated relatively comprehensive inspections of the facility. Additional correspondence pertaining to FAA oversight and recertification of THY addressed the periodic renewals of the THY Air Agency Certificate and Repair Station Operations Specifications and provided the results of FAA inspections in connection with those renewals. The Safety Board found that the renewals followed FAA inspections of the THY facility after 1- or 2-year intervals. The FAA required correction of the listed inspection discrepancies in advance of reissuance of repair station certificates. For example, in its September 5, 1991, letter to THY, the FAA PMI advised the repair station: Turkish Airlines NDT [non-destructive testing] area must be audited by the company and new procedures implemented. Calibration of black lights and calibration meter must have records of calibration by Mil-Std. Also X-ray must have a means of checking the film after X-ray by use of the penetrameters or by using a densitometer to measure density. This office recommends the supervisor of the NDT shop receive addition[al] factory training in all areas of NDT to update personnel assigned. Eye examination per Mil-Std-410 are (sic) required for all NDT personnel.

36 Corrective action of these discrepancies was required within 60 days and, according to FAA correspondence, was accomplished by THY in advance of the reauthorization of the operations specifications, which occurred on October 29, 1991. The FAA PMI with oversight responsibility for THY from 1992-1995 stated that renewals were sometimes extended to 2-year intervals because of FAA staffing shortages; he reported that in 1992, his office (International Field Office, Frankfurt, Germany) had only six persons to inspect, certify, and surveil all of the Part 145 Repair Stations in Europe; as the number of such stations grew, his office grew to its 1995 staffing level of 20 inspectors. He stated that he was personally responsible for 21 repair stations in 1992. The FAA correspondence indicated that reauthorization of the operations specifications was in part dependent on annual activity in support of U.S.-registered airplanes. The application dated August 31, 1991, stated that the specifications were to be reauthorized despite no such work in the previous 3 years. The correspondence indicated that the THY repair station activity involving U.S.-registered airplanes was quite limited in other years as well, although contracts with two U.S. air carriers have increased that activity since 1992. A four-person FAA team performed an inspection of the THY repair station from June 27 through 29, 1995. This inspection, which, according to the FAA, had been planned before the accident, was to recertify Turkish Airlines’ Part 145 repair station certificate. As a result of the accident, the team assigned two personnel to focus on areas relating to the accident investigation. A memorandum documenting the inspection indicated that the inspection team included the PMI, another maintenance inspector, an avionics inspector, and an engineer from the Aircraft Certification Office in Brussels, Belgium. According to the memorandum, the inspection team focused on two issues: (1) FAA recertification of THY’s Part 145 certificate, and (2) information regarding turbine engine maintenance. The memorandum stated that based on the audit reports of the engineer and one of the maintenance inspectors, it appeared that the repair station’s methods, techniques, and practices were satisfactory at the time of the inspection. In the maintenance inspector’s report, which was attached to the memorandum, the inspector commented about THY’s compressor disk repair capabilities. He stated that the correct P&W maintenance manual was available and that the disk repair procedures used were P&W’s instructions. According to the inspector’s report, the technicians could read and speak English and were familiar with the process for corrosion identification and removal. The work station in the visual inspection area was reported to be well lighted and the tools for blending surface damage were appropriate. The report also stated that in the plating shop, the procedures were available in both English and Turkish. The engineer’s report, which was also attached to the memorandum, indicated that THY overhauled its own engine compressor disks after a maximum of 4 years, compared with the FAA Airworthiness Directive (AD) 94-20-01 requirement for overhaul at a maximum of 10 years. According to the report, this action was taken because THY had purposely left a plated tiebolt, of

37 the same material and plating as a disk, outside for 1 year and found that it developed corrosion under the plating. One of the inspectors’ reports attached to the memorandum stated that none of the overhaul records for the failed engine were available at THY at the time of the FAA inspection. 1.17.6 ValuJet’s Flight Attendant Training Program Federal regulations38 require that certain emergency drills be conducted by crewmembers, including flight crewmembers, during initial training and recurrent training at 24- month intervals. The regulations state, in part, that crewmembers shall perform emergency exit drills, operating each type of emergency exit in both normal and emergency modes and that the drills shall replicate the actions and forces required in the deployment of the emergency evacuation slides. FAA Air Carrier Operations Bulletin (ACOB) 8-76-6, “Guidelines for Crewmember Training on Aircraft Tailcones and Approval of Tailcone Training Devices,” dated July 13, 1992, allowed air carriers to train their DC-9/MD-80 crewmembers by having an instructor or trainee operate the tailcone release handle while other trainees observed. ACOB 8-76-6 was current at the time that ValuJet was certificated on October 21, 1993, and it was current on August 30, 1995, when the FAA was queried by Safety Board investigators regarding the ACOB’s status. On January 26, 1996, the FAA issued Flight Standards Handbook Bulletin 96-02, “Guidelines for Crewmember Training on Aircraft Tailcones and Approval of Tailcone Training Devices.” This bulletin set forth acceptable means of approving tailcone training devices and required that each trainee actually operate the appropriate mechanisms to ensure evacuation through the tailcone exit. ValuJet Airlines’ flight attendant training program, which included crewmember exit drills, was approved by the FAA in a letter dated September 23, 1993, to ValuJet’s Vice President of Marketing. ValuJet’s flight attendant training syllabus in effect at the time of the accident, and which also was approved by the FAA, did not address tailcone exit drills. However, ValuJet’s Manager of Inflight Training stated that exit drills were conducted on an actual airplane, during which crewmembers simulated pulling the tailcone release handle, rather than actually operating the tailcone exit. Additionally, passenger entry door and service door training was conducted on ValuJet airplanes, during which bungee chords were attached to the doors to simulate the forces of the emergency evacuation slide being pulled from its bustle. According to ValuJet, pilots participated in the same drills as the flight attendants. After this accident, ValuJet acquired a tailcone exit training device and trained all active flight attendants with the use of this device by the end of August 1995.

38 Title 14 CFR Section 121.417.

38 Several errors in ValuJet’s DC-9 flight attendant manual were noted by Safety Board investigators. For example, although the correct operation of the tailcone exit was described, an illustration for an MD-80 aft entrance door was used rather than an illustration for the DC-9-32 airplane operated by ValuJet. Also, a diagram for the tailcone interior jettison handle stated “Note Tailcone is normally jettisoned using the passenger aft entrance door emergency handle.” This referred to MD-80 aircraft and not the DC-9-32 airplane. Another diagram depicted ValuJet’s airplanes as having both a tailcone exit door and an exit hatch, although ValuJet does not operate any DC-9 aircraft with a hatch. The flight attendant manual also contained incorrect information, or lack of information, regarding flight attendant flotation equipment, passenger safety announcements, flight attendant operation of the cabin emergency lighting switch, and use of the water fire extinguisher. The Manager of Inflight Training, who was hired in March 1995, stated that the flight attendant manual was in the process of being revised at the time of the accident. ValuJet issued a new flight attendant manual on November 11, 1995. (See Appendix F.) The new manual does not contain the errors found in the previous version. 1.17.7 Safety Board Recommendations Subsequent to the Accident Following the accident, on July 6, 1995, the Safety Board issued three safety recommendations to the FAA regarding the failure of the accident engine, the wording of P&W repair guidance, and FAA guidance to maintenance personnel. The Safety Board stated in its recommendation letter that the metallurgical examination of the 7th stage HPC disk from the ValuJet engine showed that the failure was caused by fatigue cracking that had originated at a corrosion pit in an SR hole. The letter stated that there was evidence that the corrosion pit had been plated over during an overhaul of the disk in 1991, and that, additionally, it appeared that the size of the corrosion pit exceeded the allowable limits at the time of the overhaul. The letter further stated that examination of the fatigue crack revealed a minimum of 7,000 to 8,000 fatigue striations. The letter concluded that, assuming that each striation represented one “flight cycle,” based on the 4,433 flight cycles accumulated since the last inspection, the crack would probably have been detectable by non-destructive testing or by visual inspection at the time that the engine was last overhauled. As a result, the Safety Board issued the following urgent Safety Recommendation A-95- 71 to the FAA: Issue an Airworthiness Directive to require the inspection of Pratt & Whitney JT8D engine high pressure compressor steel disks that were last overhauled and maintained by Turk Hava Yollari of Turkey prior to reaching 3,000 cycles since that last overhaul and inspection. Special attention should be given to the potential for corrosion pitting or cracks in the shielding [SR] holes in 7th stage high pressure compressor disks.

39 On September 14, 1995, the FAA reported that on July 10, 1995, a Telegraphic Airworthiness Directive (AD), T95-15-51, was issued that was applicable to certain P&W JT8D engines containing HPCs that had been inspected by THY. The AD required that those engines containing any 7th through 12th stage HPC disks that had accumulated 2,900 or more cycles on the effective date of the AD or 100 cycles in service after the effective date of the AD, whichever occurred first, be inspected in accordance with the P&W JT8D engine manual for evidence of corrosion pitting and cracks. According to P&W, no cracks were found in any of the inspected disks. The Safety Board responded that the action satisfied the intent of the recommendation, which was then classified “Closed—Acceptable Action.” The Safety Board also stated in its recommendation letter that it noted that P&W engine manuals provided overhaul facilities with inspection guidance, allowable limits for damage, and repair procedures. The Safety Board stated that the inspection material was quite detailed but that it could be difficult to understand. It was noted that such misunderstandings could be magnified when translating the instructions from English into another language. Consequently, the Safety Board issued Safety Recommendation A-95-72, asking the FAA to: Modify the wording of the inspection and damage limits provided in the Pratt & Whitney manuals and service bulletins for JT8D high pressure compressor steel disks to prevent any misunderstanding of the amount of damage allowed and the procedures required for the repair and return to service of the disks. On September 14, 1995, the FAA reported that it was working with P&W to modify the engine manual as requested. On November 20, 1995, the Safety Board classified this recommendation “Open—Acceptable Response.” By letter dated June 4, 1996, the FAA reported that the JT8D engine manual was revised to clarify the amount of damage that is allowed and the procedures required for the repair and return to service of the disks. However, the Safety Board has noted that the revised inspection sections for the 10th, 11th, and 12th stage HPC disks incorrectly show those disks as having SR holes. In addition, the inspection section for the 13th stage HPC disk, which is made of a non-magnetic nickel alloy, was revised to add an FMPI, which would only be appropriate for parts made of alloys that can be magnetized. Consequently, pending further modifications of the JT8D engine manual to correct these inaccuracies, Safety Recommendation A-95-72 remains in an “Open—Acceptable Response” status. The Board also issued Safety Recommendation A-95-73, which asked the FAA to: Provide additional guidance to designated airworthiness representatives and aviation maintenance personnel to ascertain whether facilities that have repaired or overhauled aircraft, aircraft engines, and aircraft equipment submitted for acceptance in the United States held the proper Federal Aviation Administration certificates at the time the work was accomplished.

40 In either event, the guidance should include the actions to be taken to ensure compliance with the Federal Aviation Regulations. On September 14, 1995, the FAA reported that a flight standards information bulletin (FSIB) would be issued. The FSIB would remind FAA inspectors and designees of their responsibility to ensure that aircraft, aircraft engines, propellers, and other parts imported or accepted into the United States meet the requirements of the FAA regulations and follow established FAA policy and guidance. The FAA subsequently issued FSIB for Airworthiness (FSAW) 96-14, effective July 5, 1996. The Safety Board found the FSAW responsive to the intent of Safety Recommendation A-95-73, and the recommendation has been classified “Closed— Acceptable Action.”

41

1. ANALYSIS
2. 1

General The flightcrew was properly certified and trained for the flight, and was in compliance with the Federal regulations on flight and duty time. The flight attendants had completed ValuJet’s FAA approved flight attendant training program in existence at the time of the accident. The airplane was properly certificated and operated in accordance with applicable Federal regulations. The aircraft certification process followed by the DAR was thorough and complete in that all required aircraft and record inspections were performed. The DAR’s airplane certification process was not considered relevant to the accident sequence. Visual meteorological conditions prevailed, and weather was not a factor in the accident. 2.2 Uncontained Engine Failure An uncontained failure of the right engine occurred at low speed, early in the takeoff roll. The rapid decrease in the EPR of the right engine recorded on the DFDR was the result of the uncontained failure of the right engine. As a result of the uncontained failure, engine shrapnel penetrated the fuselage, severing the right engine main fuel line. Pressurized fuel sprayed into the cabin near the aft lavatory and was most likely ignited by sparks generated by steel engine fragments contacting steel galley equipment in the cabin. Postaccident examination of the failed right engine revealed that the 7th stage HPC disk was fractured. Metallurgical examination of the two major pieces of the disk that were recovered revealed fatigue cracking in the SR hole “1” location in the larger piece of the 7th stage disk. The combined fatigue crack lengths and hole diameter accounted for an overall crack length of 1.56 inches at SR hole “1.” Also, the crack at SR hole “1” contained the largest outboard propagating fatigue crack and the only inboard propagating fatigue crack found on the disk. This combined fatigue crack length is consistent with a critical crack length expected to produce separation of the disk under normal operating conditions. Also, because this fatigue crack was the only one on a radial fracture plane that went completely through the section between the bore and rim, it was likely the primary fracture initiation area. Although the fracture was heavily damaged, analysis of fatigue striation measurements in the outboard fatigue region from SR hole “1” indicated that a crack of about 12 mm (approximately ½ inch) existed in the disk at the last reported overhaul in 1991, or 4,430 engine cycles before the disk failure.39 Thus, the Safety Board concludes that a detectable crack40 existed

39 Fatigue striation measurements in the outboard fatigue region from SR hole “1” gave estimated uniform spacings of 2 microns between 10.5 mm and 15.5 mm crack lengths and an estimated uniform 2.5 micron spacing from 15.5 mm crack length to the fatigue terminus at 22.25 mm from the hole. These measurements were used to estimate the approximate crack length at the last inspection reported as 4,430 engine cycles before disk failure. The fatigue striation spacings of 2.5 microns and less were consistent with fatigue striation development from low cycle fatigue, which equates to one striation for each flight cycle. The final stages of fatigue cracking were used to calculate the amount of cracking to account for the last 4,430 striations, as follows: (22.25 mm minus 15.5 mm) or 6.75 mm of crack propagating at 0.0025 mm (equivalent to 2.5 microns) per cycle yields 2,700 cycles for this region; (4,430 cycles

42 in an SR hole in the 7th stage HPC disk of engine SN 666966 when the disk was overhauled by THY in 1991, and therefore detectable by FMPI or MPI. Fatigue crack initiation at SR hole “1” and others was linked to corrosion pits, some as deep as .003 inch, in the SR holes that were shown to be plated over with nickel cadmium (see figure 8). Although the investigation could not determine when the pits were plated over, the plating over of the pits indicates that they existed in the disk during the overhaul inspection by THY in 1991, as that would have been the last time before the accident that the disk would have been off the engine. Plating over pitted surfaces also existed in several tiebolt holes on the 12th stage disk of the accident engine. 2.3 Overhaul Procedures by THY The size of the fatigue crack and the plating over corrosion pits in the SR holes indicate that during the overhaul of the 7th stage disk by THY in 1991, a proper inspection was not performed. The Director of THY’s overhaul shop initially contended that because the P&W engine manual did not specifically refer to the SR holes, only the tierod holes needed to be addressed in the overhaul inspection. Later in the investigation, the Director indicated that an inspection41 of the SR holes had been performed but to a different standard than that for the tierod holes--one that permitted scattered surface damage up to 0.003-inch deep to go unrepaired. If the THY repair station did perform an inspection of the disk, including the SR hole “1,” but did not repair the damage or reject the part because the damage was limited to corrosion pits of 0.003 inch or less as the Director of the THY overhaul shop contends, this raises some concerns. First, the P&W engine manual states that no unrepaired surface damage is allowed in any hole or within 0.125 inch of the edge of a hole on adjacent surfaces. If THY was uncertain about how this statement applied to the SR holes, THY should have discussed this with P&W technical representatives to clarify any uncertainties. More importantly, however, a properly performed inspection should have detected a crack estimated to be ½-inch long at the time of the THY overhaul in 1991. During an MPI inspection, the entire disk is magnetized, and magnetic particles are applied to the disk. The SR holes would inescapably be included in this type of inspection because of their proximity to the

minus 2,700 cycles) or 1,730 cycles at 0.002 mm (2 microns) per cycle yields 3.46 mm; therefore, a crack of 6.75 mm plus 3.46 mm equals 10.21 mm to propagate the last 4,430 cycles. Because this crack had an overall length of 22.25 mm at failure of which the last 10.21 mm occurred since last inspection, then approximately (22.25 mm minus 10.21 mm) or 12.04 mm of crack length existed at the last inspection. 40 A 12-mm crack extending the depth of SR hole “1,” and extending to the front and rear faces of the disk would have a probability of detection of 100 percent when inspected with either FMPI or MPI according to the current Nondestructive Testing Information Analysis Center nondestructive evaluation capabilities data book. 41 It is unclear what type of inspection THY performed, based on conflicting statements by the Director of THY’s overhaul shop. In a meeting with Safety Board officials, he claimed that an MPI inspection was performed. However, subsequently, in a letter dated June 18, 1996, he stated that an FMPI was performed.

44 tierod holes, and the ½-inch crack would have been readily visible, not only inside the SR hole, but along the surface of the disk. During an FMPI inspection, the entire disk is not only magnetized, but is also covered in a solution containing fluorescent iron particles that would further highlight any defects. Accordingly, the Safety Board concludes that THY did not perform a proper inspection when the disk was overhauled in 1991. Had the THY repair station accomplished a proper inspection of the 7th stage high compressor disk of engine SN 666966, the crack would probably have been detected, the part rejected, and consequently, the accident may have been avoided. Because of the Director of THY's overhaul shop’s earlier comments that the SR holes were not inspected because the P&W engine manual did not specifically reference the SR holes, the Board examined the manner in which the manual addressed the inspection of the holes in the disk. The P&W engine manual presents a figure of the 7th stage disk, that shows only 12 holes (rather than the 24 holes that actually exist) and refers to them as tierod holes; the figure does not show the 12 SR holes. However, the 24 holes on an actual disk are placed so close together that it is virtually impossible to inspect tierod holes without noticing the SR holes. Textual material in the manual does indicate that 0.003-inch damage can be left without blending. However, the manual also states that no damage can exist in or near any hole. As previously noted, the FAA is working with P&W to revise P&W’s JT8D engine manual in response to the Board’s Safety Recommendation A-95-72. The Safety Board concludes that although the P&W engine manual could have presented this information in a way that would have made it clearer that the SR holes in the 7th stage disk had to be inspected and could not contain any damage, the lack of clarity was not a contributing factor in the failure of the disk because the manual did clearly state that no damage was permissible in or near any hole. The Safety Board attempted to determine why a proper inspection was not performed on the 7th stage disk. In the report of its 1991 shop review of the THY repair facility, P&W indicated that because the engine manual was written in English, THY should prepare “process sheets” in Turkish that describe the specific process and repair procedures and actual shop equipment to be used, and that require signatures of appropriate shop personnel for each significant step of the procedure as that procedure is completed. P&W indicated such documentation was not then being used by the THY repair station, and following the 1995 engine failure, none has been located for the 1991 inspection/overhaul of the 7th stage disk. Further, the report of the 1991 P&W shop review also pointed out that the job card that purportedly routed the parts through the FMPI inspection did not specify the process or have a signoff line. Also, the review indicated that several parts had been tagged with green wires indicating that the parts had been subjected to an FPI when they could not have received such an inspection, as no residual fluorescent background material was present on the parts. From this evidence, the Board concludes that the THY repair station was not using detailed documentation to provide step-by- step guidance at the time of the 1991 overhaul and inspection of the 7th stage disk. The fact that the disk in this accident had plating over pitting and numerous cracks suggests that it had not received a proper overhaul or proper inspection for some time. Given that

45 there is no historical evidence that the 7th stage HPC disk of the JT8D has been prone to developing cracks and ruptures, it is likely that a low or even zero rate of detection of cracks in this disk would create an expectation that no cracks would be detected. This could lead to complacency in the inspection process. This potential for complacency in the FPI/FMPI process, coupled with the failure to detect the crack in this case, raises questions regarding the adequacy of training procedures for such inspections. The 1991 P&W shop audit noted that THY’s FPI/FMPI inspectors were trained by one another, and recommended that THY develop a formal training program or send the inspectors to a nondestructive testing school to become qualified and that they be retested every 1 to 2 years to ensure that they maintained their practical knowledge and theory. Because no additional information about THY’s FPI/FMPI training was available for that time period (1991 and prior), the Safety Board was unable to further investigate or analyze this issue. However, the adequacy of FPI/FMPI training procedures will be thoroughly investigated and addressed in the Safety Board’s ongoing investigation of the Delta Air Lines MD-88 uncontained engine failure in Pensacola, Florida.42 Nonetheless, despite the possibility that there may have been deficiencies in THY’s training for FPI/FMPI, detailed documentation that specified each individual step in the inspection and overhaul process and required signatures could have instilled in THY personnel a greater sense of accountability and increased the likelihood that each step would be accomplished. Further, if the disk was inspected only on one side, or if it was not inspected at all, it is likely that detailed documentation that was required to be signed would have increased the likelihood that these failures would not have occurred. The Safety Board concludes that use of such detailed documentation would have increased the likelihood that the disk would have received a proper inspection and that the crack would have been detected; thus, the absence of such detailed documentation contributed to the accident. Although detailed documentation would have increased the likelihood of the performance of a proper inspection, the Board is concerned that because of the dependency on human performance, a visual inspection, even enhanced (such as an MPI, FMPI, or FPI), may be an inappropriate inspection procedure when there is a low probability (expectation) of detecting a crack. The Board is examining this issue in its ongoing investigation of other uncontained engine failures and will address this issue further in its reports on those investigations. 2.4 Adequacy of FAA Recordkeeping Requirements. The Safety Board’s review of applicable regulations addressing the type and detail of records that are required to be retained by all repair stations indicates that FAA guidance in this area is insufficient and vague. Regulations governing maintenance practices in general (FAR 43.3) require that maintenance record entries contain only “a description (or reference to data acceptable to the [FAA] Administrator) of work performed.” Regulations governing repair stations (FAR 145.61) require that repair stations keep “adequate records of all work [that they do]” but do not define what constitutes “adequate records.” Regulations governing air carrier

42 DCA-96-MA-068, MD-88, Pensacola, Florida, 7/6/96.

46 maintenance programs (FAR 121.380) require carriers to keep certain “records” (including records of the last complete overhaul of each airframe, engine, propeller, rotor, and appliance until the work is superseded by work of equivalent scope and detail) but do not define what sort of information, and what degree of detail, those “records” should contain. FAA Order 8130.2C, paragraph 220, indicates that “necessary maintenance documentation” must accompany an imported product before it can be returned to service, but there is no definition or clarification in paragraph 220 of what is considered “necessary maintenance documentation.” Although it is possible that this is intended to refer to the maintenance records required to be kept by an owner or operator, as specified in FAR 91.417,43 paragraph 219, “Identification and Marking,” no such intention is explicitly stated in paragraph 220. In any event, because the records specified in FAR 91.417 are general maintenance records containing only very basic information, they are an insufficient basis on which to conclude that an item is airworthy, even assuming that is what is meant by “necessary maintenance documentation.” Although THY was alerted by P&W in 1991 that the lack of “process sheets” in the Turkish language represented a deficiency in its operation, it was not until June 1995 that such documentation (referred to as “traveler forms” by the Director of the THY overhaul shop) was used by the repair station. Further, although the documentation that the THY repair station began to use in June 1995 represents a significant improvement, those forms do not contain the level of detail contained in similar documentation used by some U.S. repair facilities. For example, the new THY “traveler forms” are generic to any disk and are not specific to any engine; that is, there is no form specific to the 7th stage HPC disk of a JT8D engine. Further, there is no reference on the form to specific sections of the engine maintenance manuals (or more detailed job instruction cards) that describe detailed instructions or references needed to complete the task. This type of information would not only help to ensure a proper overhaul or prevent a missed inspection, but would also help to assure the proper application of the overhaul and inspection procedures. Another advantage to detailed documentation is that, if retained, it provides a much better basis for verifying the serviceability (or airworthiness) of engines/components being returned to service. The Safety Board concludes that “process sheets” or similar documentation of sufficient detail to permit a complete determination of the work needed to be done and of the work that has been done is necessary for a comprehensive maintenance program to ensure the continued airworthiness of aircraft, engines, and components. Such a system of documentation could be described in an advisory circular that sets forth one acceptable method for complying with the maintenance recordkeeping requirements. Therefore, the Safety Board believes that the FAA should revise the applicable regulations and provide specific guidance on the documentation to be used and kept during inspections and overhauls, including “process sheets” or similar detailed documentation for all certificated repair stations.

43 FAR 91.417 requires each owner or operator to keep certain records, including records of maintenance, alteration, and inspections (including a description of the work performed, the date of completion, and the signature and certificate number of the person approving the aircraft for return to service); total time in service of airframes, engines, propellers, and rotors; records showing current status of life-limited parts; time since last overhaul of items required to be overhauled on a specified time basis; inspection status of the aircraft; status of airworthiness directives, including method of compliance; and copies of forms required for major alterations.

47 Although foreign repair stations are not subject to the same recordkeeping requirements as domestic repair stations, the Safety Board recognizes that most repair stations will voluntarily keep adequate records of work done and believes that the records available in this case met the minimum standards in existence at this time and were adequate for the consultant to conclude that the recordkeeping system was valid. Moreover, the Safety Board recognizes that even if THY had been subject to the same recordkeeping requirements as domestic repair stations, it still would not have been required to keep records of the 1991 disk overhauls because the engine was installed on a non-U.S. (Turkish) registered aircraft. Nonetheless, the Safety Board concludes that foreign repair stations should be subject to at least the same recordkeeping requirements as domestic repair stations and believes that the FAA should revise 14 CFR Part 145 to require Subpart C foreign repair stations to adhere to the same recordkeeping requirements of 14 CFR Part 145.61. 2.5 Maintenance Release and “Serviceable” Tags for Aircraft Components Although the tag on engine SN 666966 described only that the engine had been preserved for up to 90 days, and FAA regulations state that the signature on a maintenance record entry constitutes approval for return to service only for the work performed, the technical control director of THY’s repair station engine shop indicated that THY intended that the tag act as a full statement of serviceability and release for return to service based on a complete records review, rather than just the last maintenance action. The Safety Board is aware that “serviceable” tags are routinely used by industry, vary considerably in format, and are sometimes relied upon as assurance of overall airworthiness. However, there appears to be no clear regulatory basis for such an assurance. The Safety Board concludes that the industry practice of using serviceable tags without a clear understanding of their purpose can result in the misinterpretation of the intent of these tags. The Safety Board believes that the FAA should require that “serviceable tags” be used to return engines and other component parts to service, that they be in a prescribed format (perhaps in the format of FAA Form 8130-3) and that when there is a change of ownership, and certainly upon importation, the approval for return to service attest to the overall airworthiness of the part. The tag should reflect that a complete and thorough review of records, including “process sheets” of the last overhaul, has taken place. In the absence of such records, an overhaul of the part should be required when there is a change in ownership. 2.6 THY’s Authority to Overhaul JT8D Engines The Safety Board received conflicting interpretations of THY’s authority to overhaul JT8D engines. (Clearly, the engine involved in this accident was not overhauled under U.S. authority, but under Turkish authority.) In a memorandum dated November 16, 1995, responding to a Safety Board inquiry, the Director of the FAA’s Flight Standards Service (AFS-1) stated that THY did not have JT8D engine overhaul authority from 1986-1994. However, THY maintains that its Air Agency Certificates and associated Repair Station Operations Specifications authorized THY to overhaul JT8D and other engines during those years.

48 In the Safety Board’s view, the FAA 1986 Repair Station Operations Specifications can reasonably be read to indicate that THY’s Limited Class 3 powerplant rating (authorizing all levels of maintenance, including overhaul) permitted overhaul of certain engines, including the JT8D, and that only line maintenance was authorized for Class 3 engines that were not listed on the operations specifications. Because of the Safety Board’s difficulty in understanding the FAA’s contrary interpretation of this authorization, the Safety Board requested, in a letter to the FAA dated May 23, 1996, a clarification of the FAA’s position on this issue. In a meeting with Safety Board staff on July 10, 1996, the FAA reiterated its position that THY did not have authority to overhaul JT8D engines for U.S.-certificated operations from 1986-1994. The FAA cited a phone call from THY in 1994 that requested expansion of the operations specifications to include engine overhauls. The Board remains convinced that the language of THY’s operations specifications does not readily comport with the FAA’s position, and the Safety Board is concerned that confusion about the extent of the authority of other repair stations may exist. Thus, the Safety Board believes that the FAA should review the Air Agency Certificates and Repair Station Operations Specifications of all repair stations and ensure that language in the operations specifications clearly indicates the extent of the repair stations' authority. 2.7 Emergency Lighting and Public Address System When the airplane quickly filled with smoke after the engine failure, the pilots were able to complete only the first three items on the evacuation checklist before they exited the airplane. Further attempts by the pilots to complete the checklist could have exposed them to unnecessary risk. Because the fourth item on the checklist was not completed—moving the emergency light switch to the “ON” position—emergency lights in the cabin were not illuminated during a portion of the evacuation. Fortunately, in this accident, the lack of emergency lights in the cabin did not preclude a successful evacuation. Several factors affected the timely and successful evacuation. Perhaps the most important was the ratio of exits to occupants. Six of the seven emergency exits were opened quickly (two floor-level exits at the front of the cabin and four overwing exits) and used by all 57 passengers. Additionally, the airplane had about half of its full compliment of passengers, and except for the aft flight attendant, no occupants were injured or incapacitated, which would have slowed the evacuation. Finally, the cabin interior remained intact and no debris hampered access to the exits. The pilot’s first attempt to order an evacuation was not successful because electrical power to the PA system was lost when the engines were shut down. After the captain selected emergency electrical power (which caused the emergency lights to turn off), power was restored to the PA system and the captain successfully communicated the evacuation order. Although the delay in communicating the evacuation order did not adversely affect the evacuation, this accident again highlights the need for an independent power source for PA systems in transport-category airplanes.

49 The Safety Board has issued three safety recommendations over the years advocating an independent power source for PA systems. The first recommendation (A-74-111) was issued following a 1974 Safety Board special study44 that examined 10 U.S. carrier accidents in which emergency evacuations occurred. The Board concluded in that study that PA systems are often used to initiate emergency evacuations but that they are not always available when aircraft power is interrupted. From 1974 to 1982, the FAA informed the Safety Board on several occasions that the issue was being evaluated for consideration in rulemaking action. However, in a letter dated August 18, 1982, the FAA indicated that it had determined that the cost of compliance with such a rule would outweigh any identifiable safety benefits. In a letter dated February 14, 1983, the Safety Board classified Safety Recommendation A-74-111 “Closed—Unacceptable Action.” In 1979, the Safety Board issued Safety Recommendation A-79-64 as a result of its investigation of a DC-8 accident in Portland, Oregon.45 The recommendation urged the FAA to expedite the release of an operations review program notice that contained the 1974 recommendation for an independent power source for the PA system. The FAA subsequently issued an NPRM that contained the recommendation for an independent power source. Shortly thereafter, as a result of its investigation of a DC-8 evacuation in Phoenix, Arizona, on December 29, 1980,46 the Board issued Safety Recommendation A-81-130, urging the FAA to adopt promptly the rule proposed in the NPRM. The FAA, however, subsequently determined that the cost of the proposed rule would outweigh the safety benefits and withdrew the NPRM. Safety Recommendation A-81-130 was therefore classified “Closed—Unacceptable Action.”47 In May 1986, the FAA published an NPRM that would require an independent power source for PA systems in newly manufactured transport-category airplanes. In its comments on that rulemaking activity, the Safety Board supported the intent of the proposed rule but noted that the rule should also provide for the retrofit of all airplanes currently in service. On October 27, 1989, the FAA amended 14 CFR Part 121.318(g) to require that transport-category airplanes manufactured on or after November 27, 1990, be equipped with an independent power source for the PA system. The FAA did not include a provision for the retrofit of airplanes currently in service, as requested by the Safety Board. Following the accident, the Douglas Aircraft Company modified the evacuation checklist by placing the activation of the emergency light switch at the beginning of the checklist. However, the Board is concerned that given the importance of the first three items on the

44 National Transportation Safety Board. 1974. Safety Aspects of Emergency Evacuations from Air Carrier Aircraft. Special Study NTSB/AAS-74/3. Washington, DC. 45 National Transportation Safety Board. 1979. United Airlines, Inc., N80820, Portland, Oregon, December 28,

1. Aircraft Accident Report NTSB/AAR/79/7.

46 National Transportation Safety Board. 1981. Evacuation of United Airlines DC-8-61, Sky Harbor International Airport, Phoenix, Arizona. 47 Safety Recommendation A-79-64 had been classified “Closed—Acceptable Action” on April 6, 1981, based on the FAA’s issuance of an NPRM.

50 checklist, placing the emergency light switch first may not be the safest course of action. Further, had the PA system had its own independent source of power as the Board has asked for in the past, then the pilots would not have had to select emergency power, and the emergency lights would have remained lighted during the evacuation of the airplane. Communication is vital to a successful evacuation of any transport-category airplane, regardless of the date of manufacture. This accident again highlights the need for pilots to be able to communicate with passengers via the PA system without first turning off power to emergency lights. The Safety Board therefore believes that the FAA should require that all transport-category aircraft manufactured before November 27, 1990, be retrofitted with a PA system capable of operating on an independent power source. 2.8 ValuJet’s Flight Attendant Training Program The investigation of this accident disclosed deficiencies in ValuJet’s flight attendant training program, including emergency drills training, and the FAA’s inadequate oversight of this program. Although these deficiencies did not affect occupant survivability in this accident, they could adversely affect the outcome of future emergency situations. ValuJet’s flight attendant training program had been approved and the flight attendant manual had been accepted by the FAA principal operations inspector (POI) for ValuJet in September 1993. However, contrary to the requirements of 14 CFR Part 121, which require, in part, that crewmembers operate each type of emergency exit in its normal and emergency modes, ValuJet’s flight attendant training syllabus did not include hands-on operation of a tailcone release handle. The Safety Board has previously addressed this specific issue. Following the ground collision of a DC-9 and a B-727, and the subsequent fire on the DC-9 at Romulus, Michigan, on December 3, 1990,48 a flight attendant and a passenger, both of whom died of smoke inhalation, were found inside the DC-9 tailcone. As a result of its investigation of that accident, the Safety Board issued Safety Recommendation A-91-6 , which asked the FAA to immediately require operators of DC-9/MD-80 series airplanes to include in their flightcrew and flight attendant training programs hands-on training on the operation of the tailcone release handle in DC-9/MD-80 airplanes using actual airplanes or FAA-approved simulators. In response to this recommendation, the FAA issued Air Carrier Operations Bulletin (ACOB) 8-76-6, “Guidelines for Crewmember Training on Aircraft Tailcones and Approval of Tailcone Training Devices,” on July 13, 1992. The ACOB allowed air carriers to train their DC-9/MD-80 crewmembers by having an instructor or a trainee operate the tailcone release handle while other trainees observed. On January 6, 1993, the Safety Board classified Safety

48 National Transportation Safety Board. 1991. Northwest Airlines, Inc. Flights 1482 and 299 Runway Incursion and Collision at Detroit Metropolitan Airport/Wayne County Airport in Romulus, Michigan, on December 3, 1990. Aircraft Accident Report NTSB/AAR-91/05. Washington, D.C.

51 Recommendation A-91-6 “Closed—Unacceptable Action” because the Safety Board continued to believe that it was necessary for flightcrews and flight attendants to receive hands-on experience with every exit that they may be required to operate during an emergency evacuation. Following this accident, the FAA, on January 26, 1996, issued Flight Standards Handbook Bulletin No. 96-02, “Guidelines for Crewmember Training on Aircraft Tailcones and Approval of Tailcone Training Devices.” This bulletin sets forth acceptable means of approving tailcone training devices and ensures that trainees operate the mechanisms needed to ready the equipment for emergency evacuation, i.e., “each trainee must actually operate the appropriate mechanism to ensure evacuation through the tailcone exit.” As a result of the Safety Board’s accident investigation, ValuJet purchased a tailcone training device to ensure that flight attendants receive the required training. As of August 31, 1995, all active ValuJet flight attendants had completed the Tailcone Mock-up Drill exercise. The Safety Board is concerned, however, that the deficiencies in the flight attendant training program and the flight attendant manual raise serious questions about the adequacy of the FAA’s review of the program and the manual before approval and acceptance by the FAA in September 1993. Although the deficiencies noted in this accident were subsequently addressed by the air carrier, the Safety Board believes that the FAA should emphasize to its POIs the importance of thoroughly reviewing flight attendant training programs before approving them and manuals before accepting them. The investigation revealed that all four overwing exits were opened by passengers before the aircraft came to a complete stop. This is contrary to the ValuJet flight attendant training manual, which states that an evacuation should not be initiated until the aircraft has come to a complete stop. However, there is no indication that the flight attendants would have been able to prevent the passengers from opening the exit. Although the Safety Board concludes that there were no negative consequences in this case, the Safety Board is concerned that such premature actions may adversely affect safety and will continue to monitor this issue. 2.9 In-Lap Children over 2 Years Old The investigation determined that one child more than 24 months old was listed as a lap child, despite Federal regulations that require all passengers more than 24 months old to be restrained during takeoffs and landings. The Safety Board has long been concerned about the inadequacy and enforcement of this regulation and, in the last several years, has identified at least six accidents and one enforcement action in which children more than 2 years old were unrestrained because they were held in someone’s lap. The ages of these children ranged from 26 months to 5 years old. During the Safety Board’s public hearing following the 1989 DC-10 accident in Sioux City, Iowa, the Safety Board questioned the Air Transport Association (ATA) about the methods used by air carriers to ensure that all occupants are properly restrained. The ATA representative stated that it was “an uncertain art” and that because airlines were a “service industry,” airline

52 representatives would only question a passenger “if they felt that the casual observer could determine that the child was much larger and probably over two.” According to FAA testimony at that public hearing, enforcement of this regulation depends on an FAA inspector observing that the child is more than 2 years old. One inspector discovered a child who was 5 years old being held on a lap; the inspector initiated enforcement actions.49 The available evidence suggests that the FAA may only be enforcing this regulation when an egregious violation occurs. The Safety Board continues to strongly believe that restraints should be available for all occupants, regardless of age. However, although the Safety Board does not agree with the existing regulation, until such time as restraints are required for all occupants, the Safety Board believes that the FAA needs to provide guidance on how to implement its requirement that occupants who are older than 2 years of age be restrained during takeoffs and landings. 2.10 Notification of Flightcrew of Cabin Fire Although the right engine fire warning light illuminated, pilots received information that they had an engine fire from other pilots, and air traffic control personnel asked if emergency equipment was needed, the most timely and unambiguous information that there was a fire inside the airplane was provided by the flight attendants. The flight attendants, however, did not follow ValuJet’s procedure that required the use of the interphone six-chime emergency signal to inform the cockpit of the fire. Because of the need for a flight attendant to retrieve a cockpit key from its storage area in the galley before being able to unlock the cockpit door, use of the six-chime signal would probably have been the faster way to notify the cockpit about the fire. However, the Safety Board has some concerns regarding the use of the interphone as the sole means of notifying the cockpit of an onboard fire. In an emergency situation, the cockpit crew may be too busy with other emergency tasks to immediately answer the interphone. In fact, the Safety Board has investigated accidents in which the flight attendant’s interphone calls were not answered.50 In this particular instance, however, it was fortunate that one of the flight attendants had her own cockpit key and thus was able to quickly notify the flightcrew about the fire. The Safety Board is concerned that having only one cockpit key available and stored in the galley may not allow a key to be readily accessible to all flight attendants in an emergency. Also, relying solely on the six-chime emergency signal to be answered by the flightcrew in the cockpit when they may be preoccupied with other emergency procedures and tasks could result in the flightcrew not becoming aware as soon as possible that a fire exists in the cabin. The Safety Board concludes that all flight attendants should be able to quickly access the cockpit when appropriate.51 Therefore, the Safety Board believes that the FAA should require that each flight attendant have a cockpit key in his/her possession at all times while on duty.

49 The FAA has advised the Safety Board of only one enforcement action in response to the Safety Board’s 5/29/96 request to the FAA to provide a list of all enforcement actions related to in-lap infants. 50 NYC-86-FA-076, L-1011, Jamaica, New York, 2/15/86; DCA-96-MA-029, B-747, Jamaica, New York, 12/20/95. 51 Subsequent to this accident, ValuJet provided a cockpit key to all of its flight attendants.

53 2.11 Fire Retardant Cabin Furnishings The aircraft involved in this accident did not meet current regulations regarding flammability standards for materials used in the interiors of transport-category airplane cabins nor was it required to do so. The Safety Board has long been concerned with the FAA’s interpretation that new standard fire retardant cabin furnishing materials should be only required in the case of a “general retrofit.” Airplane owners and operators are allowed to continue to perform piece-meal replacement of cabin furnishings using existing stocks of fire retardant parts that do not meet the 1985 standards. As the regulation is currently worded, an airplane in service for 20 or more years might never be subject to a “general retrofit.” During the Safety Board’s investigation of the 1991 runway collision of a B-737 and a Metroliner at the Los Angeles International Airport,52 it was documented that the B-737, which was manufactured before the effective date of the FAA 1985 standards, was not required to be, nor was it, equipped with upgraded fire retardant cabin furnishings. Of the 22 killed on board the B- 737, 20 succumbed as a result of the inhalation of toxic smoke that was generated by the burning cabin furnishings. The Safety Board subsequently issued Safety Recommendation A-91-116, which asked the FAA to “Prohibit the use, after a specified date, of cabin materials in all transport-category airplanes that do not comply with the improved fire safety standards contained in 14 CFR 25.853.” On March 2, 1992, the FAA responded that it had evaluated this safety issue and had determined that in the case of the Los Angeles accident, it was unlikely that improved materials would have resulted in improved survivability. The FAA letter further indicated that it was not economically feasible to implement such a requirement. No further action was taken by the FAA, and the Safety Board ultimately classified the recommendation “Closed—Unacceptable Action” on September 19, 1994. On January 6, 1993, the Government Accounting Office (GAO) submitted to the Congress a report on the status of how the airlines were progressing with installing more fire-resistant cabin materials in in-service airplanes. 53 The GAO report, stated the following, in part: In establishing the stricter flammability standards, FAA anticipated that almost 85 percent of the fleet would comply by 2000 and indicated that it would consider proposing a mandatory retrofit requirement if all airlines did not meet the standards

52 National Transportation Safety Board. 1991. Runway Collision of USAir Flight 1493, Boeing 737, and Skywest Flight 5569, Fairchild Metroliner, Los Angeles International Airport, Los Angeles, California, February 1,

1. Aircraft Accident Report NTSB/AAR-91/08. Washington, D.C.

53 “Slow Progress in Making Aircraft Cabin Interiors Fireproof” Report to Congressional Requesters. General Accounting Office, GAO/RCED-93-37, January 6, 1993.

54 as anticipated. At the beginning of 1992, about 11 percent of the over 4,200 aircraft in the fleet complied with the standards. Although the number of newly manufactured aircraft meeting the standards will increase each year, no airline has replaced or plans to completely replace the interior components of aircraft that were in-service on August 19, 1990 (in service aircraft). As a result, 45 percent of the aircraft fleet is expected to be operating with cabin interiors not meeting the latest flammability standards by the end of the decade. In fact, under the current practice of replacing aircraft, the entire fleet is not expected to comply with the stricter flammability standards until 2018. The total cost to the airlines to modify aircraft not meeting the standards would be several billion dollars and average over $1 million per aircraft. Although costs can be reliably estimated, more uncertainty exists in reliably estimating the potential lives saved and their value because airline accidents occur infrequently and unpredictably, and no consensus exists on the value of a human life. FAA estimated that 9 to 16 lives could be saved each year if all aircraft met the stricter flammability standards. If the Department of Transportation’s (DOT) current value of $1.5 million for a human life were used to extrapolate a value for the potential fatalities avoided, then up to $110 million could potentially be saved by modifying aircraft to meet the standards. However, one or two significant accidents could result in the loss of hundreds of lives and, depending on how high a value was used for a human life, the potential savings could be much higher. Almost all aircraft that currently do not meet the flammability standards will undergo some type of routine heavy maintenance inspection by the end of the decade, providing airlines the opportunity to modify cabin interiors. However, airlines infrequently replace entire cabin interiors. Although a portion of the interior components is removed during a heavy maintenance inspection, airline officials told GAO that the components not meeting the standards are usually refurbished and reinstalled, rather than replaced with components that meet the standards. Industry practice is to replace a worn-out component with one that meets the standards if it is necessary to purchase a new component. However, this piecemeal replacement of individual components will likely not significantly reduce the hazards posed by a post-crash fire. As a result of its report, the GAO recommended that the Secretary of Transportation direct the FAA Administrator to reassess whether to issue a regulatory requirement mandating a specific date for all aircraft in the fleet to comply with the latest flammability standards for cabin interiors. Such a reassessment should compare the cost-effectiveness of retrofitting aircraft to meet the standards with other actions that could improve the overall safety of the U.S. aircraft fleet. In response to this recommendation, the FAA reassessed its earlier cost-benefit analysis and again concluded that mandatory retrofit of improved cabin materials would not be cost beneficial, and thus, mandatory retrofit was not warranted.

55 The Safety Board concludes that the ValuJet accident in Atlanta again illustrates the merit of the Board’s 1991 recommendation. This accident demonstrates the importance of the current standards and the need for existing aircraft to be brought up to these standards as quickly as possible. Consequently, the Safety Board believes that the FAA should prohibit the use during any type of replacement, after 1997, of cabin materials in all transport-category airplanes that do not comply with the current fire safety standards contained in 14 CFR 25.853. Furthermore, the FAA should amend 14 CFR Part 121 to prohibit, upon a transfer of the aircraft from one certificate holder to another, or by January 1, 2001, whichever occurs first, the operation of airplanes with cabin materials that do not meet the requirements of 14 CFR Part 25.853. 2.12 ValuJet Flight Attendant Uniforms The FAA provides guidance to airline passengers in a brochure titled, “Fly Smart” (U.S. Department of Transportation, Federal Aviation Administration, ASP-200, 94/002). This brochure, among other things, addresses appropriate attire for passengers when flying. The brochure instructs travelers to wear “sensible” clothing, such as clothes made of natural fabrics, and recommends long sleeves and trousers that fully cover arms and legs. The aft flight attendant who received the most serious injuries was wearing shorts and a short-sleeved shirt. Had she been wearing attire similar to that recommended in “Fly Smart,” she may not have been burned. Therefore, the Safety Board believes that the FAA should issue an operations bulletin recommending that POIs advise their air carriers to disseminate FAA safety guidance on airline passenger attire to their flight attendants. 2.13 Quality of CVR Recording The recording of the CVR installed on the accident airplane was considered to be a recording of only fair quality, in that many words were unintelligible, primarily because of the ambient noise in the cockpit. Although the quality of recording did not affect the determination of the causal factors in this accident, the Safety Board is concerned that the investigation of future accidents involving airplanes with similarly equipped CVRs could be impeded by unintelligible dialogue on the recording. The Safety Board has long been concerned about the quality of CVR recordings, as reflected in the following safety recommendation, which the Board issued to the FAA in June 1987: Amend 14 CFR Parts 23 and 25 to require that all newly manufactured aircraft and new cockpit voice recorder installations be designed such that an uninterrupted recording from the boom or mask microphones and headphones for each flight crewmember’s position and from an area microphone can be made on dedicated channels of the CVR. On those aircraft requiring only two flight crewmembers, the unused channel should record the passenger address audio signal when available. A sidetone shall be produced only when the transmitter or interphone is selected, and, in addition, all audio signals received by hand-held microphones shall be

56 recorded on the respective crewmember’s channel when keyed to the “ON” position. (A-87-88) 54 In support of that recommendation, the Safety Board noted in its letter to the FAA that the Board had found the performance of CVR installations in which the audio signal from the boom microphone of each flight crewmember is continuously recorded on a dedicated channel, often referred to as a “hot mic,” to be far superior to the standard cockpit area microphone (CAM), which is typically mounted on the cockpit overhead panel and picks up ambient noise. A CAM was installed on the ValuJet accident airplane. The Safety Board reached that conclusion after the investigation of several accidents/incidents involving both U.S.-registered and foreign-registered airplanes equipped with CVR “hot mics.”55 The Safety Board stated in its letter to the FAA that, in fact, the “hot mic” has proven to be a most significant technological improvement in CVRs and that the level of improvement far surpasses any technological improvement that could be achieved by state-of-the-art recording or signal processing equipment. In contrast, the Safety Board noted that the quality of the audio signal recorded by the standard CAM can generally be described as fair, which requires considerable time and effort to produce a transcript, and which frequently can result in unintelligible dialogue. Recent Safety Board accident investigations have continued to highlight the improved quality in recordings from CVR “hot mics.” 56 These improvements have long been recognized by other aviation authorities. The Civil Aviation Authority of the United Kingdom has required CVR “hot mics” since 1974 on all aircraft registered in the United Kingdom. The adoption of CVR “hot mic” standards (not requirements) by the ICAO and EUROCAE was prompted, in part, by the United Kingdom’s many years of experience in analyzing CVR “hot mic” recordings. The Board’s investigation of the ValuJet accident in Atlanta again raises concerns about the adequacy of CVRs equipped with the standard CAM. Given the numerous benefits of CVR “hot mics” and the slight cost of these installations, the Safety Board believes that the FAA should require all airplanes currently required to be installed with a CVR to be retrofitted within 2 years with a CVR “hot mic.”

54 Safety Recommendation A-87-88 was classified “Closed—Acceptable Action” on December 23, 1988, following rulemaking by the FAA. 55 DCA84IA029--June 23, 1984, Chicago O'Hare Airport; Tradewinds Airways Ltd., Flight 11, Boeing 707, G- SAIL; ANC85MA183--September 25,1985, Dutch Harbor, Alaska, Mark Air B737, N674MA; DEN86FA080-- February 20, 1986, Denver, Colorado, Continental Airlines, B737-300; DCA87IA015--December 18, 1986, Simmons Airlines, Flight 2860, ATR-42, N423MQ. 56 (1) National Transportation Safety Board. 1994. Stall and loss of control on final approach of Atlantic Coast Airlines, Inc., United Express Flight 6291, Jetstream 4101, N304UE, at Columbus, Ohio, on January 7, 1994. Aircraft Accident Report NTSB/AAR-94/07. Washington, D.C. (2) National Transportation Safety Board. 1995. Uncontrolled collision with terrain of Flagship Airlines Inc., doing business as American Eagle Flight 3379, BAe Jetstream 3201, N918AE, near Morrisville, North Carolina, on December 13, 1994. Aircraft Accident Report NTSB/AAR-95/07. Washington, D.C.

57

1. CONCLUSIONS
2. 1

Findings 1. The flightcrew met the certification, training, and rest requirements of the applicable Federal regulations before the accident, and the flight attendants had completed ValuJet’s FAA- approved flight attendant training program in existence at the time of the accident. 2. The airplane was certificated and operated in accordance with applicable Federal regulations. 3. An uncontained failure of the right engine occurred at low airplane and high engine rotational speed, during the initiation of the takeoff roll. As a result of the uncontained failure, engine fragments penetrated the airplane’s cabin, severing the right engine main fuel line and causing the release of pressurized fuel inside the cabin. Sparks that most likely were generated by steel engine fragments contacting steel galley components ignited a fire that quickly spread through the airplane’s cabin. 4. The uncontained failure was caused by a fatigue crack in stress redistribution hole “1” in the 7th stage high compressor disk of engine SN 666966. The fatigue crack length was consistent with a critical crack length expected to produce separation of the disk under normal operating conditions. 5. Based on an analysis of fatigue striation measurements, a detectable crack existed in SR hole “1” in the 7th stage high compressor disk of engine SN 666966 when the disk was overhauled by the THY repair station in 1991. 6. The 7th stage high compressor disk of engine SN 666966 did not receive a proper inspection in when the disk was overhauled at the THY repair station in 1991. 7. Had the THY repair station accomplished a proper inspection of the 7th stage high compressor disk of engine SN 666966, the crack would probably have been detected, the part rejected, and consequently, the accident might have been avoided. 8. The THY repair station was not using “process sheets” at the time of the 1991 overhaul and inspection of the 7th stage high compressor disk of engine SN 666966; the use of such documents would have increased the likelihood that the disk would have received a proper inspection and that the crack would have been detected. 9. Although the P&W JT8D engine manual could have presented more precise information in terms of overhaul procedures and instructions, this lack of clarity did not contribute to the failure of the disk. 10. FAA guidance on what degree of detail is required in maintenance records is insufficient and vague.

58 11. “Process sheets” or similar documentation of sufficient detail to permit a complete determination of the work needed to be done and of the work that has been done is necessary for a comprehensive maintenance program to ensure the continued airworthiness of aircraft, engines, and components. 12. Foreign repair stations are not, but should be, subject to the same FAA recordkeeping requirements as domestic repair stations. 13. The industry practice of using serviceable tags without a clear understanding of their purpose can result in the misinterpretation of the intent of these tags. 14. Although there were conflicting interpretations of THY’s authority to overhaul JT8D engines by the FAA and THY, the Repair Station Operations Specifications in question can reasonably be read to indicate that THY did have authority under Part 145 to overhaul JT8D engines at the time engine SN 666966 was overhauled in 1991. 15. The fourth item on the evacuation checklist was not completed by the flightcrew because of smoke accumulation in the cockpit; as a result, emergency lights were not available during a portion of the evacuation. Fortunately, the lack of emergency lights did not preclude a successful evacuation. 16. Although the pilot’s delay in communicating the evacuation order because of an electrical power loss did not adversely affect the evacuation, the accident again highlights the need for an independent power source for public address systems in transport-category airplanes. 17. Although deficiencies in ValuJet’s flight attendant training program, including emergency drills training, and the FAA’s inadequate oversight of this program did not affect occupant survivability in this accident, they could have. 18. Although Federal regulations require that all passengers more than 24 months old be restrained during takeoff and landing, this accident again demonstrates that this regulation is not always enforced, as one child who was more than 24 months old was listed as a lap child and was seen being held in an adult passenger’s lap. 19. Because one of the flight attendants had her own key for the cockpit, she was able to quickly notify the flightcrew about the fire. ValuJet procedures in effect at the time did not provide for prompt flight attendant access to the cockpit. 20. The aircraft involved in this accident did not meet current regulatory requirements regarding flammability standards for materials used in the interiors of transport-category airplane cabins nor was it required to do so. However, this accident demonstrates the importance of the current standards and the need for existing aircraft to be brought up to these standards as quickly as possible.

59 3.2 Probable Cause The National Transportation Safety Board determines that the probable cause of this accident was the failure of Turk Hava Yollari maintenance and inspection personnel to perform a proper inspection of a 7th stage high compressor disk, thus allowing the detectable crack to grow to a length at which the disk ruptured, under normal operating conditions, propelling engine fragments into the fuselage; the fragments severed the right engine main fuel line, which resulted in a fire that rapidly engulfed the cabin area. The lack of an adequate recordkeeping system and the failure to use “process sheets” to document the step-by-step overhaul/inspection procedures contributed to the failure to detect the crack and, thus, to the accident.

60

1. RECOMMENDATIONS

As a result of this accident investigation, the National Transportation Safety Board recommends that the Federal Aviation Administration: Review the Air Agency Certificates and Repair Station Operations Specifications of all repair stations and ensure that the language used in the operations specifications clearly indicates the extent of the repair stations’ authority. (Class II, Priority Action)(A-96-78) Revise 14 CFR Part 145 to require Subpart C foreign repair stations to adhere to the same recordkeeping requirements as domestic repair stations. (Class II, Priority Action)(A-96-79) Revise the applicable regulations and provide specific guidance on the documentation to be used and kept during inspections and overhauls, including “process sheets” or similar detailed documentation for all certificated repair stations. (Class II, Priority Action)(A-96-80) Require that “serviceable tags” be used to return engines and other components to service, that they be in a prescribed format (perhaps in the format of FAA Form 8130-3), and that when there is a change of ownership, and certainly upon importation, the approval for return to service attest to the overall airworthiness of the part and the tag reflect that a complete and thorough review of records, including “process sheets” of the last overhaul, has taken place. In the absence of such records, require an overhaul of the part when there is a change in ownership. (Class II, Priority Action) (A-96-81) Require that all transport-category aircraft manufactured before November 27, 1990, be retrofitted with a public address system capable of operating on an independent power source. (Class II, Priority Action) (A-96-82) Emphasize to principal operations inspectors the importance of thoroughly reviewing flight attendant training programs before approving them and flight attendant manuals before accepting them. (Class II, Priority Action) (A-96- 83) Provide guidance on how to implement the requirement that occupants who are more than 24 months old are restrained during takeoffs, landings, and during turbulence. (Class II, Priority Action)(A-96-84) Require that each flight attendant have a cockpit key in his/her possession at all times while on duty. (Class II, Priority Action)(A-96-85)

61 Prohibit the use during any type of replacement, after 1997, of cabin materials in all transport-category airplanes that do not comply with the current fire safety standards contained in 14 CFR 25.853. (Class II, Priority Action) (A- 96-86) Amend 14 CFR Part 121 to prohibit, upon a transfer of the aircraft from one certificate holder to another, or by January 1, 2001, whichever occurs first, the operation of airplanes with cabin materials that do not meet the requirements of 14 CFR Part 25.853. (Class II, Priority Action) (A-96-87) Issue an operations bulletin recommending that principal operations inspectors advise their air carriers to disseminate Federal Aviation Administration safety guidance on airline passenger attire to their flight attendants. (Class II, Priority Action) (A-96-88) Require all aircraft currently required to be installed with a cockpit voice recorder (CVR) to be retrofitted within 2 years with a CVR installation designed such that an uninterrupted recording from the boom or mask microphones and headphones for each flight crewmember’s position and from an area microphone can be made on dedicated channels of the CVR. A sidetone shall be produced only when the transmitter or interphone is selected, and, in addition, all audio signals received by hand-held microphones shall be recorded on the respective crewmember’s channel when keyed to the “ON” position. (Class II, Priority Action) (A-96-89) BY THE NATIONAL TRANSPORTATION SAFETY BOARD JAMES E. HALL Chairman ROBERT T. FRANCIS II Vice Chairman JOHN A. HAMMERSCHMIDT Member JOHN J. GOGLIA Member GEORGE W. BLACK Member August 30, 1996

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63

1. APPENDIXES

APPENDIX A - Investigation And Hearing 1. Investigation The National Transportation Safety Board was initially notified of this accident about 1915 on June 8, 1995, by the FAA. One investigator from the Safety Board’s Southeast Field Office was immediately dispatched to the scene. A Washington-based team departed for the scene the following morning. The team consisted of investigative groups in the areas of Operations, Structures/Systems, Performance, Materials, Powerplants, Survival Factors, and Maintenance/Records. Parties to the investigation were the FAA, ValuJet, the Douglas Aircraft Company, Pratt & Whitney, and the Association of Flight Attendants. 2. Hearing No public hearing was held in connection with this accident investigation.

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65 APPENDIX B - CVR Transcript

66 NATIONAL TRANSPORTATION SAFETY BOARD Engineering & Computer Services Division Washington, D.C. 20594 SPECIALIST’S FACTUAL REPORT OF INVESTIGATION Cockpit Voice Recorder by Albert G. Reitan Transportation Safety Specialist Warning The reader of this report is cautioned that the transcription of a CVR tape is not a precise science but is the best product possible from an NTSB group investigative effort. The transcript, or parts thereof, if taken out of context, could be misleading. The attached CVR transcript should be viewed as an accident investigation tool to be used in conjunction with other evidence gathered during the investigation. Conclusions or interpretations should not be made using the transcript as the sole source of information.

67 NATIONAL TRANSPORTATION SAFETY BOARD Engineering & Computer Services Division Washington, D.C. 20594 SPECIALIST’S FACTUAL REPORT OF INVESTIGATION Cockpit Voice Recorder ATL 95 MA 106 June 20,1995 A. ACCIDENT Location: Atlanta Hartsfield Airport - Atlanta, Georgia Date: June 8, 1995 Time: 1908 Eastern Daylight Time (EDT) Aircraft: DC-9-32, N908VJ B. GROUP Chairman: Albert G. Reitan Transportation Safety Specialist (CVR) National Transportation Safety Board Member: Martin H. (Hop) Potter Aviation Safety Inspector Federal Aviation Administration Member: Webster C. Heath Manager Tecchnical Liaison Industry Regulatory Affairs McDonnell Douglas Member: Paul D. Weston Captain ValuJet Member: Bruce A. Samborski Airworthiness Engineer United Technologies, Pratt & Whitney

68 C. SUMMARY A Fairchild model A-100A cockpit voice recorder (CVR), s/n 53333, was brought to the audio laboratory of the National Transportation Safety Board on June 9, 1995. The Cockpit Voice Recorder committee convened on June 13,

1. A transcript was prepared of the entire 31:16 minute recording.

(attached) D. DETAILS OF INVESTIGATION The exterior of the CVR showed no evidence of structural damage. It was covered with a light coating of soot. The interior of the recorder and the tape sustained no apparent heat or impact damage. The recording consisted of three channels of fair quality audio information. The area microphone channel contained a large amount of background noise so the pilot voices were read only with great difficulty. A second channel contained information from the pilots’ audio panels and a third contained the interphone and public address information. The recording started at 1838:03 EDT and continued uninterrupted except for a one second interval until 1908:20 EDT when electrical power was removed from the unit. When the recording started, the flight was at the gate preparing for departure. The recording continued as the crew prepared for departure and taxied to the departure runway. The recording ended when the aircraft stopped on the runway after experiencing an engine problem. As part of the Safety Board’s accident investigation process, the cockpit flightcrew was invited to review the CVR group’s transcript and suggest corrections or additions. The captain and first officer reviewed the CVR recording and transcript on June 28, 1995, and suggested the following changes:

69 Page 15 1902:42 {25:37} CAM-1 flaps five, before takeoff check list. Page 16 1902:56 {25:51} CAM-2 performance data and bugs? 1903:51 {26:46} CAM-1 set and, ** ANU. 1904:50 {27:45} CAM-1 five flaps, one thirty uh, climb to ten thousand feet, heading whatever they give us, * nine five. 1905:45 {28:40} CAM-1 hey Meg. Page 17 1905:51 {28:46} CAM-1

• the mark of a true professional if you can keep talking like that.

Page 18 1907:54 {30:49} CAM-? alright, here, they’re spooled . Albert G. Reitan Transportation Safety Specialist (CVR) Attachment:

70 Transcript of a Fairchild A-100A cockpit voice recorder (CVR), s/n 53333, installed on an Douglas DC-9-32, N908VJ, which was which sustained an engine failure during takeoff from Atlanta Hartsfield International Airport on June 8, 1995 LEGEND RDO Radio transmission from accident aircraft CAM Cockpit area microphone voice or sound source INT Transmissions over aircraft interphone system ATIS Radio transmission from Atlanta Departure ATIS GND Transmission received from Atlanta south ground control TWR Transmission received from Atlanta tower PA Transmission made over airacraft public address system CLR Radio transmission from Atlanta clearance delivery TR-? Radio transmission from unidentified aircraft -1 Voice identified as Pilot-in-Command (PIC) -2 Voice identified as Co-Pilot -3 Voice identified as 1st female Flight Attendant -4 Voice identified as 2nd female Flight Attendant -5 Voice identified as female ground agent -6 Voice identified as male ground agent -? Voice unidentified * Unintelligible word @ Non pertinent word # Expletive % Break in continuity ( ) Questionable insertion [ ] Editorial insertion .... Pause Note: Times are expressed in eastern daylight time (EDT). Times shown in brackets { } are computer reference times measured from the beginning of the recording.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT START of RECORDING START of TRANSCRIPT 1838:03 {00:58} CAM-6 gentlemen, any write ups? 1838:04 {00:59} CAM-2 actually our uh, transponder, TCAS fail light stays on. 1838:11 {01:06} CAM-6 fail light stays on? 1838:12 {01:07} CAM-2 yeah. so we don't get any contacts or anything that it's working. 1838:20 {01:15} CAM-6 Mar Mike, Mar Mike. 1838:23 {01:18} CAM-2 captain, do you want to write it up *? 1838:25 {01:20} CAM-? **. 1838:27 {01:22} CAM-6 anything you want to write up? 1838:27 {01:22} CAM-1 no. 1838:29 {01:24} CAM-6 you wanna wait till you get back? 1838:31 {01:26} CAM-1 yeah, we're running late. 71 72

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 1838:35 {01:30} CAM-1 depends on how long we're going to take. 1838:36 {01:31} CAM-6 we're gonna have to bring avionics guy out here and uh. 1838:40 {01:35} CAM-? and uh, 1838:46 {01:41} CAM-2 **** radar altimeter may have something to do with it. 1838:50 {01:45} CAM-1 the altimeter, yeah. 1838:53 {01:48} CAM-6 if you want it fixed, I'll call 'em out here, you know, that's up to you. 1838:57 {01:52} CAM-2 he he did not want to write it up. 1838:58 {01:53} CAM-6 he didn't? 1838:59 {01:54} CAM-2 no. 1839:00 {01:55} CAM-6 he gonna write it back up on the way in. 1839:02 {01:57} CAM-2 we will do that. 1839:03 {01:58} CAM-6 OK, alright, we just don't think **** pin it on us. 73

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 1839:35 {02:30} CAM [sound of non pertinent flight attendant conversation in back- ground] 1839:35 {02:30} ATIS this is the Atlanta departure information Tango. the At- lanta two one five zero zulu weather. sky conditions five thousand five hundred scattered, visibility one two, tem- perature niner four, dew point seven zero, wind, two niner zero at seven, altimeter two niner niner niner. simultane- ous departures in progress. departing runways two six left and two seven right. aircraft with north or west vector areas, expect runway two six left. aircraft with south or east vector areas expect runway two seven right. upon receipt of your ATC clearance, read back only your call sign and transponder code unless you have a question. advise on initial contact, you have information Tango. 1842:38 {05:33} CAM-2 hi, how you doing? 1842:40 {05:35} CAM-3 ***** please gentlemen. 1842:42 {05:37} CAM [several unintelligible flight attendant pilot comments] 1843:13 {06:08} CAM-3 what time are we gonna get home now, eleven? 1843:16 {06:11} CAM-2 let's see. we're supposed to get home at nine thirty five. that's taking off at five thirty five. ** four hours. 1843:34 {06:29} CAM-3 two hours (late, we'll get in at ** eleven thirty **). 74

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 1843:41 {06:36} CAM-2 OK, is that it now? 1843:42 {06:37} CAM-4 we're still waiting on catering. 1843:44 {06:39} CAM-2 OK, 1843:45 {06:40} CAM-? ** eighteen 1843:46 {06:41} CAM-2 OK. *****. 1843:48 {06:43} CAM-2 yeah, thirty five. 1843:52 {06:47} CAM-? [sound of laughter] 1844:00 {06:55} CAM-1 ninety three, I'll tell you what, the temperature wasn't much different down there. 1844:03 {06:58} CAM-2 oh yeah. 1844:56 {07:51} CAM [bell sound similar seat belt chime] 1844:57 {07:52} CAM-1 well. 1844:59 {07:54} CAM-1 what did they finally decide? are we taking folks with us to several cities or just Miami? 75

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 1845:07 {08:02} CAM-? I think it's Miami. *** thirty five thirty nine. 1845:19 {08:14} CAM-1 have we called 'em a couple of times already? 1845:23 {08:18} CAM-5 I haven't done anything. 1845:27 {08:22} CAM-1 you talked to them at all about catering? 1845:28 {08:23} CAM-2 no. that's the first I've heard. 1845:30 {08:25} CAM-1 OK. 1845:31 {08:26} PA-3 Good evening ladies and gentlemen. we would like to wel- come you aboard ValuJet's flight five ninety seven now non- stop service to Miami. as you are getting comfortably seated, we do need to remind you that every bit of the carry-on lug- gage you brought on board, needs to either go underneath the seat in front of you or in one of the overhead compartments. If you need any assistance with your luggage, please let one of us know at this time. in addition federal regulations require all passengers seated in emergency exit rows fourteen, fifteen, and sixteen, to be responsible for these exits and for assisting others in the event of an emergency. if you are unable or do not wish to perform these emergency duties, please let Denise know at this time, she'll be happy to change you to another seat. just a reminder, this is a non smoking flight. your com- pliance is required by federal aviation regulations. Thank you for your attention and welcome aboard. 76

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 1846:22 {09:17} RDO-1 and uh, Critter one forty seven, on ramp four with infor- mation Tango ur uh, one forty seven, thank you. 1846:29 {09:24} CLR Critter one forty seven, I don't see it yet. uhhh, let's see here. no what time are you due out? 1846:35 {09:30} RDO-1 no, I got my numbers wrong. it's five ninety seven to Mi- ami. due out at uh, five thirty five actually. 1846:40 {09:35} CLR five ninety seven, we do have that one, and what it uh, what was your ramp? 1846:44 {09:39} RDO-1 four. 1846:50 {09:45} CLR Critter five ninety seven, OK, cleared to Miami as filed. Atlanta three departure. Maintain one zero thousand. departure on one twenty five zero. squawk seven one three three. south side number one at four south. contact ground on point seventy five. 1847:04 {09:59} RDO-1 seventy one thirty three. thank you, five ninety seven. 1847:07 {10:02} CLR OK. 1847:17 {10:12} CAM-2 (one) thirty three. 1847:20 {10:15} CAM-3 they get these from you? up there? 77

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 1847:22 {10:17} CAM-? * we checked ***. 1847:27 {10:22} CAM-3 alright. 1847:33 {10:28} CAM [several unintelligible comments between pilots and flight at- tendants] 1848:11 {11:06} CAM-1 tell her we're about to *** you want to write it up ****. 1848:50 {11:45} CAM-? count thirty three and twenty four right now. thirty three up front twenty four in the back. 1849:08 {12:03} PA-1 folks good evening and welcome aboard. I'm Greg Straessle your captain along with your co-captain Steve Rasin. Rachel, Magen, and Denise in the back to take good care of you. it's a one hour nineteen minute flight down to Miami, Florida. w'be taking out of here very shortly heading on down there scattered clouds, a little cooler in Miami than it is here, actually. it's ninety three degrees in Miami, ninety four here at about ten knots of wind down there. seat belt sign's on if you would please uh, observe that and fasten 'em up snugly. we'll be un- der way very, very shortly here uh, we apologize for the delay. it started a while back uh, with a little bit of a maintenance problem that was cured but just took a little longer than we wanted it to to progress and finally get fixed. so as I say we'll be under way shortly and get you there as soon as we can. thank you for joining us today. 1850:01 {12:56} CAM [unintelligible conversation overridden by nearby jet engine noise] 78

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 1850:41 {13:36} CAM-1 ***** ninety nine? 1850:46 {13:41} CAM [more unintelligible conversation] 1852:33 {15:28} CAM-3 there's **. 1852:53 {15:48} CAM-5 hello. 1852:54 {15:49} CAM-? hi, how ya doing? 1852:56 {15:51} CAM-5 we got two hundred and ten pounds in the hold in the front. we got fifty bags in the rear, and ten bags in the front. going out southbound? take the power off and raise the stairs? 1853:13 {16:08} CAM-2 yeah, you sure can. 1853:14 {16:09} CAM-5 alright, and the stairs and hydraulics on? 1853:16 {16:11} CAM-2 yep it's on. 1853:16 {16:11} CAM-5 alright, thank you. 1854:12 {17:07} CAM-? what are they **. 1854:13 {17:08} CAM-2 uuuh. 79

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 1854:17 {17:12} CAM-? not them. 1856:53 {19:48} CAM-5 catering guy. ** you ready? 1856:55 {19:50} CAM-? we're ready. 1856:58 {19:53} CAM-5 OK, see you later. 1857:06 {20:01} CAM-5 what time are you guys goin' out? 1857:08 {20:03} CAM-1 uuuuh, fifty five, what do you want? 1857:10 {20:05} CAM-5 OK, that sounds good. 1857:18 {20:13} CAM-1 soon as they close the cargo door. 1857:26 {20:21} CAM-3 everybody's down. 1857:31 {20:26} PA-3 flight attendants prepare for departure please, cross check. 1857:57 {20:52} CAM [sound of two dings] 1858:06 {21:01} CAM-? ninety four ***. 1858:12 {21:07} CAM [sound of single ding] 80

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 1858:15 {21:10} CAM-1 ***** starting engines check list. OK. 1858:41 {21:36} CAM-1 starting two, lets go below the line please. 1858:43 {21:38} CAM-2 clearance to start? 1858:43 {21:38} CAM-1 received. 1858:44 {21:39} CAM-2 shoulder harness? on. 1858:45 {21:40} CAM-1 comin' on. 1858:46 {21:41} CAM-2 parking brakes? 1858:46 {21:41} CAM-1 they're set. 1858:47 {21:42} CAM-2 fuel quantity? twenty four one. 1858:48 {21:43} CAM-1 I see it, rechecked. twenty four plus. 1858:51 {21:46} CAM-2 pneumatic crossfeeds? 1858:52 {21:47} CAM-1 are open. 81

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 1858:52 {21:47} CAM-2 anti-collision lights? 1858:53 {21:48} CAM-1 on. 1858:54 {21:49} CAM-2 air conditioning supply switches? 1858:54 {21:49} CAM-1 off. 1858:55 {21:50} CAM-2 fuel boost pumps? 1858:56 {21:51} CAM-1 on. 1858:56 {21:51} CAM-2 ignition? 1858:58 {21:53} CAM-1 comin' on right side, that **. 1859:08 {22:03} CAM-1 oil, 1859:09 {22:04} CAM-1 N2, 1859:12 {22:07} CAM-1 N1, 1859:15 {22:10} CAM [sound of click] 1859:16 {22:11} CAM-1 fuel. 82

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 1859:21 {22:16} CAM [sound similar to engine increasing in frequency] 1859:28 {22:23} CAM-1 cut out, slower start, acceleration , on the line. 1859:40 {22:35} CAM-1 oil, 1859:42 {22:37} CAM-3 uh, 1859:51 {22:46} CAM-1 fuel 1859:52 {22:47} CAM [sound similar to engine increasing in frequency] 1900:01 {22:56} CAM [sound of two dings] 1900:05 {23:00} CAM-2 electrical panel? 1900:06 {23:01} CAM-1 set. 1900:06 {23:01} CAM-2 ignition? 1900:07 {23:02} CAM-1 off. 1900:07 {23:02} CAM-2 pitot static heat? 83

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 1900:08 {23:03} CAM-1 on. 1900:08 {23:03} CAM-2 ice protection? 1900:09 {23:04} CAM-1 off. 1900:09 {23:04} CAM-2 center tank pumps? 1900:10 {23:05} CAM-1 on. 1900:10 {23:05} CAM-2 flight attendant signal? 1900:11 {23:06} CAM-1 given. 1900:12 {23:07} CAM-2 air conditioning? 1900:12 {23:07} CAM-1 auto. 1900:13 {23:08} CAM-2 door lights? 1900:13 {23:08} CAM-1 out. 1900:14 {23:09} CAM-2 hydraulic pumps? 1900:15 {23:10} CAM-1 set. 84

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 1900:19 {23:14} CAM [several unintelligible comments overridden by loud engine noise] 1901:03 {23:58} CAM-2 clear on the right. 1901:30 {24:25} PA-3 once again good evening ladies and gentlemen. we would like to welcome you aboard ValuJet's flight 597 now non-stop service to down to Miami. on the flight deck is captain Greg Straessle. he's assisted by first officer Steve Rasin. my name is Megan. working along with me this evening are Rachel and Denise. your flight attendants are one of the most important safety features of this aircraft. we do ask for your attention for just a few minutes as we go over some very important informa- tion with you. we do request that you please read the safety information card located in the seat pocket in front of you as we explain the safety features of our DC-9-32 aircraft. at this time Denise and Rachel will demonstrate the easy operation of your seat belt. first insert the flat metal end into the buckle. to ad- just pull on the loose strap. to release simply lift up on the buckle. seat belts should always be fastened when the seat belt sign is illuminated. on this particular aircraft there are three door exits, two at the front of the aircraft and the tail cone exit at the rear of the aircraft. all door exits are equipped with evacuation slides. in addition there are four window exits, two over each wing. all exits are clearly marked to assist you in lo- cating them. there is also a lighting system in the floor which will illuminate in an emergency. red lights indicate you have reached or are near an exit. the cabin is pressurized for your comfort, however if oxygen is needed an oxygen panel will drop from a compartment above your seat. you would reach up and pull down on the mask until the tubing is fully extended. place the mask over your nose and mouth, secure it with the 85

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT elastic band, and breath normally. the oxygen bag may not appear to inflate, however oxygen is flowing. for those of you traveling with small children please adjust your mask first and then assist your child. the passenger seat cushions on this aircraft can be used as flotation equipment. detailed instruc- tions on its use are found on the back side of the safety in- struction card. smoking is not permitted at any time on board our aircraft. federal law prohibits tampering with the smoke detectors that are in our aircraft lavatories. your compliance with crewmembers' instructions, all placards, lighted seat belt and no smoking signs is required. also please keep in mind that due to possible interference with our navigational systems the following electronic devices may not be used during takeoff and landing: portable compact disk players, portable comput- ers, and cellular phones should now be in the off position and stowed. in preparation for our takeoff this evening please dou- ble check and make sure your seat belts are securely fastened around you. please bring your tray tables and seat backs to the their full upright and locked position, and all carry on lug- gage should be underneath the seat in front of you completely, or in one of the overhead bins. the captain has informed me that our flying time down to Miami will be one hour and nine- teen minutes. we sincerely do appreciate your attention, and welcome aboard. 1902:25 {25:20} RDO-2 Atlanta ground, Critter five ninety seven approaching four south with Tango. 1902:31 {25:26} GND Critter five ninety seven Atlanta ground, taxi to runway two seven right via Mike. 1902:34 {25:29} RDO-2 two seven right via Mike, Critter five ninety seven. 86

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 1902:42 {25:37} CAM-1 flaps five *** check list. 1902:43 {25:38} CAM-2 flaps five. 1902:56 {25:51} CAM-2 data and bugs? 1902:57 {25:52} CAM-1 alright I see *** do you agree? 1903:49 {26:44} CAM-2 trim controls? 1903:51 {26:46} CAM-1 set and, 1903:55 {26:50} CAM [sound similar to stabilizer trim in motion] 1904:15 {27:10} CAM-1 set and six. 1904:18 {27:13} CAM [unintelligible conversation between pilot and flight attendant] 1904:45 {27:40} CAM-1 looks like we're gonna get right outta here. 1904:50 {27:45} CAM-1 five flaps, one thirty uh, ten thousand feet, heading whatever they give us, * nine five. 1905:22 {28:17} CAM [several unintelligible comments between pilots] 87

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 1905:45 {28:40} CAM-2 hey Meg. 1905:50 {28:45} CAM-3 what, yes sir. 1905:51 {28:46} CAM-2

• the mark of a true faithful if you can keep talking like that.

1906:02 {28:57} TWR Critter five ninety seven Atlanta tower runway two seven right, taxi into position and hold. 1906:04 {28:59} RDO-2 position and hold two seven right, Critter five ninety seven. 1906:09 {29:04} PA-2 flight attendants take your seats for departure. 1906:21 {29:16} CAM-2 anti-skid? 1906:22 {29:17} CAM-1 yep. 1906:29 {29:24} CAM-2 cockpit door? locked. 1906:30 {29:25} CAM-2 ignition? on. 1906:30 {29:25} CAM-2 APU? off. 1906:31 {29:26} CAM-2 flight attendant signal? given. 88

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 1906:32 {29:27} CAM-2 anti-skid? is armed. 1906:33 {29:28} CAM-2 TCAS transponder? TA RA. 1906:34 {29:29} CAM-2 pneumatic cross-feeds? closed. 1906:35 {29:30} CAM-2 annunciator panel? checked. 1906:36 {29:31} CAM-2 takeoff briefing? accomplished. before takeoff checklist com- plete. 1907:34 {30:29} TWR Critter five ninety seven middle marker turn left heading two five zero, runway two seven right, cleared for takeoff. 1907:39 {30:34} RDO-2 two five zero at the marker, cleared for takeoff two seven right, Critter five ninety seven. 1907:45 {30:40} CAM [sound similar to increase in engine RPM] 1907:54 {30:49} CAM-?

• here * .

1907:58 {30:53} CAM [one second interruption in CVR audio] 1907:58 {30:53} CAM [repetitive thumping sounds lasting for three seconds] 1908:00 {30:55} 89

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT TR-? ValuJet rolling on the runway you got a fire in the right en- gine. 1908:02 {30:57 RDO-2 Critter five ninety seven understand we have a fire in the right engine. we'll be stopping here on the runway. 1908:06 {31:01} TWR five ninety seven roger, do you need the equipment? 1908:08 {31:03} CAM-3 **. 1908:08 {31:03} CAM-1 OK. 1908:09 {31:04} CAM-1 yes, roll the equipment. 1908:10 {31:05} RDO-2 affirmative, roll the equipment, roll the equipment. 1908:10 {31:05} CAM [sound of commotion from passenger cabin] 1908:15 {31:10} PA-3 flight attendant, ladies and gentlemen, please wait until the plane comes, ladies. 1908:20 {31:15} CAM [sound similar to engine decreasing in RPM] 1908:21 {31:16} END of RECORDING END of TRANSCRIPT 90

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE 1908:08 {31:03} CAM-3 **. 1908:08 {31:03} CAM-1 OK. 1908:09 {31:04} CAM-1 yes, roll the equipment. 1908:10 {31:05} RDO-2 affirmative, roll the equipment, roll the equipment. 1908:10 {31:05} CAM [sound of commotion from passenger cabin] 1908:15 {31:10} PA-3 flight attendant, ladies and gentlemen, please wait until the plane comes, ladies. 1908:20 {31:15} CAM [sound similar to engine decreasing in RPM] 1908:21 {31:16} END of RECORDING END of TRANSCRIPT 90

126 APPENDIX F - Examples of ValuJet’s Flight Attendant Manual Emergency Equipment— Before and After Revision in November 11, 1995 F L I G H T ATTENDANT MANUAL Page: 2-9 Date: 1/13/94 Revision: 1

127 VALUJET Page: 3-19 Date: 11/11/95 FLIGHT ATTENDANT MANUAL Revision: 5 3.21 LOCATION OF EQUIPMENT ON AIRCRAFT 3.21.1 A/C #901 -907,909-923,965 FWD. OVERHEAD BIN A/C LEFT OVERWING AFT OVERHEAD BIN A/C LEFT AFT JUMPSEAT AREA am I I IL OVERWING AFT OVERHEAD BIN A/C RIGHT

128 APPENDIX G - Comparison of Requirements for Domestic and Foreign Repair Stations Certificated Under FAR Part 145 DOMESTIC FOREIGN Ratings . Ratings are issued for “classes” of . Same as Domestic items within the following categories: Airframe, Powerplant, Propeller, Radio, Instrument, and Accessory. Example: a “Class 2“ Powerplant rating authorizes the repair station to work on reciprocating engines of more than 400 horsepower; a “Class 3“ Powerplant rating authorizes the repair station to work on Turbine engines. . Limited ratings maybe issued for a particular make or model within a class of airframe, powerplant, propeller, radio, instrument or accessory, or for other specialized services. (145.33). Housing and facility G Must provide suitable housing, G Same as Domestic. requirements space, and facilities to protect work and workers. Detailed requirements for segregation of equipment and functions, appropriately organized storage areas, lighting requirements, etc. (145.35) G Additional requirements for housing of airframes, suitable means for segregating engines or accessory assemblies, storage of propellers, and protection of radio and instrument parts, (145,37)

129 DOMESTIC FOREIGN Inspection systems • Must have an inspection system that will produce satisfactory quality control. Detailed requirements for qualifications of inspection personnel. Detailed requirements for inspection systems. Must maintain a manual containing inspection procedures. (145.45) • Same as Domestic. Equipment and materials • Must have equipment and materials necessary to competently and efficiently perform functions appropriate to the ratings and classes sought. Detailed and specific requirements are set forth. (145.47 and .49) • Same as Domestic. Performance standards • Must abide by maintenance regulations in FAR Part 43. Must maintain manufacturers manuals, instructions, and bulletins. • Same as Domestic. Work for Part 121 operators • Must abide by requirements of carrier’s continuing airworthiness program, and work must be in accordance with carrier’s manual. (145.2) • Same as Domestic. Inspection of work performed • Before approving an item for return to service, must be inspected by qualified inspector and must certify on maintenance record that it is airworthy with respect to the work performed. (145.49) • Same as Domestic. Inspection by FAA • Must allow FAA to inspect (for adequacy of inspection system, records, and general ability to comply with Part 145) at any time. FAA will notify repair station of defects found. (145.23) • Same as Domestic.

130 DOMESTIC FOREIGN Issuance of Certificate • Application must include copy of inspection procedures manual, and list of maintenance functions to be “contracted out”. • Applicant who meets requirements of Part 145 is “entitled” to a certificate. (145.11) • In addition to information required by 145.11, must submit brochure describing facilities, inspection system, organizational chart, names/titles of supervisory personnel, and list of functions to be “contracted out” and contractor names. (145.13) • Applicant must also show that the certificate “will be necessary for maintaining U.S. registered aircraft or parts. (145.71) Duration of Certificate • Does not have to be renewed. (145.17) • Must be renewed within 12 months of initial issuance, and every 24 months thereafter. (145.17) Privileges of certificate • May maintain/alter and approve for return to service any aircraft or part for which it is rated. (145.51) • Same as domestic, but limited to U.S. registered aircraft or parts. (145.73)

131 DOMESTIC FOREIGN Personnel requirements (including certification) • Must have enough personnel to keep up with volume of work. • All supervisory and inspection personnel must be FAA-certified as mechanics or repairmen. • Personnel directly in charge of maintenance functions must have 18 months of practical experience in the applicable procedures. • For each rating, must have employees with detailed knowledge of applicable maintenance functions/techniques based on attending factory school or long experience. • Must document and update work history and experience of all supervisory and inspection personnel. (145.39, .41 and .43) • Must have enough personnel to keep up with volume of work. • No personnel are required to have FAA (or any) certification . • Supervisors and inspectors must be able to read, write, and understand English, and must show they understand the FARS and manufacturer’s instructions. (145.75) Record-keeping • Must maintain “adequate records of all work that it does,” including names of mechanics and inspectors, for 2 years. (145.61) • Exempt from 145.61. • But must maintain records of all maintenance/alterati on done on U.S registered aircraft [no time period specified], and any other records the FAA “finds necessary.” (145.79) Reports of unairworthy conditions • Must report defects and unairworthy conditions to FAA within 72 hours of discovery. (145.63) • Same as Domestic, but reporting requirement only applies to U.S. registered aircraft. (145.79)

FD07171 ｜ 1996_美国_AAR9604.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1996 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

PB96-910404 NTSB/AAR-96/04 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT RUNWAY DEPARTURE DURING ATTEMPTED TAKEOFF TOWER AIR FLIGHT 41 BOEING 747-136, N605FF JFK INTERNATIONAL AIRPORT, NEW YORK DECEMBER 20,1995 667 1A

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Information about available publications may be obtained by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (202)314-6551 (800)877-6799 Safety Board publications may be purchased, by individual copy or by subscription, from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (703)487-4600

NTSB/AAR-96/04 PB96-910404 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT RUNWAY DEPARTURE DURING ATTEMPTED TAKEOFF TOWER AIR FLIGHT 41 BOEING 747-136, N605FF JFK INTERNATIONAL AIRPORT, NEW YORK DECEMBER 20, 1995 Adopted: December 2, 1996 Notation 6671A Abstract: This report explains the runway departure during attempted takeoff of Tower Air flight 41, N605FF, a Boeing 747-136 at John F. Kennedy International Airport, New York, on December 20, 1995. The safety issues discussed in this report include the adequacy of Boeing and air carrier procedures for B-747 operations on slippery runways; adequacy of flight simulators for training B-747 pilots in slippery runway operations; security of galley equipment installed on transport category aircraft; role of communications among flight attendants and between the cabin crew and the flightcrew; adequacy of Tower Air galley security training; compliance of Tower Air’s maintenance department with its established procedures; failure of the FDR system to function during the accident; adequacy of the Tower Air operational management structure; adequacy of FAA surveillance and workload imposed on POIs; adequacy of runway friction measurement requirements, including correlation of runway friction measurements with aircraft braking and ground handling performance. Safety recommendations concerning these issues were made to the Federal Aviation Administration (FAA) and Tower Air, Inc.

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iii CONTENTS EXECUTIVE SUMMARY_____________________________________________________ vii

1. FACTUAL INFORMATION _________________________________________________ 1
2. 1 History of Flight_______________________________________________________________ 1
3. 2 Injuries to Persons _____________________________________________________________ 4
4. 3 Damage to Airplane ____________________________________________________________ 4
5. 4 Other Damage ________________________________________________________________ 5
6. 5 Personnel Information__________________________________________________________ 5
7. 5.1 The Captain_______________________________________________________________________ 5
8. 5.2 First Officer_______________________________________________________________________ 5
9. 5.3 Flight Engineer ____________________________________________________________________ 6
10. 6 Airplane Information___________________________________________________________ 6
11. 6.1 General __________________________________________________________________________ 6
12. 6.2 Maintenance Records Review_________________________________________________________ 7
13. 7 Meteorological Information ____________________________________________________ 10
14. 8 Aids to Navigation ____________________________________________________________ 11
15. 9 Communications______________________________________________________________ 11
16. 10 Airport Information__________________________________________________________ 11
17. 10.1 General ________________________________________________________________________ 11
18. 10.2 Runway Conditions_______________________________________________________________ 11
19. 10.3 Previous Safety Board Recommendations _____________________________________________ 13
20. 10.4 Air Carrier Slippery Runway Events__________________________________________________ 14
21. 11 Flight Recorders_____________________________________________________________ 14

iv 1.11.1 Flight Data Recorder______________________________________________________________ 14 1.11.2 Cockpit Voice Recorder ___________________________________________________________ 14 1.12 Wreckage and Impact Information _____________________________________________ 15 1.13 Medical and Pathological Information __________________________________________ 17 1.14 Fire________________________________________________________________________ 17 1.15 Survival Aspects_____________________________________________________________ 17 1.15.1 Cabin Interior Layout and Damage___________________________________________________ 17 1.15.2 Galley Equipment Description ______________________________________________________ 19 1.15.3 Flight Attendant Galley Preflight Procedures ___________________________________________ 22 1.15.4 Flight Attendant Galley Preflight Activities ____________________________________________ 22 1.15.5 Events in the Cabin During the Accident Sequence ______________________________________ 23 1.15.6 Deplanement ____________________________________________________________________ 24 1.15.7 Flight Attendant Training __________________________________________________________ 24 1.16 Tests and Research___________________________________________________________ 26 1.16.1 Flight Recorder Tests _____________________________________________________________ 26 1.16.2 Cockpit Voice Recorder Sound Spectral Study _________________________________________ 27 1.17 Organizational and Management Information____________________________________ 27 1.17.1 Reporting Relationships Among Operational Managers___________________________________ 27 1.17.2 Director of Flight Safety ___________________________________________________________ 29 1.18 Additional Information _______________________________________________________ 29 1.18.1 Operating Procedures - Boeing 747 __________________________________________________ 29 1.18.2 Flightcrew Training_______________________________________________________________ 31 1.18.3 Pilot Techniques for B-747 Takeoffs _________________________________________________ 32 1.18.4 B-747 Simulator Activity __________________________________________________________ 33 1.18.5 Recent Tower Air Accidents and Incidents_____________________________________________ 35

v 1.18.6 FAA Surveillance ________________________________________________________________ 36 1.18.7 Aircraft Performance______________________________________________________________ 38

1. ANALYSIS_______________________________________________________________ 40
2. 1 General _____________________________________________________________________ 40
3. 2 Flightcrew Actions and Decisions________________________________________________ 40
4. 2.1 Pre-takeoff Events_________________________________________________________________ 40
5. 2.2 The Attempted Takeoff and Loss of Control ____________________________________________ 41
6. 2.3 Timeliness of the Rejected Takeoff ___________________________________________________ 42
7. 2.4 B-747 Slippery Runway Operating Procedures __________________________________________ 43
8. 2.5 Training Simulators for B-747 Slippery Runway Operations ________________________________ 45
9. 2.6 Summary of Flightcrew Actions and Decisions __________________________________________ 45
10. 3 Galley Security _______________________________________________________________ 46
11. 4 Flight Attendant Actions and Training ___________________________________________ 46
12. 4.1 Flight Attendant Communication _____________________________________________________ 46
13. 4.2 Flight Attendant CRM Training ______________________________________________________ 48
14. 4.3 Flight Attendant Galley Training _____________________________________________________ 48
15. 4.4 Purser Training ___________________________________________________________________ 48
16. 5 Company Management ________________________________________________________ 49
17. 5.1 Maintenance _____________________________________________________________________ 49
18. 5.2 Operations_______________________________________________________________________ 51
19. 6 FAA Surveillance _____________________________________________________________ 51
20. 7 Runway Contamination Evaluation______________________________________________ 53
21. CONCLUSIONS __________________________________________________________ 55
22. 1 Findings_____________________________________________________________________ 55

vi 3.2 Probable Cause_______________________________________________________________ 57

1. RECOMMENDATIONS____________________________________________________ 58
2. APPENDIXES____________________________________________________________ 61

APPENDIX A - INVESTIGATION AND HEARING _______________________________ 61

1. Investigation __________________________________________________________________ 61
2. Public Hearing ________________________________________________________________ 61

APPENDIX B- COCKPIT VOICE RECORDER TRANSCRIPT ______________________ 62

vii EXECUTIVE SUMMARY On December 20, 1995, at 1136, Tower Air flight 41, a Boeing B-747, veered off the left side of runway 4L during an attempted takeoff at John F. Kennedy International Airport (JFK), Jamaica, New York. The flight was a regularly scheduled passenger/cargo flight conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 121. Of the 468 persons aboard (451 passengers, 12 cabin crewmembers, 3 flightcrew members, and 2 cockpit jumpseat occupants), 24 passengers sustained minor injuries, and a flight attendant received serious injuries. The airplane sustained substantial damage. The weather at the time of the accident was partially obscured, with a 700-foot broken cloud ceiling, 1½ mile visibility, light snow, and fog. The National Transportation Safety Board determines that the probable cause of this accident was the captain’s failure to reject the takeoff in a timely manner when excessive nosewheel steering tiller inputs resulted in a loss of directional control on a slippery runway. Inadequate Boeing 747 slippery runway operating procedures developed by Tower Air, Inc., and the Boeing Commercial Airplane Group and the inadequate fidelity of B-747 flight training simulators for slippery runway operations contributed to the cause of this accident. The captain’s reapplication of forward thrust before the airplane departed the left side of the runway contributed to the severity of the runway excursion and damage to the airplane. The safety issues discussed in this report include the adequacy of Boeing and air carrier procedures for B-747 operations on slippery runways; adequacy of flight simulators for training B-747 pilots in slippery runway operations; security of galley equipment installed on transport category aircraft; role of communications among flight attendants and between the cabin crew and the flightcrew; adequacy of Tower Air galley security training; compliance of Tower Air’s maintenance department with its established procedures; failure of the FDR system to function during the accident; adequacy of the Tower Air operational management structure; adequacy of FAA surveillance and workload imposed on POIs; adequacy of runway friction measurement requirements, including correlation of runway friction measurements with aircraft braking and ground handling performance.

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NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT RUNWAY DEPARTURE DURING ATTEMPTED TAKEOFF TOWER AIR FLIGHT 41 BOEING B-747-136, N605FF JOHN F. KENNEDY INTERNATIONAL AIRPORT, NEW YORK DECEMBER 20, 1995

1. FACTUAL INFORMATION
2. 1

History of Flight On December 20, 1995, at 1136, 1 Tower Air flight 41, a Boeing B-747, veered off the left side of runway 4L during an attempted takeoff at John F. Kennedy International Airport (JFK), Jamaica, New York. The flight was a regularly scheduled passenger/cargo flight conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 121. Of the 468 persons aboard (451 passengers, 12 cabin crewmembers, 3 flightcrew members, and 2 cockpit jumpseat occupants), 24 passengers sustained minor injuries, and a flight attendant received serious injuries. The airplane sustained substantial damage. The weather at the time of the accident was partially obscured, with a 700-foot broken cloud ceiling, 1½ mile visibility, light snow, and fog. N605FF was flown from JFK to Miami, Florida, and back to JFK on December 19, 1995. The captain on those flights reported no problems with the airplane. On December 20, 1995, the airplane was moved to the gate in preparation to depart at 1000 for the first leg of a round trip from JFK to Miami and return for the three flightcrew members. The cabin crew of 12 included a purser, assistant purser, and deadheading flight attendant (in uniform), who was occupying a passenger seat in the cabin. The captain stated that he met the first officer and flight engineer in company operations before 0830. He received what he described as a thorough weather briefing prepared by Tower Air’s dispatch department, which included special weather conditions for JFK. He was aware of reports of compacted snow on the runways and that some of the runways were closed; he was concerned about both the accumulated snow and a forecast storm. He spoke with the Tower Air maintenance controller, who advised him that the airplane had no outstanding

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

2 discrepancies, and proceeded to the airplane. The flight engineer had previously completed the external safety inspection and was seated in the cockpit. The first officer joined them shortly, and all preflight checks were completed by 0930. The captain was the flying pilot for this leg and gave a briefing to the flightcrew. According to the captain, the crew discussed the weather and deicing at the gate. They obtained the holdover times 2 from the Tower Air General Operations Manual. The crew then discussed the amount of snow accumulation, the slippery conditions on the taxiways and runways, 3 the need to taxi slowly, taxi procedures on packed snow and ice, and their plans to use engine anti- ice and wing heat. The flight was pushed back from the gate at 1036, and the final deicing/anti-icing with both Type I and Type II fluids 4 began at 1100. The flight was cleared to runway 4L and taxied out at 1116. According to the captain’s statements, he taxied forward several hundred feet and made a 90o left turn to join the taxiway. The ramp was covered with packed snow and patches of ice, but some spots were bare. The nosewheel skidded a little in the turn, but the captain taxied slowly (about 3 knots according to the captain’s inertial navigation system display), and the braking action was adequate. He stopped the airplane to clear the engine of any ice by increasing power to 45 percent N1 5 for 10 seconds, but the airplane began to slip as power was advanced, and they could not complete the procedure at that time. Shortly after this attempt, about 1124, the crew of another flight inquired about the availability of runway 31L, and ground control advised that it was closed, transmitting, “I don’t know when it’s gonna open—probably be a couple of hours, may want to call the Port Authority.” The captain stated that based on this information, he did not consider runway 31L to be a viable option for his flight’s takeoff. Several minutes later, flight 41 was instructed, “...cross [runway] three one left. On the other side monitor [frequency one] nineteen one....” As they taxied on the parallel taxiway alongside runway 4L, the flight engineer left the cockpit to visually inspect the wings. He returned and reported, “It’s very clean out there.” A few seconds later, at 1132:06, the flight was cleared to taxi into position and hold on runway 4L.

2 Holdover time is the estimated time the application of deicing or anti-icing fluid will prevent the formation of frost or ice, and the accumulation of snow on the treated surfaces of an aircraft. It begins when the final application of the fluid commences, and it expires when the fluid loses its effectiveness. 3 In this report, the term “slippery,” as it pertains to runways, is defined as runway surface condition when the effective runway coefficient is less than the certificated bare and dry value, i.e., when the runway is not bare and dry. 4 Type I fluid, primarily used for deicing, contains a high glycol content (minimum 80 percent) and a relatively low viscosity. Type II fluid, normally used for anti-icing, can be operationally defined as fluid containing a minimum glycol content of 50 percent (with 45-50 percent water plus thickeners and inhibitors). 5 N1 is the engine fan speed expressed as a percentage of the maximum rpm.

3 The captain stated that as he taxied into position on the runway, he centered the airplane and moved the nosewheel steering tiller to neutral as the airplane was barely moving. He came to a complete stop, set the parking brake, and did the engine anti-ice runup. The airplane did not move during the runup. The captain said that he could see the runway centerline intermittently. He noted a strip of dark granular material about the width of a dump truck as he looked down the center of the runway. Packed snow was on either side of the strip, and there was some bare pavement. Snow was blowing horizontally from left to right across the runway. The crew completed the “Before Takeoff Checklist” while holding in position. At about 1136, the local controller transmitted, “Tower forty one heavy, wind three three zero at one one, runway four left RVR’s one thousand eight hundred, cleared for takeoff.” The captain said that he instructed the first officer to hold left aileron (for the crosswind correction) and forward pressure on the control column. The first officer stated that he held those inputs. The captain released the parking brake and held the toe brakes while he increased the power to 1.1 EPR. 6 He then released the brakes and advanced the power to 1.43 EPR, and at 1137:04 called, “Set time, takeoff thrust.” He said that he scanned the EPR gauges, and all were normal. The flight engineer confirmed that the power was stable at 1.1 EPR, and as power was applied slowly and evenly to 1.43 EPR, he ensured that power was symmetrical and the rpm gauges were matched. The captain stated that the takeoff began normally, with only minor corrections to maintain the runway centerline. Before receiving the 80-knot call he expected from the first officer, the captain felt the airplane moving to the left. He said he applied right rudder pedal (inputs to the rudder control surface and nosewheel steering) without any effect. He stated that he added more right rudder and then used the nosewheel steering tiller, but both were ineffective. He stated that he had no directional control and that the nose of the airplane continued to turn left. He knew where the runway centerline was, but he was unable to control the direction of movement. The captain said that while the airplane was still on the runway with the veer and drift to the left increasing, he applied full right rudder and nosewheel steering tiller. He said that he then retarded the power levers to idle and applied maximum braking. He said that he intentionally did not use reverse thrust because of the airplane’s slow speed at the time of the abort, the long runway, and the possibility that reverse thrust could have worsened directional control. The airplane then departed the left side of the runway. The first officer stated that shortly after thrust was set and the airplane began moving forward, it appeared to be left of the centerline. He stated that the nose was pointed slightly left of the centerline in a minor deviation. He said that he looked down, noted that the airspeed was less than 70 knots, looked back outside, and observed that the airplane had veered further to the left. He stated that he was able to distinguish the runway edges at this time, and it

6 Engine pressure ratio (EPR) is a measure of engine thrust, comparing the total turbine discharge pressure to the total pressure of the air entering the compressor.

4 was apparent to him that the airplane’s veer to the left could not be corrected. He said that he commented on this to the captain and the flight engineer while the captain was attempting to stop the airplane. The flight engineer stated that after he set takeoff power and cross-checked the engine instruments, he noted that the nose had started to veer to the left. He observed the captain using right rudder and tiller and thought that the airplane would return to the centerline. He recalled that the captain immediately pulled all four thrust levers to idle, and that the captain applied the brakes just before the airplane left the runway. A deadheading first officer who occupied the aft cockpit jumpseat during the attempted takeoff stated that the captain reduced thrust only seconds after the flight engineer called “power set.” He stated that he felt no swerve, and that his first indication of trouble was when the captain retarded the thrust levers. He thought that the airplane was yawed left but tracking straight for a while, and then it started to track to the left off the runway. He thought that about 2 seconds elapsed between the power reduction and the time that the airplane left the runway. The captain recalled that after the airplane came to a stop off the runway, the first officer called the control tower, and the flight engineer made a public address (PA) announcement for the passengers to remain seated. The captain and flight engineer then performed the memory shutdown items. The crew discussed whether to order an evacuation. Based on the crew’s determination that there was no fire, that the airplane was basically intact and not in imminent danger, and that there was a low wind chill factor outside, the captain elected to keep everyone on board. 1.2 Injuries to Persons Injuries Flightcrew Cabin Crew Passengers Other Total Fatal 0 0 0 0 0 Serious 0 1 0 0 1 Minor 0 0 24 0 24 None 3 11 427 2 443 Total 3 12 451 2 468 1.3 Damage to Airplane The airplane sustained substantial damage, and it was written off as a constructive total loss.

5 1.4 Other Damage A 12-foot double-sided sign and two 8-foot single-sided signs were damaged when the airplane hit them after departing the runway. In addition, an FAA-owned transformer was destroyed. 1.5 Personnel Information 1.5.1 The Captain The captain, age 53, was hired by Tower Air on May 23, 1992, as a first officer on B-747 airplanes. He was reassigned as captain on the B-747 on April 23, 1994. He held an airline transport pilot (ATP) certificate, with ratings for L-188, DC-9, B-747, and airplane multiengine land. His most recent proficiency check was accomplished on January 11, 1995, and he completed the required recurrent simulator training in lieu of a proficiency check on July 31,

1. He received his last line check before the accident on May 7, 1995. His Federal Aviation

Administration (FAA) first-class medical certificate was issued on July 17, 1995, with the limitation that he must possess corrective lenses. At the time of the accident, company records indicated that he had accumulated approximately 16,455 total flying hours. He had logged 2,905 hours in the B-747, of which 1,102 hours were as pilot-in-command. The captain flew on active duty in the U.S. Navy from 1967-1971, and in the Naval Air Reserve an additional 15 years in multiengine turboprop airplanes. He flew for Transamerica Airlines from 1978 through 1984, and for Midway Airlines from 1984 through November 1991. The captain held a reserve bid 7 for December, but he was not assigned any flight duties by Tower Air from December 12-18, 1995. On December 18, 1995, he was notified that he would be performing the accident trip on December 20. He was on reserve on December 19, 1995, but again was not called for duty that day. He napped for about 2 hours in the afternoon and retired about 2200. On December 20, 1995, he awoke at 0400, anticipating bad weather, traffic, and the possible need to shovel snow. He arrived at Tower Air operations at 0645. The company reporting requirement was 1½ hours before departure, which would have been 0830 in this case. He had never flown with the first officer before, but he had flown with the flight engineer five times in the past. 1.5.2 First Officer The first officer, age 56, was hired by Tower Air on January 16, 1995, as a first officer on B-747 airplanes. He held an ATP certificate, with ratings for LR-JET, N-265, B-747, B-727, airplane multiengine land, and commercial privileges for single-engine land, B-707, B- 720, and L-T33. He completed his most recent proficiency check on February 15, 1995, and his

7 A pilot on a reserve bid is on stand-by duty for assignment to flights.

6 recurrent simulator training in lieu of a proficiency check on July 26, 1995. His most recent FAA first-class medical certificate was issued on December 8, 1994, with the limitation that he must possess corrective lenses. Company records indicate that at the time of the accident, he had accumulated 17,734 total flying hours, of which 4,804 hours were in the B-747. The first officer had been off duty for 17 days before the accident trip. He commuted from his home in Miami, Florida, to a hotel in New York on December 19, 1995. He went to bed about 2230, slept well, and arose at 0600. He reported to operations at 0720. He did not recall having flown with the captain previously, but he had flown with the flight engineer once. 1.5.3 Flight Engineer The flight engineer, age 34, was hired by Tower Air on March 10, 1995, as a flight engineer on B-747 airplanes. He held a flight engineer certificate with a turbojet powered rating; a mechanic certificate with airframe and powerplant ratings; and a private pilot certificate with ratings for airplane single-engine land. His most recent FAA first-class medical certificate was issued on December 8, 1995, with the limitation that he must possess corrective lenses. He had a Statement of Demonstrated Ability issued on April 2, 1994, for defective color vision demonstrated on a special flight test. His most recent proficiency check was accomplished on March 9, 1995, and his recurrent training was completed on September 19, 1995. Company records indicate that at the time of the accident, he had accumulated a total of 4,609 total flying hours, of which 2,799 hours were as a flight engineer in the B-747. The flight engineer flew the JFK-Miami-JFK round trip that included flight 41 on December 17, and he was off duty December 18-19, 1995. On December 19, 1995, he left his home in Delaware about 1230 in his car, arrived in New York about 1730, and checked into the hotel about 2000. He went to bed about 2100. He arose at 0500 on December 20, 1995, left the hotel at 0720, and arrived at the operations office at 0730. 1.6 Airplane Information 1.6.1 General N605FF, a Boeing B-747-136, was delivered new to the British Overseas Airline Corporation in July 1971. Trans World Airlines, Inc. (TWA), acquired it in March 1981, and subsequently sold it to Tower Air in March 1991. At the time of the accident, it had been flown 90,456.7 hours, with 17,726 cycles. It was equipped with four Pratt & Whitney JT9D-7A engines. The Boeing 747-136 model is equipped with a hydraulic-powered nosewheel steering system to assist pilots with directional control during ground operations. Hydraulic fluid under pressure is used to turn the nosewheel in response to control inputs by the captain and first officer. All B-747s are equipped with a nosewheel steering tiller located at each pilot’s side panel. Nosewheel steering through the tiller is capable of 70o of nosewheel deflection, at full

7 tiller input. In addition to the steering capability through the tiller, N605FF (as well as many other B-747s) was equipped with rudder pedal steering that turned the nosewheel in response to control inputs through the rudder pedals at each pilot’s foot position. Because of the rudder pedal steering, a pilot’s inputs to the rudder pedals would result in coordinated movement of the nosewheel and the rudder control surface at the tail of the airplane. In contrast to the tiller, the rudder pedals were capable of 10o of nosewheel deflection, at full rudder pedal input. The flight data recorder (FDR) system on N605FF was an Aeronautical Radio, Incorporated (ARINC) Characteristic Number 563 digital FDR system. This system consisted of a central electronics unit (CEU) and three digital acquisition units (DAU), in addition to the flight data recorder unit. The three DAUs were located in the system’s main equipment center, center equipment center, and upper equipment center. Each DAU acquired, converted, and multiplexed inputs from FDR data sensors located near the unit (e.g., DAU #3 handled the vertical and longitudinal acceleration and stabilizer position data). A processed, digital signal was sent from each of the DAUs to the CEU for further conditioning and processing. The CEU, located in the main equipment center, acted as a final signal processor, and sent the signal to the FDR for recording. (Figure 1 shows the location of the FDR system components.) Following the accident, the baggage and cargo on the airplane were weighed. The actual takeoff gross weight was found to be 566,963 pounds. The maximum allowable takeoff gross weight was 625,609 pounds. The actual center of gravity (CG) was found to be 22 percent mean aerodynamic chord (MAC). According to the Tower Air B-747 Flight Manual, the CG limits for this weight were between 13.8 and 31.5 percent MAC. 1.6.2 Maintenance Records Review Tower Air maintained N605FF under an FAA-approved continuous maintenance program. All appropriate airworthiness directives (ADs) had been accomplished. British Airways performed a “C” check 8 on N605FF from December 30, 1993, through January 29, 1994, at its facility in London. Tower Air sent two inspectors to the facility to monitor the work and to ensure that the maintenance was performed in accordance with the Tower Air General Maintenance Manual (GMM). Random inspection of selected work cards by the Safety Board revealed that the individual work cards had been signed off by British Airways personnel. However, the Tower Air inspectors did not complete the “C” check work accountability form that would have attested to the completion of the entire “C” check, as required by the GMM.

8 The FAA-approved maintenance program for Tower Air includes seven specific checks that must be accomplished at various calendar or operating time intervals. They range from Transit Service, completed at each departure, to “D” checks performed every 72 months. The 15-month service is accomplished at a mid-point (9-15 months) between “C” checks, which are at 24-month intervals.

9 A 15-month service check was accomplished on N605FF in March 1995 at the Tower Air facility at JFK. During the service check, all landing gear were removed because of time-in-service limitations. The part numbers of the replacement landing gear (appropriate for the B-747-121 model) were different from those specified in the Tower Air illustrated parts catalogue for the B-747-136. Documentation from Boeing showed that the part numbers of the replacement gear could be substituted on the B-747-136. However, Tower Air maintenance personnel had installed the gear without the documentation from the manufacturer; this documentation was obtained when the issue was raised during the Safety Board’s investigation of the accident. Interviews with the mechanics, maintenance supervisors, inspectors, parts stores personnel, and purchasing personnel involved in the landing gear replacement revealed that no one had cross-checked the part numbers on the landing gear with the carrier’s illustrated parts catalog. The Tower Air GMM specified that it was the responsibility of each mechanic and inspector to ensure that all parts being installed were approved in the manual. The GMM also required the receiving inspector to compare the serial number, part number, and quantity with the applicable purchase order or repair order. On September 28, 1995, FDR S/N 2074 was removed from N605FF for a routine annual check of the airplane’s FDR systems. The annual check is performed to determine the validity and accuracy of the mandatory recorded parameters and consists of a readout of the data recorded during recent flights. Nominal data for all recorded parameters would indicate normal functioning of the FDR, CEU, and three DAUs. FDR S/N 2074 was replaced with S/N 2461. The readout was performed by TWA. On November 3, 1995, after FDR S/N 2074 was read out, TWA issued a memorandum to Tower Air identifying six data parameters that were “suspect.” These parameters were (1) elevator position; (2) radio communications; (3) flap outboard position; (4) vertical acceleration; (5) longitudinal acceleration; and (6) No. 2 reverser position. Aircraft maintenance log page No. 38147 for N605FF, dated December 1, 1995, indicated two specific writeups on the FDR system. The first indicated that the FDR “OFF” light (located on the pilot’s overhead panel) flickered in flight. The corrective action shown in the logbook was to replace FDR S/N 2461 with FDR S/N 2152. This action eliminated the flickering light. The second writeup indicated that the FDR system test (located on the flight engineer’s panel) was inoperative in flight and on the ground. The corrective action for this item was deferred initially. On December 2, 1995, the CEU was replaced and the system checked satisfactorily. The aircraft was then returned to service. On December 4, 1995, the six “suspect” FDR system parameters were entered in the aircraft maintenance log, and the discrepancies were transferred to the deferred items log. According to the maintenance log, on December 7, 1995, the last day that the discrepancy could be deferred according to the FAA-approved Master Minimum Equipment List (MMEL), the corrective action taken was to replace DAU #1. There was also the annotation, “Performed functional check as per 31-31-00 [Maintenance Manual].”

10 According to the mechanic/supervisor who did the work, the required functional check of the FDR on N605FF was not accomplished immediately after DAU #1 was replaced because the “thumb wheel” test equipment was not available during the night shift, when the DAU was replaced. The day shift mechanic/supervisor stated that he performed the required functional check of the FDR after he obtained the tester from TWA. A sales ticket issued by TWA for rental of a “thumb wheel” tester indicated that it was issued to Tower Air at 0800 on December 7, for 4 hours. The mechanic/supervisor could not remember when he obtained the tester or who assisted him, but he stated that the test required about 1½ to 2 hours with another person’s help. He stated that the test could be done at the gate; however, he indicated that any maintenance on the airplane (including the functional test of the FDR system) must be completed 2 hours before the scheduled departure time. Tower Air records indicate that N605FF departed JFK at 0955 on December 7, 1995, and did not return until 2015 that evening. 1.7 Meteorological Information The National Weather Service (NWS) surface analysis charts for 1000 and 1300 showed a strong area of low pressure located southeast of Nantucket Island moving slowly northeast. Instrument meteorological conditions (IMC), moderate-to-strong northerly surface winds, and light-to-moderate snow were indicated west and southwest of the system over the New England area. Pertinent surface weather observations at JFK were, in part, as follows: 1050--Record--partial obscuration, estimated ceiling 700 feet broken, 2,000 feet overcast, visibility 1 1/2 miles, light snow and fog, temperature 24 oF, dew point 21 oF, wind 350o at 13 knots, altimeter setting 29.54 inches of Hg; Remarks--0.5 sky obscured by snow. 1150--Record--partial obscuration, estimated ceiling 700 feet broken, 2,000 feet overcast, visibility 1 1/2 miles, light snow and fog, temperature 24 oF, dew point 21 oF, wind 330o at 11 knots, altimeter setting 29.53 inches Hg; Remarks--0.5 sky obscured by snow. The JFK Surface Weather Observations Form for December 20, 1995, showed that 1.3 inches of snow had fallen between 0645 and 1245. The form also indicated that the peak wind for the day had been from the north at 24 knots at 1014. No local or special weather observation was made at the time of the accident, as required by NWS directives, because the weather observer was not notified of the accident in time to fulfill this requirement. The wind direction and speed measurements included in the official weather observations at JFK were obtained from the NWS anemometer located 20 feet above the airport surface, between runways 4L-22R and 4R-22L, about ¾ mile northeast of where the airplane departed off the side of the runway. Given the prevailing northwesterly winds, this location was downwind of the terminal buildings at JFK. Research indicates that no significant sheltering

11 effects exist beyond 20 building-heights downwind of an obstacle. The anemometer was more than 50 building-heights downwind of the terminal buildings. An NWS Automated Surface Observing System (ASOS) unit that included an anemometer positioned 10 meters above the surface was located about ½ mile further to the northeast. This unit had been calibrated and was operating on the day of the accident, but it had not yet been commissioned by the NWS. Consequently, the weather data that it collected were not included in official observations. The ASOS unit recorded a gust of 22 knots between 1111 and 1121 (15 to 25 minutes before the accident). 1.8 Aids to Navigation There were no pertinent problems with navigational aids. 1.9 Communications No external communications difficulties were reported. 1.10 Airport Information 1.10.1 General JFK Airport is located 13 feet above sea level. It is owned by the City of New York and operated by the Port Authority of New York and New Jersey (PNY&NJ). It was certificated under 14 CFR Part 139, and is an Index E aircraft rescue and fire fighting (ARFF) facility. 9 The runway configuration includes four runways: 4L/22R, 4R/22L, 13L/31R, and 13R/31L. Runway 4L, the accident runway, is 11,351 feet long and 150 feet wide, with an asphalt surface that has transverse grooves the full length. It is configured for Category I instrument landings and is equipped with high intensity runway edge lights and centerline lights. 1.10.2 Runway Conditions On the morning of the accident, runway 4L had been closed to aircraft operations for snow removal, sanding, and inspection until about 1000. Runway 31L was closed until about 1134, when the airport duty manager informed the control tower that the runway had checked satisfactorily. According to the transcript of radio transmissions on Kennedy Air Traffic Control Tower ground control frequency, at 1131 the ground controller transmitted, “…American fourteen seventy three the word is just now (we’re) switching to thirty one left [at taxiway] double kilo for departure so you can plan on that.”

9 Title 14 CFR Part 139 requires, for scheduled air carrier service with aircraft at least 200 feet in length, that at a minimum the airport be equipped with at least three ARFF vehicles with at least 6,000 gallons of water for foam production.

12 FAA Advisory Circular (AC) 150/5200-30A advises airport operators to perform friction checks of runway surfaces during ice/snow conditions. The AC does not specify the method of friction measurement to be used, although it provides a list of recommended methods. The PNY&NJ operations services supervisor stated that she conducted a coefficient of friction measurement survey of runway 4L at 0933, using a Saab friction test vehicle, just after the runway had been sanded. After driving the full length of the runway, 20 feet to the right of centerline, the supervisor estimated that the surface was approximately 60 percent covered with patches of snow and ice. The friction coefficient results from the test, which was completed at 0950, averaged 0.32; with 0.39 in the touchdown zone, 0.26 at the mid- point, and 0.31 in the rollout area. Two additional friction tests were run after the accident at 1147 and 1155 indicating 0.31 and 0.27, respectively, in the touchdown zone area of runway 4L, where the on-runway portion of the accident sequence occurred. PNY&NJ procedures state, “When [friction] readings are 0.40 and below for any one-third of the runway and taken on acceptable conditions, they should be reported to the tower [emphasis in original].” PNY&NJ Operations Office personnel stated that the 0933 friction results were relayed to the control tower by telephone before runway 4L was reopened at 1000. The control tower had no record that this information was received from PNY&NJ. The 0933 coefficient of friction measurements were entered into the PNY&NJ operations office computer at 1240 (after the accident), with the annotation, “ATCT advised.” The PNY&NJ assistant chief operations supervisor, who was serving as the airport duty manager at the time of the accident, stated that runway 4L had been plowed and sanded full length and width just before the 0933 friction test on December 20, 1995. He stated that he inspected the runway before it was reopened at 1000, and he issued two notices to airmen (NOTAMS), as follows:

1. Runway 4L-22R, patches of one inch-deep compacted snow and

ice. Runway sanded.

1. Runway 4L-22R, centerline lights obscured.

Both NOTAMS were valid at the time of the accident. FAA Order 7110.65J, “Air Traffic Control,” paragraph 3-3-4 (d)(1) provides the following procedures for air traffic controllers to use in providing information to pilots about runway friction measurements received from airport management: Furnish information as received from the airport management to pilots on the ATIS at locations where friction measurement devices such as…Saab Friction Tester…are in use. Use the Runway followed by the MU number for each of the three runway segments, time of report, and a word describing the cause of the runway friction problem.

13 1.10.3 Previous Safety Board Recommendations In 1982, the Safety Board addressed the issue of runway surfaces contaminated 10 by ice or snow in three investigation reports. 11 As a result of these investigations, the Safety Board issued the following safety recommendations to the FAA concerning runway friction measurement technologies and procedures: Amend 14 CFR 25.109 and 14 CFR 25.125 to require that manufacturers of transport category airplanes provide data extrapolated from demonstrated dry runway performance regarding the stopping performance of the airplane on surfaces having low friction coefficients representative of wet and icy runways and assure that such data give proper consideration to pilot reaction times and brake antiskid control system performance. (A-82-165) In coordination with the National Aeronautics and Space Administration (NASA), expand the current research program to evaluate runway friction measuring devices which correlate friction measurements with airplane stopping performance to examine the use of airplane systems to calculate and display in the cockpit measurements of actual effective braking coefficients attained. (A-82-168) In a June 19, 1987, response to Safety Recommendation A-82-165, the FAA informed the Safety Board that it had drafted a notice of proposed rulemaking to enable aircraft manufacturers to furnish performance information “for slippery runways in unapproved sections of airplane flight manuals .…” Further, the FAA stated that it had amended its guidance material regarding performance information for operations on slippery runways, AC 91-6, in conjunction with the proposed regulatory changes. However, on April 1, 1988, after reviewing what the Board characterized as “the limited actions taken by the FAA during the [preceding] five years,” including the FAA’s failure to issue a final rule in this area, the Safety Board classified Safety Recommendation A-82-165 “Closed—Unacceptable Action.” In response to Safety Recommendation A-82-168, the FAA informed the Safety Board on April 1, 1983, that the FAA and NASA were initiating a test program “to develop a means to provide runway braking condition information which has a more quantitative basis than subjective pilot reports.” However, on May 5, 1987, the FAA informed the Safety Board of its concerns that such runway friction and aircraft braking measurements could not be made

10 In this report, the term “contaminated,” as it pertains to runways, is defined as being when the runway is not bare and dry or when the runway surface is altered such that the effective runway friction coefficient is less than the certificated bare and dry value. 11(1) National Transportation Safety Board. 1982. Air Florida collision with 14th Street bridge, Washington, D.C., January 13, 1982. Aircraft Accident Report NTSB/AAR-82/8; (2) National Transportation Safety Board. 1982. World Airways, Boston, Massachusetts, January 23, 1982. Aircraft Accident Report NTSB/AAR-82/15; and (3) National Transportation Safety Board. 1982. Large airplane operations on contaminated runways. Special Investigation Report NTSB/SIR-82/15.

14 meaningful and might encourage operations from a runway with a very low friction coefficient. The Safety Board disagreed and on April 1, 1988, classified Safety Recommendation A-82-168 “Closed—Unacceptable Action.” 1.10.4 Air Carrier Slippery Runway Events Since 1982, a review of Safety Board accident data for 14 CFR Part 121 and 135 operators showed that 15 accidents occurred during periods of ice and snow contamination. The contamination on the surface was found to be the probable cause in two cases, and a contributing factor in nine others. According to the FAA Administrator’s Daily Alert Bulletin reports reviewed by the Safety Board, six air carrier operations experienced excursions from runways or high speed taxiways in surface conditions of ice, snow or slush contamination during the winter season of 1995-96. 12 Additionally, air carrier operations experienced five excursions from taxiways under such conditions during the same period. 1.11 Flight Recorders 1.11.1 Flight Data Recorder The aircraft was equipped with Sundstrand 573 FDR S/N 2152. The FDR was received at the Safety Board laboratory in good condition, with no signs of external or internal damage. However, the readout revealed that all parameters recorded by the FDR, except time and synchronization, lacked orderliness and reflected random values not resembling any type of flight operation. The FDR data were also transcribed at the TWA facility in St. Louis, Missouri, where the system was initially installed, but the data transcription yielded the same results. Finally, the data were provided to a private contractor, who also concluded that no meaningful data were on the tape. 1.11.2 Cockpit Voice Recorder The aircraft was equipped with Fairchild model A-100 cockpit voice recorder (CVR), S/N 2059. The exterior of the CVR showed no evidence of damage, and the interior of the recorder and tape were also undamaged. The recording from 1106:40 to 1137:21 was of good quality. 13 It began during the preparation to start engines and ended shortly after the aircraft

12 Business Express BAE-146, Rifle CO, 2/20/96; Continental Airlines B-737, Kansas City MO, 1/18/96; Delta Airlines B-727, Salt Lake City UT, 1/26/96; Delta Airlines B-757, Portland OR, 2/5/96; American Airlines MD-80, Richmond VA, 2/17/96; USAir B-737, Charlotte NC, 2/3/96. 13 The Safety Board generally uses the following criteria to assess the quality of a CVR recording: a “poor” recording is one in which a transcription is nearly impossible given that a large portion of the recording is unintelligible; a “fair” recording is one in which a transcription is possible, but the recording is difficult to understand; a “good” recording is one in which few words are unintelligible; and an “excellent” recording is very clear and easily transcribed.

15 went off the runway. The Safety Board transcribed the complete duration of the tape (see appendix B). 1.12 Wreckage and Impact Information The first marks on the runway attributed to N605FF consisted of four pairs of black marks located approximately 2,000 feet from the threshold of runway 4L, and centered approximately 40 feet left of the runway centerline (see figure 2). The four pairs of tire marks were consistent with the tires of the airplane left main wing landing gear (LMWLG), left body landing gear (LBLG), right body landing gear (RBLG), and right main wing landing gear (RMWLG). The tire marks on the runway were continuous, and each mark was approximately 8 inches wide. No tire marks were found from the nose landing gear either on the runway or on the ground. The marks were identified by tracing ground, taxiway, and runway marks back from the airplane using the known dimensions of the airplane’s landing gear and tires. 14 When tire marks were correlated with the landing gear that left the marks, it was determined that the LMWLG departed the left edge of the runway (which is 75 feet left of the centerline) 2,100 feet from the threshold, and the RMWLG departed the left edge of the runway 2,300 feet from the threshold. Both the LBLG and the RBLG tire marks paralleled the other tire tracks. The landing gear made ruts 8-12 inches deep in the soft, snow-covered ground. The RMWLG ruts intersected an area of 8”x12” asphalt blocks about 2,400 feet from the threshold and 105 feet left of the runway centerline. Just beyond this area, the tire marks crossed an asphalt service road connecting the runway and the parallel taxiway. The road sloped away from the runway so that the surface elevation was about 2-3 feet higher at the RMWLG tracks than at the LMWLG tracks. The RMWLG ruts continued to approximately 2,500 feet from the threshold and 240 feet left of the runway centerline, where the ruts began to shallow and then ended about 2,600 feet from the threshold and 290 feet left of the runway centerline. The ruts from the remaining main landing gear continued to where the airplane came to rest. Two new ruts approximately 30 feet apart and to the right of the RMWLG ruts that disappeared were associated with the Nos. 3 and 4 engines. The outboard rut ended at an electric transformer. The transformer and its concrete base were destroyed, and pieces of the nosegear assembly were found approximately 35 feet to the left of the transformer. The No. 4 engine was located about 3,700 feet from the runway threshold and 500 feet left of the runway centerline. The airplane came to rest approximately 4,800 feet from the runway threshold and 600 feet to the left of the runway centerline.

14 The distance between the LMWLG strut and the RMWLG strut is 36.1 feet. The distance between the LBLG and the RBLG is 12.6 feet. The distance between the center of an inboard and outboard tire for each landing gear is 4 feet.

17 The fuselage forward of the No. 2 main entry door and below the floor level received severe impact damage. It was crushed upward where the nose landing gear had collapsed, still attached, aft into the fuselage. The collapse of the nose landing gear and subsequent crushing of the fuselage lower lobe resulted in significant damage to the electronics bay, and disrupted the normal operation of the PA and interphone systems. There was no impact damage to the fuselage above the floor line, and fuselage damage aft of the No. 2 main entry door was limited to fiberglass fairings. The left wing, flight controls, and pylons for engine Nos. 1 and 2 were not damaged. The primary structure of the right wing and ailerons was not damaged. The inboard leading edge flaps and the inboard trailing edge mid and aft flaps received impact damage. The No. 3 engine pylon was severely damaged and bent slightly inboard. The No. 4 engine pylon was also severely damaged and separated forward of the rear engine mounts. 1.13 Medical and Pathological Information In accordance with the requirements of Appendix I of Part 121, each flightcrew member submitted a urine sample at the Kennedy Medical Offices at JFK Airport for the required testing for five drugs of abuse. 15 The samples were analyzed by Labcorp of America, located in Research Triangle Park, North Carolina. The results were negative for all three crewmembers. In accordance with Appendix J, 14 CFR Part 121, each flightcrew member also submitted to a Breath Alcohol Test. The tests were accomplished between 1416 and 1427 on December 20, 1995. The results were negative for all three crewmembers. 1.14 Fire There was no fire. 1.15 Survival Aspects 1.15.1 Cabin Interior Layout and Damage The interior of N605FF was divided into six zones, as shown in figure 3: • Zone A - Cabin forward of the L1/R1 doors • Zone B - Cabin between the L1/R1 and L2/R2 doors • Zone C - Cabin between the L2/R2 and L3/R3 doors • Zone D - Cabin between the L3/R3 and L4/R4 doors • Zone E - Cabin aft of the L4/R4 doors • Upper Deck - Cabin area above the main deck, aft of L1/R1 doors

15 The five drugs of abuse specified by the regulation for postaccident testing are marijuana, cocaine, opiates, phencyclidine, and amphetamines.

19 The cabin floor sustained substantial damage in Zone A. The floor was displaced upward approximately 2 feet in the center of the cabin at seat rows 6, 7, and 8. At least three of the four attach points for each of the seats in this area remained secured to the seat tracks, and no injuries were reported in this area. 1.15.2 Galley Equipment Description The cabin of N605FF had three galley complexes, each of which consisted of two galleys facing each other. The forward complex was between the L1/R1 exits; the mid complex was between the L2/R2 exits; and the aft complex was between the L4/R4 exits. Each galley contained both permanent equipment and removable equipment. Permanent equipment included ovens, coffee makers, and waste bins. Removable equipment included carts (meal or beverage carts used in the aisles), and containers (also referred to as bins, and usually not moved during the flight). Ice carts, slightly larger than the meal and beverage carts, were also part of the removable equipment on the former TWA airplanes in the Tower Air fleet, including N605FF. According to Tower Air procedures, the ice carts are installed by the caterers before each flight. Flight attendants do not move them from the galley during the in-flight service, but they are responsible for ensuring security of the galley equipment, including the ice carts, based on their training, the Flight Attendants Manual, and the Galley & Service Equipment Training Manual. Tower Air required that all of the removable equipment, including the ice carts, be secured with both primary and secondary locking devices. Primary latching of meal and beverage carts on N605FF was accomplished by placing each cart over a "mushroom" (a restraining spool mounted on the floor under the galley counter). The carts were secured to the mushrooms by a locking mechanism mounted beneath the cart. A cart could be removed from the mushroom by releasing the cart's brakes, which released the cart from the mushroom. In contrast to the “mushroom” locking mechanism used to secure meal and beverage carts, the ice cart in each galley area of N605FF locked onto a retaining tongue mounted on the floor of the galley with a lever located on the bottom of the cart. The lever movement inserted a pin through a circular opening in the retaining tongue (see figure 4). Secondary latches were installed for each cart in the galleys of N605FF. The secondary latches were levers that when rotated, covered a portion of the cart to prevent the cart from moving from its stowage location. In N605FF, some secondary latches were mounted to the galley counter, some were mounted on galley support structures, and some were mounted on trash bin doors. The secondary latch for the ice cart located in the forward-facing portion of the aft galley was mounted on the galley counter.

21 Based on its manufacture date of 1971, according to the FAA, N605FF was subject to type certificate requirements regarding the prevention of items of mass, stowed in a passenger or crew compartment, from becoming a hazard by shifting under the appropriate maximum load factors corresponding to the specified flight and ground load conditions, and to the emergency landing conditions of 14 CFR 25.561(b) and (c). 16 The airplane was also subject to provisions of 14 CFR Part 25.785(h)(4), which required that each flight attendant seat be “located to minimize the probability that occupants would suffer injury by being struck by items dislodged from service areas, stowage compartments, or service equipment.” TWA had installed secondary latches on N605FF in 1982. The TWA engineering drawings for the installation of those latches included some latches mounted on doors rather than rigid structure. On N605FF, in the galleys where waste bins were installed, secondary latches were mounted on the waste bin doors. Further, the engineering drawings did not include a latch mounted on the galley counter as the secondary latch for the ice cart, as found in the aft galley of N605FF. TWA advised the Safety Board that the latches were installed when decorative, non- structural doors, were removed. The modification order stated that FAA approval was not required; however, a copy of the modification order was provided to the FAA. On January 6, 1994, the FAA issued AC 25.785-1A, “Flight Attendant Seat and Torso Restraint System Installations.” The AC provided the following guidance on secondary latching mechanisms: If the primary latching devices fail, the additional restraint devices [secondary latches] should be designed to retain all items of mass under the inertial loads specified as a part of the airplane type certification basis…. ...Service experience with galleys, stowage compartments, and serving carts has shown that some of the presently designed latches or locks, of themselves, may not adequately minimize the probability of items being dislodged under operational and emergency load conditions…. Flight attendant seats that are located within a longitudinal distance equal to three rows of seats measured fore and aft from the center of a galley or

16 14 CFR 25.561 concerns Emergency Landing Conditions. It states, in part, that the airplane must be designed to protect each occupant as follows:...(b) The structure must be designed to give each occupant every reasonable chance of escaping serious injury in a minor crash landing when - (1) Proper use is made of seats, belts, and all other safety design provisions;...(3) The occupant experiences the following ultimate inertia forces acting separately relative to the surrounding structure: (i) Upward, 3.0g, (ii) Forward, 9.0g (iii) Sideward, 3.0g on the airframe; and 4.0g on the seats and their attachments. (iv) Downward, 6.0g (v) Rearward, 1.5g (c) The supporting structure must be designed to restrain, under all loads up to those specified in paragraph (b)(3) of this section, each item of mass that could injure an occupant if it came loose in a minor crash landing.

22 stowage compartment area, with the exception of underseat and overhead stowage bins, are not in compliance with para. 25.785(j) [sic (h)(4)] unless additional restraint devices (dual latching devices or equivalent) are incorporated to retain all items of mass in the galley...under the inertia loads specified as part of the airplane type certification basis. 1.15.3 Flight Attendant Galley Preflight Procedures According to the Tower Air Flight Attendant Manual, all company flight attendants had preflight duties, and four flight attendants on a B-747 were specifically responsible for preflight preparation and inspection of the galleys. The R1 flight attendant 17 was responsible for preflighting the forward galley; L2, the mid galley; L4 (who was designated assistant purser on the flight), the aft galley; and UD, the upper deck galley. These preflight duties included testing cart brakes, primary locking mechanisms, and secondary latches. Following this accident, Tower Air Inflight Service Department issued a memorandum to all flight attendants on January 31, 1996, describing the operation of the ice module locking mechanism and the flight attendant responsibility to ensure that carts are properly locked. 1.15.4 Flight Attendant Galley Preflight Activities The R1, L2, L4, and UD flight attendants on the accident flight stated that their galleys were secure for takeoff. These flight attendants stated that they secured the carts by engaging the cart brakes and placing secondary latches over the carts. The L4 flight attendant was responsible for securing the aft galley. This was her first trip working the galley. She recalled that she was able to secure everything without difficulty. The L4 flight attendant stated that she secured the ice cart module in the aft galley by moving the lever underneath the cart to the secured position. In contrast to the statements of the L4 flight attendant, the R4 flight attendant recalled that while she was icing down her beverage cart before departure, she noted that the ice cart swing brake was not secured to the retaining tongue. She stated that she tried to lock the cart, but could not. She stated that she advised the L4 flight attendant that the ice cart was not secure and asked the R5 flight attendant if he could secure the cart. The R5 flight attendant did not recall the R4 attendant making this request.

17 This report refers to flight attendants according to their emergency exit door assignments (refer back to figure 2 for cabin layout and door labels).

23 1.15.5 Events in the Cabin During the Accident Sequence The R4 flight attendant, who was seated in the aft-facing jumpseat at door R4, reported that during the accident sequence, she sensed movement toward the right side of the runway with a skidding sensation. Later she heard “crunching, tearing” noises, and saw the No. 4 engine skidding down the runway before the airplane stopped. She recalled that while the airplane was still moving, many overhead bins opened and spilled their contents. The larger side bins in the cabin nearby also opened and spilled even more debris. During the airplane’s slide, she heard a “metal sound” in the aft galley, and she saw an ice cart and a beverage cart come loose. The ice cart hit her right shoulder, and she suffered a broken right shoulder. The ice cart continued to move forward and stopped upright in front of the empty passenger seats across from her jumpseat. The loose beverage cart hit the ice cart and then came to rest tilted against the seats, blocking the R4 exit. The R4 flight attendant recalled that she and several passengers smelled kerosene after the airplane stopped. She commented that if she had not been injured, she would have evacuated. The L4 flight attendant stated that when the aircraft stopped abruptly, the overhead bins in Zone E opened, and luggage spilled “all over the place.” After the airplane stopped, the L4 attendant noted that the secondary latch for the ice cart on the forward-facing side of the aft galley was bent upward. The R2 flight attendant observed that a bin in the mid galley had popped out about 2-3 inches during the accident sequence, and that the L2 flight attendant got out of her seat to secure it while the airplane was still sliding. The UD flight attendant reported that the doors to several bins opened during the accident sequence. She recalled that various items of personal equipment she had stowed came out of the bins. Based on the recollections of all flight attendants, the only flight attendants who shouted brace position commands during the accident sequence while the airplane was still moving, as required by Tower Air procedures, were those at the R1, R4, and UD positions. The purser stated that when the airplane stopped, he tried to call the cockpit on the interphone. Although he heard the interphone tone, he received no answer. He ran upstairs to the cockpit to get instructions from the captain, and was told that because there was no fire or danger, the passengers should be kept on board out of the weather. He recalled that the captain also advised him that the rescue personnel would come to the L1 door. The purser stated that the captain did not inquire about the cabin condition or injuries, and the purser did not report the upward displacement of the floor in the forward cabin (Zone A). The purser returned to the L1 door position and made a PA announcement instructing passengers to remain seated. Flight attendants stated that, following the accident, PA announcements were heard in the front of the airplane, but they were not heard in Zones D and E or the rear part of Zone C. Three flight attendants stated that they attempted to use the interphone to communicate with the purser, and

24 these attempts were unsuccessful. According to their statements, none of the flight attendants attempted to use the megaphones. The deadheading company flight attendant identified himself to the purser and asked if he needed help. The purser told him, “Just keep the people seated.” The deadheading flight attendant then repeated the announcement for the passengers to remain seated using the PA at the L2 station. The purser stated that he did not think they were going to evacuate at any time. He also thought that the PA announcements were heard throughout the entire cabin, and he did not attempt to make an “All Call” 18 interphone call to communicate with the other flight attendants. According to the flight attendants, both the PA and interphone systems were operating properly before the accident. 1.15.6 Deplanement When the rescue personnel arrived at the airplane, they proceeded to the L1 exit. The purser was unable to disarm the emergency evacuation slide at the L1 door because the arm- disarm handle would not move to the manual position. He next tried the R1 door, but the girt bar 19 remained engaged even after the arm/disarm handle was moved to the manual position. He next tried the L2 handle, which he was able to place in the manual position, and the L2 door was opened by the rescue personnel. The purser then announced instructions about deplanement over the PA system. Passengers deplaned by rows and boarded buses. The purser stated that he learned about the injured flight attendant during the deplanement. 1.15.7 Flight Attendant Training Flight attendants at Tower Air were trained in accordance with an FAA-approved program. At the time of the accident, under the provisions of this program, new hires received 40 hours of basic indoctrination covering safety regulations, company policies, procedures, forms, and organizational and administrative practices. They then received 16 hours of initial training (14 hours classroom and 2 hours competency check) on B-747 cabin familiarization (including the aircraft systems they would be operating), authority of the pilot-in-command, and passenger handling. They also received 28 hours of emergency procedures training, including drills that provided instruction and practice in the use of emergency equipment and procedures.

18 The communication system includes a “master call indicator panel” and PA and interphone headset at each flight attendant station as well as in the cockpit. The “All Call” signal permits simultaneous interphone communication with all flight attendant stations and the cockpit. When the “All Call” code is used, a chime sounds at every station, and the crew call light on its master call indicator panel will flash (as opposed to a steady light for a normal crew call). 19 A bar installed through a sleeve in the girt extension of the evacuation slide, which is installed in floor-mounted brackets to enable automatic slide deployment when the slide is in the “armed” position.

25 Training on operating the serving carts was included in the 16-hour initial training module. This training was conducted in a classroom, and one of the three types of carts in the fleet was brought to the classroom for demonstration purposes. Students were shown how the brakes operated and were given a chance to maneuver the cart. According to routine flight attendant training practices at Tower Air, the cart used for this demonstration could have been any of the meal or beverage carts found on any of the various models of the Tower Air airplanes. Ice carts, which have different primary attachment mechanisms from those of most other carts, were not specifically included in classroom cart demonstrations. At a separate time, students were shown the galleys while performing a “walkaround” on the actual airplane; however, no carts were installed in the galleys during the “walkaround” training session. Neither slides nor photographs of carts were included in the Tower Air initial flight attendant training program. Students received a “Galley & Service Equipment” handbook during initial training that included a diagram showing an “Atlas”-style cart, which was used on some B-747s in the Tower Air fleet, but not on the former TWA aircraft. The “Atlas” cart had a different primary attachment mechanism from the “TWA” beverage and ice carts installed on N605FF. This handbook also described preflight procedures for the galley, again without specific reference to the “TWA”-type carts. Flight attendants did not receive crew resource management (CRM) training at Tower Air, nor were they required to at the time of the accident. As part of its 1992 special investigation report 20 on flight attendant training, the Safety Board issued Safety Recommendation A-92-77 to the FAA: Require that flight attendants receive Crew Resource Management training that includes group exercises in order to improve crewmember coordination and communication. Subsequently, the FAA amended 14 CFR 121.421, “Flight Attendants: Initial and Transition Ground Training,” and 121.427, “Recurrent Training,” to require CRM training for flight attendants. The effective date for the new requirement was March 19, 1996, with all flight attendants to be trained by March 1999. Also, the FAA completed rulemaking that mandates CRM training for flightcrews and flight attendants and issued Advisory Circular AC 120-51B, Crew Resource Management Training, which recommends initial and recurrent training including communication and coordination exercises. Because of these actions, the Safety Board classified Safety Recommendation A-92-77 “Closed--Acceptable Action” on July 15, 1996. However, based on safety issues previously identified by the Board in its accident investigations, the Board encouraged the FAA to provide additional guidance to air carriers about the importance of group

20 National Transportation Safety Board. 1992. Flight attendant training and performance during emergency situations. Washington, DC. June 9, 1992. Special Investigation Report NTSB/SIR-92/02.

26 exercises involving both cockpit cabin coordination and coordination among the individual members of a flight attendant crew. At the time of the accident, Tower Air flight attendants qualified for the purser and assistant purser positions 21 after receiving 5 additional days of training. Much of the subject matter was related to customer service functions, but the training also included reviews of emergency procedures, safety regulations, and coordination and communication among flightdeck crew, flight attendants, ground staff, and operations personnel. Before departure, the flight attendant who had originally been scheduled to serve as purser on the accident flight was replaced by the scheduled assistant purser. This flight attendant had completed a 5-day training course for purser qualification in March 1995. However, he had not served as purser before this flight. Tower Air procedures assign the assistant purser to the L4 door position. The flight attendant who was assigned the duties of assistant purser at the L4 door, as a result of the last-minute cabin crew change, had not attended the assistant purser training program. 1.16 Tests and Research 1.16.1 Flight Recorder Tests To determine the operating capability of the FDR components installed on N605FF at the time of the accident, the Safety Board installed and tested the CEU and DAUs in various combinations on a sister ship (N606FF) that had an operative FDR system and components. During the test, individual parameter data sent to the FDR were monitored and recorded by use of an ARINC 563 hand-held tester, which samples the data stream sent to an FDR by the CEU. When the three DAUs from N605FF were tested with the sister ship's CEU, DAUs #1 and #2 operated normally, but no data were output from DAU #3. In addition, the CEU self-test identified DAU #3 as inoperative. When the CEU from N605FF was tested with the sister ship's DAUs, only the synchronization and time data were valid, and a valid CEU self-test could not be performed. This data condition was similar to the conditions found on the accident FDR recording.

21 The positions of purser and assistant purser are not FAA-mandated; the company uses these positions as part of its cabin crew assignments. According to the Tower Air Flight Attendants Manual, the purser provides “work guidance” to all flight attendants and has complete “responsibility for passenger service and safety requirements of the flight.” The manual states that the assistant purser directs flight attendants in the performance of their duties, ensures accurate provisioning of galleys, and ensures compliance with proper service procedures.

27 1.16.2 Cockpit Voice Recorder Sound Spectral Study The area microphone channel of the CVR contained tones that were associated with sounds of the aircraft engines. The recording was examined on a computerized spectrum analyzer that displays and records frequencies. The engine speeds corresponding to the sound signatures were calculated. The engine traces were identifiable above 27 percent N1 (engine fan speed). During the initial takeoff roll, two distinct traces were audible, but once the engines exceeded 70 percent N1 only one engine-related sound signature was identified. It could not be determined which engines were creating the identified sound. After air traffic control’s (ATC) issuance of the takeoff clearance to flight 41, as recorded on the CVR, the engines accelerated to approximately 40 percent N1 and leveled off for approximately 4 seconds. The engine sounds then increased in frequency for 13 seconds, and they stabilized at the equivalent of 87.5 percent N1 after a brief overshoot to approximately 89 percent. The sounds continued at a constant frequency for approximately 6 seconds (35 seconds after the airplane was cleared for takeoff). After this period, the engine sound began to decrease to a minimum of 72.6 percent N1. Approximately 42 seconds after takeoff clearance, the engine sound then began to increase again, reaching a maximum of about 91 percent N1. The engine sound then decreased sharply after 2 seconds and was finally lost in the background noise at approximately 59 percent N1. 1.17 Organizational and Management Information Tower Air, Inc., was incorporated in 1982 and obtained an air carrier certificate in

1. At the time of the accident, the company provided scheduled and charter passenger and

cargo service in diverse international and domestic markets. Between 1990 and 1995, the carrier increased its fleet of B-747s from 4 to 17 airplanes. At the time of the accident, Tower was operating 18 B-747s with 132 pilots, 69 flight engineers, and 805 flight attendants. 1.17.1 Reporting Relationships Among Operational Managers At the time of the accident, the vice president of operations (VPO) exercised daily operational control of Tower Air through the director of operations (DO), the chief pilot, the manager of flight control, and the director of crew scheduling, all of whom reported directly to the VPO. The Federal Aviation Regulations do not require air carriers to have a VPO; nor do these regulations define the responsibilities or minimum qualifications of the VPO when this management position exists at an air carrier. In contrast, the DO is a required management position for all air carriers, under the provisions of 14 CFR 121.59 and 119.65. Minimum qualifications of the DO are set forth in 14 CFR 121.61 and 119.67. Among other requirements, the DO is required to hold an ATP certificate and have previous experience as a manager or PIC of flight operations conducted under Part 121.

28 Under 14 CFR 121.133, Tower Air was required to “prepare and keep current a manual for the use and guidance of flight and ground operations personnel in conducting its operations.” The Tower Air document that fulfilled this requirement was the company’s General Operations Manual (GOM). Tower Air personnel records indicate that the owner’s son, who was not a pilot, was appointed VPO on November 20, 1995. The former VPO became the DO and vice president of training and publications. At that time, the reporting relationships between the new VPO and subordinate personnel also were changed. The DO reported directly to the VPO. The chief pilot, who was managing the daily flight activities, the flightcrew training, and supervision of the pilots, check airmen, and flight instructors of the airline, also reported directly to the VPO. According to statements of the VPO, the DO, and the chief pilot, these reporting relationships were in effect before the date of the accident. The Tower Air GOM, section 2.2, revision 153, dated February 1, 1996, included descriptions of these revisions to the company’s organization structure and management duties and responsibilities. This section of the revised GOM described the duties and responsibilities of the DO, in part, as follows: Plans, administers, and directs the overall accomplishment of flight operations in accordance with FAA regulations and company policy and procedures. Despite these responsibilities given the DO by the GOM, the reporting relationships established by Tower Air before the accident did not provide the DO with the responsibility to supervise the daily operational and training activities, and the operational personnel, that were under the control of the chief pilot. According to the FAA principal operations inspector (POI), the FAA first received verbal notification of this change in management personnel and reporting relationships on December 20, 1995, before the accident occurred. The POI described the notification he received on that date as one of a planned management change, rather than a management change that had already occurred. In a letter dated January 25, 1996, the POI assigned to Tower Air requested an updated organizational chart and a list of duties and responsibilities of the VPO, DO, and chief pilot. The company provided the POI with GOM revision 153, dated February 1, 1996. On February 29, 1996, the POI sent a letter rejecting the new organization, stating the following, in part: The Vice President of Operations has been assigned several duties and responsibilities for which he lacks the qualifications. The Operations Organizational Chart shows the chief pilot, Director of Crew Scheduling, and Manager of Flight Control reporting directly to the Vice

29 President of Operations and not through the appropriate chain of command, normally associated with aviation experience. Tower Air’s chief executive officer responded on March 20, 1996, in part, that, “Our research of the applicable laws, regulations, and legal precedents reveals no objective basis for your decision. Nevertheless, this is to advise that your position will be addressed in revision 154 of the General Operations Manual.” This revision subsequently was issued and reflected the chief pilot reporting through the DO to the VPO. 1.17.2 Director of Flight Safety In August 1995, Tower Air engaged the part-time services of a consultant to fill the company’s newly created position of director of flight safety and evaluation. He served as a “contract employee” with a guarantee of 10 paid days per month, and a daily rate for additional days worked. To foster the communication of safety information from line crews to managers, the director of flight safety and evaluation established a “CEO’s hotline,” developed a concern form with drop boxes on company premises, and reviewed crewmembers’ trip reports. At the time of the accident, he had developed an internal evaluation program, including provisions for internal and external audits of station, flight operations, cabin, and ramp safety. However, at the time of the accident, Tower Air had not yet formalized the personnel assignments to perform these audits, and none had been performed. 1.18 Additional Information 1.18.1 Operating Procedures - Boeing 747 The Tower Air B-747 Flight Manual (p. 4.30.3) states, “Takeoffs on slippery runways are not recommended if the crosswind exceeds 15 knots…” The manual describes the following technique for nosewheel steering use during takeoffs (p.4.24.3): Rudder pedal steering [nosewheel steering controlled by pilot inputs through the rudder pedals] should be used after the aircraft is aligned on the takeoff runway with the tiller guarded only until 80 knots. If deviations from the runway centerline cannot be controlled during the start of the takeoff prior to rudder effectiveness, immediately reject the takeoff. It also specifies the following for takeoffs on slippery runways (p.4.30.3 and pp.4.30.3-5): Set takeoff thrust slowly and smoothly and correct deviations from the runway centerline with immediate steering and/or rudder action and slight differential

30 thrust if required.… During takeoffs on icy runways, the lag in nosewheel steering and the possibility of nosewheel skidding must be realized and corrections must be anticipated. Directional control from nosewheel steering and aerodynamic rudder forces should be optimized during the low speed portions of the takeoff roll by limiting the rudder pedal input to approximately 1/2 of the full rudder pedal travel for airplanes with rudder pedal steering. For airplanes without rudder pedal steering, limit the tiller input to 10o and use the rudder as required. Rudder effectiveness is less than nosewheel steering effectiveness below approximately 50 knots. Increased directional control may be obtained by the use of the ailerons between 60 and 100 knots. The manual contains guidance for landing on slippery runways (p.4.30.6), as follows: Avoid large, abrupt steering and rudder pedal inputs that may lead to overcontrol and skidding.… The optimum nosewheel steering angle varies with runway condition and airplane speed, and is about 1-2o for a very slippery runway. Keep forward pressure on the control column to improve nosewheel steering effectiveness. The manual further amplifies a discussion of the landing rollout that the optimum nosewheel steering angle for a slippery runway is 3-5o, and 1-2o for a very slippery runway. A Tower Air 1994 Standards Memo, dated February 11, 1994, provided the following additional guidance in a section entitled, “Steering”: Use rudder pedal steering for takeoff. Use of the tiller is not recommended unless rudder steering is not sufficient during the early takeoff roll. As the speed increases during takeoff with a crosswind, apply ailerons as required to maintain wings level. Avoid large changes in control inputs. The directional control from the rudder becomes more effective than nosewheel steering at about 50 knots. If directional control cannot be maintained by 50 knots without the use of the tiller, the takeoff should be aborted. The Boeing 747 Operations Manual states the following (p.4.23.04A): On airplanes without rudder pedal steering, limit tiller input to approximately 15o....The pilot flying should maintain control of the thrust levers until directional control is assured (approximately 50 knots)....If deviations from the runway centerline cannot be controlled during the start of the takeoff roll or until the rudder becomes effective, immediately reject the takeoff. The Boeing 747 Flight Crew Training Manual contains the following additional information:

31 When taxiing on a slick surface at reduced speeds, use of differential outboard engine thrust will assist in maintaining airplane momentum through the turn. Differential braking may be more effective than nose wheel steering on very slick surfaces. Keep the airplane on the center line with rudder pedal steering and rudder. The rudder becomes more effective than the rudder pedal steering at about 50 knots. Do not use nosewheel tiller during takeoff roll unless required initially due to crosswind. At aft CG and light weights, nose wheel steering effectiveness is reduced, especially on slick surfaces. Application of takeoff thrust and a sudden brake release will lighten the nose wheel loading. With this condition, a rolling takeoff is preferred with slow, steady thrust application to takeoff thrust during the initial roll. Hold the control column forward to improve nose wheel steering. 1.18.2 Flightcrew Training At the time of the accident, Tower Air conducted flightcrew training from a base in New York, using leased flight simulators in a variety of locations. The manager of flight training handled administrative aspects of the program and reported to the vice president of training. However, actual training and flight standards activities were managed directly by the chief pilot. The training staff consisted of the chief pilot, classroom instructors, and six simulator instructors. The simulator instructors were line-qualified captains who were current employees or retired captains who served under direct contract with the company. They were also qualified as check airmen. According to the chief pilot, the company was able to hire pilots already qualified in the B-747 for a period after startup. Later it became more difficult to hire only those pilots who were already qualified in the B-747, and hiring was opened to other applicants. At the time of the accident, the minimum hiring requirement was 3,000 total hours, but the average experience level of new hires was 6,000-8,000 hours with substantial experience in heavy airplanes. The chief pilot also stated that the training program for new hires provided little training in slippery runway procedures, because the new hires started as first officers, and first officers would not be performing the takeoffs or landings under these conditions (captains would perform all of these operations, according to Tower Air practices). The chief pilot stated that during upgrade training for captain qualification, adverse weather takeoff procedures were presented in ground school as these procedures were described in the Tower Air B-747 flight manual. The simulator training phase of upgrade training introduced students to a slippery runway condition during landing that rendered the airplane uncontrollable. Tower Air training personnel indicated that the B-747 simulators

32 available for flightcrew training were not capable of adequately simulating the more realistic slippery runway scenarios, in which the airplane would be controllable given proper control technique. The Tower Air CRM training program for flightcrews included a 1-day ground school on CRM fundamentals. This class was taught by an individual who was experienced in CRM classroom instruction from his work at other air carriers. The CRM instructor worked under contract for Tower Air. Nearly all cockpit personnel, including the three crewmembers involved in the accident, had received this training by the time of the accident. Also, Tower Air integrated CRM elements into recurrent simulator training by including line-oriented challenges for the crew that required coordination among the flightcrew, dispatchers, and maintenance personnel. Recurrent simulator training was conducted with complete crews (the company elected to provide biannual recurrent training for most first officers). 1.18.3 Pilot Techniques for B-747 Takeoffs The captain stated that his usual takeoff procedure was to hold the tiller with his left hand until the 80-knot callout, at which time he called, “I’ve got it” and transferred his left hand to the yoke. He stated that he used the tiller on every takeoff, and he relied on the 80-knot call to ensure rudder effectiveness. He stated that there was no company-established maximum speed for using the tiller. He was unable to recall the recommended maximum crosswind limit for a slippery runway without referring to the manual. The first officer stated that his usual takeoff procedure was to use the tiller early in the takeoff roll, until about 80 knots when the rudder becomes effective. He commented that the tiller becomes more sensitive as speed increases. He said that he used the tiller more in crosswind situations. He also pointed out that rudder pedal movement gives some nosewheel steering. He stated that the maximum crosswind component for a slippery runway was 15 knots. The chief of flight standards described Tower Air’s standard takeoff technique at the time of the accident: During the takeoff roll, the flying pilot should guard the tiller with one hand for possible use during the spoolup phase from 1.1 EPR to takeoff power, in case of asymmetrical thrust. At about 50 knots the rudder becomes controlling. At 80 knots, the flying pilot should release the tiller and take control of the yoke. The chief of flight standards emphasized that the proper nosewheel steering technique for the takeoff roll should be to use rudder pedal steering, not the tiller. He explained that the Tower Air procedure of guarding the tiller during the takeoff until attaining 80 knots was carried over from an early Pan American procedure. The older model B-747s operated by Pan American were not equipped with rudder pedal steering. During the 1980s, Tower Air had also operated a small number of B-747s that were not equipped with rudder pedal steering. Although at that time instructors encouraged the use of the tiller during the initial takeoff roll, the airline’s policy changed about 1989 with the retirement from the fleet of the last airplane not equipped with rudder pedal steering.

33 The chief of flight standards stated that proper tiller use, including limitations on the use of the tiller, had been periodically emphasized in training. He added that pilots used the tiller during taxi, and there was sometimes a natural tendency to revert to its use on the runway. He also indicated that instructors emphasized the Boeing training manual language that recommends limiting rudder pedal steering input to ½ full travel to get optimal cornering friction. He indicated that it is clear that if a pilot cannot control the airplane with ½ rudder pedal travel, the takeoff should be rejected. The chief pilot reported that the tiller should be guarded by the flying pilot, and it should be used for directional control only in the initial alignment with the runway centerline as the transition is made to rudder pedal steering. He stated that the tiller can aggravate directional control at higher speeds. He said that reverse thrust would not be used on slow-speed rejected takeoffs (below 80 knots) and added that reverse thrust presents possible directional control problems on slippery runways. 1.18.4 B-747 Simulator Activity In a flight simulator study on August 8, 1996, pilots from the Safety Board, FAA, Boeing, Tower Air, and the Tower Air Cockpit Crewmembers Association (TACCA) evaluated various pilot inputs and their effects on directional control. The study was conducted at the Boeing Airplane Systems Laboratory in Seattle, Washington. The simulator employed in the tests was the “747 Cab,” a B-747 engineering simulator in the laboratory capable of being systematically modified to reflect selected environmental conditions, aircraft performance characteristics, and aircraft responses to control inputs. It was programmed to reflect the operating weight, CG, flap setting, and outside air temperature applicable to the accident flight. 22 During the simulator sessions, takeoffs were attempted under dry, wet, snowy, and icy runway friction conditions, with crosswind components of 12 and 24 knots (corresponding to the greatest wind velocities reported by ATC to the accident crew and recorded at any time during the morning of the accident, respectively). Gust conditions were simulated by introducing gusts of 12 and 20 knots, with 2-second and 6-second durations. Gusts were introduced at airspeeds varying from 20 to 65 knots. The evaluation pilots who had actual experience operating the B-747 on slippery runways (those representing the FAA, Boeing, Tower Air, and TACCA) agreed that the Boeing engineering simulator adequately reflected the ground handling characteristics of the actual airplane in slippery conditions. Further, they agreed that the ground handling characteristics of the Boeing engineering simulator were more realistic than those of the simulators used by Tower Air for flightcrew training.

22 The simulator was a B-747-400 model, with the simulator modified to reflect the performance of the B- 747-136 model involved in the accident. Modifications included engine thrust, stabilizer trim setting, rudder travel, and icy runway friction coefficient.

34 Operating the simulator under slippery runway conditions, with a left crosswind component of 12 knots, the evaluation pilots were able to reproduce the approximate path of the accident airplane as it deviated from the centerline and departed the runway. In these simulations, the deviations were initiated when tiller inputs were introduced to correct minor heading changes that occurred immediately following brake release, while the simulated airplane was moving at slow speed. The simulator responsiveness to tiller inputs was reduced by the slippery runway conditions. When the pilots reacted to the decreased control responsiveness by adding more tiller, the nosewheel quickly exceeded the critical angle at which the traction available for steering was maximized. This critical angle, which varies as a function of runway slipperiness, airplane ground speed, and airplane slip angle, was one of the parameters recorded during the simulations. Once the critical angle was exceeded, the nosewheel began to skid. Further tiller inputs in either direction were ineffective, and the airplane veered to the left in a weathervaning response to the crosswind. During most of the simulated takeoffs that reproduced the approximate path of the accident airplane, the airplane did not completely depart the runway surface before it attained sufficient airspeed for the aerodynamic rudder to become effective (50-80 knots). The simulator was capable of responding to right rudder inputs with a corrective, rightward yaw once this airspeed was attained. At that time, pilots were able to arrest the leftward veer with rudder inputs to regain runway heading with some or all of the simulated airplane remaining on the runway surface. The simulator was not programmed to exhibit any additional drag or yaw that may develop when a real airplane landing gear leaves the runway surface. The takeoff attempts during which the left veer could not be arrested with right rudder were those in which the heading deviation was initiated by overcontrol of tiller at the earliest part of the takeoff roll, while airspeed was well below rudder effectiveness. In contrast to the results obtained with pilot inputs to the tiller, simulated takeoffs could be successfully completed without significant deviation from the runway centerline using control inputs limited to the rudder and the nosewheel steering through the rudder pedals. The takeoffs were controllable in the absence of tiller inputs under all runway surface conditions from dry through icy, and with crosswinds of up to 24 knots. Further, without tiller inputs, takeoffs were controllable under crosswind conditions of 20 knots gusting to 40 knots. A simulated takeoff during which no aerodynamic rudder or nosewheel steering inputs were made resulted in the simulated airplane initially drifting downwind (to the right) momentarily, then weathervaning into the wind, and departing the left side of the runway. Takeoffs attempted under slippery runway conditions, with a lower thrust value from the No. 1 engine, resulted in an uncontrollable deviation to the left of centerline. Specifically, when an asymmetric thrust of 0.05 EPR was used at the beginning of the takeoff attempt, the simulator departed immediately from the left side of the runway, at low speed, and before rudder effectiveness was attained. Introduction of asymmetric thrust later in the takeoff roll had varying effects on directional controllability, depending on the airspeed attained and the consequent rudder effectiveness.

35 During simulated takeoff attempts incorporating use of the tiller under slippery runway conditions, variations in elevator and aileron position did not appear to significantly affect directional controllability at low speeds. 1.18.5 Recent Tower Air Accidents and Incidents Safety Board records reveal that Tower Air experienced two accidents and three incidents between August 14, 1995, and June 17, 1996. In addition to the accident that is the subject of this report, there were two uncontained engine failures (one of which was an accident), an in-flight engine gearbox fire that had to be extinguished by an ARFF unit, and a landing approach incident. On August 14, 1995, a B-747-130, N603FF, operated by Tower Air, had an uncontained engine failure in the No. 1 engine during the departure climb from JFK. 23 The crew reported a severe vibration at 14,000 feet, declared an emergency, and returned to JFK. The flight landed safely and taxied to the gate, where the 436 occupants deplaned normally without injury. The JT9D7A engine had been leased to Tower Air and had accumulated 105 cycles since it was installed on July 7, 1995. Examination of the engine revealed that pieces of a turbine shroud had penetrated the turbine exhaust case at the 6 to 9 o’clock position, exited the cowling, and punctured the No. 2 outboard reserve fuel tank. There was a fuel leak, but no fire developed. On October 23, 1995, N613FF, a B-747-121, had a failure of the No. 4 engine during the takeoff roll at Miami International Airport, Miami, Florida. 24 This was a cargo flight with three crew and two passengers. When the airplane came to a stop, the crew observed a fire in the area of the JT9D7A No. 4 engine. The five occupants evacuated the airplane. There were no injuries, but the airplane was substantially damaged. Examination of the airplane revealed that an uncontained failure of a low pressure turbine hub of the No. 4 engine damaged the cowling, pylon, wing, aileron, flaps, fuselage, and right horizontal stabilizer. On December 10, 1995, N616FF, a B-747-212B, sustained damage during an instrument landing approach in fog at Schiphol Airport, Amsterdam, Netherlands. 25 The flight executed a missed approach and landed uneventfully following a second approach. A post- landing inspection revealed that the No. 4 engine cowling and right wingtip were damaged. None of the 288 occupants were injured. On December 20, 1995, this accident occurred at JFK.

23 NTSB file number NYC95IA192, B-747, N603FF, JFK Airport, Jamaica, NY, August14, 1995. 24 NTSB file number MIA96FA013, B-747, N613FF, Miami, FL, October 23, 1995. 25 NTSB file number DCA96WA018, B-747, N616FF, Amsterdam, Netherlands, December 10, 1995.

36 On June 17, 1996, N606FF, a B-747-136, experienced a fire warning light in the No. 2 engine at 35,000 feet, during the arrival/descent to JFK. 26 The crew shut down the engine, discharged both engine fire extinguishing bottles, and declared an emergency. The airplane was met by ARFF equipment, which foamed the engine. The 414 occupants deplaned by mobile stairs, without any injuries. 1.18.6 FAA Surveillance At the time of the accident, the FAA New York Flight Standards District Office (FSDO-EA15), located at Garden City, New York, was responsible for surveillance of Tower Air. The FSDO organization included two Certificate Management Units (CMU): one managing Tower Air and Atlas Air, and the other managing North American Airlines and the USAir Shuttle. The FAA POI assigned to Tower Air joined the FAA as a geographic operations inspector in 1988. He was assigned to the Tower Air certificate as an assistant POI in 1989 and became the POI in 1991. His previous background included experience in the commuter industry as a director of operations and a chief pilot. He held type ratings in the B-737 and B-747, both of which he received after he was hired by the FAA. His B-747 training was provided by TWA to FAA personnel only, as transition training, and it lasted 1 month in June 1990. As part of that training, he obtained about 2 hours in the airplane. The remainder of his B-747 training and subsequent experience was obtained in the simulator. His most recent B-747 recurrent training was completed in January 1995. He stated that since 1991, he had always been assigned as the POI of one or more other air carriers in addition to Tower Air. In 1993, he was assigned as the POI of Atlas Air. At the time of the accident, Tower Air was operating 18 B-747s; Atlas was operating 11 B-747s; and both carriers were expanding. He estimated that his time was equally divided between the two carriers. He said that his workload was “near its limits.” At the time of the accident, he was receiving support from an assistant POI, the geographic unit, a navigation specialist, and a cabin safety specialist, all within FSDO-EA15. He stated that he had requested additional geographic inspection support (surveillance of Tower Air operations by inspectors based at other domestic and international FAA flight standards offices). The POI stated that he obtained feedback from the geographic inspections by reviewing information entered by the geographic inspectors into the FAA Program Tracking and Reporting Subsystem (PTRS) data system. He stated that he attempted to review these entries quarterly, but that his most recent review before the accident was made in June 1995. A review of FAA PTRS records for Tower Air indicated that the POI had performed one cockpit en route inspection from October 1, 1994, through December 31, 1995. That inspection was performed on January 27, 1995.

26 NTSB file number IAD96IA098, B-747, N606FF, JFK Airport, Jamaica, NY, June 17, 1996.

37 The assistant POI for Tower Air was hired in 1991 as a geographic inspector. He was appointed as an assistant POI for both Tower Air and Atlas in 1993. He had been a pilot for TWA for 34 years and retired as a B-747 captain. He commented that he and the POI assigned to Tower Air and Atlas were not overloaded, but whereas each carrier had been expanding at different times previously, the two airlines were both expanding simultaneously at the time of the accident. He stated that this had resulted in a backlog for check rides and insufficient time for the POI and him to conduct routine en route checks. He stated that he visited the Tower Air corporate offices about once per week, and said that he conducted en route inspections for certification and initial operating experience (IOE). The assistant POI said that Tower Air flightcrew training was conducted by line pilots. He was not able to describe the company’s CRM training program for flightcrews. He was aware that Tower Air had established a safety department about 2 months before the accident, but he did not know whether the safety officer was a full-time employee. A review of PTRS records revealed that the assistant POI did not perform any en route inspections at Tower Air that were not certification related from October 1, 1994, through December 31, 1995. The manager of FSDO-EA15 had held that position since October 1994. Previously, he was the assistant manager of the Eastern Region Flight Standards Division. He stated that at the time of the accident, maintenance and avionics inspector staffing at FSDO-EA- 15 were at the authorized levels. He said, however, that the operations inspector staff was nine short, including an Aircraft Program Manager (APM) position that he did not expect would be filled. He stated that he had received authorization to fill five of the operations inspector positions in FY 1996. He stated that he hoped to fill the remaining three positions during FY

1. He commented that a single international en route inspection required 32 hours of an

operations inspector’s 40-hour week. He stated that FSDO-EA-15 needed more geographic inspection support from other FAA flight standards offices. According to the FSDO manager, as a result of an internal staffing review, it was his intention to reorganize the office to create three CMUs. The Tower Air certificate would be managed by one of these CMUs, with a dedicated POI and assistant POI. In September 1996, the Safety Board was informed through informal staff communications with the FAA that these changes had not yet occurred, but were impending. A review of the PTRS records for Tower Air revealed that 160 operations inspections were completed from October 1, 1994, through December 31, 1995. Most of the inspections focused on ramp, en route cockpit and cabin, training records, check airmen, and facilities. Also, one line station and two in-depth inspections were conducted in FY 1995. About half of the operations inspections were conducted by geographic inspectors from the FAA’s Eastern Region, which included FSDO-EA-15. Despite the worldwide operations of Tower Air, no cockpit en route surveillance had been performed by inspectors from the Frankfurt, Brussels,

38 or London offices, and no operational inspections of any type had been performed by the Miami International Field Office. The FAA conducted a national aviation safety inspection program (NASIP) inspection at Tower Air from September 11-20, 1995. The inspection resulted in 34 findings, of which 23 were maintenance related and 11 were operational. The 23 maintenance discrepancies discovered in the NASIP inspection included 11 items in which procedures were either not found in the maintenance manual or were not being followed. Ten items related to discrepancies in maintenance logbooks, and two items related to maintenance training. All maintenance items were closed either through Tower Air action or a note of explanation provided by FSDO-EA-15. The 11 operational findings included four related to flight, duty, and rest time recordkeeping; four involved training records of flightcrew members and dispatchers; two related to manuals; and one related to aircraft differences in emergency egress equipment that were not reflected in safety briefings by flight attendants and in passenger briefing cards. One of the training record discrepancies credited a captain with training in New York while he was flying a line trip to the Far East. All 11 findings were closed by the time of the accident. Two findings, including this pilot training record discrepancy, resulted in enforcement action by the FAA. The executive summary of the NASIP inspection stated: Findings documented during the inspection that are being investigated for possible non-compliance with [Federal Aviation Regulations] are: manuals and procedures, training records, passenger briefing cards, [Minimum Equipment List] usage, and life limited parts records. A review of the FAA enforcement records for Tower Air indicated that 120 enforcement actions had been closed since the carrier’s inception. As of January 1996, 17 cases were open. Two were operational and the others were maintenance related. 1.18.7 Aircraft Performance Because no meaningful data from the FDR were available, a study was conducted to investigate the aircraft movement during the attempted takeoff. The aircraft manufacturer derived total airplane thrust values from the results of the Board’s CVR sound spectrum study (see section 1.16.2). The derived engine thrust was used to calculate ground speed and distance traveled data, using the Boeing engineering computer simulator. Selected comments and sounds from the CVR were also correlated to the time base. The derived information was then used to graphically represent the probable airplane movement during the accident sequence. This showed that at 1136:25, flight 41 was cleared for takeoff. By 1137:02, engine N1 rpm had reached 88 percent (approximately 160,000 pounds of total thrust), the airspeed had increased to about 40 knots, and the airplane had traveled about 630 feet from the

39 runway threshold (including a nominal 250 feet to turn onto the runway and align the nosewheel before initiating the takeoff). At 1137:04, the captain said, “Set time, takeoff thrust.” The power remained stable at about 88 percent N1. The takeoff continued normally as the flight engineer confirmed the request. At 1137:10 the words “watch it” were spoken twice. At this time, 25 seconds after the start of the takeoff roll, the airspeed had increased to about 80 knots, and the airplane had traveled 1,350 feet. Within a second there was an audible “click” on the CVR, and the engine rpm began to decrease from about 88 percent to 75 percent by 1137:13. Within 2 seconds thrust began to increase to a maximum of 91 percent N1, about the time the airplane departed the left edge of the runway. Between 1137:12 and 1137:15 there were comments from various flightcrew members (“OK, losing it”; “going to the left”; “to the right”; “you’re going off”; and “going off”). During the same period, the airspeed increased from 88 knots to 94 knots, and the airplane traveled from 1,650 feet to 2,100 feet down the runway. At 2,100 feet, the LMWLG departed the runway edge. The aircraft performance study indicated that the airspeed was about 97 knots at this time. The RMWLG departed the runway edge at 1137:16.5, at an airspeed of about 100 knots. Based on the Safety Board’s measurements of the tire marks on runway 4L associated with the landing gear of the accident airplane, between 2,000 and 2,050 feet from the runway threshold, the airplane was at an angle of 15.4o from the runway centerline. Between 2,050 feet and the 2,100-foot point where the LMWLG left the runway edge, the angle was 11.5o from the centerline. The tire marks over the next 200 feet of travel indicated that the airplane departed the runway at an angle of 10.4o to the left of the runway centerline.

40

1. ANALYSIS
2. 1

General The flightcrew was properly certificated and qualified in accordance with applicable regulations and company requirements. All three crewmembers were experienced at their respective positions. Evidence from crew duty time, flight time, rest time, or off-duty activity patterns did not indicate that behavioral or physiological factors affected the flightcrew on the day of the accident. The ATC personnel involved with the flight were all properly certificated and qualified. The airplane was properly certificated, equipped, and maintained (with the exception of the FDR system) in accordance with FARs and approved regulations. The weight and balance were within allowable limits. In analyzing this accident, the Safety Board focused on flightcrew actions and decisions, B-747 procedures for slippery runway operations, the performance of air carrier training simulators for B-747 operations on slippery runways, flight attendant actions and cabin safety issues, Tower Air management oversight of maintenance and operations, FAA surveillance of Tower Air, and FAA policies and procedures regarding the evaluation of slippery runways. 2.2 Flightcrew Actions and Decisions 2.2.1 Pre-takeoff Events Although the flightcrew was not provided the runway friction values obtained by the airport operations crew, they had obtained sufficient indications from the slipperiness of the taxiways, the appearance of runway 4L, and the blowing snow to recognize that they were operating in a challenging environment of wind, reduced visibility, and runway slipperiness. Based on the existing surface and wind conditions on the day of the accident, the captain might have considered using runway 31L (which was more favorably oriented to the wind) for his departure. However, when the captain overheard the response of JFK ground control to another flight’s inquiry about runway 31L that it would remain closed for another couple of hours, he determined that runway 31L was not a viable option for departure. Although 5 minutes before the accident ATC changed the departure runway to 31L for traffic following flight 41, the Safety Board recognizes that the captain’s decision to use runway 4L was based on the limited information available to him at the time. Further, air traffic controllers were not required to offer flight 41 the option of switching to runway 31L, once the airplane was established holding short at runway 4L. Based on the absence of definitive runway friction measurements for runway 4L, reported winds of less than 15 knots (the maximum recommended crosswind component for B-747 takeoffs on slippery runways), the flightcrew’s reports of acceptable visibility down the runway, and the reported unavailability of the alternative runway

41 31L, the Safety Board concludes that the captain’s decision to attempt the takeoff on runway 4L was appropriate. 2.2.2 The Attempted Takeoff and Loss of Control Flight 41 attempted its takeoff under crosswind conditions with a runway contaminated with packed snow and patchy ice. At the approximate time of the takeoff attempt, there were crosswinds of 10-12 knots. Gusts of up to 22 knots were reported in the general area near the time of the accident. Asymmetric thrust (for example, inadequate thrust from the No. 1 engine) could have resulted in the loss of directional control experienced by flight 41. In the absence of a cross-check of other engine instruments, a malfunctioning EPR indicator could have led the flightcrew to unknowingly set inadequate thrust for the No. 1 engine. However, given the flight engineer’s recollections of evenly matched engine acceleration and consistent EPR and N1 indications from all four engines, and the absence from the CVR of flightcrew discussions of abnormal throttle alignment, the Safety Board concludes that asymmetric thrust was not a factor in the loss of directional control. Having verified the realism of the Boeing engineering flight simulator in reproducing the ground handling characteristics of the B-747 on slippery runways, the Safety Board applied the findings of its August 8, 1996, flight simulation study to the circumstances and events in this accident. In all simulations in which the pilot did not use the nosewheel steering tiller for directional control (including those conducted with icy runway conditions and winds gusting up to 40 knots), the simulated airplane was controllable along the runway centerline. In contrast, when pilots attempted to maintain the runway centerline using the tiller under slippery runway conditions with a 12-knot crosswind, a slight overcontrol at the very beginning of the takeoff roll repeatedly led to the loss of traction and steering capability from the nosewheel, followed by the loss of directional control. Given that it is very unlikely that the captain did not try to control the airplane’s tendency to weathervane into the crosswind, and given the consistent controllability of the airplane under accident conditions when the tiller was not used (during the simulation study), the Safety Board concludes that the captain’s failure to correct the airplane’s deviation from the centerline resulted from his overcontrolling the nosewheel steering through the tiller. This conclusion is supported by the captain’s statement that he added increasing amounts of tiller steering input during the loss of control sequence and departed the runway still holding full right tiller. The Safety Board was unable to determine with certainty the event that precipitated the captain’s overcontrol with tiller inputs. Simulation study results suggest that the B-747 has a tendency to react to crosswinds at very slow airspeeds with an initial, slight downwind drift. It would have been natural for the captain to have reacted to this slight

42 deviation with a tiller input, because the deviation would have occurred at a slow airspeed as the airplane was just beginning its takeoff roll. However, there could have been a number of additional reasons for why the captain applied steering inputs through the rudder or tiller at the start of the takeoff roll. These include a line-up that was slightly off the runway centerline, a wind gust, or a slight thrust imbalance from one or more engines as they accelerated to takeoff power. Still, regardless of the reason for beginning the control inputs, the simulation study indicated that the runway deviation was unlikely to have precipitated a loss of control without excessive steering inputs through the tiller. It is logical that overcontrol of the tiller on any aircraft would be more likely on a slippery runway than a dry runway, because airplane heading is less responsive to tiller inputs in slippery conditions. When a pilot makes a tiller input and does not obtain the expected reaction from the airplane, it is possible that the pilot will, at least initially, provide additional input to obtain the expected reaction. The lag in airplane response followed by additional control input could result in overcontrol of the tiller to the extent that the nosewheel exceeds its critical angle and loses traction. The simulation study also demonstrated that at least enough rudder effectiveness was obtained by 50-80 knots airspeed to shallow the simulator’s leftward veer before it departed the runway. In most simulations, directional control could be regained by timely use of the rudder. Given the effectiveness of rudder inputs in controlling heading deviations in the simulation study, the Safety Board sought to understand why the captain of the accident airplane was unable to recover directional control before the airplane departed the left side of the runway. The Safety Board’s aircraft performance study of the tire marks on runway 4L from the accident airplane (see section 1.18.7) indicated that it departed the left edge of the runway with a shallowing leftward veer. This evidence implies that the captain was beginning to regain control of the airplane when it left the runway. The simulation study results indicated that tiller inputs alone would have been incapable of this recovery of control. When interviewed after the accident, the captain recalled that he had applied increasing amounts of right rudder as the airplane veered to the left. However, based on the consistent effectiveness of rudder inputs in the simulation study and the tire mark evidence that directional control was being regained at the runway’s edge, the Safety Board concludes that the captain of flight 41 first relied on right tiller inputs as the airplane continued to veer left, then applied insufficient or untimely right rudder inputs to effect a recovery. 2.2.3 Timeliness of the Rejected Takeoff In his postaccident interview with the Safety Board, the captain stated that after noting the airplane’s failure to respond to his initial input of right rudder, and before deciding to reject the takeoff, he applied additional right rudder and tiller steering inputs. He then described

43 his attempts to reject the takeoff by retarding power to idle and applying maximum braking, right rudder, and nosewheel steering input. Thus, instead of rejecting the takeoff immediately after experiencing difficulty obtaining directional control, the captain continued to attempt to regain directional control with progressively greater rudder and nosewheel steering inputs. Because the FDR was not working, the Safety Board did not have sufficient information to measure the delay between the first indication of loss of control and the captain’s subsequent reduction of engine power. However, some measure of the extent of the delay can be gained from the simulation and performance studies. The simulation study showed that loss of directional control began at the relatively slow airspeeds when the aerodynamic rudder had not yet become effective (less than 50 knots), while the aircraft performance study showed that the accident airplane departed the left side of the runway at a relatively high speed (approximately 97 knots). The captain stated that he reduced power while the airplane was still on the runway, and that he had no recollection of subsequently reapplying power. However, the Safety Board’s CVR spectrum analysis clearly indicated that the thrust was partially reduced and then reapplied in significant amounts as the airplane left the runway. Physical evidence from the engines and flightcrew statements confirmed that the engine rpm increase recorded on the CVR was not an engagement of reverse thrust. Because the CVR ceased recording shortly after the reapplication of power to the engines, the Safety Board was unable to determine the amount of time that the airplane traveled off the runway under significant power. However, based on the spectrum analysis of engine sounds on the CVR, the Safety Board determined that the captain abandoned his attempt to reject the takeoff, at least temporarily, by restoring forward thrust. The Board’s aircraft performance study indicated that as a result of the reapplication of thrust, the airplane continued to accelerate as it approached the edge of the runway. 2.2.4 B-747 Slippery Runway Operating Procedures Because the Safety Board recognized that on a slippery runway, directional control of the B-747 could be lost rapidly by overcontrol of the tiller, it evaluated the existing procedures established by Tower Air and Boeing for operating the B-747 on slippery runways. As a result of the Tower Air procedure to guard the tiller during takeoff until 80 knots, the captain was ready to use the tiller during the beginning of the takeoff roll. Tower Air and Boeing procedures urge pilots to use the rudder and rudder pedal steering during takeoff. However, B-747 procedural information produced by both the airline and the manufacturer permit the tiller to be used at the beginning of the takeoff. In its 1994 Standards Memo, Tower Air stated, “Use of the tiller is not recommended unless rudder pedal steering is not sufficient during the early takeoff roll.” Boeing stated in its Flight Crew Training Manual for the B-747, “Do not use nosewheel tiller during takeoff roll unless required initially due to crosswind.” The Safety Board is concerned that these procedures encourage use of the

44 tiller at the beginning of the takeoff roll, during which the Safety Board’s simulation study found the B-747 to be most susceptible to loss of control on slippery runways. The Safety Board concludes that current B-747 operating procedures provide inadequate guidance to flightcrews regarding the potential for loss of directional control at low speeds on slippery runways with the use of the tiller. The Safety Board believes that the FAA should require modification of applicable operating procedures published by Boeing and air carrier operators of the B-747 to further caution flightcrews against use of the tiller during slippery runway operations, including low-speed operations (for airplanes equipped with rudder pedal steering) and to provide appropriate limitations on tiller use during these operations (for airplanes not equipped with rudder pedal steering). The Safety Board was informed by Tower Air after the accident that it had reevaluated and eliminated its standard procedure of guarding the tiller during the takeoff roll through 80 knots. The Safety Board concludes that this procedural change by Tower Air will make overcontrol of the tiller less likely for its own operations; however, other air carrier operators of the B-747 may need to make similar changes to their procedures. Consequently, the Safety Board believes that the FAA should issue a flight standards information bulletin (FSIB) to POIs assigned to air carriers operating the B-747, informing them of the circumstances of this accident and requesting a review and modification, as required, of each air carrier’s takeoff procedure regarding pilot hand position with respect to the tiller. The Safety Board recognizes that it may be a natural reaction for a pilot to persevere in a takeoff attempt when faced with an apparently minor hesitation of an airplane to respond to rudder input. However, the circumstances of this accident indicate that during takeoff in a B-747 on a slippery runway, the pilot must abort at the very first indication of a directional control loss. The Boeing B-747 Operations Manual and Tower Air B-747 Flight Manual direct pilots who are performing takeoffs on slippery runways to immediately reject the takeoff if deviations from the runway centerline cannot be controlled. While this accident demonstrates the soundness of this advice, the accident also indicates that the provisions in these manuals are not adequately specific, particularly in their references to deviations that “cannot be controlled.” Tower Air’s chief of flight standards suggested a criterion for rejecting takeoffs under slippery runway/crosswind conditions that may be useful for pilot decisionmaking in the future. He linked the takeoff rejection decision to the recommended procedure of limiting rudder pedal steering input to one-half full travel to get optimal cornering friction. He indicated it was clear that if a pilot could not control the airplane with one-half rudder pedal travel, the takeoff should be rejected. This advice may be operationally useful for all B-747 pilots, if it can be verified by the FAA and aircraft manufacturer. The Safety Board concludes that current B-747 flight manual guidance is inadequate about when a pilot should reject a takeoff following some indication of a lack of directional control response. Consequently, the Safety Board believes that

45 the FAA should require Boeing to develop operationally useful criteria for making a rapid and accurate decision to reject a takeoff under slippery runway conditions; then require that B-747 aircraft flight manuals, operating manuals, and training manuals be revised accordingly. 2.2.5 Training Simulators for B-747 Slippery Runway Operations The air carrier and FAA pilots who participated in the August 8, 1996, simulation study believed that the Boeing engineering simulator had more realistic ground handling performance than the simulators Tower had provided for pilot training. The Board is concerned that air carrier B-747 pilots currently are not able to obtain needed training on slippery runway procedures, including proper tiller and rudder techniques, because training simulators have not incorporated the latest ground handling model (such as that implemented on the Boeing engineering simulator). Further, although existing flight test data on slippery runway handling characteristics are limited, the increasing use of high capacity FDRs and quick access maintenance recorders enables data on slippery runway handling to be obtained from actual line flying experience. Many B-747-400 models are equipped with these recorders. The Safety Board concludes that improvements in the slippery runway handling fidelity of flight simulators used for B-747 pilot training are both needed and feasible. Consequently, the Safety Board believes that the FAA should evaluate B-747 simulator ground handling models and obtain additional ground handling data, as required, to ensure that B-747 flight simulators used for air carrier flightcrew training accurately simulate the slippery runway handling characteristics of the airplane. The Safety Board also believes that after completing this evaluation, the FAA should issue an FSIB urging POIs assigned to air carrier operators of the B- 747 to enhance simulator training for slippery runway operations, including limitations on tiller use and instructions for rudder use during the takeoff roll. 2.2.6 Summary of Flightcrew Actions and Decisions The captain’s use of the tiller control for nosewheel steering during the takeoff roll, combined with his untimely or inadequate use of rudder inputs, allowed the loss of directional control to develop. As this occurred, the airplane’s deviation from the centerline and its unresponsiveness to steering inputs provided cues that, regardless of the adequacy of existing procedures and training methods, should have prompted the captain to reject the takeoff more quickly than he did. Therefore, the Safety Board concludes that the captain’s failure to reject the takeoff in a timely manner was causal to the accident. Still, better procedures for operating the B-747 under slippery runway conditions and improved ground handling fidelity of the flight simulators used for B-747 pilot training could have better prepared the captain for handling the situation that confronted the accident flight. Therefore, the Safety Board concludes that the inadequate B-747 slippery runway operating procedures developed by Tower and Boeing, and the inadequate fidelity of B-747 flight training simulators for slippery runway operations, contributed to the cause of this accident.

46 Further, the Safety Board concludes that the captain abandoned his attempt to reject the takeoff, at least temporarily, by restoring forward thrust before the airplane departed the left side of the runway; this contributed to the severity of the runway excursion and damage to the airplane. 2.3 Galley Security Service carts, galley containers, drawers and other galley items were not contained during the off-runway excursion. The most serious breach of galley security occurred in the aft galley complex, between the R4 and L4 exits. The two carts that came loose injured the R4 flight attendant and blocked the R4 exit. The Safety Board could not determine whether the primary latching mechanisms were engaged on the carts that were released from the aft galley. However, the bending in the secondary latches indicated that those latches were engaged, but were not adequate to secure the carts. The Safety Board was unable to calculate the inertial loads imposed on N605FF during the crash sequence because of the malfunctioning FDR. However, the condition of the seats and the comments of the various occupants suggest that the airplane did not experience the loads specified in 14 CFR 25.561(b). Because the crash forces were not severe enough that the latch material should have failed, the Safety Board concludes that the material or installation of secondary latches in the galleys of N605FF was inadequate. Consequently, the Safety Board believes that the FAA should develop certification standards for the installation of secondary galley latches; then use those standards to conduct an engineering review of secondary galley latches on all transport-category aircraft. Further, the FAA should require changes to existing installations as necessary to ensure that the strength of secondary latches and their installation are sufficient to adequately restrain carts. 2.4 Flight Attendant Actions and Training 2.4.1 Flight Attendant Communication Several flight attendants acknowledged seeing or hearing things not associated with normal operations, such as crunching and tearing noises, engine separation, and significant spillage of carry-on luggage, during the airplane’s off-runway excursion. However, only three of the 12 flight attendants on board the accident airplane shouted commands to passengers to “Grab Ankles! Stay Down!” during the impact sequence. Because these commands are important instructions that can prevent or reduce passenger injuries, the Safety Board is concerned that nine of the flight attendants did not shout any commands. The Board recognizes that in the large cabin of the B-747, not all flight attendants had access to the same information about the event; therefore, flight attendants might have formed different opinions about the gravity of the situation. However, the Safety Board concludes that during this accident sequence, despite some ambiguity about the situation, there were ample indications in most parts of the passenger cabin to have caused a greater number of flight attendants to shout brace commands before the airplane came to a stop. The Safety Board

47 believes that the FAA should issue an FSIB to POIs of 14 CFR Part 121 air carriers to ensure that flight attendant training programs stress the importance of shouting the appropriate protective instructions at the first indication of a potential accident, even when flight attendants are uncertain of the precise nature of the situation. Further, the inconsistent pattern of the flight attendants’ emergency commands before the airplane came to a stop, the large cabin layout of the B-747, and the large size of its cabin crew highlight the importance of communication among flight attendants. Communication was an issue in the cabin crew’s actions immediately after the airplane came to a stop. While the decision not to evacuate the airplane (made independently by the flight attendants and the flightcrew) may have been appropriate, these decisions were made without adequate knowledge of the postaccident condition of the airplane. Flight attendants had vital information that they did not relay to the purser or the flightcrew. For example, flight attendants did not provide information to the flightcrew about the separation of the No. 4 engine, the severe floor disruption in the forward cabin, the smell of smoke and kerosene in the cabin, or the condition of the injured flight attendant. Normally, the PA and interphone systems provide effective means of communications among flight attendants and between the cabin and flight deck. In this accident, the purser was unaware that his PA announcements were only audible in the forward cabin, and thus passengers and flight attendants in the rear of the airplane did not receive any information about the decision not to evacuate. Further, the purser and three flight attendants attempted to use the interphone system without success. Flight attendants did not use megaphones as an alternative to these communications systems. The deadheading flight attendant went forward in the cabin to find out what was planned, but he did not return to the aft cabin to share the information with the other flight attendants. The Safety Board’s review of Tower Air flight attendant procedures revealed that no back-up procedures had been established for communicating or assessing conditions in the postaccident contingency of inoperative or unpowered PA and interphone systems. However, the likelihood of impact damage to PA and interphone equipment, as demonstrated in this accident, indicates that such back-up procedures are essential. The Safety Board recognizes that not all of the flight attendants involved in this accident had adequate information to realize the need to establish communications throughout the cabin. However, after an unusual occurrence such as a rejected takeoff (especially on a wide- body airplane), positive communications are essential to coordinate the crew’s response, even if the decision is not to evacuate. The Safety Board concludes that the existing Tower Air flight attendant procedures provided inadequate guidance to flight attendants on how to communicate to coordinate their actions during and after the impact sequence. Further, because the Safety Board is concerned that the flight attendant procedures of other air carriers may also be inadequate, the Safety Board believes that the FAA should issue an FSIB requiring POIs of 14 CFR Part 121 air carriers to ensure that their air carriers have adequate procedures for flight attendant

48 communications, including those for coordinating emergency commands to passengers, transmitting information to flightcrews and other flight attendants, and handling postaccident environments in which normal communications systems have been disrupted. 2.4.2 Flight Attendant CRM Training The circumstances of this accident imply that flight attendants (particularly those assigned to wide-body aircraft) would benefit from the opportunity to practice communications procedures and coordination skills. CRM training can provide this opportunity. While the FAA has issued guidance on this training, the Safety Board recognizes that the new requirements for flightcrew and flight attendant CRM training do not specify the specific form and content of this training. The communication and coordination issues raised by this accident, both among flight attendants and between flight attendants and flightcrew would be appropriately addressed in joint CRM training by providing experience and practice in a realistic, line-oriented setting. Therefore, the Safety Board believes that the FAA should issue an FSIB that encourages the use of this accident as a case study for CRM training. 2.4.3 Flight Attendant Galley Training Although Tower Air operated B-747s with three different kinds of galleys and service carts (with significant differences in the method used to secure each type of cart), new flight attendants were only provided “hands on” training with a single empty cart. Further, their classroom did not have a galley mock-up, and the actual airplane galleys used for “walkaround” training usually were not equipped with carts when trainees were brought aboard. Therefore, flight attendants did not actually operate carts in a galley setting until they began flying. The Safety Board concludes that Tower Air flight attendant galley security training was inadequate because flight attendants had not received “hands on” training with all the galley equipment that they were required to operate. The Safety Board believes that Tower Air should revise its initial flight attendant training program to include “hands-on” training for securing each type of galley and cart included in its B-747 fleet. 2.4.4 Purser Training The Safety Board is concerned that the flight attendant serving as the assistant purser on the accident flight had not received the training appropriate to that position. While the assignment of a purser and assistant purser was not required by regulation, and was not currently practiced by many air carriers, formal designation of leadership roles in the cabin crew is very beneficial, especially in wide-body aircraft. Although the lack of purser training was not causal in this accident, such training could have resulted in better coordination/communication by the cabin crew if there had been an evacuation.

49 2.5 Company Management 2.5.1 Maintenance The Safety Board is concerned that Tower Air failed to recognize the results of the annual check of the FDR system of N605FF in a timely manner. Based on the results of this check, TWA notified Tower Air in a memorandum dated November 3, 1995, that the FDR system had six suspect data parameters. It was more than 1 month later, on December 4, 1995, when Tower Air responded to this notification by entering the discrepancy in the maintenance log of N605FF. Further, although the company recorded in its maintenance records that the required FDR functional test had been performed on December 7, 1995, the Safety Board concludes, based on the limited amount of time between the rental of the test equipment and the movements of the airplane, that Tower Air did not perform the FDR functional test. If Tower Air had performed this test, it would have identified the malfunctioning CEU and DAU #3 units (as the Safety Board was able to do in its postaccident testing). Consequently, the Safety Board concludes that Tower Air’s failure to conduct the FDR functional test resulted in the loss of FDR data related to the accident flight that were of critical importance to the Safety Board’s investigation. On July 11, 1996, the Safety Board issued the following safety recommendations to the Federal Aviation Administration: Require that the operators of all airplanes equipped with a Teledyne Controls Aeronautical Radio Incorporated 563 digital flight data recorder system perform a self test of the central electronics unit each flight day to ensure that the system is operating properly. (Class II, Priority Action) (A-96-45) Modify Master Minimum Equipment Lists to ensure that flight with an inoperative flight data recorder is permitted only until the airplane’s first arrival at a suitable repair facility, but not to exceed 3 days. (Class II, Priority Action) (A-96-46) Increase oversight of flight data recorder system maintenance practices by Tower Air to ensure that repairs are performed in accordance with the maintenance manual. (Class II, Priority Action) (A-96-47) In a September 6, 1996, letter, the FAA responded to these recommendations. In response to Safety Recommendation A-96-45, the FAA said that it would issue an FSIB to require that a repetitive self-test inspection be performed by operators of the ARINC 563 system at no more that 60 flight-hour intervals. While the recommendation calls for the test to be performed daily, the Board acknowledges that the 60-hour interval will allow operators

50 flexibility in accomplishing this inspection. Therefore, pending the Safety Board’s review of the FSIB, the Board classifies Safety Recommendation A-96-45 “Open—Acceptable Response.” In response to Safety Recommendation A-96-46, the FAA said that it would revise MMEL Policy Letter #29 as requested and anticipated that the revised letter would be issued by November 1996. Pending the Safety Board’s review of the revised policy letter, the Board classifies Safety Recommendation A-96-46 “Open—Acceptable Response.” In response to Safety Recommendation A-96-47, the FAA said that it was evaluating current oversight of FDR system maintenance practices by Tower Air to ensure that repairs were being performed in accordance with the maintenance manual. Pending the Safety Board’s review of the evaluation, which is expected to be completed by December 1996, the Board classifies Safety Recommendation A-96-47 “Open—Acceptable Response.” The Safety Board recognizes that on July 9, 1996, the FAA issued a notice of proposed rulemaking (NPRM) that, if adopted, could affect the continued usage of the ARINC 563 system. The NPRM proposes to increase the number of mandatory parameters recorded by airplane FDRs. For B-747s with the ARINC 563 system installed (such as N605FF), the airplane would be required to record additional parameters, such as pitch, roll, and yaw control input positions. During the investigation, the Safety Board learned that the manufacturer of the ARINC 563 system’s CEU and DAU components had stopped manufacturing these system components. Additionally, the manufacturer no longer issues updates to the system software. To comply with the proposed rulemaking, airplanes equipped with the ARINC 563 system would need installation of additional sensors and wiring. In addition, system software would need to be upgraded to handle the additional parameters. Because the system is no longer supported by the manufacturer, airlines would most likely replace the entire FDR system, rather than attempt an in-house upgrade. This may result in the elimination of the ARINC 563 system within the U.S. registry and render Safety Recommendations A-96-45 through -47 obsolete. However, because airlines may request and the FAA may grant waivers for certain rules, the Safety Board cannot definitively determine whether the ARINC 563 system will be eliminated. Therefore, the Safety Board urges the FAA to fulfill the Board’s objectives in issuing these safety recommendations and ensure that existing ARINC 563 systems continue to function adequately. As shown by the maintenance history of the FDR that failed to function during the accident sequence, as well as the findings of the FAA NASIP inspection, the installation of the landing gear without assuring it was appropriate for this airplane, and the inadequately documented “C” check, the Safety Board concludes that the Tower Air maintenance program deviated in significant ways from the procedures established in the company’s GMM. Although these deviations were not related to the cause of this accident, they are cause for concern.

51 The Safety Board is equally concerned that the Tower Air continuing airworthiness surveillance and reliability programs, which are the carrier’s internal audit and trend monitoring functions, failed to identify these deficiencies. The Safety Board concludes that the continuing airworthiness surveillance and reliability programs in the maintenance department of Tower Air were performing inadequately at the time of the accident. Consequently, the Safety Board believes that the FAA should review the structure and performance of the continuing airworthiness surveillance and reliability programs in the Tower Air maintenance department. Also, the Safety Board believes that the FAA should reassess inspectors’ methods of evaluating maintenance work, focusing on the possibility of false entries through selective detailed analysis of records and unannounced work site inspections. 2.5.2 Operations The November 1995 revisions to the reporting relationships among managers in the Tower Air operations department were significant because they left the DO, who was assigned the responsibility for the proper conduct of flight operations under the GOM, without authority over the day-to-day operations of the airline, flightcrew training, or the activities of the chief pilot and flightcrews. This organizational change was rejected by the POI when it was finally submitted to him for approval following the accident, and the Safety Board concurs with this rejection. Not only does an airline need individual managers who have appropriate technical qualifications, but the reporting relationships among managers must be such that the operational functions of the airline report through the DO, who has the responsibility for regulatory and procedural compliance in flight operations. Because Tower Air did not have this organizational hierarchy, the Safety Board concludes that Tower Air was operating with an inadequate management structure at the time of the accident. While the regulations contained in 14 CFR Part 119 outline the required technical qualifications for certain operational management positions at air carriers (including the DO), they do not specify the reporting relationships that provide the DO with the necessary authority. Consequently, the Safety Board believes that the FAA should revise 14 CFR Part 119 to specify that the chief pilot and all operational functions under that position report through the DO. The Safety Board is concerned that Tower Air failed to report significant management personnel and organizational changes to the POI before their implementation, even though this failure did not contribute to the accident. The carrier is responsible for maintaining the accuracy of its GOM, which specifies the company’s operational management positions and reporting relationships. Tower Air failed to issue a revised GOM for more than 2 months following its implementation of changes in these areas. The fact that the FAA did not recognize this significant change in the company for this length of time is also disturbing. 2.6 FAA Surveillance

52 The FAA POI and assistant POI assigned to Tower Air were also responsible for overseeing the certificate of Atlas Air. At the time of the accident, both companies were fast- growing B-747 operators engaged in worldwide flight operations. The assistant POI acknowledged that neither he nor the POI had sufficient time to conduct routine surveillance of Tower Air. The only en route inspections he performed were those that were also required for a new captain’s certification during IOE. The POI conducted one en route check from October 1, 1994, through December 31, 1995. Because the POI and assistant POI were not able to perform routine surveillance of Tower Air, this surveillance was dependent on the support of geographic inspectors from other FAA offices. Although inspectors involved in geographic support probably would notify an air carrier POI immediately if they detected a gross violation, these inspectors would not necessarily recognize deviations from procedures specific to the airline. Further, they would be unable to recognize trends in inspection findings. Therefore, the success of the FAA’s geographic inspection program depends on the POI’s review and integration of the inspection results. The POI assigned to Tower Air acknowledged that his primary source of feedback from geographic surveillance was from reviews of the reports filed in the FAA PTRS data base, which he attempted to review quarterly. However, he stated that he had been unable to review these reports during the 6 months before the accident because of workload. Further, the Safety Board is concerned that the POI and assistant POI were so burdened with certification activities involving their two carriers that they were unfamiliar with significant, inappropriate management changes occurring at Tower Air. Although these changes were eventually recognized and rejected by the POI, he was unable to detect the change until the formal notification was submitted for his signature. Based on the POI’s dependence on geographic inspections for routine surveillance, his inability to review the findings of these inspections in a timely manner, and his inability to recognize and correct an inadequate operational management structure at Tower Air in a timely manner, the Safety Board concludes that the POI and assistant POI assigned to Tower Air were overburdened, and the FAA program for routine surveillance of the operational functions of Tower Air was inadequate. Consequently, the Safety Board believes that the FAA should immediately implement its plan to assign the Tower Air certificate to a POI and assistant POI who do not have oversight responsibility for any other carriers. Further, based on the circumstances of this accident and Tower Air’s recent accident history, the Safety Board believes that the FAA should develop, by December 31, 1997, standards for enhanced surveillance of air carriers based on rapid growth, change, complexity, and accident/incident history; then revise national flight standards surveillance methods, work programs, staffing standards, and inspector staffing to accomplish the enhanced surveillance that is identified by the new standards. Although the Safety Board recognizes that the FAA needs to rely on locally based inspector resources to accomplish surveillance in each geographic area, the Board has long been concerned about the effectiveness of the FAA geographic inspection program. This program has

53 needed greater standardization of air carrier certifications across FAA regional boundaries, better training for inspectors to make them more knowledgeable about both individual air carrier procedures and industry-wide standards, adequate tools for geographic inspectors to communicate their findings and concerns to POIs, and adequate tools for POIs to use in identifying significant trends in the results of routine geographic surveillance. The Safety Board examined the FAA geographic surveillance program during its investigation of the February 16, 1995, accident at Kansas City International Airport involving an attempted three-engine takeoff in a Douglas DC-8-63. As a result of this investigation, on November 11, 1995, the Safety Board issued Safety Recommendation A-95-110, recommending that the FAA review the effectiveness of the geographic unit oversight program, with particular emphasis on the oversight of supplemental air carriers and their international operations, and the improvement of overall communications between POIs and geographic inspectors. In a February 12, 1996, response to Safety Recommendation A-95-110, the FAA stated its plans to implement two improvements to the geographic surveillance program: an Enhanced Certificate Management Plan that will position additional inspectors dedicated to surveillance of a specific air carrier at outlying locations, and a Safety Performance Analysis System that will provide POIs with improved capabilities for monitoring trends in negative inspection findings. On July 5, 1996, citing the FAA’s failure to place special emphasis on geographic surveillance of supplemental air carriers and their international operations, the Safety Board classified Safety Recommendation A-95-110 “Closed—Unacceptable Action.” However, immediately following the Safety Board’s July 1996 classification of this safety recommendation, the FAA conducted a “90 Day Safety Review,” 27 which generated several internal recommendations for improvements in air carrier surveillance systems, including the geographic surveillance program. Although the Safety Board intends to further evaluate the “90 Day Safety Review” report with respect to a number of specific safety issues, the Board is encouraged by this internal review process. Pending final action by the FAA to implement its internal recommendations to enhance the effectiveness of air carrier surveillance, Safety Recommendation A-95-110 is classified “Open—Acceptable Response.” 2.7 Runway Contamination Evaluation In this accident, the airport personnel completed a runway friction test of runway 4L at 0933 and obtained a reading that, by their own procedures, required a report to the control tower. Although the airport personnel claimed that the report was made, there was no documentation of a timely report in their records; the only such record was of a postaccident entry in the operations office computer. The control tower was required by FAA Order 7110.65J to advise pilots of runway friction readings when they were received from airport management, but the control tower personnel claimed that they did not receive these reports. The Safety Board

27 Federal Aviation Administration. FAA 90 Day Safety Review. Washington, DC. September 16, 1996 (mimeo).

54 was unable to determine whether the runway friction measurement data were sent or received. However, the Safety Board concludes that the failure of the PNY&NJ or FAA air traffic control tower personnel to provide these data to the pilots of flight 41 did not contribute to this accident. Although the guidance currently provided by the FAA on runway friction measurement and reporting may be helpful to airport operators, it is incomplete because friction coefficient measurements of various types are not correlated with braking performance of different airplane types or configurations. The International Civil Aviation Organization (ICAO) Guidance Material Supplementary to Annex 14, Volume I, 6, includes a table of friction coefficient measurements correlated with descriptive values, i.e., good, medium, poor. However, this table is provided for informational use only, and it, too, does not establish clearly defined parameters applicable to airplane types. The Safety Board is concerned about the frequent occurrence of veeroffs, overruns, and other related events by large airplanes when runways are contaminated with ice, snow, and/or slush (including this accident). The continuing problem with safety during ground operations is related to several problems. There is a clear need to measure the slipperiness of runway and taxiway surfaces. However, those values must then be quantified into meaningful information that pilots can use to evaluate the expected performance of their specific airplane. This would require airport operators to maintain their equipment within specific tolerances, and it would require the technicians operating the equipment to adhere to appropriate standards in using the equipment. If the FAA had been responsive to the Safety Board’s 1982 safety recommendations on this subject (see section 1.10.3), the industry might have already resolved these problems. The FAA has made considerable progress in providing and implementing procedures for airport operators to perform friction measurements during periods of ice/snow and slush contamination. However, such measurements are still not required, and there is no standardization of the equipment currently being used. Further, there are no means to compare measurement standards or translate the data into aircraft performance. A key issue is that no significant progress has been made in correlating stopping distance data from airplane manufacturers’ flight tests and calculations with the friction values obtained from measuring devices. An outcome of these correlations could be the establishment of objective standards for air carrier operations on slippery runways, perhaps extending to the establishment of appropriate minimum runway friction levels for operational use. The Safety Board concludes that the circumstances of this accident indicate that the issue of correlating airplane stopping performance with runway friction measurements should be revisited by the Government and the air transportation industry. Consequently, the Safety Board believes that the FAA should require the appropriate Aviation Rulemaking and Advisory Committee to establish runway friction measurements that are operationally meaningful to pilots and air carriers for their slippery runway operations (including a table correlating friction values measured by various types of industry equipment), and minimum coefficient of friction levels for specific airplane types below which airplane operations will be suspended.

55

1. CONCLUSIONS
2. 1

Findings

1. The flightcrew was properly certificated and qualified in accordance with

applicable regulations and company requirements.

1. The air traffic control personnel involved with the flight were all properly

certificated and qualified.

1. The airplane was properly certificated, equipped, and maintained (with the

exception of the flight data recorder system) in accordance with approved regulations. The weight and balance were within allowable limits.

1. The captain’s decision to attempt the takeoff on runway 4L was appropriate.
2. Asymmetric thrust was not a factor in the loss of directional control.
3. The captain’s failure to correct the airplane’s deviation from the centerline

resulted from his overcontrolling the nosewheel steering through the tiller.

1. The captain of flight 41 first relied on right tiller inputs as the airplane

continued to veer left, then applied insufficient or untimely right rudder inputs to effect a recovery.

1. Current Boeing 747 operating procedures provide inadequate guidance to

flightcrews regarding the potential for loss of directional control at low speeds on slippery runways with the use of the tiller.

1. The procedural change by Tower Air to reevaluate and eliminate its standard

procedure of guarding the tiller during the takeoff roll through 80 knots will make overcontrol of the tiller less likely for its own operations; however, other air carrier operators of the Boeing 747 may need to make similar changes to their procedures.

1. Current Boeing 747 flight manual guidance is inadequate about when a pilot

should reject a takeoff following some indication of a lack of directional control response.

1. Improvements in the slippery runway handling fidelity of flight simulators

used for Boeing 747 pilot training are both needed and feasible.

1. The captain’s failure to reject the takeoff in a timely manner was causal to the

accident.

1. The inadequate Boeing 747 slippery runway operating procedures developed

by Tower Air and the Boeing Commercial Airplane Group, and the inadequate fidelity of B-747

56 flight training simulators for slippery runway operations, contributed to the cause of this accident.

1. The captain abandoned his attempt to reject the takeoff, at least temporarily,

by restoring forward thrust before the airplane departed the left side of the runway; this contributed to the severity of the runway excursion and damage to the airplane.

1. The material or installation of secondary latches in the galleys of N605FF was

inadequate.

1. Despite some ambiguity about the situation, there were ample indications in

most parts of the passenger cabin to have caused a greater number of flight attendants to shout brace commands before the airplane came to a stop.

1. The existing Tower Air flight attendant procedures provided inadequate

guidance to flight attendants on how to communicate to coordinate their actions during and after the impact sequence.

1. Tower Air flight attendant galley security training was inadequate because

flight attendants had not received “hands on” training with all the galley equipment that they were required to operate.

1. Based on the limited amount of time between the rental of the test equipment

and the movements of the airplane, Tower Air did not perform the flight data recorder (FDR) functional test; this resulted in the loss of FDR data related to the accident flight that were of critical importance to the Safety Board’s investigation.

1. The Tower Air maintenance program deviated in significant ways from the

procedures established in the company’s general maintenance manual.

1. The continuing airworthiness surveillance and reliability programs in the

maintenance department of Tower Air were performing inadequately at the time of the accident.

1. Tower Air was operating with an inadequate management structure at the time

of the accident.

1. The principal operations inspector (POI) and assistant POI assigned to Tower

Air were overburdened, and the Federal Aviation Administration program for routine surveillance of the operational functions of Tower Air was inadequate.

1. The failure of the Port Authority of NY & NJ or Federal Aviation

Administration air traffic control tower personnel to provide friction measurement data to the pilots of flight 41 did not contribute to this accident.

57

1. The circumstances of this accident indicate that the issue of correlating

airplane stopping performance with runway friction measurements should be revisited by the Government and the air transportation industry. 3.2 Probable Cause The National Transportation Safety Board determines that the probable cause of this accident was the captain’s failure to reject the takeoff in a timely manner when excessive nosewheel steering tiller inputs resulted in a loss of directional control on a slippery runway. Inadequate Boeing 747 slippery runway operating procedures developed by Tower Air, Inc., and the Boeing Commercial Airplane Group and the inadequate fidelity of B-747 flight training simulators for slippery runway operations contributed to the cause of this accident. The captain’s reapplication of forward thrust before the airplane departed the left side of the runway contributed to the severity of the runway excursion and damage to the airplane.

58

1. RECOMMENDATIONS

As a result of the investigation of this accident, the National Transportation Safety Board makes the following recommendations: --to the Federal Aviation Administration: Require modification of applicable operating procedures published by the Boeing Commercial Airplane Group and air carrier operators of the B-747 to further caution flightcrews against use of the tiller during slippery runway operations, including low-speed operations (for airplanes equipped with rudder pedal steering) and to provide appropriate limitations on tiller use during these operations (for airplanes not equipped with rudder pedal steering). (A-96-150) Issue a flight standards information bulletin to principal operations inspectors assigned to air carriers operating the B-747, informing them of the circumstances of this accident and requesting a review and modification, as required, of each air carrier’s takeoff procedure regarding pilot hand position with respect to the tiller. (A-96-151) Require the Boeing Commercial Airplane Group to develop operationally useful criteria for making a rapid and accurate decision to reject a takeoff under slippery runway conditions; then require that B-747 aircraft flight manuals, operating manuals, and training manuals be revised accordingly. (A-96-152) Evaluate Boeing 747 simulator ground handling models and obtain additional ground handling data, as required, to ensure that B-747 flight simulators used for air carrier flightcrew training accurately simulate the slippery runway handling characteristics of the airplane. (A-96-153) After completing this evaluation, issue a flight standards information bulletin urging principal operations inspectors assigned to air carrier operators of the Boeing 747 to enhance simulator training for slippery runway operations, including limitations on tiller use and instructions for rudder use during the takeoff roll. (A-96-154) Develop certification standards for the installation of secondary galley latches; then use those standards to conduct an engineering review of secondary galley latches on all transport-category

59 aircraft. Require changes to existing installations as necessary to ensure that the strength of secondary latches and their installation are sufficient to adequately restrain carts. (A-96-155) Issue a flight standards information bulletin to principal operations inspectors of 14 CFR Part 121 air carriers to ensure that flight attendant training programs stress the importance of shouting the appropriate protective instructions at the first indication of a potential accident, even when flight attendants are uncertain of the precise nature of the situation. (A-96-156) Issue a flight standards information bulletin requiring principal operations inspectors of 14 CFR Part 121 air carriers to ensure that their air carriers have adequate procedures for flight attendant communications, including those for coordinating emergency commands to passengers, transmitting information to flightcrews and other flight attendants, and handling postaccident environments in which normal communications systems have been disrupted. (A-96-157) Issue a flight standards information bulletin that encourages the use of this accident as a case study for crew resource management training. (A-96-158) Review the structure and performance of the continuing airworthiness surveillance and reliability programs in the Tower Air maintenance department. (A-96-159) Reassess inspectors’ methods of evaluating maintenance work, focusing on the possibility of false entries through selective detailed analysis of records and unannounced work site inspections. (A-96-160) Revise 14 CFR Part 119 to specify that the chief pilot and all operational functions under that position report through the director of operations.(A-96-161) Immediately implement the plan to assign the Tower Air certificate to a principal operations inspector (POI) and assistant POI who do not have oversight responsibility for any other carriers. (A-96-162) Develop, by December 31, 1997, standards for enhanced surveillance of air carriers based on rapid growth, change, complexity, and accident/incident history; then revise national flight standards surveillance methods, work programs, staffing

60 standards, and inspector staffing to accomplish the enhanced surveillance that is identified by the new standards. (A-96-163) Require the appropriate Aviation Rulemaking and Advisory Committee to establish runway friction measurements that are operationally meaningful to pilots and air carriers for their slippery runway operations (including a table correlating friction values measured by various types of industry equipment), and minimum coefficient of friction levels for specific airplane types below which airplane operations will be suspended. (A-96-164) --to Tower Air, Inc.: Revise Tower Air’s initial flight attendant training program to include “hands-on” training for securing each type of galley and cart included in its Boeing 747 fleet. (A-96-165) BY THE NATIONAL TRANSPORTATION SAFETY BOARD JAMES E. HALL Chairman ROBERT T. FRANCIS II Vice Chairman JOHN A. HAMMERSCHMIDT Member JOHN J. GOGLIA Member GEORGE W. BLACK Member December 2, 1996

61

1. APPENDIXES

APPENDIX A - INVESTIGATION AND HEARING 1. Investigation The National Transportation Safety Board was notified of the accident at 1150 on December 20, 1995. A partial go-team was dispatched to the scene. The following investigative groups were formed: Operations, Air Traffic Control, Airports, Weather, Survival Factors, Maintenance Records, Structures/Powerplants, Systems, Flight Data Recorder, and Cockpit Voice Recorder (CVR). Subsequently a Metallurgical Group was formed and a Sound Spectrum Study of the engine sounds on the CVR was completed. Parties to the investigation included the Federal Aviation Administration, Tower Air, Inc., the Tower Air Cockpit Crew Association, the Association of Flight Attendants, the Boeing Commercial Airplane Group, and Pratt & Whitney. 2. Public Hearing A public hearing was not held in connection with this investigation.

62 APPENDIX B- COCKPIT VOICE RECORDER TRANSCRIPT

63 Transcript of a Fairchild A-100 cockpit voice recorder (CVR), s/n 2059, installed on an Tower Air B-747-136, N605FF, which was involved in runway excursion during takeoff from the John F. Kennedy International Airport, Jamaica, New York, on Dec. 20, 1995. LEGEND RDO Radio transmission from accident aircraft. CAM Cockpit area microphone voice or sound source. INT Transmissions over aircraft interphone system. GND Radio transmission from JFK control ground control. ATLD Radio transmission from Atlanta departure control. A9140 Radio transmission from American flight # 9140. D9901 Radio transmission from Delta flight # 9901. SB117 Radio transmission from British Airways flight # 117. KW134 Radio transmission from Carnival flight # 134. GMTC Radio transmission from ground maintenance vehicle. UNK Radio transmission received from unidentified aircraft. PA Transmission made over aircraft public address system. -B Sounds heard through both pilot’s hot microphone systems. -1 Voice identified as Pilot-in-Command (PIC) -2 Voice identified as Co-Pilot. -3 Voice identified as Flight Engineer. -4 Voice identified as 1st ground crewman. -5 Voice identified as 2nd ground crewman. -6 Voice identified as jump seat rider. -? Voice unidentified * Unintelligible word @ Non pertinent word

Expletive % Break in continuity Note: Times are expressed in eastern standard time (EST).

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 64 START of RECORDING START of TRANSCRIPT 1106:40 CAM-? wind shifted a little bit. it's three thirty at thirteen instead of three fifty. 1107:07 GND Blue Ridge two thirty five, check information Kilo you'll continue by the inner and Kilo-Alpha to cross three one left. 1107:18 A9140 American ninety one forty is clear going to Tango. 1107:20 GND American ninety one forty Kennedy roger use caution uh, braking action reported nil on that turn, make the right on the outer. 1108:09 INT-4 OK, cockpit? 1108:11 INT-1 go ahead. 1108:12 INT-4 OK, everything is done, and uh, you're cleared to start. 1108:16 INT-1 OK uh, the de-ice coordinators name please? 1108:21 INT-4 yes, hold on a second.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 65 1108:34 INT-4 Graciano, Graciano. with a G. 1108:40 INT-1 OK and the type of uh, fluid used? was it a fifty fifty mixture type one? 1108:47 INT-4 uh fifty five ... 1108:57 INT-5 yes on the uh, type one it's fifty five forty five. 1109:00 INT-1 OK and type two is uh, one hundred zero? 1109:03 INT-5 absolutely. 1109:04 INT-1 OK thanks uh, here comes number four engine and uh, will you call the N ones for me on each engine please? 1109:12 INT-5 absolutely. 1109:13 INT-1 thank you. 1109:14 CAM-3 EPR's set. ******. 1109:21 INT-1 here comes number four. 1109:22 INT-4 OK.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 66 1109:27 CAM [miscellaneous unintelligible background conversation] 1109:29 CAM-1 uh, he's just gotta check. 1109:30 CAM-3 the pre-takeoff ice check ***. 1109:36 CAM-1 OK, go ahead and check that * put it in. 1109:39 CAM-3 first of all, standby. let's get some bleed air back ** guys. 1109:43 CAM-2 uuh. 1109:46 CAM [several unintelligible comments] 1109:47 CAM-1 let's do a uh, let's do a before start check list. 1109:53 CAM-3 ** pressurizing. 1109:55 CAM-2 OK uh, we'll go uh, INS? 1109:57 CAM-1 three in nav. 1109:58 CAM-2 beacon? 1109:59 CAM-1 on.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 67 1110:00 CAM-2 doors? 1110:00 CAM-3 checked lights out. 1110:01 CAM-2 brake pressure? 1110:02 CAM-3 pump on and checked. 1110:04 CAM-2 fuel boost pumps? 1110:05 CAM-3 on. 1110:06 CAM-2 gear down lock pins? 1110:07 CAM-3 removed. 1110:09 CAM-2 OK, number one air pump? 1110:10 CAM-3 auto. 1110:12 CAM-2 cabin report? 1110:12 CAM-1 verified.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 68 1110:14 INT-1 OK, here comes number four. 1110:15 INT-4 OK guys. 1110:17 CAM-? start pressure's a little low but I don't .... 1110:18 CAM-3 yeah, it's indicating about twenty seven **. 1110:20 CAM-? alright. 1110:22 CAM-3 turn number four. 1110:29 INT-4 N one. 1110:38 CAM-3 max motoring. 1110:44 CAM-1 light off. 1110:46 CAM-? well you know **... 1110:48 CAM [sound similar to momentary power interruption] 1110:54 CAM-3 I'm going to get the warning CB off? 1110:56 CAM-1 OK.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 69 1110:57 CAM-3 OK. 1111:05 CAM-3 OK, I'll reach up and cross check. *** I've got forty psi duct pressure **** bleed valves engine, bleed air valves open. 1111:13 CAM-1 OK, call the N one for me again. we're going to motor this thing a bit. 1111:17 INT-4 OK captain. uh, the packs are off? 1111:19 INT-1 yeah they are. 1111:20 INT-4 OK. 1111:22 CAM-3 OK, turn number four. 1111:24 INT-1 here comes four. 1111:25 INT-4 OK, captain. 1111:26 INT-1 you guys having fun yet? 1111:28 INT-4 lots of fun, I love it. ha ha. 1111:32 INT-4 N one.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 70 1111:34 INT-1 [sound similar to two microphone clicks] 1111:40 CAM-3 EGT below a hundred. max motoring. 1111:45 CAM-? *** area. 1111:47 CAM [several unintelligible comments] 1111:51 CAM-3 twenty five. 1111:54 CAM-3 thirty. 1111:58 CAM-3 thirty five. 1112:04 CAM-3 forty. 1112:07 CAM-3 forty five. 1112:08 CAM-3 starter cutout. 1112:09 INT-1 here comes three. 1112:11 INT-4 *.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 71 1112:14 CAM-3 do you want me to transfer number four electrics? 1112:17 CAM [sound similar to electrical power transfer] 1112:18 CAM-2 anti-ice OK? 1112:19 CAM-1 please. 1112:20 CAM-3 OK start number three. 1112:22 CAM-1 ***. 1112:31 INT-4 rotation. 1112:33 CAM [sound similar to two microphone clicks] 1112:38 CAM-3 max motoring. 1112:45 CAM-1 light-off. 1112:48 CAM-3 twenty five. 1112:52 CAM-3 thirty. 1112:56 CAM-3 thirty five.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 72 1113:00 CAM-3 forty. 1113:04 CAM-3 forty five starter cutout. 1113:06 INT-1 here comes two. 1113:07 INT-4 *. 1113:09 CAM-3 turn number two. 1113:13 CAM-1 I'm not using rich by the way seems to be ***. 1113:17 INT-4 *. 1113:25 CAM-3 max motoring. 1113:33 CAM-1 light up 1113:35 CAM-3 twenty five. 1113:40 CAM-3 thirty. 1113:46 CAM-3 thirty five.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 73 1113:50 CAM-3 forty. 1113:54 CAM [sound of click] 1113:55 CAM-4 forty five starter cutout. 1113:56 INT-1 here comes one. 1113:57 INT-4 *. 1113:58 CAM-3 turnin' one. 1114:05 INT-4 *. 1114:07 INT-1 [sound similar to two microphone clicks] 1114:14 CAM-3 max motoring. 1114:22 CAM-1 light up. 1114:24 CAM-3 twenty five. 1114:28 CAM-3 thirty. 1114:32 CAM-3 thirty five.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 74 1114:37 CAM-3 forty. 1114:40 CAM [sound of two clicks] 1114:40 CAM-3 forty five starter cutout. 1114:41 CAM-1 flaps ten. 1114:43 CAM [sound of numerous clicks] 1114:51 INT-4 cockpit. 1114:54 INT-1 OK you're cleared to disconnect. show the pin on the left side and uh, we're going to do a control check right here if you want to watch it and we'll be out of here. thanks a lot for your help and we'll see you tonight. 1115:03 INT-4 OK captain. give me your last name please sir. they need it for de-icing. 1115:06 INT-1 yeah Law, L A W, Lima Alpha Whiskey. 1115:10 INT-4 thank you sir. 1115:11 CAM-3 ship's power.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 75 1115:13 CAM-1 after start checklist. 1115:14 CAM-2 electrical power? 1115:15 CAM-3 set. 1115:16 CAM-2 APU bleed? 1115:18 CAM-3 closed. 1115:18 INT-4 OK you can do your uh, flight control check, while I'm standing by. 1115:22 INT-1 OK. 1115:24 CAM-1 go ahead. 1115:25 CAM-2 hydraulics? 1115:25 CAM-3 auto, normal, quantity checked. 1115:28 CAM-2 nose steer pin? 1115:30 CAM-1 ah well we have that. let me do a control check here Ralph.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 76 1115:32 CAM-3 OK. 1115:33 CAM-3 two up on the left, one down on the right. neutral. two up on the right, one down on the left. neutral. two down, two neutral, two up, two neutral. 1115:45 INT-1 OK, the control check is complete. show the pin on the left side. thanks a lot. 1115:49 INT-4 have a nice day. 1115:55 CAM-2 how about flaps? 1116:06 CAM-1 after start check. where are we here? 1116:08 CAM-2 uh, we're down to nose steering uh, area clearance. 1116:12 CAM-1 nose steering checked, area clearance, clear on the left. 1116:15 CAM-2 clear right. 1116:18 RDO-2 Tower Air four one coming out of uh, Golf Quebec. 1116:21 GND Tower forty one, taxi via Quebec. hold short of Novem- ber. Expect runway four left for departure.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 77 1116:27 CAM-1 ask him how long if's any delays. 1116:29 RDO-2 thank you, we'll hold short uh, four left. do you know if there are any delays at this time? 1116:31 GND at this time, no delays. 1116:32 RDO-2 thanks. 1116:35 CAM-2 leave the flaps still down **? 1116:37 CAM-? *. 1117:03 CAM-1 started to taxi at sixteen. 1117:05 CAM-3 OK. 1117:14 CAM-? ouch. 1117:52 CAM-2 expect four left Ralph. 1117:54 CAM-3 OK. and uh, we checked that already *. 1118:03 CAM-2 that's less than **.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 78 1118:04 CAM-3 yeah, that's true. 1118:22 CAM [sound of yawn] 1118:31 CAM-2 the flakes are getting bigger. does that mean it's going to stop soon, or does that mean it's going to accumulate more snow? 1118:46 CAM-1 you ready on the rudders Ralph? 1118:47 CAM-3 yes I am. 1118:49 CAM-3 two left... two neutral... two right... two neutral. two up on the left, one down on the right. neutral... two up on the right one down on the left... neutral... two down... two neutral... two up... two neutral. 1119:12 CAM-1 taxi check. 1119:13 CAM-3 taxi check list. nacelle anti-ice? 1119:15 CAM-2 on. 1119:17 CAM-3 flight ‘n nav instruments? 1119:20 CAM-2 uh, set, and cross check uh, how do you want your flight di- rector?

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 79 1119:24 CAM-? *. 1119:26 CAM-3 altitude selector? 1119:27 CAM-2 five thousand feet armed. 1119:29 CAM-3 flaps ten? 1119:30 CAM-2 ten indicate uuuh, at least ten. and flaps ** green light. 1119:38 CAM-3 eight green. controls? 1119:40 CAM-2 checked. 1119:42 CAM-3 stab and trim, five point three units? 1119:45 CAM-2 five point three. OK. set one two three checked. 1119:54 CAM-3 takeoff data V speeds, one three four, one four zero, one five zero. and three rating one point four three. 1120:04 CAM-1 checked set. 1120:05 CAM-2 checked set.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 80 1120:06 CAM-3 annunciator lights? checked. 1120:15 CAM-3 taxi checklist complete. 1120:27 GND Tower forty one heavy, pick up information Kilo. 1120:31 RDO-2 uh, Kilo I believe we have that. stand by one. 1120:42 RDO-2 forty one has Kilo, thank you. 1120:45 GND roger. 1122:10 GND Tower forty one continue on the inner. at Mike join the outer. cross three one left at Kilo. 1122:19 CAM-2 OK by the inner and uh, Mike outer and uh, Kilo Alpha, cross three one left uh, Tower Air. 1122:29 CAM-1 going to four left, Mike. 1122:30 CAM-? yeah. 1122:37 CAM-1 inner outer at Mike. cross at Kilo four left. 1122:38 CAM-2 Kilo Alpha.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 81 1122:43 CAM-2 no, let me recheck. I think it was Kilo. 1122:46 CAM-1 that's alright. 1122:47 CAM-2 OK. 1122:56 CAM-1 I'm gonna uh, stop and run these engines right here. 1123:00 CAM-2 OK. 1123:09 CAM-1 Mike, keep your eye outside. if we start to move let me know. 1123:13 CAM-2 ** tell ground what we're doing? 1123:14 CAM-1 naw. 1123:16 CAM [sound similar to increase in engine RPM] 1123:20 CAM-2 feels like we're moving. 1123:21 CAM [sound of click] 1123:23 CAM [sound similar to decrease in engine RPM] 1123:25 CAM-6 it started to move.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 82 1123:26 CAM-? yep. 1123:27 CAM-6 slippery out there. 1123:33 D991 and ground, Delta nine (niner) one. 1123:35 CAM-1 it's an ice rink here. 1123:37 GND Delta ninety nine zero one, ground. 1123:40 D991 yes sir, any word on uh, thirty one? 1123:44 GND no, it's still closed. 1123:46 D991 the estimate uh, is what now? 1124:06 GND I don't know when it's gonna open. probably be a couple of hours. may want to call the Port Authority. 1124:11 DL9901 OK, earlier they had an eleven o'clock. that's why we were checking. 1124:16 GND alright.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 83 1124:24 GND Tower forty one heavy, you can stay on the inner. cross three one left at Kilo. 1124:29 RDO-2 inner to three one left at Kilo, thank you, Tower forty one. 1125:45 CAM-1 boy they got some sick # at America West with their pay sheets, don't they? 1125:49 CAM-2 I tell you I ***. 1125:52 CAM-6 shades of Braniff. 1125:53 CAM [sound of laughter] 1125:55 CAM [sound similar to electric seat motion] 1125:58 CAM-? ***. 1126:05 GND Tower forty one heavy, cross runway three one left. on the other side monitor nineteen one, good day. 1126:10 RDO-2 Tower forty one, we'll monitor on the other side. thanks. 1128:50 CAM-? ***. 1129:04 CAM-2 *** body gear steering.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 84 1129:35 CAM-?

• right.

1129:49 CAM-1 get around the corner here, Ralph take a little walk and check the wings for me will you. 1129:53 CAM-3 sure. 1130:06 CAM [sound of clicks similar to crew harness release] 1130:42 CAM-1 OK? 1130:42 CAM-3 OK. 1130:46 CAM [sliding sound similar to seat adjustment] 1130:55 CAM [sound of clicks similar to cockpit door operating] 1131:46 SB117 uh, Speed Bird uh, one one seven, just for your informa- tion, we'll be leaving our flaps down ***. 1131:52 TWR uh Roger, I can't see you from up here anyway. you uh, it'll be full flaps down? 1131:53 SB117 uh, yes.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 85 1131:59 CAM [sound similar to cockpit door operating] 1132:01 CAM-3 it's very clean out there. 1132:03 CAM-1 OK. 1132:03 CAM-3 **. 1132:07 TWR Tower forty one heavy, four left, taxi into position and hold. traffic down field right to left. 1132:11 CAM-1 right. 1132:13 RDO-2 position and hold ni.. four left, Tower Air forty one heavy. 1132:15 CAM-1 position and hold, before takeoff check list. 1132:16 CAM-3 before takeoff check list. 1132:17 TWR DHL seven, wind three two zero at one one. frequency change approved. 1132:23 CAM-3 flight attendants please be seated for takeoff. thank you. 1132:35 CAM-3 takeoff announcement is complete.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 86 1132:47 CAM-3 air condition packs off. 1132:52 CAM [sound of three clicks] 1132:53 CAM-3 ignition, flight start. 1132:54 CAM-3 transponder and radar? 1132:56 CAM-2 on and on. 1132:58 CAM-3 and stand by for body gear steering. 1133:40 TWR TWA one eighty six, cleared to land. wind three three zero at one two. 1134:00 GMTC tower car nine nine. 1134:01 TWR nine nine, Kennedy. 1134:02 GMTC OK uh, all clear of runway three one left. the runway will be (ops) at this time, full length, and uh safety check and brake check. 1134:10 TWR nine nine, roger.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 87 1134:14 KW134 and tower, Carnival one thirty four with you on the ILS four right. 1134:18 TWR Carnival one thirty four, Kennedy tower runway four right, braking action reported fair to good towards the middle of the runway and poor at the turn off. wind three three zero at one two, number two. 1134:26 CAM-2 I don't guess you'll be able to get much of a run up. 1134:29 CAM-1 no. just do the best we can. if it starts to move, we're going to take it. 1134:34 CAM-? OK. 1134:35 CAM [sound similar to crew seat operation] 1135:09 CAM-2 I see an airplane looks like it's clear down the end. 1135:12 CAM-? hold on. 1135:18 CAM-3 body gear steer? 1135:22 CAM [sound of click] 1135:22 CAM-3 disarmed, before takeoff check list complete.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 88 1135:25 CAM-? OK. 1135:26 RDO-2 Tower Air four one is in position four left. 1135:29 TWR yes sir, just continue holding. 1135:34 CAM-1 try a run up here and see what happens. 1135:39 CAM [sound similar to increase in engine RPM] 1135:47 CAM-1 start your clock **. 1135:49 CAM-? **. 1135:52 CAM-3 it's about forty five right there. 1136:02 CAM-2 it’s about fifteen. 1136:04 CAM [sound of click and sound similar to decrease in engine RPM] 1136:15 CAM-1 pretty good uh, cross wind from the *. 1136:25 TWR Tower forty one heavy, wind three three zero at one one, runway four left, RVR's one thousand eight hundred, cleared for takeoff.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 89 1136:31 RDO-2 cleared for takeoff four left, Tower Air forty one. 1136:34 CAM-1 check list is complete? 1136:35 CAM-3 yes. check list is complete. 1136:39 CAM [sound of click similar to parking brake release] 1136:40 CAM [sound similar to increase in engine RPM] 1136:44 CAM-3 power's stable. 1136:48 CAM [sound similar to crew seat operation] 1137:00 CAM [low frequency sound similar to further increase in engine RPM] 1137:04 CAM-1 set time, takeoff thrust. 1137:05 CAM-3 set the takeoff thrust. 1137:10 CAM-? watch it. 1137:10 CAM-? watch it.

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 90 1137:11 CAM [sound of click] 1137:11 CAM [low frequency sound similar to engine noise can no longer be heard] 1137:12 CAM-3 OK, losing it. 1137:12 CAM-2 going to the left. 1137:13 CAM-? going to the left. 1137:13 CAM-3 to the right. 1137:14 CAM-3 you're going off. 1137:15 CAM-? going off. 1137:16 CAM-1 aw #. 1137:17 CAM-1 easy guys. 1137:18 CAM-1 OK. 1137:19 CAM [first sound of impact]

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME & TIME & SOURCE CONTENT SOURCE CONTENT 91 1137:20 CAM-? pull up. pull up. 1137:21 CAM [second sound of impact] 1137:21 END of RECORDING END of TRANSCRIPT

FD07172 ｜ 1996_美国_AAR9605.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：1996 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

PB96-910405 > NTSB/AAR-96/05 DCA96MA008 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT COLLISION WITH TREES ON FINAL APPROACH AMERICAN AIRLINES FLIGHT 1572 McDONNELL DOUGLAS MD-83, N566AA EAST GRANBY, CONNECTICUT NOVEMBER 12, 1995 . . m %L’bww&*+ ‘. ‘. - .,, -. --3 6638B

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Information about available publications may be obtained by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 L'Enfant Plaza, S.W. Washington, D.C. 20594 (202)314-6551 (800)877-6799 Safety Board publications may be purchased, by individual copy or by subscription, from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (703)487-4600

NTSB/AAR-96/05 PB96-910405 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT COLLISION WITH TREES ON FINAL APPROACH AMERICAN AIRLINES FLIGHT 1572 McDONNELL DOUGLAS MD-83, N566AA EAST GRANBY, CONNECTICUT NOVEMBER 12, 1995 Adopted: November 13, 1996 Notation 6638B Abstract: This report explains the accident involving American Airlines flight 1572, an MD-83 airplane, which was substantially damaged when it impacted trees in East Granby, Connecticut, while on approach to runway 15 at Bradley International Airport, Windsor Locks, Connecticut, on November 12, 1995. Safety issues in the report include tower shutdown procedures, non-precision approach flight procedures, precipitous terrain and obstruction identification during approach design, the issuance of altimeter settings by air traffic control, low level windshear system maintenance and recertification, and emergency evacuation issues. Recommendations concerning these issues were made to the Federal Aviation Administration.

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iii CONTENTS EXECUTIVE SUMMARY .................................................................. vi 1. FACTUAL INFORMATION 1.1 History of Flight ..................................................................................... 1 1.2 Injuries to Persons .................................................................................. 11 1.3 Damage to Aircraft ................................................................................. 11 1.4 Other Damage......................................................................................... 11 1.5 Personnel Information ............................................................................ 11 1.5.1 The Captain............................................................................................. 11 1.5.2 The First Officer ..................................................................................... 12 1.5.3 The Approach Controller Controlling Flight 1572................................ 12 1.6 Airplane Information.............................................................................. 13 1.7 Meteorological Information ................................................................... 13 1.7.1 Surface Weather Observations ............................................................... 13 1.7.2 ATIS (Automatic Terminal Information Service) “Victor” Broadcast . 14 1.7.3 Turbulence Definitions........................................................................... 16 1.7.4 WSR-88D Doppler Weather Radar Data ............................................... 16 1.7.5 Low Level Windshear Alert System (LLWAS)..................................... 17 1.7.6 NCAR Atmospheric Simulation............................................................. 18 1.7.7 SIGMETs and AIRMETs ....................................................................... 19 1.7.8 Weather Information Provided Under AAL Procedures........................ 21 1.7.9 Weather Information Received Via ACARS ......................................... 24 1.8 Aids to Navigation.................................................................................. 24 1.9 Communications..................................................................................... 24 1.10 Airport Information ................................................................................ 25 1.11 Flight Recorders ..................................................................................... 25 1.12 Wreckage and Impact Information......................................................... 26 1.12.1 Altimeter Setting Documentation........................................................... 26 1.12.2 Wreckage Distribution............................................................................ 26 1.12.2.1 Impact with Trees ................................................................................... 26 1.12.2.2 Ground Impact Information.................................................................... 29 1.12.3 Structural Damage .................................................................................. 29 1.12.3.1 Fuselage .................................................................................................. 29 1.12.3.2 Wings...................................................................................................... 30 1.12.3.2.1 Left Wing ............................................................................................. 30 1.12.3.2.2 Right Wing........................................................................................... 30 1.12.3.3 Landing Gear .......................................................................................... 31 1.12.3.4 Empennage ............................................................................................. 31

iv 1.12.3.5 Hydraulic System ................................................................................... 32 1.12.3.6 Powerplants............................................................................................. 32 1.13 Medical and Pathological Information................................................... 33 1.14 Fire.......................................................................................................... 33 1.15 Survival Aspects..................................................................................... 33 1.16 Tests and Research ................................................................................. 34 1.16.1 Systems Tests.......................................................................................... 34 1.16.1.1 Pitot-Static System ................................................................................. 34 1.16.1.2 Autopilot Systems .................................................................................. 35 1.16.1.3 Windshear Warning System................................................................... 36 1.16.1.4 Ground Proximity Warning System....................................................... 37 1.16.1.5 Other Systems......................................................................................... 38 1.17 Organizational and Management Information....................................... 38 1.17.1 American Airlines - General .................................................................. 38 1.17.1.1 Pilot Training.......................................................................................... 38 1.17.1.2 American Airlines Single Visit Training ............................................... 39 1.17.1.3 Company Altimeter Procedures ............................................................. 40 1.17.1.4 Actions of American Airlines Since the Accident................................. 42 1.17.2 FAA Surveillance of AAL Flight Operations ........................................ 45 1.17.3 FAA Instrument Approach Design Procedures...................................... 46 1.17.3.1 Terminal Instrument Procedures (TERPS) and the VOR Approach to Runway 15............................................................................................ 47 1.17.3.2 Visual Descent Point Clearances............................................................ 49 1.17.3.3 Required Obstacle Clearance for VOR Runway 15............................... 50 1.17.3.4 Precipitous Terrain Approach Adjustments........................................... 50 1.17.3.5 VASI Obstacle Clearances ..................................................................... 51 1.18 Additional Information........................................................................... 51 1.18.1 Air Traffic Control Aspects.................................................................... 51 1.18.1.1 The TRACON Supervisor in the Tower Cab......................................... 52 1.18.1.2 TRACON Altimeter Setting Transmissions........................................... 53 1.18.1.3 Minimum Safe Altitude Warning (MSAW)........................................... 54 1.18.2 Industry Actions to Improve the Safety of Non-precision Approaches 55 1.18.2.1 Approach Plate Terrain Depictions........................................................ 55 1.18.2.2 Non-precision Approach Flight Procedures........................................... 55 1.18.2.3 Controlled Flight into Terrain (CFIT) Training Aids ............................ 56 1.18.2.4 Previous Recommendations on CFIT .................................................... 57

v 2. ANALYSIS 2.1 General.................................................................................................... 61 2.2 Adequacy of Weather Information......................................................... 61 2.2.1 NWS SIGMETs...................................................................................... 61 2.2.2 Weather Conditions at BDL................................................................... 62 2.3 Altimeter Settings................................................................................... 63 2.3.1 Other Altimeter Errors............................................................................ 65 2.4 The Descent Below MDA ...................................................................... 66 2.5 Actions After Tree Strike ....................................................................... 68 2.6 Terminal Instrument Procedures (TERPS) ............................................ 68 2.6.1 Precipitous Terrain ................................................................................. 70 2.6.2 Approach Plate Terrain Depictions........................................................ 71 2.7 Air Traffic Control Factors..................................................................... 73 2.7.1 ATC Altimeter Setting Distribution Procedures.................................... 73 2.7.2 Tower Closure and Assistance Provided by the TRACON Supervisor 74 2.7.3 MSAW (Minimum Safe Altitude Warning)........................................... 75 2.7.4 The Outdated ATIS Broadcast ............................................................... 76 2.8 Weather Conditions at the Time of the Accident................................... 77 2.8.1 LLWAS Equipment................................................................................ 79 2.9 Survival Factors...................................................................................... 80 2.9.1 The Malfunctioning Escape Slide .......................................................... 80 2.9.2 Evacuation Route Difficulties ................................................................ 81 3. CONCLUSIONS 3.1 Findings .................................................................................................. 85 3.2 Probable Cause ....................................................................................... 90 4. RECOMMENDATIONS ..................................................................... 91 5. APPENDIXES Appendix A--Investigation and Hearing................................................ 95 Appendix B--Cockpit Voice Recorder Transcript ................................. 96 Appendix C--Excerpt from AAL Flight Manual on Altimeter Setting Procedure.................................................................................. 128

vi EXECUTIVE SUMMARY On November 12, 1995, at 0055 eastern standard time a McDonnell Douglas MD-83, N566AA, owned by American Airlines and operated as flight 1572, was substantially damaged when it impacted trees in East Granby, Connecticut, while on approach to runway 15 at Bradley International Airport (BDL), Windsor Locks, Connecticut. The airplane also impacted an instrument landing system antenna as it landed short of the runway on grassy, even terrain. Flight 1572 was being conducted under Title 14 Code of Federal Regulations, Part 121, as a scheduled passenger flight from Chicago, Illinois, to Bradley International Airport. The National Transportation Safety Board determines that the probable cause of this accident was the flightcrew’s failure to maintain the required minimum descent altitude until the required visual references identifiable with the runway were in sight. Contributing factors were the failure of the BDL approach controller to furnish the flightcrew with a current altimeter setting, and the flightcrew’s failure to ask for a more current setting. The safety issues in the report focused on tower shutdown procedures, non-precision approach flight procedures, precipitous terrain and obstruction identification during approach design, the issuance of altimeter settings by air traffic control, low level windshear alert system maintenance and recertification, and emergency evacuation issues. Recommendations concerning these issues were made to the Federal Aviation Administration.

NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT COLLISION WITH TREES ON FINAL APPROACH AMERICAN AIRLINES FLIGHT 1572 McDONNELL DOUGLAS MD-83, N566AA EAST GRANBY, CONNECTICUT NOVEMBER 12, 1995

1. FACTUAL INFORMATION
2. 1

History of Flight On November 12, 1995, at 0055 eastern standard time (EST)1, a McDonnell Douglas MD-83, N566AA, owned by American Airlines (AAL) and operated as flight 1572, was substantially damaged when it impacted trees in East Granby, Connecticut, while on approach to runway 15 at Bradley International Airport (BDL), Windsor Locks, Connecticut. The airplane also impacted an instrument landing system (ILS) antenna as it landed short of the runway on grassy, even terrain. Flight 1572 was being conducted under Title 14 Code of Federal Regulations (CFR), Part 121, as a scheduled passenger flight from Chicago, Illinois, to Bradley International Airport. On November 10, 1995, at around 1700, the captain, first officer and three flight attendants reported to Washington’s National Airport (DCA) to begin a 3-day flight sequence together. The scheduled departure time was at 1800 and consisted of three flight segments the first day from DCA to Nashville, Tennessee, (BNA) continuing to Chicago’s O’Hare International Airport (ORD) and to Denver, Colorado (DEN). The airplane departed DCA at 1758, according to company records, flew the three segments, and arrived at DEN at 0310. The crew was on duty for 10 hours and 25 minutes, and had accumulated 5 hours and 53 minutes actual flight time. Due to the crew’s late arrival in DEN, the regularly scheduled layover of 15 hours and 18 minutes was reduced to 13 hours and 35 minutes.

1All times in this report are eastern standard time unless otherwise noted.

2 At 1615, on November 11, the flightcrew departed the hotel in DEN for a scheduled check-in time of 1700. The airplane they were to fly arrived late from ORD; the inbound flightcrew reported that N566AA was a “good airplane.” Flight 1572 originated in DEN and departed there at 1809, with the first officer as the flying pilot, arriving at ORD at 2047. The flight was 23 minutes late, based on the scheduled arrival time of 2024. The flightcrew stated that the airplane performed normally and that the flight was uneventful. Originally, flight 1572 was scheduled to depart ORD for BDL at

1. However, due to the late arrival of connecting passengers and weather,

the flight was delayed about 2 hours. The airplane departed ORD for BDL at 2305, with the captain as the flying pilot. After takeoff, the American Airlines dispatcher, via the Automatic Communications and Recording System (ACARS), provided the flightcrew with updated weather and wind conditions at BDL as part of the flight plan review message. The remark, “PRESFR” (pressure falling rapidly)2 was included on the weather sequence in the message. The flightcrew reported that the flight was uneventful during cruise, although the captain stated that he changed from a cruise altitude of FL3330 (about 33,000 feet) to FL350 (about 35,000 feet) to avoid an area of turbulence. According to the captain, the flight was cleared direct to BDL about 300 miles from the airport. During the descent, the flightcrew received two messages over the ACARS relating to the BDL weather. The first message was sent by American’s dispatcher at 0030 and provided the flightcrew with the altimeter setting of 29.23 inches Hg. that would cause the flightcrew’s altimeters to indicate feet above field elevation (QFE), and the altimeter setting of 29.42 inches Hg. that would cause the standby altimeter to indicate feet mean sea level (msl) (QNH) at BDL.4 At 0031, another message was sent to the

2Pressure Falling Rapidly (PRESFR): A fall in pressure at the rate of 0.06 inch [Hg.] per hour which totals 0.02 inch or more. 3Flight Level - Level of surface of constant atmospheric pressure assuming a datum of 29.92 inches Hg., expressed in hundreds of feet; thus, if the actual atmospheric pressure is 29.92 inches Hg., FL220 indicates exactly 22,000 feet. If the actual atmospheric pressure is greater (or less) than 29.92 inches Hg., FL220 will be at an altitude correspondingly higher (or lower). 4It is AAL’s policy to set the flightcrew’s altimeters to QFE and the standby altimeter to QNH when below 10,000 feet. Following the accident, neither crewmember

3 flightcrew by the dispatcher advising them that airplanes had been making landings at BDL, and that those airplanes had been experiencing turbulence and windshear on final approach. At 0032, the airplane was instructed to descend to FL190 (about 19,000 feet) by the air route traffic control center (ARTCC) controller. Also at that time, the cockpit voice recorder (CVR) recorded the last part of the automatic terminal information service (ATIS) information "Victor" for BDL. This part of information Victor gave an altimeter setting of 29.50 inches Hg. and stated that the significant meteorological information (SIGMET) “X-ray three” was in effect, which reported severe turbulence below 10,000 feet. At 0033, the flightcrew received further instructions from the ARTCC controller to descend and maintain 11,000 feet and the controller announced the Bradley altimeter setting to be 29.40 inches Hg. The flightcrew acknowledged the altimeter setting and the clearance. As recorded on the CVR, the first officer then listened to the entire ATIS information “Victor” message at 0034. He then noted to the captain that the ATIS information was about 1 ½ hour old. During the descent, at 0032:23, the captain advised the flight attendants to secure the cabin due to turbulent conditions. At 0038:45, as part of the before-landing checklist, the first officer asked, “altimeters?” The captain said, “twenty nine fifty.” The first officer stated, “they called twenty nine forty seven5 when we started down...what ever you want.” The captain replied, “OK.” The flightcrew briefed for the VOR6 approach to runway 15. The CVR recorded the captain stating at 0042:48, “One seventy four’s the elevation so, twenty nine, twenty three. Set and cross checked.” The first officer responded, “minus uh,” to which the captain replied,

remembered the 0030 ACARS message or the associated altimeter settings provided them by the company. However, papers retrieved from the accident airplane included the ACARS message annotated with the handwritten ATIS information “Victor” that was copied onto the ACARS message 1 minute after that message was received. 5It is not known why the first officer announced an altimeter setting of 29.47 inches Hg. The ACARS message at 0030 gave a setting of 29.42 inches Hg., and the ARTCC controller gave a setting of 29.40 inches Hg. at 0033. 6Very high frequency omnidirectional radio range.

4 JEPPESEN WINDSOR LOCKS, CONN ,0 z ATIS 118.15 1 BRADLEY lNTL RADLEY Approach (R) 125.8 3500’ 2700’ VOR Rwy 15 RADLEY Tower 120.3 t (GPS) VOR 109.OBDL 2 Ground 121.9 MSA -. BDL VOR KBDL Apt. Elev 174’ ; MOIOS Maximum holding airspeed at Mistr Int 265 Kts. I 2.QO D;~foN 819’0 DO. 2

• - - - - - - - - ;

~ MISSED , APCH FIX , , DODA Y G 700’ 1 I 1 7s.m 71.s0 ! $g~ 1 J .1391’ Y :)109.0 80L -... . . . . . . Maxi mum holding airspeed at Mistr Int 265 kts. VOR - A4;4,:R D::LON i Min 1680- +328” I 3 5 0 0 ’ p~48”- 2000’ ~ DO.2 (JJ28’) I

• (182~’J ~~i<

I 5.0 I 4.a ~TDZE 172’ APT. 174’ MISSED APPROACH: Climb to 3000’ outbound via BDL VOR R-149 to DODAY [NT/ D1l. O BDL VOR and hold. STRAIGHT. IN LANDING RWY 15 I CIRCLE. TO-LAND .wo~(H 1080’( 900’) M., Kfs MOA(HI 90 1 Y, ]080’{906’:-1 YA I 10 2 Y4 140 lo81)’906,;-7~4 3 165 1080’ 906; -3 ;.@ ,o**a .x,’ :.- vo ;cJ I )20 {40 160 I Figure 1.--BDL VOR runway 15 instrument approach plate. 5 “showing seventy...check seventy7 feet difference.” The flightcrew contacted approach control at 0043:41 and the flight was told to “expect [the] VOR runway [15] approach.”8 At 0045:54, approach control instructed the flight to descend to 4,000 feet. Approach control stated the winds were “one seven zero at two nine gusts three nine.” A vector for the runway 15 final approach course was then issued. (See Figure 1.) At 0049:41, the approach controller cleared the flightcrew for the runway 15 approach. At 0049:57, he advised the flightcrew that the tower was temporarily closed because of a problem with one of the windows, and to report the “down time” on approach control frequency. According to the first officer, the flightcrew intercepted the approach course at around 3,500 feet about 15 miles from the airport, and the captain began configuring the airplane for landing. The captain stated that he had the radar on the 20-mile range, observed no convective activity between their position and the airport, and then turned the radar off. The descent and approach were flown using the autopilot, and the CVR indicated that the flightcrew had selected 11 degrees of flaps prior to crossing the 10 nautical mile DME (distance measuring equipment) fix named MISTR. The captain stated that he selected the VOR/LOC (localizer) mode for the autopilot during the approach; however, due to the strong winds, the autopilot attempted to apply about a 30-degree course correction and the “autopilot couldn't hold it.” Approach control then advised the flightcrew that the airplane was left of course. (See Figures 2a, 2b and 2c.) The captain stated that he changed the mode of the autopilot to HDG SEL (heading select) to manually recapture the inbound course. After crossing MISTR, the airplane was configured for landing with 40 degrees flaps and the landing gear down. At 0051:44, the captain began the descent to 2,000 feet using the VERT SPD (vertical speed) mode for pitch control on the autopilot mode control panel. Two thousand feet was the final approach fix crossing altitude. The captain stated that the airplane encountered moderate turbulence and very heavy rain during this part of the descent.

7The CVR group reported the word “seventy” to be unintelligible. The accident flightcrew offered the word as being “seventy” after they reviewed the CVR. 8The runway 15 approach to BDL is used primarily when the winds are such that the speed and direction preclude the safe use of the airport’s primary runway (06/24).

6 The autopilot captured the airplane’s altitude at 2,000 feet, prior to their arrival at the final approach fix, named DILLN, which was 5 DME from the VOR. After passing DILLN, the captain told the first officer to set the missed approach altitude of 3,000 feet in the flight guidance control panel (FGCP). He began the descent to the minimum descent altitude (MDA)9 of 908 feet above the field elevation, using the VERT SPD mode of the autopilot. At 0054:22, the captain asked the first officer to “give me a thousand down.” Although the tower was temporarily closed at this time, a TRACON supervisor was in the tower cab and communicated with the flightcrew. (See Section 1.18.1.1 for details.) At 0054:51, the TRACON supervisor in the tower issued a windshear alert giving winds for the centerfield, northeast boundary, and southeast boundary of the airport. At 0055:06, the first officer stated, “there’s a thousand feet...cleared to land.” At 0055:11, he further stated, “...now nine hundred and eight is your uh...” The captain replied, “right.” The first officer later told investigators that he had ground contact “straight down” and, as the airplane was “at the base of the clouds,” he began looking for the field visually. He then looked back at his altimeter and saw that the airplane was descending below the MDA. Following a short period of flying through turbulence, at 0055:26.3, the first officer stated “you’re going below your….”10 According to the captain's interview and the flight data recorder, at this point the captain pushed the altitude hold button for the autopilot. According to the CVR, the “sink rate” warning was heard approximately four seconds prior to the first impact with trees. At 0055:30.4, the CVR recorded a sound of impact.11 The captain later stated that he then heard a “loud report,” followed by severe turbulence.

9The lowest altitude, expressed in feet above mean sea level, to which descent is authorized on final approach or during circle-to-land maneuvering in execution of a standard instrument approach procedure where no electronic glideslope is provided. 10During a postaccident interview, the captain stated that the first officer said, "100 below" at that time, rather than "you're going below your.…" 11Investigators determined that the first impact point was with trees on the top of a ridge line approximately 2.54 nautical miles northwest of the approach end of runway 15.

10 According to the first officer, the captain called for a go-around and “firewalled the throttles.” Flaps were selected to 15 degrees, and the landing gear handle was placed in the “up” position. Both flight crewmembers reported that the on-board windshear warning system and the ground proximity warning system (GPWS) activated after the impact, which was confirmed by the CVR recording. The captain stated that in a “second or two,” the turbulence stopped, and, at 0055, according to the CVR recording, he said to the first officer “Left motor's failed.” The airspeed started to decrease, and the airplane began a slow descent. The rain stopped, and the first officer saw the runway. According to the captain, the right engine was not sustaining full thrust, and, at 0056, he said, “Tell 'em we're goin down.” The first officer complied. The first officer then stated to the captain, “you're going to make it,” and queried whether the captain wanted the landing gear lowered. The first officer then selected the landing gear to the “down” position. The captain stated that he then called for flaps to be lowered to 40 degrees to achieve a “balloon effect” to reach the runway. The airplane clipped the top of a tree near the end of the runway, impacted and destroyed most of the ILS antenna array located at the end of the safety overrun area for runway 33, and landed on the edge of the stopway. The airplane rolled down the stopway and continued down runway 15, stopping on the runway beyond the intersection of runway 6/24 near the tower. An evacuation was initiated and the passengers and crewmembers exited the airplane. The initial tree strike occurred at approximately 41 degrees, 58.22 minutes north latitude and 072 degrees, 44.38 minutes west longitude during the hours of darkness. The ground elevation of the first impacted tree was 728 feet above msl, and the height of the tree where it was determined to be struck was about 770 feet msl.

11 1.2 Injuries to Persons Injuries Flightcrew Cabincrew Passengers Other Total Fatal 0 0 0 0 0 Serious 0 0 0 0 0 Minor 0 0 1 0 1 None 2 3 72 0 77 Total 2 3 73 0 78 1.3 Damage to Airplane According to American Airlines officials, damage to the airplane amounted to approximately $9,000,000. 1.4 Other Damage According to FAA and Bradley International Airport officials, damage to the ILS antenna array and other airport equipment amounted to approximately $74,620.00 1.5 Personnel Information 1.5.1 The Captain Date of birth: 07-01-56 Ratings and Certificates: Airline Transport Pilot Certificate Number 92480401, issued 08-05-91. Type Rating: DC-9/Airline Transport Pilot Flight Engineer Certificate Number 92480401, issued 05-24-85 Rating: Turbojet powered/FE Medical certificate: First Class issued 08-29-95, no restrictions Date of hire with AAL: 04-11-85 Second in Command (SIC) time (MD80) since 09-08-86: 2,716 hours Pilot in Command (PIC) time, (DC-9/MD80) since 08-22-91: 1,514 hours Total flying time: 8,000 hours total, 5,000 hours civilian, 2,300 military Total flying time last 24 hours: 10 hours Total flying time last 7 days: 10 hours Total flying time last 30 days: 20 hours

12 Total flying time last 60 days: 55 hours Total flying time last 90 days: 55 hours Last recurrent training: 08-21-95 Last proficiency check: 08-21-95 Last line check: 07-17-95 1.5.2 The First Officer Date of birth: 11-16-56 Certificates and ratings: Airline Transport Pilot Certificate Number 527063950, issued 08-27-88 Airplane Multiengine Land/Airline Transport Pilot Airplane Single Engine Land/Commercial Pilot Medical: First Class issued 03-13-95, no restrictions Date of hire with AAL: 05-24-89 Second in Command (SIC) time, (MD-80) since 08-21-90: 2,281 hours Total flying time: 5,100 hours total, 2,500 hours military, 2,600 hours civilian Total flying time last 24 hours: 10 hours Total flying time last 7 days: 13 hours Total flying time last 30 days: 60 hours Total flying time last 60 days: 123 hours Total flying time last 90 days: 167 hours Last recurrent training: 08-19-95 Last proficiency check: 08-19-95 Last line check: 08-21-90 1.5.3 The Approach Controller Controlling Flight 1572 Date of hire by FAA: December, 1991 Last Tape Talk: May 25, 1995 (no deficiencies noted) Medical Certification: November 6, 1995 (no restrictions or limitations) Facility records indicated that the approach controller was current in all refresher and supplementary training. These topics included Severe Weather, Traffic & Safety Advisories, Emergencies, Seldom Used Procedures, Unusual Situations, Low Level Windshear, Winter & Summer Operations, Revised MVA Video Map, various operational bulletins, and operational error prevention bulletins. No remedial training was noted. There was no evidence of an operational error or deviation in the past 2 years.

13 1.6 Airplane Information N566AA, serial number 49348, is a McDonnell Douglas MD-83 twin engine transport category airplane. At the time of the accident, the total airframe time was 27,628 hours. Based on flight plan data, estimated fuel remaining on approach to BDL was 15,600 pounds, and estimated landing weight was 118,360 pounds with an estimated center of gravity (CG) of 18.1 percent mean aerodynamic chord (MAC). The allowable CG range from the MD-80 Approved Aircraft Flight Manual at 118,050 pounds is -0.8 percent to 33.4 percent. The airplane was equipped with two Pratt & Whitney JT8D-219 turbofan engines with a normal takeoff thrust rating of 21,000 pounds and a maximum takeoff thrust rating of 21,700 pounds. Engine times and cycles: LEFT RIGHT Serial Number 725677 708519 Total time (hrs) 13,014 34,681 Total cycles 7,409 19,992 1.7 Meteorological Information The National Weather Service (NWS) Surface Analysis for November 12 at 0100 showed a deep low (986 millibars) over Quebec with an occluded front extending south across Eastern New York State. A secondary low pressure center was located over New York City. There were strong southerly winds ahead of the front and strong westerly winds behind it. A large area of rain existed over New England. 1.7.1 Surface Weather Observations Surface Weather Observations at BDL are made by the NWS during the day, and a private contractor, Midwest Weather Inc., during the

14 evening hours. The following weather observations for BDL were made by Midwest Weather: November 11 at 2352: Record 2,200 feet scattered; measured ceiling 2,800 feet overcast; visibility 5 miles; light rain; temperature 61 degrees F; dew point 57 degrees F; winds 160 degrees at 28 knots gusts to 40 knots; altimeter setting 29.42 inches Hg; peak wind 160 degrees at 42 knots at 2318; pressure falling rapidly. The observation was transmitted to the BDL Air Traffic Control Tower, at 2353. November 12 at 0051: Record 1,700 feet scattered; measured ceiling 2,800 feet overcast; visibility 3 miles; moderate rain; temperature 61 degrees F; dew point 58 degrees F; winds 170 degrees at 25 knots gusts to 40 knots; altimeter setting 29.35; pressure falling rapidly. Peak wind 170 degrees at 43 knots at 0018. The observation was transmitted to the BDL control tower at 0057. 1.7.2 ATIS (Automatic Terminal Information Service) “Victor” Broadcast BDL ATIS recordings are created by BDL Federal Aviation Administration (FAA) personnel and use weather information from the NWS or Midwest Weather, depending upon the time the weather information is formulated. ATIS broadcast "Victor," recorded at 2251, included the information below. The next ATIS broadcast was not created until after the accident. Bradley Airport Information Victor zero three five one Zulu [2251 EST]: Weather two thousand two hundred scattered, measured ceiling two thousand seven hundred overcast, visibility one zero, light rain, temperature six two, dew point five seven, wind one six zero at two eight gust three niner, altimeter two niner five zero, approach in use ILS runway two

15 four or VOR runway one five. Notice to Airmen: runway two four and runway one five open and wet, low level windshear advisories are in effect. Taxiway tango restricted to aircraft with a wingspan of less than one hundred seventy one feet. SIGMET X-ray Three is valid for severe turbulence below one zero thousand [SIGMET X-ray Three actually noted severe turbulence below one three thousand]. Predeparture clearances are available, advise on initial contact you have Victor. ATIS Victor broadcast continually through the time of the accident. The Air Traffic Control Handbook, FAA Order 7110.65, states that a new ATIS recording should be made “Upon receipt of any new official weather regardless of whether there is or is not a change in values.” The controller responsible for updating the ATIS hourly said that he had been planning to make a new recording but was waiting for the new weather to be displayed on the SAIDS (Systems Atlanta Information Display System). He said that he left the tower about midnight, and, at that time, the most current weather conditions had not appeared on the SAIDS equipment. He did not advise the on-coming controller that the weather had not yet appeared, and that a new ATIS should be made. When he gave the briefing to the relieving controller, the new weather conditions were still not available, and the telephones to the NWS did not work. He said that in such situations, controllers usually call the airport police station, and an officer goes across the hall to the NWS office, which, in turn, calls the tower and relays the weather information. He also said that this situation has occurred many times. However, this procedure was not implemented on the night of the accident. The relieving tower controller said that he listened to the ATIS, but he did not notice the time on it. He did not notice if the SAIDS incoming information warning light was blinking, which would have indicated that new weather information was available. He said that the environment was very noisy (wind noise), and that he heard no SAIDS incoming information warning tones.

16 1.7.3 Turbulence Definitions The following definitions are given in the Forecasting Guide on Turbulence Intensity, National Weather Service Operations Manual, Chapter D-22: Light turbulence .. Absolute value of vertical acceleration (G)

.2 G to .5 G.

Moderate turbulence .. Absolute value of vertical acceleration

.5 G to 1.0 G.

Severe turbulence .. Absolute value of vertical acceleration

1.0 G to 2.0 G.

Review of the FDR vertical acceleration trace for flight 1572 from the time of the tree strike indicates an absolute value of the maximum change in vertical acceleration of about .5 G. The absolute value of the maximum change in indicated airspeed is about 10 knots. 1.7.4 WSR-88D Doppler Weather Radar Data The Velocity Azimuth Display (VAD) Vertical Wind Profile from the Brookhaven, New York, WSR-88D radar (70 nautical miles south of BDL) showed the following estimated values at 0055: Height Wind Direction (degrees) Wind Speed (knots) 1,000 160 60 2,000 170 80 3,000 170 80 The VAD Vertical Wind Profile for 0051 from the WSR-88D Doppler Weather Radar at the National Weather Service Forecast Office, Taunton, Massachusetts (69 nautical miles east of BDL) showed: Height Wind Direction Wind Speed 1,000 160 45 2,000 160 60 3,000 180 75

17 Estimated upper winds generated on the Safety Board's McIDAS12 workstation, based on November 11 at 1900 upper air data, showed the following for the BDL area: Height Wind Direction Wind Speed 1,000 170 51 2,000 170 54 3,000 180 56 4,000 180 60 1.7.5 Low Level Windshear Alert System (LLWAS) A Phase II LLWAS was installed and operational at BDL at the time of the accident. The system consists of five wind sensors; one is located at the centerfield and the other four are situated around the periphery of the airport [northeast, northwest, southwest, southeast]. The system was recertified on November 12, 1995, the day of the accident, and was found to be within tolerances. According to FAA Airways Facilities personnel, recertification involves removing each sensor from its stationary base and then testing it to ensure it operates properly. The recertification process does not include checking for proper alignment of the sensors on their stationary bases. The approximate location of the first tree strike was about 289 degrees at 1.5 nautical miles from the northwest LLWAS wind sensor, the closest sensor to the tree strike. The following wind information was recorded from this sensor: Time Direction/Speed 0055:17 220/12 0055:27 214/12 0055:37 208/10 Time Direction/Speed 0056:57 215/20 0057:07 215/18 0057:17 215/16

12McIDAS - Man Computer Interactive Data Access System. McIDAS is an interactive meteorological analysis and data management computer system. McIDAS is administered by personnel at the Space Science and Engineering Center at the University of Wisconsin at Madison. Data are accessed and analyzed on an IBM PS/2 Model 77 computer.

18 0055:47 210/09 0055:57 223/06 0056:07 227/08 0056:17 225/13 0056:27 215/18 0056:37 215/21 0057:27 216/15 0057:37 210/14 0057:47 203/12 0057:57 201/10 0058:07 203/10 0056:47 214/22 FAA personnel reviewed the BDL LLWAS data from October 31 to November 12, via the FAA Site Performance Evaluation System (SPES). The analysis indicated that the northwest LLWAS sensor was misaligned by approximately 20 degrees. On February 5, 1996, the Safety Board requested that the FAA provide information on whether the alignment of the northwest sensor was checked and whether any corrections were made. Shortly thereafter, the FAA replied that the Weather Systems Engineering Branch, AOS-250, received the latest LLWAS meteorological data (the analysis period was from January 13, 1996 to January 21, 1996) from BDL on February 14, 1996, and the northwest sensor still appeared to be misaligned. A copy of all pertinent SPES data was faxed to the airways facilities technicians at BDL on February 15, 1996, and an inspection of the northwest sensor's anemometer alignment was performed by certified LLWAS technicians at the airport. The anemometer was found to be out of alignment by 38 degrees and was corrected on February 16, 1996. The FAA indicated that the misaligned sensor did not appear to degrade the system during the analyzed period. According to FAA Airways Facilities personnel, the SPES information is analyzed monthly. Misaligned LLWAS wind sensors as well as failed components are identified and field personnel at the affected airports are notified. However, due to staffing limitations, it may be 3 to 6 months before the alignment of the wind sensors is physically checked by field personnel. 1.7.6 NCAR Atmospheric Simulation A theoretical atmospheric simulation was accomplished to estimate the meteorological conditions that affected flight 1572 during the approach to BDL. The simulation was performed by scientists at the National

19 Center for Atmospheric Research (NCAR). The simulation was run on a Cray supercomputer using averaged information from horizontal increments of about 42 meters. The results of the simulation indicated that a pressure decrease of about 1 millibar (1 millibar = 0.03 inch of Hg.) and downdrafts of about 400 feet per minute occurred near and to the northwest (lee side) of the ridge where the airplane contacted the trees. The pressure decrease and downdrafts extended to the lee side of the ridge for a horizontal distance of about 0.3 nautical miles. According to an NCAR scientist, the decrease in pressure may have been underestimated by 2 to 3 times over distances smaller than the horizontal resolution of the simulation. The strength of the downdrafts was not underestimated. 1.7.7 SIGMETs and AIRMETs The following SIGMETs13 and AIRMETs14 were applicable to the time and route of flight of the accident airplane. They were generated by the NWS Aviation Weather Center, Kansas City, Missouri. AIRMET Tango was issued on November 11 at 2145 and was valid until November 12 at 0400: Turbulence - Moderate turbulence below 15,000 feet due to strong winds and cold front moving across the area. Moderate turbulence between 15,000 and 40,000 feet due to strong winds and mid/upper level trough. Conditions mainly southwestern half of area spreading across remainder of area by 0400.

13Significant meteorological information. An in-flight advisory forecast issued by the NWS Aviation Weather Center that advises of weather (other than convective activity) that is potentially hazardous to all aircraft. These reports cover large geographic areas of at least 3,000 square miles. 14Airman’s meteorological information - An in-flight advisory forecast issued by the NWS Aviation Weather Center that advises of weather (other than convective activity) that may be hazardous to light aircraft, aircraft operating under visual flight rules (VFR), and inexperienced pilots. AIRMETs include moderate icing, moderate turbulence, and IFR conditions. These reports cover large geographic areas of at least 3,000 square miles.

20 Strong Surface Winds - Sustained surface winds greater than 30 knots expected. Low Level Windshear Potential throughout the entire area. AIRMET Zulu was issued on November 11 at 2145 and was valid until November 12 at 0400: Icing - Occasional moderate rime icing in cloud between freezing level to 20,000 feet. At 2200 freezing level 7,000 to 9,000 feet western portions of area, sloping 10,000 to 12,000 feet eastern sections. AIRMET Sierra was issued on November 11 at 2215 and was valid until November 12 at 0400. IFR - Occasional ceilings below 1,000 feet and visibility below 3 miles in precipitation and fog. SIGMET November 2 was issued on November 11 at 1930 and was valid until November 11 at 2330: Moderate occasional severe rime/mixed icing in cloud and in precipitation between 12,000 and 18,000 feet.15 SIGMET November 3 was issued on November 11 at 2235 and was valid until November 12 at 0235: Moderate occasional severe rime/mixed icing in cloud and in precipitation between 12,000 and 18,000 feet. Severe mixed reported by ATR-42 near Bridgeport at 2208 (November 11). SIGMET X-ray 3 was issued on November 11 at 1840 and was valid until 2240:

15Canaan, New York, (approximate beginning of descent of flight 1572) is about 20 nautical miles east of the eastern extent of the area outlined by this SIGMET.

21 Moderate occasional severe turbulence below 13,000 feet due to strong low level winds. Low level windshear also expected. SIGMET X-ray 4 was issued on November 11 at 2240 and was valid until November 12 at 0240: Moderate occasional severe turbulence below 13,000 feet due to strong low level winds. Low level windshear also expected. The SIGMETs and AIRMETs were not given to the flightcrew of flight 1572 because AAL has its own meteorology department that prepares weather information for its flightcrews. 1.7.8 Weather Information Provided Under AAL Procedures An American Airlines meteorologist who worked the 1600 to 0000 shift on November 11 stated that a SIGMEC16 was issued for BDL during the day on November 11, 1995, to cover low level windshear, moderate turbulence below 8,000 feet and moderate icing in clouds and in precipitation between 10,000 to 18,000 feet. The SIGMEC was valid from November 11 at 1400 to November 12 at 0300 and stated: Occasional moderate turbulence is expected below 8,000 feet as strong winds develop during the afternoon and evening. Low level windshear also possible. Occasional moderate icing likely especially in the evening as widespread precipitation approaches/develops across the area. Affected altitudes 10,000 to 18,000 feet.

16An FAA-approved weather product issued by AAL weather staff to support AAL flight operations. SIGMECs are issued when weather conditions exist for moderate or greater icing, low level turbulence, low level windshear, and/or thunderstorm activity in the vicinity of the terminal area. The terminal area is defined as about a 25 mile radius of the airport. En route SIGMECs are issued for significant weather conditions to include moderate or greater icing or turbulence and thunderstorms. SIGMECs cover geographic areas more specific to a particular AAL route of flight than do the more wide-ranging NWS SIGMETs.

22 The SIGMEC was based upon the following weather conditions: 1. Observed surface winds 160 degrees at 28 knots with gusts to 40 knots. 2. Observed winds aloft were between 60 to 80 knots from the surface to 5,000 feet. 3. Surface barometric pressure was falling rapidly due to approaching low pressure system. 4. Weather radar indicated heavy rain showers and isolated thunderstorms approaching BDL from Long Island Sound. 5. Numerous reports of low level windshear and moderate turbulence were received throughout the day from heavy aircraft in the New England area due to strong and gusty winds. A meteorologist who worked the 0800 to 1600 shift stated that the SIGMEC was issued on the evening of November 11, 1995, for icing and turbulence because of icing reports from the area of the United States from which the weather was coming and because winds were forecast to be at an intensity/shear level that would justify possible low level windshear and moderate turbulence around BDL that evening. To the best of the meteorologist's recollection, reports from larger airplanes were indicating moderate turbulence "upstream" from the area of concern. A meteorologist who came on duty at midnight on November 12 noted that the SIGMEC for BDL was in effect. He concluded that the SIGMEC continued to be valid based upon meteorological information and pilot reports available to the meteorologist. Therefore, the meteorologist believed that no further action was required to update this SIGMEC. The AAL meteorology staff stated that the NWS SIGMETs and AIRMETs were not provided to flight 1572 because the AAL Weather Services is the FAA EWINS (Enhanced Weather Information System)- approved source of weather information. They further stated that the

23 SIGMECs generated by AAL Weather Services are an approved part of the EWINS agreement with the FAA. SIGMECs are designed to cover adverse weather phenomena, such as turbulence, icing and volcanic ash activity, along a particular aircraft’s route of flight. According to the AAL meteorology staff, NWS SIGMETs are not usually provided to flightcrews by dispatchers because the dispatchers use the products of the AAL meteorologists rather than the NWS and because SIGMECs provide more specific information pertinent to the route of flight. The dispatcher of flight 1572 stated that per AAL’s dispatcher procedures, the flight release contained company-generated SIGMECs, but that NWS SIGMETs were available to dispatchers by computer at the dispatch position. The flight release information provided by the dispatcher to the flightcrew of flight 1572 included the terminal SIGMEC for BDL, and the terminal SIGMEC for Syracuse, New York (SYR) issued on November 11 at 1205 valid until November 12 at 0100, stating: Occasional moderate icing in clouds and in precipitation is expected from 10,000 feet to flight level 18,000 feet, as widespread precipitation develops through the afternoon. Lower limit of icing is expected to approach surface from west to east this afternoon as a wintery mix of precipitation approaches the area. Occasional moderate turbulence is also expected below 8,000 feet as strong low level southerly winds shift to strong northerly and northwesterly winds after frontal passage. Brief low level windshear is possible especially near the cold front. An American Airlines En Route Turbulence Index of "2" was indicated at flight plan altitude from top of climb to beginning of descent. According to American Airlines meteorologists, a "2" indicates a forecast of at most moderate chop.

24 1.7.9 Weather Information Received Via ACARS The following weather information was transmitted to the flightcrew during the flight via the American Airlines ACARS: Time 2320 - BDL 2250 surface weather observation - 2,200 feet scattered, measured ceiling 2,700 feet overcast; visibility 10 miles, light rain; temperature 62 degrees F; dew point 57 degrees F; winds 160 degrees at 26 knots gusts to 35 knots; altimeter setting 29.51 inches Hg.; peak wind 160 degrees at 35 knots; pressure falling rapidly. Time 0030 - Weather Data as of 12/0001: Altimeter setting 29.42 msl. Pressure Altitude 645 feet ABV. Conversion 29.23 Inches Hg. Temperature 61 degrees F. Time 0031 - Attention [captain's name] - Have information from BDL Tower that aircraft have been making landings but have advised of turbulence and low level windshear on final. Winds are more aligned with runway at BOS if that becomes necessary. 1.8 Aids to Navigation The FAA Maintenance Management System Log Incident Summary Listing stated that the postaccident BDL VOR flight check was satisfactory. The Summary Listing also stated that an evaluation of technical performance of ground equipment was completed for the BDL VORTAC, BDL VASI, and BDL ATIS, and no problems were noted. 1.9 Communications There were no known communications difficulties associated with flight 1572.

25 1.10 Airport Information Bradley International Airport is served by three paved runways. The field elevation is 174 feet msl. Runway 6/24 is 9,502 feet long and 200 feet wide. There is an ILS CAT I and a VOR or global positioning system (GPS) approach to runway 24 and an ILS CAT II and III, VOR, a nondirectional beacon (NDB) or GPS to runway 6. Runway 1/19 is 5,145 feet long and 100 feet wide. There are no instrument approach procedures published for this runway. Runway 15/33 (the accident runway) is 6,846 feet long and 150 feet wide, with a 998 foot unpaved safety overrun area for runway 33. There is an ILS CAT I approach to runway 33 and a VOR (GPS) approach to runway 15. The BDL runway 15 VOR approach is used most often when the speed and direction of the winds preclude the use of the primary runway 06/24. The runway 15 threshold elevation is 170 feet msl and the touchdown zone elevation is 172 feet msl. Runway 15 is equipped with high intensity runway lights (HIRL), runway end identifier lights (REIL), and a visual approach slope indicator (VASI)-L (angle 3.5 degrees.). The runway is grooved. The BDL VOR is located just north of the intersection of runways 6/24 and 15/33. The control tower and airline terminal buildings are located south of the intersection of runway 6/24 and 15/33. The airport has an FAA-approved emergency plan, and it is certificated as Aircraft Rescue and Fire Fighting (ARFF) Index D, in accordance with 14 CFR 139.17 1.11 Flight Recorders The airplane was equipped with a Sundstrand Model UFDR (S/N 7605) digital flight data recorder (DFDR). It recorded 78 parameters.

17Index D is the FAA ARFF index for air carrier aircraft of at least 126 feet but less than 159 feet in length. 14 CFR 139 requires that a minimum of three ARFF vehicles be available that carry an amount of water and commensurate quantity of fire- fighting foam so that the total quantity of water for foam production carried by all three vehicles is at least 4,000 gallons.

26 The flight recorder tape was found undamaged with no evidence of excessive wear. The airplane was also equipped with a Fairchild model A-100A cockpit voice recorder (CVR) (S/N 53395). See Appendix B for a transcript of the CVR recording that lasts 31 minutes and 29 seconds. Figures 3a and 3b contain pertinent FDR parameters overlaid with pertinent flightcrew comments recorded on the CVR. 1.12 Wreckage and Impact Information 1.12.1 Altimeter Setting Documentation Following the accident, the barometric pressure settings in the altimeters were observed to be as follows: Captain's:

1. 23 inches Hg.

First officer's: 29.23 inches Hg. Standby: 29.47 inches Hg. 1.12.2 Wreckage Distribution 1.12.2.1 Impact with Trees The initial impact mark from the airplane was with a tree located on the top of Peak Mountain Ridge, approximately 2.54 nautical miles northwest of the approach end of runway 15. Numerous additional trees also had indications of being impacted. The ground elevation at the bottom of the first impacted tree was 728 feet msl; the tree was determined to have broken at 770.5 feet. The approximate location of this tree was identified by GPS equipment as 41o 58.22' N and 72o 44.38' W. A survey of tree heights on and around the ridge performed shortly after the accident indicated that the trees in the area of initial impact were approximately 60 feet tall. Debris from the airplane and small broken tree branches were found along the wreckage path in the wooded area on the ridge. The airplane pieces found were leading edge skin, trailing edge flap skin, belly and flap fairing fittings, and a clear wing tip lens cover. The right main landing gear outboard door was also located in the wreckage path. The total length of the wreckage path on the ridge was 290 feet. The bearing from the first to the last impacted tree on the ridge was approximately 137o magnetic.

29 About 1,100 feet prior to the initial ground impact mark, a tree, located in the flightpath of the airplane landing on runway 15, sustained a sharp metal strike mark 76 feet above the ground. This tree was at an elevation of about 170 feet msl. 1.12.2.2 Ground Impact Information A total of 14 orange metal posts were fastened to 14 pairs of concrete pads to support the localizer antenna. Post No. 13 exhibited evidence of a black tire mark about 6 feet above the ground. Posts Nos. 3 to 12 were destroyed and were broken into numerous pieces. Three localizer antenna posts (Nos. 1, 2 and 14) exhibited no impact damage. The first ground scar, consisting of a black tire mark, was located below post No. 10. This pad was approximately 18 feet to the right of stopway centerline. A ground scrape mark progressed from below post 10 and extended toward the runway overrun area, in the direction of flight. The left and right main landing gear tire marks crossed the runway threshold mark on the left side. A runway threshold light (second from the left) sustained impact damage and was found on the left side of the runway. The left main landing gear tire marks departed the runway edge at the threshold mark and remained on the pavement. The right main landing gear tire mark remained inside the runway edge line. These tire marks curved back toward the runway centerline after crossing taxiway "J". The airplane came to rest on the runway approximately 3,137 feet from the runway threshold. 1.12.3 Structural Damage 1.12.3.1 Fuselage The airplane was damaged from its impact with the trees and localizer antenna posts. There was no fire damage to the fuselage and no impact damage to the fuselage above the floor line. No impact damage or

30 skin waviness18 was noted in the areas around the pitot tubes or static ports. The fuselage section forward of the wing front spar had no impact damage. The fuselage belly honeycomb fairing, aft of the wing front spar, sustained impact damage with numerous punctures and some scrape marks from forward to aft. The left main landing gear forward wheel well structure, which supports the honeycomb fairing, sustained impact damage and was bent aft. Orange paint transfer marks were found in the area of impact. The hydraulic lines in the wheel well just aft of the impact location were severed. The right main landing gear forward wheel well structure was damaged and bent slightly aft. Wood fibers were found embedded at the right main landing gear impact location, and there were no paint transfer marks. The lower section of the aft pressure bulkhead was crushed radially inward. About 12 inches of structure on either side of the bulkhead centerline were bent upwards. The main vertical beam remained intact and was undamaged. The right side stringers were deformed slightly upwards. 1.12.3.2 Wings 1.12.3.2.1 Left Wing The left wing remained attached to the fuselage with damage to the leading and trailing edge control surfaces. The damage consisted mainly of dents and tears, forming a semicircular shape, with wood fiber embedded at the impact locations. The leading edge of the three inboard slats exhibited impact damage at numerous locations. The trailing edge flaps remained attached to the wing and were found extended to 40 degrees. The inboard flap suffered damage at two locations. 1.12.3.2.2 Right Wing The right wing remained attached to the fuselage with damage to the leading and trailing edge control surfaces. The leading edge slats

18Skin waviness is mild wrinkling of the fuselage skin because a skin panel does not always conform to the exact outer mold line of an airplane. Skin waviness in the vicinity of static ports could alter the local static pressure sensed by the ports.

31 remained attached to the wing and sustained severe impact damage. The trailing edge flaps remained attached to the wing and were found extended to 40 degrees. The inboard flap sustained one large area of impact damage at its inboard end, and two such areas on its outboard end. 1.12.3.3 Landing Gear The nose landing gear was extended and remained attached to the airplane with minor impact damage. Both nose landing gear taxi lights were broken. Small pieces of nose landing gear taxi light glass and a retainer ring were found on the ridge. Small tree limbs, about 8 inches long and 1 inch in diameter were found wedged between the taxi light fixtures. Both tires remained inflated and there was no evidence of flat spots or lateral scrape marks on the tires. The right main landing gear was extended and remained attached to the airplane with impact damage to the strut scissors assembly. The landing gear tires remained inflated. The outboard gear door was missing and was located on the ridge. The inboard gear door remained attached and was found in the open position. The left main landing gear was extended and remained attached to the airplane with minor impact damage. The outboard tire of the left main landing gear had burst at some point in the accident sequence, and was replaced on the runway to facilitate towing the airplane to the hangar. Small twigs were found wedged between the tires. 1.12.3.4 Empennage There was no evidence of any damage to the vertical stabilizer, rudder, and rudder trim tab. The right horizontal stabilizer leading edge contained a 3-inch-wide area of impact damage 5 feet inboard from the tip. The damage was about 3 inches wide, and the leading edge was crushed aft. Wood bark was found embedded in the impact location. There was no other damage to the right horizontal stabilizer.

32 1.12.3.5 Hydraulic System Hydraulic lines in both main landing gear wells were damaged in the vicinity of other wheel well structural damage. On the forward wall of the left main landing gear well, the left system ground service and power transfer suction lines were broken. In addition, a brake return line near the control module was bent and leaking. In the right wheel well, several lines were broken between the brake control module and the landing gear. 1.12.3.6 Powerplants Both engines had tree branches and sticks in the inlets. The fan blades on both engines had soft body impact damage and wood fibers were found on the underside of the mid-span shrouds. The left engine cases and fan ducts did not have any holes or penetrations, and the fourth stage turbine blades were intact. The right engine fan duct and intermediate case were burned in the plane of the seventh and eighth stage compressor stages; however, the cowling was not burned. The forward side of the mixer lobes and struts had metal spatter build up. The right engine did not have any other apparent damage. Internal examination of the engines revealed that the left engine low pressure compressor (LPC) stages were damaged due to the impact of the rotors with the stators, particularly in the third stage area. The high pressure compressor (HPC), high pressure turbine (HPT), and low pressure turbine (LPT) were not damaged, but they had metal spatter on the airfoil surfaces. The right engine LPC stages were also damaged due to the impact of the rotor with stator airfoils. The HPC seventh, eighth, and ninth stage blades were burned, almost down to the airfoil platforms. Metal spatter was found on the HPT and LPT airfoils. The fuel controls and fuel pumps were bench tested and found to be working correctly. The flight data recorder engine pressure ratio parameters indicated that the engines were operating at engine pressure ratios of about 1.5 at the time of the ridge line tree strike. No mention of engine problems prior to the ridge line tree strike were noted upon review of the cockpit voice recording.

33 1.13 Medical and Pathological Information Shortly after the accident, both flight crewmembers underwent standard drug testing. The results of these tests were negative. 1.14 Fire See Section 1.12.3.6 for description of fire damage to the right engine. 1.15 Survival Aspects According to interviews with the flight and cabin crewmembers, after the airplane stopped, the captain ordered an evacuation. A flight attendant opened the aft emergency exit/galley door, but the slide did not inflate automatically, as intended. He pulled the manual inflation handle, and the slide then inflated. An unknown number of passengers and two flight attendants evacuated through this exit. Because the evacuation slide failed to inflate automatically, it was examined by investigators from the Safety Board, American Airlines, and the FAA at the facilities of the manufacturer, Air Cruisers Company. Three tests were conducted on the airplane’s emergency evacuation slide assembly. The first two tests followed the Douglas maintenance manual instructions which did not call for the inflation cable to be routed through the grommet on the girt bar grommet tab. The instructions stated, “check that loop on firing lanyard is secured to girt tab with retaining ring on manual inflation handle; then secure lanyard cover flap over firing lanyard.” In those two tests, the slide dropped down but did not unfold or inflate. In the first test, the manual inflation handle remained within view when the door was opened, and within reaching distance of the cabin door. In the second test, the handle dropped over the side of the fuselage, and it could not be seen from the cabin by someone standing at the door. In the third test, the inflation cable was routed through the grommet on the girt bar grommet tab. When it was tested, the slide inflated properly. In July, 1996, McDonnell Douglas incorporated revised text and graphics on the installation of floor level emergency evacuation slides into the

34 FAA-approved MD-80 and DC-9 maintenance manuals. That revision instructs the installer to “[p]ass [the] inflation cable19 loop through [the] grommet tab,” and includes two diagrams illustrating the proper routing of the inflation cable through the grommet tab. According to the flight attendants and questionnaires that passengers provided to the Safety Board, during the evacuation, flight attendants shouted commands to passengers to remove their shoes (regardless of shoe style) and to leave carry-on luggage on the airplane. About a third of the passengers who completed questionnaires stated that shoe removal either slowed their evacuation or that shoes in the aisle obstructed their exit. Passengers (including a woman carrying a 10-month old baby) reported that they stumbled or tripped over piles of shoes in the aisle and galley areas. American Airlines is the only major air carrier that commands passengers to remove all shoes during an evacuation. 1.16 Tests and Research 1.16.1 Systems Tests 1.16.1.1 Pitot-Static System The airplane was equipped with three pitot-static systems. The captain's system provides inputs to digital central air data computer (CADC) No. 1, which drives the captain's primary flight instruments (Mach/airspeed indicator, vertical speed indicator, and altimeter). The first officer's system provides inputs to CADC No. 2, which drives the first officer's primary flight displays. The third system, known as the auxiliary system, provides inputs directly to the standby altimeter and airspeed indicator. Each system has its own pitot probe and static ports.

19In the revised text and graphics, the term “inflation cable” is sometimes used in place of the previously used term for the same part, “firing lanyard.” However, the term “firing lanyard” is still used to designate that part in several diagrams and unchanged portions of the maintenance instructions for removal and installation of evacuation slides.

35 Following the accident, an atmospheric leak check was performed on all three systems in accordance with the AAL Maintenance Manual. According to the test procedure, the maximum allowable changes in altitude and airspeed during the test are 100 feet and 5 knots in 1 minute (i.e., leakage in the system may not result in more than 5 knots airspeed deviation or 100 feet difference in altitude). All three systems successfully passed this test. An additional test was performed to determine the relative accuracy of the pitot static systems. All three systems were tested at simulated approach flight conditions, and the cockpit airspeed and altitude readings were recorded. Indications from all three sets of flight instruments were within 25 feet and 3 knots of each other at all flight conditions tested. The CADCs have a self-test capability. Both computers successfully passed this test. In addition, it was noted that the magnetic fault indicators (fault balls) on the computers were not tripped. The heater elements in the pitot probes and static ports were tested and found to be functioning properly. 1.16.1.2 Autopilot Systems The airplane was equipped with two autopilot systems, each controlled by a digital flight guidance computer. In the vertical axis, the autopilots can fly the airplane through various flight maneuvers such as maintaining an existing altitude and climbing or descending to a preselected altitude and holding that altitude. Selection of modes is done through the flight guidance control panel. Following the accident, the E-24 circuit breaker (DC Autopilot 1) was found tripped in the cockpit. It could not be determined when the circuit breaker tripped. During systems group testing, electrical power was applied to the airplane, and the E-24 circuit breaker was reset. It remained in for the duration of the testing without tripping. An autoland preflight test, normally initiated during the autoflight portion of the daily preflight, was performed after the accident, and both autopilot systems successfully passed this test. Further, a return-to-

36 service test, normally performed by maintenance personnel following replacement of an autoflight system component, was also accomplished, and both systems successfully passed this test. Several additional tests were performed to evaluate the effect of the E-24 (DC Autopilot 1) circuit breaker on Autopilot 1 system operation. With the system engaged, tripping the circuit breaker caused the blue AP 1 engagement lights on the flight mode annunciators to go out and the red flashing AP DISCONNECT lights to illuminate. In another test, it was determined that if the circuit breaker was already tripped, Autopilot 1 would not engage. Following the accident, the flight guidance system of an American Airlines MD-80 simulator was used to capture a VOR course on a VOR instrument approach and to establish rates of descent using the vertical speed mode of the autopilot. Prior to the final approach fix (FAF) for the VOR instrument approach, altitude capture was accomplished using the altitude select window. After passing the FAF, altitude capture was accomplished using the altitude hold button on the flight guidance panel. With manual capture of altitude, using the altitude hold button, a vertical speed of 1,100 feet per minute, and the "rough air" feature of the simulator activated, the rate of descent was simulated. When the altitude hold button was engaged, the simulator continued to descend an additional 120 to 130 feet. The simulator then recovered, or climbed back up to, the selected altitude. In simulated smooth air, the simulator recovered with less total loss of altitude. For example, with rate of descent of 700 feet per minute, when altitude hold was engaged, the loss and recovery took about 50 feet. Similarly, with a rate of descent of 1,100 feet per minute, a recovery from about 80 feet below the desired altitude occurred. 1.16.1.3 Windshear Warning System The airplane was equipped with a Honeywell Standard Windshear System, which is designed to provide warnings to the flightcrew in the event of a potentially hazardous windshear condition. The computer activates yellow caution lights if it detects an increasing performance windshear, and it activates red warning lights and an aural "WINDSHEAR, WINDSHEAR, WINDSHEAR" warning if it detects a decreasing

37 performance windshear. A successful self-test of the windshear warning system was performed in accordance with the AAL Maintenance Manual.20 1.16.1.4 Ground Proximity Warning System The airplane was equipped with an Allied-Signal Mark II Ground Proximity Warning System (GPWS) computer. This computer utilizes a radio altimeter21 and barometric altitude rate information to determine proximity with the ground. The GPWS is designed to activate electronically produced word warnings and visual light warnings to warn the flightcrew when a hazard is detected. The system operates in several modes to provide warnings for various unsafe flight conditions. These modes include: excessive descent rate, excessive terrain closure rate, descent after takeoff, descent in wrong configuration, and excessive deviation below the glideslope. During a non-precision approach, with the airplane configured for landing (gear and flaps down), the only mode available is excessive rate of descent warning. In this mode, the computer monitors barometric sink rate beginning with the airplane descending below 2,450 feet (agl). If the sink rate exceeds a threshold value, a "SINK RATE" aural warning is issued. At approximately 200 feet (agl), the threshold value is approximately 1,200 feet per minute. According to the CVR transcript, the "SINK RATE" warning is heard 4 seconds before the sound of the first impact with the trees. A ground proximity warning system (GPWS) ground test was performed according to the AAL Maintenance Manual. The test was successfully completed, and all annunciations and aural warnings operated normally. According to Allied-Signal, development is underway on an upgraded GPWS system known as Enhanced GPWS. This system

20During the accident sequence, the windshear warning system did not activate until just after the ridge line tree strike occurred. 21A radio altimeter, sometimes called a radar altimeter, does not require accurate barometric pressure settings, but rather gives readouts of height above the ground by time-varying frequency and by measuring differences in frequency of received waves, proportional to time and height.

38 incorporates aircraft position data (from the flight management system) with a self-contained terrain database to offer enhanced protection from descent into terrain. On a non-precision approach, the enhanced GPWS can anticipate the terrain features within a 25 mile radius of the airport and offer warnings to protect against premature descent into terrain, regardless of airplane configuration. This system is expected to be certified by the FAA for use in aircraft in 1996. 1.16.1.5 Other Systems The follow-up rod that drives the left flap position sensor was bent and damaged. It was not possible to determine how this damage would have affected the flap position indication. During the initial on-scene investigation, the flap track indicators showed that the flaps were in the 40 degree position. No anomalies were seen during flight control cable tension tests. All six fuel boost pumps were tested and found to operate normally. A DME functional/accuracy test was performed, and no problems were noted. 1.17 Organizational and Management Information 1.17.1 American Airlines - General 1.17.1.1 Pilot Training The American Airlines McDonnell Douglas MD-80 fleet is in applicant status for the Advanced Qualification Program (AQP).22 Accordingly, pending development/completion of the AQP, pilot qualification, including training and certification, is conducted under the terms of Exemption Number 5950, which grants relief from some of the traditional pilot qualification requirements of 14 CFR Part 121. For example, the FAA grants permission to perform a single visit training (SVT) session, which is once per year training, to any carrier that applies to develop an AQP, while the AQP development is in progress (see Section 1.17.1.2). The AQP

22The Advanced Qualification Program is described in Special Federal Aviation Regulation (SFAR) 58. The purpose of the AQP is to “provide for approval of an alternate method for qualifying, training, certifying, and otherwise ensuring competency of crewmembers, aircraft dispatchers, other operations personnel, instructors, and evaluators who are required to be trained or qualified under Parts 121 and 135 of the FAR....”

39 development process may take 2 or more years to complete for each airplane type. American Airlines applied for approval of an AQP in April 1994 for SVT on all its airplanes, beginning with the Fokker F-100. Once the AQP has been approved by the FAA, pilot qualification will be conducted in accordance with the AQP requirements of SFAR Number 58. At that time, Exemption Number 5950 will no longer be applicable. 1.17.1.2 American Airlines Single Visit Training Single Visit Training differs from traditional FAR Part 121 training and checking requirements in that it is conducted annually for captains and first officers rather than bi-annually. A training session every 6 months, as opposed to every 12 months under SVT, is conducted only for initial upgrade captains, captains who fail a SVT proficiency check, or captains who require additional training. Single visit training consists of on- site ground and flight training/checking for a 4- or 5-day period. Two days of the recurrent ground training cover security, crew resource management, aircraft systems, performance and emergency equipment review. Two 4-hour simulator sessions are scheduled with specified briefing and debriefing periods. The first simulator is a practice session overseen by a simulator pilot to review and practice required maneuvers. The second 4-hour simulator session, overseen by a check airman, includes a recurrent line operated simulation (LOS)23 period followed by an annual proficiency check for both flight crewmembers. The FAA approved Exemption 5950 for AAL based upon a SVT training plan with certain conditions and limitations. One of the limitations imposed upon AAL is that the airline must include a pretraining "first-look" evaluation that addresses at least a core set of Part 121, Appendix F,24 material prior to the repeated execution of any such core set items in a simulator or training device. The maneuvers, tasks, or procedures are those most likely to be sensitive to loss of proficiency because of infrequency of

23Line operational simulation (LOS) is the FAA’s revised terminology for training that was formerly known as line oriented flight training (LOFT), and includes special purpose orientation training and line operational evaluation. The revised definition (FAR Part 142.3) was adopted on May 23, 1996, and became effective on August 1, 1996. 24Appendix F sets forth maneuvers and procedures required to be demonstrated in pilot proficiency checks.

40 practice. Data on the first look maneuvers is provided to the FAA on a de- identified basis. The MD-80 Worksheet, dated February 1995, included four items designated as "first-look" maneuvers. One of the first-look maneuvers is the non-precision approach. Further, AAL requires this non-precision approach to be included in the first-look evaluation in all the fleet training programs that AAL operates. The captain completed American Airlines 4-day SVT on August 21, 1995. The first officer completed SVT training on August 19, 1995. Both flight crewmembers received satisfactory performance reports during their training. 1.17.1.3 Company Altimeter Procedures AAL is the only United States airline that uses the QFE (height above field elevation) altimeter setting system during the takeoff, departure, approach, and landing phases of flight.25 American Airlines procedures require flightcrews to set their primary altimeters so that they read altitudes above the elevation of the airport they are departing from or at which they are arriving, while the standby altimeter continues to show altitude above sea level. Other U.S. airlines use the QNH (height above sea level) altimeter setting system during all flight phases. These airlines set all their altimeters to show altitudes above sea level at the departure and arrival airports. During the cruise phase of flight, all airlines use the QNH altimeter setting method. The details of American Airlines QFE altimeter setting methodology follow. During a descent, AAL procedures call for the flightcrew to set the proper QNH altimeter settings in both the primary altimeters (the captain’s and the first officer’s) and the standby altimeter located on the center instrument panel. This is to be accomplished when passing down through the flight level 180 (in the United States). After reaching the AAL "changeover altitude" (10,000 feet), the flightcrew is to set the captain's and first officer's altimeters to a QFE setting so that they read height above

25The former Eastern Airlines also used the system in its operations. Currently, several foreign carriers use the system in international operations. There are certain airports within the AAL system with very high field elevations that require the pilot to use only QNH (height above sea level) altimeter settings during approaches. Mechanical limitations within the altimeters preclude the adjustment of the altimeters to satisfy QFE requirements.

41 destination field elevation. As a cross-check to ensure that the company- provided QFE setting is accurate, a comparison should then be made between the altitude shown on the flightcrew’s altimeters and that shown on the third standby altimeter containing the QNH (height above sea level) setting. The difference, in feet, between the flightcrew's altimeters and the standby altimeter should equal the published elevation of the airport of intended landing. During descent and prior to arrival at the final approach fix (FAF), AAL procedures require the flightcrew to use the standby altimeter with the QNH setting for intermediate air traffic control or approach plate directed level-offs. According to AAL procedures, upon arrival at the FAF, the flightcrew should begin using their primary altimeters which are set QFE. If a missed approach is commenced, the flightcrew should revert to the standby altimeter (QNH) for altimeter information. After landing, AAL flightcrews’ primary altimeters should read zero feet. Flightcrews of airlines that use the QNH system, on the other hand, should see altimeters that read the field elevation of the airport after landing. According to many AAL flightcrews, one advantage of the QFE system over the QNH system is the standardization of approaches with regard to altitudes seen by flightcrews from the FAF until landing. This is especially true, they said, during ILS approaches that usually have minimum altitudes of 200 feet above the ground. Most approaches flown by AAL flightcrews are ILS approaches. Regardless of the field elevation above sea level, flightcrews become accustomed to using 200 feet above the ground as a minimum altitude. Each approach, no matter what the airport elevation, will appear the same to flightcrews, concerning minimum altitude. According to the AAL DC-9 Operating Manual, the following mandatory altitude callouts are to be made by the pilot not flying during an approach to land: 1. 1,000 feet above field level 2. 100 feet above minimum descent altitude (MDA) 3. MDA

42 The first officer, who was the pilot not landing, called out: “There’s a thousand feet” at 0055:06 The flight recorders revealed that this one thousand foot callout was made when the primary altimeters indicated that the aircraft was about 1,140 feet above the field elevation, based upon the altimeter setting of 29.23 (QFE). The CVR does not reflect a callout at 100 feet above MDA. 1.17.1.4 Actions of American Airlines Since the Accident On December 20, 1995, 38 days after the accident involving AAL flight 1572, AAL flight 965, a regularly scheduled passenger flight from Miami, Florida, to Cali, Colombia, struck terrain near Buga, Columbia, 33 miles northeast of the Cali (CLO) VOR navigation aid, in night visual meteorological conditions, during a descent for a landing at Cali. The airplane was destroyed, and 159 of 163 passengers and crewmembers aboard lost their lives. The Colombian civil aviation authority determined that the probable causes of that accident were:

1. The flightcrew’s failure to adequately plan and execute

the approach to runway 19 at [the airport] and their inadequate use of automation.

Failure of the flightcrew to discontinue the approach into Cali, despite numerous cues alerting them of the inadvisability of continuing the approach.

The lack of situational awareness of the flightcrew regarding vertical navigation, proximity to terrain, and the relative location of critical radio aids.

Failure of the flightcrew to revert to basic radio navigation at the time when the FMS-assisted navigation became confusing and demanded an excessive workload in a critical phase of flight. Contributing to the cause of the accident were:

The flightcrew’s ongoing efforts to expedite their approach and landing in order to avoid potential delays.

43

1. The flightcrew’s execution of the GPWS escape maneuver

while the speedbrakes remained deployed.

FMS logic that dropped all intermediate fixes from the display(s) in the event of execution of a direct routing.

FMS-generated navigational information that used a different naming convention from that published in navigational charts.26

Discussions between FAA and AAL officials in early January 1996 led to AAL’s formation of a Safety Assessment Program to examine seven critical phases of American’s operations. AAL plans to have quarterly progress meetings and issue a final report in January 1997. AAL also implemented immediate actions after the accident that included raising the:

1. minimum descent altitude and visibility requirements for

all non-precision approaches by 100 feet and 1/2 mile, respectively,27

visibility minima on all NDB approaches by 1 statute mile, and

the ceiling of the “sterile cockpit” from above 10,000 feet to above 25,000 feet in Latin American airspace. On January 19, 1996, AAL distributed to all of its DC-9 captains and first officers DC-9 Operating Manual Bulletin No. DC-9-2 (in the form of additional checklist pages) entitled “Non-Precision Approach Crew Coordination Procedures.” The bulletin states, in part: Despite its name a non-precision approach must be executed with exacting precision.

26Aircraft Accident Report, “Controlled Flight Into Terrain, American Airlines Flight 965, Boeing 757-223, N651AA, Near Cali, Colombia, December 20, 1995.” Aeronautica Civil of the Republic of Colombia. 27These restrictions have since been eliminated following the completion of other phases of the Safety Assessment Program.

44 MDAs and step-down altitudes are limits. Any altitude level- off variation must be above the MDA or step-down altitude rather than below [italics in original bulletin]. The primary attention of both pilots will be directed to the level-off at the step-down altitude or MDA. After level-off at the MDA, the pilot-not-flying will direct primary attention outside the airplane and call out visual references in the sequence required. AAL’s examination of its operations was to be carried out through seven assessment teams, each with representatives of the airline, the pilot’s union and the FAA. The seven areas addressed by these teams are:

1. Human factors issues pertaining to the recent accidents,

including approach charts, procedures, and training;

1. Division-specific items, dealing with issues relevant to

unique geographic features;

1. Advanced technology relating to flight management

system (FMS) and GPWS modifications;

1. Operations structures and procedures, including corporate

culture or organizational influences on flight operations;

1. Flight Operations Quality Assurance (FOQA), and

evaluation of its implementation in conjunction with AAL’s “Airline Safety Action Partnership” (ASAP) program to improve training in general for feedback into the Advanced Qualification Program (AQP);

1. Confidential reporting system data analyses; specifically,

examination of all available information, and assess any new and useful techniques from other operators for accident prevention; and

45

1. Pilot communications, including visits by the Senior Vice

President, Flight Operations, and the President, APA, to meet all pilots and flight managers at all crew bases. In addition, AAL established a Controlled Flight Into Terrain (CFIT) Task Force and a Non-Precision Approach Working Group. It also inserted specific guidance on flightcrew response to CFIT scenarios in the Advanced Aircraft Maneuvering Program. All AAL simulators now have specific terrain profiles in which flightcrews will receive GPWS terrain warnings and are expected to extract maximum aircraft performance in recovery. The airline briefed the Safety Board at the 6 month or midpoint of its Safety Assessment Program and has reported that the assessment program’s report is expected to be completed on schedule in January 1997. 1.17.2 FAA Surveillance of AAL Flight Operations The FAA conducted a National Aviation Safety Inspection Program (NASIP) inspection of AAL from August 21 through September 1,

1. Both airworthiness and operations were inspected. One area of

potential deficiency noted involved operations training. Specifically, it was found that AAL broke up crew pairs in the SVT training program, contrary to the terms of Exemption 5950 and the AAL Approved Training Manual. A crew pair consists of a captain and a first officer. Both documents state that pairs of crewmembers should remain together as much as possible through all phases of training and checking. During the NASIP inspection, 35 cockpit en route inspections were performed. Those en route inspections resulted in no findings concerning flight operations. The captain had been observed by FAA flight inspectors during four en route inspections. FAA records indicated that the captain does not have an accident/incident or violation history. There is no record of FAA en route inspections for the first officer. FAA records indicated that the first officer does not have an accident/incident or violation history.

46 1.17.3 FAA Instrument Approach Design Procedures In the past, the FAA instrument procedures development personnel were collocated with Flight Inspection Area Office (FIAO) personnel, and, in fact, served as copilots on FIAO flight inspection missions. Following the loss of a Beech Super King Air 300/F flight inspection airplane near Front Royal, Virginia, on October 26, 1993, the Safety Board issued Safety Recommendation A-93-165 to the FAA on November 24, 1993. Subsequently, the procedures development program was separated from the flight operations inspection program. Safety Recommendation A-93-165 asked the FAA to: Direct the Office of Aviation System Standards to evaluate the recommendations in the 1989 System Safety Survey relating to the second-in-command responsibilities and flying proficiency and to establish duties as appropriate. The Administrator responded to this recommendation by stating: On February 5, 1995, all procedures development duties were removed from the second-in-command (SIC) position description, and SIC duties are restricted to flying responsibilities. FAA Terminal Instrument Procedures (TERPS) Handbook, FAA Order 8260.3B, contains standardized methods for designing instrument flight procedures for non-precision approaches. The development and final approval of a non-precision instrument approach is accomplished in several steps. First, the basic procedure is developed by the National Flight Procedures Office in Washington, D.C. (AVN-100) in coordination with the nearest regional Flight Procedures Office (FPO) to the airport where the approach is to be used. Once developed, the procedure is sent to the Technical Support Branch, AVN-160, for a quality control review. After the review, the procedure is sent to the Flight Inspection Operations Division, AVN-200, through the FIAOs, to ensure that the descents and turns on the approach are within realistic flight inspection tolerances. AVN-200 is also responsible for ensuring that obstacles marked on the chart are actually where they are depicted, and that the obstacles are as high as the chart depicts.

47 According to the FAA, the FIAO is responsible for final approval of instrument flight procedures by ensuring that: (1) Data used to develop the instrument approach procedure was correct. (2) The instrument approach procedure was developed in accordance with FAA Order 8260.3B TERPS and Order 8260.19 [C], Flight Procedures and Airspace, and other appropriate directives.… In reference to obstacle data accuracy, paragraph 270 of FAA Order 8260.19 states: The evaluations can provide accurate, consistent, and meaningful results and determinations only if FIAO and regional flight procedures specialists apply the same rules, criteria, and processes during development, review, and revision phases. The National Flight Procedures Office (AVN-100) uses maps, charts, surveys and mathematical data to develop the basic approach procedure. The FIAOs under AVN-200 use airplanes, theodolites (optical devices to measure angles and thus heights), and other direct measuring equipment for obstacle height verification. The Atlantic City, New Jersey, Flight Inspection Area Office (FIAO), initially verified the height of the obstacles on the BDL VOR runway 15 approach as it was being developed. This office also rechecked the obstacles after this accident. On both occasions, the FIAO determined that the approach was “obstacle free.” 1.17.3.1 Terminal Instrument Procedures (TERPS) and the VOR Approach to Runway 15 The instrument approach to runway 15 was first published and became effective on February 9, 1989. The controlling obstacle in the final segment (the highest obstacle that could affect the approach) was 739 feet of

48 terrain and an additional 8028 feet tree height, for a total height of 819 feet msl. This is the ridge line and trees that the flight 1572 initially struck. Amendment 1 to the procedure was effective on the same date, February 9, 1989. The amendment revised the missed approach point (MAP) from a point defined by time and distance to one based upon the BDL VOR. Amendment 2, effective on July 20, 1995, included several changes to the procedure. One change included the addition of a visual descent point (VDP) to the approach. A VDP is defined as a point on the final approach from which normal descent from the MDA to the runway touchdown point may be commenced, provided that visual reference is established. The VDP was 3.1 nautical miles from the BDL VOR, which is 2.86 nautical miles from the threshold of the runway. On April 8, 1994, the Air Line Pilots Association (ALPA) sent a letter to the Manager of the Flight Procedures Review Branch in the FAA’s New England Region. In part, the letter stated that several pilots had experienced GPWS warnings while descending from the 5 nautical mile FAF to the 3.1 nautical mile VDP. ALPA stated that the steep nose-down attitude might have been exacerbated by the close proximity in that segment of the ridge line struck by flight 1572. In the summer of 1994, as a result of ALPA’s concerns, an analysis of the VDP was undertaken by the FAA. The FAA procedures analyst indicated that a “no-VASI” standard (3 degree descent angle) had been used in the VDP placement, thereby placing the VDP at 3.1 nautical miles from the VOR. This is 0.6 nautical mile farther away than the VDP would have been located using a “with-VASI” standard (3.5 degree descent angle). Because a 3.5 degree VASI was already on runway 15 at BDL, it was determined that the VDP located according to a no-VASI 3 degree descent standard should not have been published, and it was removed by Amendment

28Although FAA standards specify 60 feet as an acceptable tree allowance in the Connecticut area, the procedures specialist stated that he retained the original 80 foot value (used when the approach was first designed) to provide an added safety measure. It could not be determined why the 80 foot value was used when the approach was first designed. The exact height of the trees struck by the airplane could not be determined because the tops were torn into many small pieces.

49 2A. Amendment 2A was the latest amendment to the procedure, and it was the chart used by the accident flightcrew. 1.17.3.2 Visual Descent Point Clearances According to the TERPS Handbook 8260.3B, paragraph 251a, 1) where a VASI is installed, the VDP shall be located at the point where the lowest VASI glideslope intersects the lowest MDA. The Handbook also states, “Do not establish a VDP if penetrations of the VDP surface exist....” Based on the downwind bar of the runway 15 VASI at 3.0 degrees, a VDP would be placed at around 2.5 DME. TERPS criteria also require a 2 degree obstacle clearance surface for the installation of the VDP. On June 26, 1996, as a result of this accident, the Safety Board made the following recommendations to the FAA: A-96-31 Publish a visual descent point (VDP) for runway 15 in the appropriate location, and ensure that the VDP is present on all VOR runway 15 instrument approach charts used by pilots flying into Bradley International Airport (BDL). A-96-32 If the inclusion of a VDP on approach charts to runway 15 is not possible due to obstacles, because charting methodology rather than empirical measurement was used to determine obstacle clearance, then ensure that a warning about the 3.5- degree glideslope and the high terrain along the approach path is placed on VOR runway 15 instrument approach charts for BDL, or make such a warning a permanent Notice to Airmen (NOTAM) for BDL, or use some other means to disseminate such a warning on a permanent basis. On September 4, 1996, the FAA responded favorably to Safety Recommendation A-96-31 by stating that: The Federal Aviation Administration (FAA) agrees with this safety recommendation and on August 15, 1996, published a visual descent point (VDP) at 2.3 nautical miles (BDL 2.4

50 DME) on the VOR RWY 15 instrument approach procedure for Windsor Locks/Bradley International Airport, Connecticut. Because of this response, Safety Recommendation A-96-31 is being classified “Closed--Acceptable Action,” and A-96-32 is being classified “Closed--No Longer Applicable.” 1.17.3.3 Required Obstacle Clearance for VOR Runway 15 According to TERPS Handbook, FAA Order 8260.3B, the required obstacle clearance (ROC) for VOR approaches with final approach fixes is 250 feet rounded to the next higher 20-foot increment. Using this criteria, the 819 foot msl ridge line results in 1,080 feet msl ROC (908 feet agl). Because no adjustments were deemed necessary by the FAA for the VOR runway 15 approach, this number is also used as the MDA. 1.17.3.4 Precipitous Terrain Approach Adjustments The forward of TERPS Handbook, FAA Order 8260.3B, states: This publication prescribes standardized methods for use in designing instrument flight procedures….These criteria do not relieve procedures specialists and supervisory personnel from exercising initiative or taking appropriate action in recognizing both the capabilities and limitations of aircraft and navigational aid performance. Paragraph 323 of that handbook pertains to minimums’ adjustments. Paragraph 323 (a) states that consideration should be given to induced altimeter errors and pilot control problems in precipitous terrain that may result when winds are 20 knots or more over such terrain. TERPS Handbook, FAA Order 8260.3B does not, however, define precipitous terrain. According to the FAA, the flight procedures specialists do not automatically add adjustments to ROCs for precipitous terrain. Rather, they rely on flight inspection reports and user inputs. According to the BDL air traffic control tower personnel, there have never been any complaints or comments regarding the effect of the ridge line on altimeters or its effect upon

51 airplane control on the approach course to runway 15. The FAA did not adjust the BDL VOR runway 15 approach MDA for precipitous terrain. 1.17.3.5 VASI Obstacle Clearances BDL has a VASI-4 system for runway 15. The upwind bar is aimed at 3.5 degrees and the downwind bar is aimed at 3.0 degrees. FAA Order 6850.2A, paragraph 301b, states that the VASI should have a clear 2 degree obstacle clearance surface originating at the VASI downwind bar and extending to 4 nautical miles. In 1987, the FAA’s New England Region, Airways Facilities Branch, had the obstacle clearance surface checked by survey and it was validated “clear” of obstacles. On November 13, 1995, the day after the accident, a flight inspection of the approach was conducted by the Atlantic City Flight Inspection Area Office. The flight inspection form reports that the VASI was checked satisfactory for obstacle clearances. During the initial development of the BDL VOR runway 15 approach, the procedures specialist that designed the approach determined, based upon charts, that a 55-foot obstruction existed within the required obstacle clearance plane of the VASI. In June, 1996, the FAA responded to Safety Board requests about obstacle clearance relative to the VASI, indicating that the 819-foot obstruction on the ridge line penetrated the required 2 degree clearance surface by 55 feet. 1.18 Additional Information 1.18.1 Air Traffic Control Aspects The BDL TRACON provides separation and sequencing to arriving and departing airplanes at Bradley International Airport. The BDL tower controls takeoffs and landings at BDL. The accident occurred during a late evening shift. The normal staffing at that time (and the actual staffing at the time of the accident) for BDL TRACON is one area supervisor and one full performance level (FPL) radar controller. The control tower cab is normally staffed with one FPL controller on late evening shifts.

52 1.18.1.1 The TRACON Supervisor in the Tower Cab Because of high winds on the night of the accident, one of the windows in the BDL air traffic control tower began to flex and water began to leak inside the tower cab. A decision was made to temporarily close the tower and the TRACON Area Supervisor in Charge made notifications of tower closure to the New England Communications Center and airport management. He then asked the Bridgeport automated flight service station (AFSS) to issue a NOTAM [Notice to Airmen] concerning tower closure. He then ensured that local and ground control frequencies, normally handled by local and ground controllers in the tower, were being monitored in the TRACON. The TRACON supervisor then escorted the airport carpenters to the tower cab to inspect the windows, and he saw that the window closest to the local control position appeared to be bowing more than the others. He noted water at the bottom seal. The carpenters determined that the window could be fixed and then departed the tower. The TRACON supervisor remained in the tower cab, and then told the approach controller, located in the radar room beneath the tower cab, that if he wanted to put flight 1572 on the tower frequency it would be fine because "I'm up here and this way if I need to tell him anything, I can." The TRACON controller and the TRACON supervisor in the tower were not providing air traffic control services to other airplanes at the time. The approach controller then told American Airlines flight 1572 that there was “someone in the tower,” that while it was “not really officially open,” the flight could change to tower frequency. Flight 1572 proceeded to do so. At 0053:27, flight 1572 transmitted, "Hey, tower American Airlines flight 1572 we're on a six-mile final for runway one five." The TRACON supervisor in the tower cab transmitted to flight 1572, "landing is at your discretion, sir. The winds 170 at 25, peak gusts 40, and ah the runway does appear clear, you can land and taxi to the gate at your discretion." At 0054:51, the TRACON supervisor transmitted:

53 Windshear alert. Uh, centerfield one seven zero at two five. The uh, northeast boundary, one seven zero at two four, one niner zero at twelve at the southeast boundary. Flight 1572 responded with, “Copy.” About 1 minute later, at 0056:02, flight 1572 transmitted, “Tower, call for emergency equipment..., we’re going down on the runway.” At 0056:25, the TRACON supervisor issued the wind as 170 degrees at 22 knots. Flight 1572 then transmitted again to call for emergency equipment, and the supervisor stated that the equipment was inbound. About 10 seconds later the airplane touched down. The TRACON supervisor had been a full performance level tower controller 3 years previously, and he also possessed a current multiengine commercial pilot's license with an instrument rating, and a flight instructor's certificate. His total flying time was about 670 hours. 1.18.1.2 TRACON Altimeter Setting Transmissions The controllers in the tower and the TRACON obtain current altimeter information from the DASI (Digital Altimeter Setting Indicator). The DASI system is a self-contained instrument located in the tower’s equipment room, and it transmits the current altimeter to readouts located in both the tower and TRACON. In turn, the reading on the DASI is used to update the automated radar terminal system (ARTS) so that the altitude readouts on the controllers’ radar displays are correct. The ARTS system always reads in msl. According to air traffic control procedures in the ATC Handbook, FAA Order 7110.65, the altimeter setting should be transmitted to the flight upon initial radio contact. The ARTS record of keyboard entries shows that at 0021:14, the approach controller entered 29.38 inches Hg. in the ARTS systems area of the computer. The record of entries further shows that at 0044:34 he entered 29.34 inches Hg., and at 0048:07, he entered 29.36 inches Hg. The atmospheric pressure continued to drop and was calculated to be 29.24 inches Hg. at the time of the accident. Boston ARTCC issued flight 1572 an altimeter setting of 29.40 inches Hg. at 0033:30, about 21 minutes prior to the tree strike, and approximately 11 minutes before handing the flight off to the BDL TRACON.

54 This was the last altimeter setting issued to the flight from an air traffic controller. The TRACON approach controller did not issue a current altimeter setting to flight 1572 upon initial radio contact with the flight at 0043:49. At that time, the DASI readout indicated a setting of 29.38 inches Hg. A review of the BDL Facility Status Logs from October 1, 1995, through November 11, 1995, revealed no reports of outages or complaints concerning the tower’s DASI. 1.18.1.3 Minimum Safe Altitude Warning (MSAW) MSAW is a computer program to warn a controller when an airplane descends or will descend below a predetermined altitude. The MSAW at BDL was programmed to provide an alarm if the aircraft’s Mode C transponder transmitted two signals when the airplane was at or below 1,050 feet msl. However, if the radar does not pick up the aircraft’s mode C transponder signal, the program cannot function. The BDL approach control radar system produced an MSAW alarm for flight 1572 at 0055:39. The radar tracking data showed that when this alarm was produced, the aircraft was at 800 feet msl and the aircraft had already struck the trees. FAA personnel stated that under normal circumstances, the MSAW should have produced an audible alarm at that time in the tower cab, and a visual alarm should have occurred on the radar display and on the DBRITE [bright radar indicator tower equipment] in the radar room and tower cab. Radar tracking data showed no radar "hits" from flight 1572’s mode C transponder between 0055:23 and 0055:32, and also none between 0055:05 and 0055:23. The radar antenna produces returns about every 4.5 seconds. FAA personnel reported that the reason for the absence of these hits was the shielding of the airplane from the radar by the ridge line. FAA technicians later explained that if the radar could not "paint" the airplane, the MSAW computer program could not warn the controller that the airplane was at an unsafe altitude. According to FAA equipment design personnel, if a steady stream of Mode C information had been available to the computer, the MSAW alarm would have sounded as soon as the aircraft descended past 1,100 feet msl. They indicated that on final approach, a standardized set of

55 MSAW parameters is used, not taking into account obstacles such as the ridge. BDL FAA personnel said that in an attempt to improve radar coverage prior to the accident, they had changed or optimized the tilt on the radar antenna, but that the ridge still obstructed radar coverage. 1.18.2 Industry Actions to Improve the Safety of Non-precision Approaches 1.18.2.1 Approach Plate Terrain Depictions The Safety Board reviewed several other airlines’ BDL VOR runway 15 approach plate terrain depictions. This review revealed that the information provided to the flightcrews varied among the carriers. The British Airways approach chart for the BDL VOR to runway 15 (published by Aerad) had terrain contours depicted in color. The ridge line and the associated 819 foot obstruction was depicted on the approach chart. The Delta Air Lines approach plate for runway 15 included an additional information sheet depicting terrain along the approach from MISTR to DILLN and the airport. The 819 foot obstruction and the ridge line were depicted on the supplement. The other approach charts reviewed by the Safety Board were similar to the one used by AAL in that they contained only a notation of the 819 foot obstacle, but they did not depict the ridge line. 1.18.2.2 Non-precision Approach Flight Procedures To reduce the glidepath variability that may occur in non- precision approaches (as opposed to precision approaches with constant glidepaths) some airlines are devising methods to fly non-precision approaches in ways that more closely resemble precision approaches. In airplanes that have modern flight management system suites, some airlines are recommending that their flightcrews fly a stabilized approach with a constant glidepath to a point near the MDA. In other words, flightcrews are to overfly intermediate level-off points at higher altitudes, while maintaining a stable rate of descent, rather than fly down to intermediate level-off points, level off, then descend again to reach the next

56 lowest altitude authorized by the approach procedure. To ensure that flightcrews do not descend below the MDA using the new stabilized approach technique, one airline adds an additional 50 foot safety buffer to the MDA to allow the airplane to "round out" its descent above the actual MDA before a missed approach climb is established. 1.18.2.3 Controlled Flight Into Terrain (CFIT) Training Aids The Boeing Commercial Airplane Group, as part of a larger aviation industry effort to prevent CFIT accidents, has produced a five-part CFIT Education and Training Aid for use by all operators. Section One of the aid gives top managers of airlines a broad overview of the CFIT problem and possible solutions. Section Two, a Decision Maker’s Guide, describes areas of line airline operations, whereby those who regulate and lead the aviation industry can aim their efforts toward CFIT elimination. Section Three is an Operator’s Guide describing specific causal factors of CFIT accidents, traps in which flightcrews can find themselves, and specific in-flight escape maneuvers. Section Four describes a model CFIT education program for an airline, and Section Five provides further background information on the CFIT problem via selected readings and topical accident and incident information. The Flight Safety Foundation (FSF)-sponsored CFIT Task Force has developed a CFIT checklist to aid in the avoidance of CFIT accidents. This checklist was created to identify the degree of potential for a CFIT accident prior to each flight. The checklist user evaluates risk factors associated with a particular flight by assessing the relative danger of each risk factor and the safety-enhancing aspects of the proposed flight in a numerical fashion. The checklist is divided into two diagnostic parts: CFIT Risk Assessment (includes negative destination CFIT risk factors such as VOR/DME approaches, airports near mountainous terrain, and radar coverage limited by terrain masking, and risk multipliers such as IMC [instrument meteorological conditions] weather and long crew duty days). CFIT Risk Reduction Factors (includes positive company management traits and the availability of CFIT training programs).

57 Within the highest set of CFIT risk factors, according to the FSF, are flying at night in IMC conditions, and using the autopilot in the vertical speed mode close to the ground. 1.18.2.4 Previous Recommendations on CFIT The Safety Board has made many safety recommendations to the FAA concerning CFIT accidents and GPWS during the last 25 years. The first recommendation, A-71-053, concerned a Southern Airways DC-9 that struck power lines on approach to the Gulfport, Mississippi Municipal Airport. The FAA responded that existing instrumentation and procedures were safe and adequate to prevent these accidents provided cockpit disciplines were maintained. However, CFIT accidents continued to occur, and in 1975 the FAA made GPWS mandatory on Part 121 airplanes. In 1986 the Safety Board asked FAA to extend GPWS coverage to Part 135 operations. FAA studied the issue, and made GPWS mandatory on Part 135 turbine-powered airplanes with 10 or more passenger seats in 1994. The Board has also issued numerous recommendations on improving GPWS equipment and flightcrew training over the years. The catastrophic losses of life and property from CFIT accidents have not been restricted to Parts 121 and 135. In 1995, the Board recommended that coverage be extended to all turbojet aircraft with 6 or more passenger seats, including Part 91 operations. The Department of Transportation (DOT) recently released a study29 for the FAA on Part 91 turbine-powered aircraft that shows a “significant potential for CFIT accident prevention in the aircraft fleet studied.” FAA staff have informed Safety Board staff that the FAA is preparing a notice of proposed rulemaking (NPRM) that would require enhanced GPWS on all Part 91, 121, and 135 aircraft that are turbine powered with 6 or more passenger seats.

29DOT report, “Investigation of Controlled Flight Into Terrain, Aircraft Accidents Involving Turbine-Powered Aircraft with Six or More Passenger Seats Flying Under FAR Part 91 Flight Rules and the Potential for Their Prevention by Ground Proximity Warning Systems,” Project Memorandum #DOT-TSC-FA6D1-91-01, by Robert O. Phillips, March, 1996.

58 After the investigation of the AAL Cali, Columbia, accident, the Aeronautica Civil of the Republic of Colombia made the following recommendations to the FAA: Require that all approach and navigation charts used in aviation graphically portray the presence of terrain that is located near airports or flightpaths. Encourage manufacturers to develop and validate methods to present accurate terrain information on flight displays as part of a system of early ground proximity warning. (Enhanced GPWS) Develop a mandatory CFIT training program that includes realistic simulator exercises that are comparable to the successful windshear and rejected takeoff training programs. Evaluate the CFIT escape procedures of air carriers operating transport category aircraft to ensure that the procedures provide for the extraction of maximum escape performance, and ensure that those procedures are placed in operating sections of the approved operations manuals. The Aeronautica Civil of the Republic of Colombia made the following CFIT recommendation to the International Civil Aviation Organization: Evaluate and consider the adoption of the recommendations produced by the CFIT Task Force that have been created under the initiative of the Flight Safety Foundation. Following the investigation of the AAL Cali, Columbia, accident, the Safety Board made the following recommendations to the FAA on October 16, 1996:

59 A-96-93 Evaluate the terrain avoidance procedures of air carriers operating transport-category aircraft to ensure that the procedures provide for the extraction of maximum escape performance and ensure that those procedures are placed in procedural sections of the approved operations manuals. A-96-94 Require that all transport-category aircraft present pilots with angle-of-attack information in a visual format, and that all air carriers train their pilots to use the information to obtain maximum possible airplane climb performance. A-96-95 Develop a controlled flight into terrain training program that includes realistic simulator exercises comparable to the successful windshear and rejected takeoff training programs and make training in such a program mandatory for all pilots operating under 14 CFR Part 121. A-96-98 Develop and implement standards to portray instrument approach criteria, including terminal environment information and navigational aids on FMS-generated displays, that match, as closely as possible, the corresponding information on instrument approach charts. A-96-101 Examine the effectiveness of the enhanced ground proximity warning equipment and, if found effective, require all transport-category aircraft to be equipped with enhanced ground proximity warning equipment that provides pilots with an early warning of terrain. A-96-102 Require that all approach and navigation charts graphically present terrain information.

60 A-96-106 Revise Advisory Circular 120-51B to include specific guidance on methods to effectively train pilots to recognize cues that indicate that they have not obtained situational awareness, and provide effective measures to obtain that awareness.

61

1. ANALYSIS
2. 1

General The flightcrew had the proper FAA airmen certifications and were qualified in accordance with applicable regulations and company requirements. They received the proper amount of crew rest before the accident flight and did not appear to be under unusual psychological pressure. The airplane was properly fueled; passengers and cargo were loaded in accordance with AAL weight and balance requirements. The flight was released in accordance with AAL dispatch procedures. The weather at BDL was at or above the required minimums for landing, and included overcast clouds, visibility restricted by moderate rain, and strong, gusty wind conditions. All components of the VOR runway 15 instrument approach were operating normally. No malfunctions of the visual approach slope indicator (VASI) for runway 15 were reported by the airport. There was no evidence of a malfunction of the pitot-static system, the autopilot system, the ground proximity warning system, the windshear warning system, or any flight control system, that could have contributed to this accident. In addition, no structural failures occurred prior to the airplane striking trees. According to the FDR and postaccident examination, the left engine rolled back to a low power level shortly after the ridge line tree impact due to low pressure compressor damage. The right engine continued to operate at a high power setting until a fire burned away the high pressure compressor airfoils. Both engines were operating normally prior to the tree strike. 2.2. Adequacy of Weather Information 2.2.1 NWS SIGMETs There were a number of NWS SIGMETs in effect pertinent to the route of flight 1572. These SIGMETs were not included in the flight release or provided to the flightcrew while en route to BDL by American Airlines dispatch. However, the flight release of flight 1572 included an American Airlines Terminal SIGMEC for moderate turbulence, moderate icing, and low level windshear for the BDL area. Severe icing or turbulence

62 was not forecast by American Airlines' meteorological staff, although the NWS meteorologists were forecasting occasional severe turbulence and icing in a larger area that included the route of flight for flight 1572. The Safety Board concludes that, regarding the operation of flight 1572, AAL weather forecasts, as documented in the SIGMECs, were substantially correct. NWS SIGMETs covered broader geographic areas than the more focused AAL SIGMEC reports, and contained, in this case, information on occasional severe icing and turbulence that did not apply to flight 1572. The Safety Board also concludes that AAL’s FAA-approved system of providing flightcrews with more focused forecasts, in the form of SIGMECs, is a valid method of weather dissemination. Should a flightcrew be forced to divert to an area not covered by a SIGMEC forecast, ample opportunity exists, via ACARS or air-to-ground radio, to obtain current weather in the divert area. In addition, providing flightcrews with both SIGMECs and SIGMETs might prove confusing to flightcrews when the reports are inconsistent, as they were in this case. 2.2.2 Weather Conditions at BDL The National Center for Atmospheric Research (NCAR) study conducted for this investigation stated that the predicted pressure decrease of 1 millibar could be underestimated by a factor of 2 or 3. The Safety Board concludes that such an underestimation did not occur at the time of the accident because the FDR altitude trace did not contain an altitude spike that would have resulted from a significant atmospheric pressure change. The flightcrew was given the BDL weather conditions prior to departure that forecast strong winds, moderate turbulence and possible low level windshear during their time of expected arrival. After takeoff, the first officer stated that they received a normal ACARS message that included a 2300 BDL weather observation. The message also stated that the pressure was falling rapidly (PRESFR). During the descent, the flightcrew received two messages over the ACARS relating to the BDL weather. The first message was sent at 0030 and provided the flightcrew with the altimeter setting for conversion to an above field elevation (QFE) setting and the altimeter setting for mean sea

63 level (QNH) at BDL. At 0031, another message was sent to the flightcrew advising them of turbulence and windshear on final approach. At 0034, the first officer received the ATIS information for BDL, and he recognized that it was “over an hour and a half old.” However, the flightcrew did not request more current information about the conditions at BDL. Interviews revealed that both flight crewmembers were aware of the turbulence and windshear advisories at the field. They were also aware of the possibility of a low but legal ceiling and visibility. The CVR revealed that they made appropriate preparations with the lead flight attendant regarding the passengers and cabin service in preparation for approach and landing in turbulent conditions. They were also aware that the tower was closed due to wind damage. Although it would have been prudent to request a weather update from the BDL final approach controller, the Safety Board concludes that with the exception of a current altimeter setting (discussed below), the flightcrew had adequate information concerning the weather at BDL as they began their descent to the airport. 2.3 Altimeter Settings The altimeter settings (29.42 inches Hg. (QNH) and 29.23 inches Hg. (QFE)) received by the flightcrew in the 0030 ACARS message were based upon a 2352 weather report. Thus, these altimeter settings were 29 minutes old when the flightcrew received them and 54 minutes old when the airplane struck the trees on the ridge line. The altimeter setting they received from Boston Center at 0033:27 (29.40 inches Hg.) was 22 minutes old when they struck the trees. The altimeter setting they received in the ATIS message at 0034 (29.50 inches Hg.) was based on a 2251 recording of the weather, and was 1 hour and 46 minutes old when the tree strike occurred. About the time of the accident the correct QFE altimeter setting for the airport was about 29.15 inches Hg. Using this value, the Safety Board concludes that the indicated altitude (height above airport elevation) that the airplane’s QFE altimeter was indicating was about 76 feet too high (based on the altimeter setting received at 0030), resulting in the airplane being 76 feet lower than indicated on the primary altimeters.

64 The Safety Board concludes that because they knew that the atmospheric pressure was falling rapidly, the flightcrew should have requested a current altimeter setting from the BDL approach controller when one was not given by the controller, as required, upon initial radio contact. If they had done so, they would have received a current altimeter setting of 29.38 inches Hg. (QNH) which would most likely have resulted in the aircraft being 40 feet higher30 than it was when it struck the trees, or approximately 71 feet above the terrain. The survey of tree heights that was performed shortly after the accident indicated that trees in the area of initial impact were approximately 60 feet tall. Therefore, an additional 40 feet might have given the aircraft enough clearance to miss the trees on the downslope of the ridge. Accordingly, the Safety Board concludes that the flightcrew’s failure to request a current altimeter setting from the approach controller was a contributing factor in this accident. AAL procedures require that the flightcrew change the primary altimeters from QNH (height above sea level) to QFE (height above the ground) during the descent at 10,000 feet. To accomplish this, flightcrews use either the QNH and QFE settings obtained from AAL ground station personnel at the airport of intended landing or they use both settings from company meteorologists obtained over ACARS. In this case, the flightcrew received an ACARS message at 0030 that contained a QFE setting of 29.23 inches Hg. and a QNH setting of 29.42 inches Hg. According to AAL procedures, the flightcrew should have then set their individual altimeters to QFE and compared them to the third (standby) altimeter that would still be set to QNH. The difference between the two settings should be equal to the published field elevation of the airport of intended landing. After the accident, the primary altimeters were found set at 29.23 inches Hg., which is consistent with the setting given in the ACARS message. However, the standby altimeter was set at 29.47 inches Hg., which does not match the setting found in the ACARS message, or with any of the other altimeter settings given to the flightcrew. During the descent, the first officer stated to the captain that 29.47 inches Hg. (QNH) was what had been given to them when they started to descend. In fact, the Boston ARTCC had given, and the first officer acknowledged, a setting of 29.40 inches Hg. (QNH).

1. 25 feet for each 0.01 inch of Hg. between 29.38 and 29.42.

65 If the flightcrew had set the altimeters to 29.23 (QFE) and 29.42 (QNH) the settings would have produced the proper difference in indicated altitudes, which would have been equal to the field elevation (174 feet msl). Although the flightcrew used an incorrect standby altimeter setting during the initial descent below 18,000 feet, the mistake could have been detected if the proper procedures31 had been used at the changeover altitude of 10,000 feet. First, when the pilots switched from using the standby altimeter to determine their altitude, set in error at 29.47 (QNH), to their primary altimeters, set at 29.23 (QFE), their altimeters displayed an indicated altitude that was about 240 feet lower than the standby altimeter. Second, using the QFE setting of 29.23 inches Hg. given the flightcrew by the 0030 ACARS message, the field elevation would have been inconsistent with any altimeter setting on the third altimeter, except the setting of 29.42 inches Hg. (QNH). Following the accident, neither crewmember stated that they remembered the ACARS message or the associated altimeter settings that the company provided to them. However, documents retrieved from the accident airplane revealed that the ATIS information was handwritten on the ACARS message received from the company. The Safety Board could not determine who wrote this information on the message. However, the Safety Board concludes that, although the flightcrew did not use the most current QNH setting they had available in the standby altimeter (29.40 inches Hg.), this error did not affect the accident sequence of events because the flightcrew had the correct, but outdated, QFE setting (29.23 inches Hg.) in the altimeters they were using when the accident occurred. 2.3.1 Other Altimeter Errors Safety Board investigators determined that there were two potential sources of altimeter errors in addition to the incorrect altimeter setting already discussed. They are (1) the error resulting from differences between the true mean temperature of the column of air below the airplane and the mean temperature assumed for the air column in the standard atmosphere; and (2) the error associated with departure of the distribution of

31AAL procedures require flightcrews to compare the differences between the primary and standby settings to the field elevation. If there is a discrepancy, they would be expected to read the ACARS message again for the correct settings, or, most effectively, to ask the approach controller for a current setting.

66 pressure from hydrostatic equilibrium.32 The effect of errors resulting from these two sources was found to be insignificant in this case. 2.4 The Descent Below MDA According to the AAL DC-9 Operating Manual the pilot not landing is responsible for calling out 1,000 feet above field level, 100 feet above minimum descent altitude (MDA), and MDA. The first officer, who was the pilot not landing, called out: “There’s a thousand feet” at 0055:06. A correlation of the CVR with the FDR revealed that this 1,000-foot callout was made at around 1,140 feet agl, based upon the flightcrew’s altimeter setting of 29.23 inches Hg. (QFE). Although this mandatory callout was made, the first officer did not follow additional company procedures by also calling out 100 feet above MDA (1,008 feet above the field elevation). However, 5 seconds later, at 0055:11, the first officer stated to the captain, “now nine hundred and eight is your uh...,” which indicated that he was aware of the close proximity of the MDA (908 feet agl) to the 1,000 above field level callout. At that time, the airplane was about 1,050 feet agl. The captain replied, “right.” The first officer stated that he then looked out the airplane windshield to locate the airport. When he looked back at the instrument panel, he saw that the airplane had descended below MDA. At 0055:25, the first officer said, “You’re going below your.…” At that time the airplane was about 350 feet above the ground and 5 seconds away from contact with the trees. Information from the DFDR indicates that a constant rate of descent of 1,100 feet per minute was maintained until the first officer uttered his “you’re going below your….” statement. The Safety Board concludes that if the first officer had monitored the approach on instruments until reaching MDA and delayed his search for the airport until after reaching MDA, he would have been better able to notice and immediately call the captain’s attention to the altitude deviation below the MDA.

32Hydrostatic equilibrium is a balance between gravity and pressure gradient force. Strong winds flowing over high terrain can result in nonhydrostatic equilibrium.

67 Further, if the flightcrew had computed a visual descent point (VDP) for their approach to runway 15, as described in the AAL flight manual, the DME associated with a VDP would have provided the flightcrew with a specific point in space to leave the MDA for landing. There would be no reason for the first officer or the captain to be looking away from the instruments and out the windscreen for the airport until just before or at the VDP. Both of them could have been concentrating upon the level off at the MDA. However, in this case, no VDP was calculated, the first officer began looking for the airport prior to reaching the MDA in the critical stages of the descent to MDA, and he was not adequately monitoring the flight instruments to serve as an additional backup to the captain. If the captain had planned for a VDP, he could have set up a more shallow rate of descent commensurate with reaching the target altitude at or just prior to the VDP. The reduced rate of descent would have allowed the captain to better monitor his descent progress toward the MDA. Also, a reduced rate of descent would have enabled the airplane to capture the MDA with less of a roundout (altitude loss) when the autopilot altitude hold button was depressed. A reduced rate of descent would also have given the captain a greater opportunity to arrest the descent at the MDA if he had manually taken control of the airplane. The captain stated that he attempted to “level off” the airplane at MDA, using the altitude hold button of the autopilot. However, that feature of the autopilot was not engaged until after the first officer uttered his “you’re going below your....” statement. The captain never took manual control of the airplane to either arrest his descent at the MDA or to initiate a more positive and immediate recovery to the MDA once he flew below this altitude. In summary, regardless of the outdated altimeter setting that affected the indicated altitude that the flightcrew observed, they allowed the airplane to descend about 309 feet below the indicated MDA for the instrument approach. The captain initially did not recognize the descent below MDA, and he failed to react immediately when he was alerted to the altitude deviation by the first officer. The Safety Board concludes that the flightcrew’s failure to maintain the required MDA until the required visual references identified with the runway were in sight directly caused this accident.

68 2.5 Actions After Tree Strike Regardless of the fact that the flightcrew descended below the MDA, their actions after the initial tree strike were noteworthy. The leading edge and trailing edge flaps of the airplane were severely damaged, power from one engine failed almost immediately after the tree strike, and power from the other engine failed shortly thereafter. Any mistakes in glidepath management, ground track management, or airplane configuration timing by the captain and first officer would probably have caused the airplane to land in unsuitable terrain prior to the clear area at the end of the runway and undoubtedly would have resulted in more severe injuries to crew and passengers. The Safety Board concludes that the excellent crew resource management and flight skills that the flightcrew used, as reflected on the CVR recording following their encounter with the trees, were directly responsible for limiting the number of injured passengers to one individual. 2.6 Terminal Instrument Procedures (TERPS) As discussed below, the manner in which AVN-100 procedures specialists evaluated the obstacles on the instrument approach in question is markedly different from that of the flight procedures inspectors in the FIAO, making it possible to come to a different conclusion concerning the height of obstacles along the flightpath. In spite of the procedures that required the FAA FIAO to coordinate with the flight procedures specialists in the event of data or charting errors, such coordination apparently was never effectively accomplished. The instrument procedures development program was separated from the flight operations inspection program in 1994. The procedures specialists, who design the instrument approaches, are now part of the FAA’s Office of Aviation System Standards (AVN) and design an approach based upon charting methodology, rather than actual physical surveys to determine obstacle clearance surfaces. The specialists never directly measure obstacle heights, glidepath angles, and other variables, when they design an approach, but rather they rely upon graphs, charts, maps, and tables of information to do so. During the initial development of the BDL VOR runway 15 approach, the procedures specialist that designed the approach determined, based upon charts, that a 55 foot obstruction existed within the required obstacle clearance plane of the VASI. Further, if a VDP were to be established at the

69 intersection of the VASI with the MDA, the same obstruction would penetrate the required obstacle clearance plane by 55 feet. This was inconsistent with the FIAO determination, both during the approach development and after the accident by means of flight inspection, that the obstacle clearance plane was not penetrated by the ridge line and trees. Order 8260.19C, paragraph 430, states, in part: Establish a VDP on a non-precision approach, providing the [standard instrument approach procedure] SIAP meets the requirements of TERPS.... But, paragraph 432, further states, in part: If a VDP is not established, give the reason; e. g., obstacles.... An examination of FAA records revealed no reason for the absence of a VDP for the approach to runway 15 at BDL. If the VASI geometry designed by the procedures specialist indicated an encroachment by obstacles of 55 feet, then FAA procedures should have required re-examination of the approach to determine the adequacy of clearance, and the VASI should have been moved or decommissioned until the required obstacles were removed. If, on the other hand, the VASI obstruction clearance plane was “clear,” then in the Safety Board’s opinion, an appropriately located VDP should have been placed on the approach plate to provide flightcrews with an appropriate DME fix from which a visual descent for landing could be made more safely. Based upon TERPS criteria for VDP location, the DME fix for the VDP should have been located on the flightpath past the ridge line and trees. This would provide flightcrews with adequate required obstacle clearance and a defined point from which a visual descent could be made, past the ridge line. It would also tend to keep approaching airplanes at a safer altitude until after passing the ridge line where they would begin their descents to the MDA. The flight procedures unit used maps, charts, surveys and mathematical data to support their conclusions, whereas the flight inspection unit used airplanes and a theodolite (an optical device to measure angles and heights) for obstacle height verification. In this case their results were

70 different with regard to the height of the trees on the ridge line and whether they constituted an obstruction within the VASI-required obstacle clearance plane. The different methods of verification can be a good check and balance to ensure accuracy of measurements; however, when the two branches differed in conclusions, there should have been, but was not, a mechanism in place to resolve the differences. The Safety Board concludes that quality control was inadequate within the FAA for accurately resolving the height of the trees on the ridge line. Therefore, the Safety Board believes that the FAA should examine and make more effective the coordinating efforts of the flight inspection program and the procedures development program, with emphasis placed on ensuring quality control during the development, amendment, and flight inspection process for instrument approaches. The Safety Board also concludes that there is great value in flying non-precision approaches with a constant rate or angle of descent until the airport environment can be visually acquired, if the avionics aboard the airplane can safely support such a procedure. Therefore, the Safety Board believes that the FAA should evaluate TERPS design criteria for non- precision approaches to consider the incorporation of a constant rate or constant angle of descent to MDA in lieu of step-down criteria. 2.6.1 Precipitous Terrain The TERPS Handbook states that consideration should be given to induced altimeter errors and pilot control problems in precipitous terrain that may result when winds are 20 knots or more over such terrain. No changes to the instrument approach procedure for runway 15 at BDL were made to account for precipitous terrain. Precipitous terrain is not defined in the TERPS Handbook. However, the BDL runway 15 approach is used primarily when the winds are such that their speed and direction preclude the use of the primary runway 06/24. Such conditions are likely to result in wind velocities in excess of 20 knots over the ridge line, which occurred the night of the accident. Such winds adversely affect airplane altimetry, and although it does not appear to have been a factor in this accident, the Safety Board concludes that the FAA should have, but did not, consider the issue of precipitous terrain when developing and modifying the approach to runway 15.

71 The Safety Board believes that the FAA should incorporate precipitous terrain adjustments in the runway 15 approach. In addition, the Safety Board believes the FAA should include a more comprehensive set of guidelines concerning precipitous terrain adjustments in the TERPS (FAA Order 8260.3B) Handbook, clarifying the definition of precipitous terrain, and establishing defined criteria for addressing the potential effects of such terrain. FAA flight inspections of instrument approaches are not normally flown during adverse wind and turbulence conditions, such as those on the night of the accident, because the flight inspection pilots must fly under visual flight rules (VFR) to observe man-made obstacles and high terrain. Therefore, the flight inspectors may not be fully aware of how such adverse conditions affect the safety of a particular instrument approach. Because the Safety Board is concerned that non-precision approaches at airports other than BDL may be adversely affected by wind and turbulence associated with precipitous terrain, the Safety Board believes that the FAA should review and evaluate the appropriateness of the let-down altitudes for all non-precision approaches that have significant terrain features along the approach course between the initial approach fix and the runway. Airline safety departments and pilot labor organizations, such as the Allied Pilots Association and the Air Line Pilots Association, should be consulted as part of this review. In addition, the Safety Board believes that the FAA should solicit and record user comments about difficulties encountered in flying a particular approach to evaluate approach design more accurately. 2.6.2 Approach Plate Terrain Depictions The single 819-foot obstacle depicted on the final approach course of most BDL runway 15 VOR approach plates could lead flightcrews to believe that there was one discrete obstacle, and that it was the only dangerous point on the final approach (see Figure 1). However, the Safety Board concludes that the entire ridge line is an obstacle, and that it and similar terrain close to other airports should be fully depicted on the appropriate approach charts. As an example, see Figure 4, the BDL approach plate used by British Airways. The Safety Board continues to believe, as reflected in Safety Recommendation A-96-102, following the accident near Buga, Colombia, that the FAA should require that all approach and navigation charts graphically present terrain information.

73 2.7 Air Traffic Control Factors 2.7.1 ATC Altimeter Setting Distribution Procedures The approach controller is required to issue the QNH (above sea level) altimeter setting on initial contact with an arriving flight, in accordance with the Air Traffic Control Handbook, FAA Order 7110.65. AAL flight 1572 first contacted the approach controller at 0043:41. The controller should have issued the current altimeter setting of 29.38 inches Hg. at that time. The controller said that the omission was inadvertent. If the controller had issued the current altimeter setting on initial contact, the aircraft would most likely have been 40 feet higher than it actually was when it struck the trees.33 The survey of tree heights that was performed shortly after the accident indicated that the trees in the area of initial impact were approximately 60 feet tall. Therefore, an additional 40 feet might have given the aircraft enough clearance to miss the trees on the downslope of the ridge. Accordingly, the Safety Board concludes that this omission by the controller was a contributing factor in this accident. There is no requirement for an approach controller to issue an altimeter change to an aircraft after the initial contact. However, considering the fact that the pressure changes were described by the weather observer as "pressure falling rapidly," and especially in light of the controller’s failure to issue the current altimeter setting (29.38 inches Hg.) upon initial radio contact and his 0044:34 entry of 29.34 inches Hg. in the ARTS system while the accident aircraft was on his frequency,34 the Safety Board concludes that it would have been prudent for the approach controller to have issued the altimeter setting changes as the airplane neared the airport. The latest altimeter setting available to the approach controller while the accident flight was on his frequency was 29.36 inches of Hg. If the flightcrew had received and correctly entered this setting, it would have resulted in the aircraft being

33The altimeter setting of 29.42 inches Hg. (the QNH equivalent of the 29.23 inches Hg. QFE setting the flightcrew was using on final approach) minus 29.38 inches Hg. equals .04, or 40 feet of indicated altitude. 34When he entered 29.34 inches Hg., the controller should have recognized that this was a substantially lower barometer reading than existed when the accident airplane initially reported on the frequency (29.38), and it should have reminded him that he had not provided the flightcrew with a current altimeter setting.

74 approximately 60 feet higher, thus likely enabling it to clear the trees on the ridge line. This accident illustrates the safety hazards that may result when flightcrews of landing aircraft are not informed of current altimeter settings in circumstances of rapidly falling atmospheric pressure. Therefore, the Safety Board believes that for arriving aircraft executing instrument approaches at all airports, during periods in which the weather observer has included in the weather report the remark, "pressure falling rapidly," controllers should be required to issue, as frequently as practical, altimeter setting changes to flightcrews in addition to the altimeter setting issued on initial contact. 2.7.2. Tower Closure and Assistance Provided by the TRACON Supervisor The winds on the evening of the accident were strong enough to bow tower windows and allow water to enter the tower cab, posing an electrical hazard to the tower controller. The Safety Board therefore concludes that the closure of the tower was a good managerial decision because the safety of people in the tower was compromised by the adverse wind and rain. The TRACON supervisor's presence in the tower to monitor repairs, and his provision of wind and runway information to the aircraft was beneficial to the flight. He informed the flight that the runway was clear, provided landing winds, and he also provided a windshear alert. This information would not otherwise have been provided to the flightcrew. Although additional information regarding the current altimeter setting would have been even more helpful to the flightcrew, the TRACON supervisor was not required to provide that, or any, information. He was voluntarily assisting the flight by providing advisory information, and he was not officially serving as an air traffic controller. Further, the flightcrew had been told by the approach controller that the tower was not “officially” open, and therefore, the flightcrew could reasonably assume that there was no “official” ATC service in the tower. The Safety Board notes that the supervisor was very careful in his wording and did not give flight 1572 clearance to land. His exact words were, “Bradley tower, uh, landing is at your discretion, sir....runway does appear clear, you can land and taxi to the gate at your discretion.”

75 The first officer on two occasions (0054:04 and 0055:06) used the words “cleared to land,” in conversation with the captain. However, because the tower was closed, the captain of flight 1572 could land the airplane only on his own authority. The Safety Board concludes that the TRACON supervisor’s communications with the flight were appropriate and aided the flightcrew. He acted in a professional manner, and should be commended for his willingness to assist the flight under the circumstances. As further discussed in Section 2.7.4, the ATIS report broadcast at the time of the accident was based on weather observations almost 2 hours old, information that would be of little use to flightcrews in the area. Therefore, the Safety Board concludes that as part of the tower closure procedure, the ATIS broadcast should have been updated to reflect the temporary tower closure, and it should have advised flightcrews to obtain local weather and airport information from another source. 2.7.3 MSAW (Minimum Safe Altitude Warning) MSAW is a computer program to warn a controller when an airplane descends or will descend below a predetermined altitude. If the radar does not receive a signal from a target, the program cannot function. The MSAW at BDL was set to alarm if the aircraft transmitted two mode C returns at or below 1,050 feet msl (30 feet below the MDA for the runway 15 VOR approach). There was no alarm as flight 1572 descended below the MDA because the aircraft was not in radar contact at that point because of shielding by the ridge line. There was a radar return recorded at 1,300 feet (above the MSAW envelope) but because of shielding from the ridge, the aircraft was out of radar contact for three radar sweeps and was therefore not visible to the controllers. Then, a single radar return was recorded at 900 feet, followed by another radar sweep with no recording of the flight, and then two radar returns were recorded at 800 feet. The MSAW then sounded an alarm, as it should have under those conditions.35 However, this alarm sounded about 4 seconds after the airplane had struck the trees.

35Two consecutive sweeps with radar contact with an airplane are required to set off the MSAW alarm. This is the reason that the MSAW did not alarm following the single radar contact at 900 feet.

76 According to the FAA, because of the lack of radar coverage close to the ridge, the minimums for the VOR 15 approach would have to be raised to give MSAW protection for this approach. It is not desirable for an MSAW alarm to occur above the MDA. This would result in an MSAW false alarm sounding on every approach, making the occasional valid alarm likely to be ineffective. Because the last radar return before the airplane struck the trees was recorded at 1,300 feet, the lowest altitude at which the MSAW could be programmed to activate and be effective is 1,300 feet. Therefore, to have full MSAW coverage, the approach minimums for this approach would have to be raised from 1,080 feet msl to somewhat above 1,300 feet msl, to keep the MDA above the alarm point for the MSAW. However, an MDA this high would defeat the purpose of the instrument approach. The descent from a 1,350-foot MDA to the runway would have to start far back along the final approach course, and the ceiling and visibility minimums would be unrealistically high. The Safety Board therefore concludes that despite the lack of full MSAW coverage along the approach, the MSAW operated properly, and that because of topographical limitations of the BDL local area, it is not practical to provide full MSAW coverage. 2.7.4 The Outdated ATIS Broadcast The ATIS report information Victor, based on 2251 EST weather (from a weather observation taken almost 2 hours before the accident) was broadcast continually through the time of the accident. Because of the age of the observation, ATIS Victor was of little use to flights in the area of BDL. The relieving tower controller, who “entered the tower a couple of minutes before midnight” said that he listened to the ATIS but did not notice the time on it, nor did he notice if the SAIDS incoming information warning light was blinking. This would have indicated that new weather information was available. He said that the environment was very noisy (because of wind noise) and that he did not hear SAIDS incoming information warning tones. The weather sequence, taken at 2252, was time stamped at 2249:21. However, the clock making the time stamp was about 4.5 minutes slow. Therefore, the Safety Board believes that it was actually received at around 2253. The 2351 weather sequence would have actually been received at around 2358. The Safety Board believes that the weather information would have been on the display prior to the closing of the tower. However, the time stamps and readout of the SAIDS indicated

77 that the information was sent at 2358 and would probably have been displayed when he began his shift. The information would also have been on the display at the time the tower closed. If the ATIS had been updated, the altimeter setting would have been 29.42 inches Hg., (based on the 2352 local observation) a less current altimeter setting than the one that the flightcrew received from Boston ARTCC (29.40 inches Hg., based on the 2333 observation). The flightcrew had actually received an earlier ACARS setting of 29.42 inches Hg. (erroneously entered in the standby altimeter as 29.47 inches Hg.), the same setting that would have been provided on the unbroadcast ATIS.36 The Safety Board concludes that the tower controller being relieved should have advised the relieving controller that the ATIS needed to be updated, even if it meant that they had to use the airport police to tell the weather observer to call the tower with more current weather. Although the failure to update the ATIS was not a factor in this accident, this failure raises concerns because of the potential hazards of not having current weather information available for flights inbound to BDL. Therefore, the Safety Board believes that the FAA should revise Facility Operation and Administration handbook 7210.3, or other appropriate orders, to require that when a tower shuts down for any reason, and if the tower controllers have time to record a new ATIS indicating that the tower is closed, they should do so. 2.8 Weather Conditions at the Time of the Accident Possible downdrafts of about 400 feet per minute may have existed near the lee (northwest) side of the ridge where the tree strike occurred, according to the NCAR simulation. Douglas estimated a maximum updraft of about 600 feet per minute in this same geographical area. However, updrafts are not common on the lee side of ridge lines (downdrafts usually occur on the lee side of an obstacle). On the other hand, the NCAR simulation is dependent on an initial steady wind direction of 160 degrees, which probably does not accurately represent the accident conditions, as the winds were variable, not steady. Variation of the wind direction would result in a change in the location of updrafts and downdrafts in relation to the ridge. In addition, the presence of a horizontal axis vortex

36The unbroadcast ATIS wind direction, velocity and gust factor would have been similar to that of the earlier ATIS broadcast.

78 on the lee side of the ridge could have produced a localized updraft along the flightpath of the airplane. The Safety Board concludes that, although the variable wind conditions at the time of the accident may have caused localized updrafts and downdrafts in the area, the DFDR data indicates that there were no large-scale updrafts or downdrafts that would have affected the accident aircraft. During the approach to runway 15, to the point at which flight 1572 struck the trees, the airplane would have encountered moderate turbulence and localized updrafts and downdrafts due to the interaction between strong low altitude winds and rough terrain along the flightpath. Windshear due to strong gusty low altitude winds also occurred following the tree strike, as the airplane was on approach to the runway. An estimated mean wind profile indicated a decreasing headwind as the airplane descended to the runway. Although windshear was occurring as the airplane approached and passed over the ridge line, it was the gustiness of the low altitude winds, rather than a small-scale weather feature, that significantly affected airplane performance. Airspeed excursions amounted to only about 10 knots. Further, a descent rate of about 1,100 feet per minute was initiated by the flightcrew from about 1,840 feet msl and was maintained until tree contact. The linear nature of the pressure altitude trace indicates that the airplane’s flightpath was probably not significantly affected by updrafts, downdrafts, or windshear. Such an effect would be seen as a deviation from the near linear pressure altitude trace. Therefore, the Safety Board concludes that the decreasing headwind shear seen in the estimated mean wind profile data was not severe enough to cause the flightcrew to deviate below the MDA. Along the approach to runway 15, cloud bases were near 2,000 feet with multiple cloud layers above, and the tops of the clouds were above 15,000 feet. Flight visibility was near 0 miles in the clouds and 2 to 3 statute miles below the lowest cloud base. The first officer reported "there's the runway straight ahead " at 0055:57. The airplane was about 2.1 miles from the end of the runway at this time. Moderate rain probably occurred along the approach to the runway with more intense rain near the runway. Given the above described conditions, the Safety Board concludes that the weather at the time of the accident was not severe enough

79 to cause the aircraft to deviate below the MDA, and did not contribute to the accident. 2.8.1 LLWAS Equipment The northwest LLWAS sensor was physically out of alignment by 38 degrees and was corrected subsequent to the accident. Analysis of the LLWAS data, according to the FAA, indicated that this sensor did not appear to degrade the entire LLWAS system to any significant degree during the analyzed period. The Safety Board could not determine whether the LLWAS system would have provided another windshear alert if the sensor had not been misaligned. Nevertheless, the Safety Board considered the possibility that if the northwest sensor had been correctly aligned, it might have alerted due to erratic wind conditions; and an LLWAS alert from this sensor in the area of flight 1572 might have prompted the flightcrew to perform a missed approach. The Safety Board could not rule out this possibility. However, the Safety Board believes that it is more likely that if the flightcrew had received a northwest LLWAS alert from the tower controller, they would have continued the approach because under the known turbulence and erratic wind conditions, LLWAS alerts are to be expected. Thus, under these conditions, it would not be unreasonable for a flightcrew to react to such a warning by more closely monitoring their airspeed, rather than immediately initiating a missed approach. Therefore, the Safety Board concludes that the misaligned LLWAS sensor did not contribute to this accident. According to the FAA, procedures are in place to check and correct the alignment of sensors based on the SPES analysis, which is run on a regular basis. However, the FAA also indicated that because of manpower shortages, it can take 3 to 6 months after discrepancies are noted for the alignment of the sensors to be examined and adjusted by airport personnel. The Safety Board concludes that 3 to 6 months after discrepancies are noted is an unacceptable period of time to verify the accuracy of sensor alignment, since wind direction can have a direct bearing on the windshear detection capability of the system. Therefore, the Safety Board believes that the FAA should develop a plan to physically check and correct wind sensor alignment in a more timely manner.

80 The Safety Board is also concerned that the FAA’s process of “recertifying” the LLWAS--despite the implication that “recertification” signifies that the system has been found to comply with all original certification requirements--does not include checking that the sensors are properly aligned. Although the FAA indicated that the misalignment did not appear to degrade the system during the analyzed period (October 31, 1995 to November 12, 1995), this result is relevant only to the wind conditions experienced during that period. A misalignment of 38 degrees could clearly compromise the effectiveness of the system under some wind conditions. Accordingly, the Safety Board believes that the FAA should evaluate its LLWAS recertification process, and ensure that the process addresses the total functional capability of the system. 2.9 Survival Factors 2.9.1 The Malfunctioning Escape Slide Instructions for rigging the inflation cable, contained in the Douglas DC-9/MD-80 Maintenance Manual 25-62-00-2-2, page 204, paragraph 11, were ambiguous. At the time of the accident, they stated: “Check that loop on firing lanyard is secured to girt tab with retaining ring on manual inflation handle; then, secure lanyard cover flap over firing lanyard.” The instructions did not specifically call for the inflation cable to pass through a grommet on a tab near the girt bar before the cable is connected to the retaining ring on the manual inflation handle. In addition, the diagram in the rigging instructions did not display the grommet or the tab, or the inflation cable passing through the grommet on the tab near the girt bar before the cable is connected to the manual inflation handle (see Figure 5). This is required for the slide to inflate properly. The Safety Board concludes that because of the ambiguous instructions that appeared in the Douglas Maintenance Manual, operators of MD-80 and DC-9 series airplanes could be misrigging emergency evacuation slides. Therefore, the Safety Board believes that the FAA should require all operators to inspect immediately all MD-80 and DC-9 floor level exits to ensure that evacuation slides have been properly rigged. As a result of this accident, American Airlines took immediate action to clarify instructions in its maintenance manual and is conducting a fleet-wide inspection of all emergency evacuation slides on its MD-80

81 airplanes. Douglas also took action and revised its maintenance manual instructions for installation of evacuation slides to include improved diagrams showing proper routing of the inflation cable through the grommet tab, and to include instructions to “[p]ass [the] inflation cable loop through [the]grommet tab.” (See Figure 6.) (The “inflation cable” had previously been referred to in the manual as the “firing lanyard.”) Although these revisions clearly and accurately depict the proper routing of the inflation cable, the Safety Board is concerned that the change in terminology from “firing lanyard” to “inflation cable” was not reflected in all the maintenance manual diagrams and instructions dealing with the installation and removal of evacuation slides. In several places, the cable is still referred to as a “firing lanyard.” The Safety Board concludes that because Douglas uses two different terms (“firing lanyard” and “inflation cable”) for the same part in its MD-80 and DC-9 maintenance manuals, the manual remains potentially confusing. Therefore, the Safety Board believes that the FAA should require Douglas Aircraft Company to review and amend its MD-80 and DC-9 maintenance manuals so that terminology used in graphics and instructions pertaining to the installation and removal of evacuation slides are clear and consistent. 2.9.2 Evacuation Route Difficulties The aisle and areas in front of the escape doors that constituted the escape routes were partially blocked by passenger shoes during the evacuation. This could have caused injuries or loss of life in the case of an interior fire or other critical situation. The practice of commanding all passengers to remove shoes during evacuations was originally targeted primarily at high heeled shoes, and was intended to prevent slide punctures. But modern slide design and strengthened fabric material now used in slide manufacturing make the policy outdated. In addition, (with the exception of high heeled shoes) safety is served by passengers wearing shoes because they can exit an airplane and move away from an evacuated airplane more readily. It may still be appropriate for crewmembers to instruct female passengers to remove high-heeled shoes that could cause injuries during an evacuation. Experience has shown that ankle and leg injuries are more likely to result from passengers wearing high heels. In addition, other injuries could also occur to rescue personnel and passengers, as the passenger wearing high heels slides down to waiting individuals at the bottom of the slide.

82 GIRT BAR HOO IRING ANYARD YARD COVER P (CLOSED) HANDLE (ARMED POSITION) KS Figure 5.--Instruction diagram for rigging the firing lanyard (inflation cable).

83 f MANUAL INFLATION INFLATION CABLE , HANDLE \/ p VELC . \ & KEY RING GRo-TT.~G’”= GIRT ~ UNARMED RO Figure 6.--Revised instruction diagram for rigging the inflation cable,

84 However, the Safety Board concludes that directing all passengers to remove shoes during evacuations may not be in the best interests of safety. There is no FAA policy regarding issuing commands for shoe removal during an evacuation. Although American Airlines is the only major carrier the Safety Board is aware of that instructs passengers to remove shoes during an evacuation, the Safety Board is concerned that there is no uniform policy or standard to which all operators (large and small) must adhere. The Safety Board therefore believes that the FAA should develop a uniform policy on shoe removal during evacuations, and require that all operators train their flight attendants to issue commands during an emergency evacuation consistent with that policy.