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U.S. DEPARTMEHT OF COMMERCE Natiml Technical Informatin Smite .

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NTlSUB/C/104-007

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Aircraft Accident Report ?an American World Airways, Inc., b e i n g 707-3215, Nk54A, ?ago Pago, American Samoa, January 30, 1974

National Transportation Safety Board, \bicshin(pton,

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Report No.

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Performing O G a n i z a t i o n Name a n d Address t i a t i o n u l T r a n s p o r t a t i o n S a f e t y Board Uureau of A c c i d e n t I n v e s t i g a t i o n , Waahingron; D.Q .--2 U W

-l2.Sponsoring

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I3.Type of Report and P e r i o d Covered

Agency Name and Address

TRANS?ORTATION SAFETY BOARD Washington, 0. C . 20534

N'4TTIOIIAL

A i r c r a f t Accident Report J a n u a r y 30, 1974 1b.Sponsoring Agency Code

The f o l l o w i n g r e p o r t r e f l e c t s t h e f i n d i n g s of t h e N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d ' s r e i n v c s t i g a t i a n . 'Illis r e p o r t s u p e r c e d e s and r r p l a c e s

.About :3:tl, American Samoa s t a n d a r d . t i m e , on J a n u a r y 30. 1 9 7 4 , Pan American World Airways F l i g h t 806 crashrJ 3,365 fcc? s h o r t of runway 5 a t Pago Paso T n t e r n a t i o n n l A i r p o r t . 'lhe f l i g h t was making an 1LS approach a t n i g h t . Of t h e 101 p e r s o n s aboard t h e a i r c r a f t , o n l y 5 survived t h e a c c i d e n t . One survivor d i e d of i n j w i c s 9 d a y s a f t o r t h e a c c i d e n t . The a i r c r a f t v a s d e s t r u v e d by impact ar;d f i r e . The N a t i o n a l T r a n s p i r t a t i o n S a f e t y Board d e t e r m i n e s t h a t t h e probable cause of the a c c i d e n t vas t h e f l i g h t c r e w ' s l a t e r e c o g n i t i o n m d f a i l u r e

t o c o r r e c t i? a t i n e l y manner a n excessive d e s c e n t r a t e wbic!? developed as a r e s n l t of t h e a l r c r n f t ' s p e n e t r a t i u n through d c s t a b i l l z i n g wind changes. The winds c o n s i s t e d of h o r i z o n t a l and v e r t i c a l components produced by a heavy rsinrstoxm and i n f l - m c e d hy uneven t e r r a i n c l a n r L O t h e a i r c r a l t ' s approach pn;h. The c a p t a i n ' s r e c o g n ' l t i o n was hampered by r e s t r i c t e d v i s i b i L i . t y , t h e i l l u s o r y e f f e c w of a " blackhole" a p p r o a c h , i n a d e q u a t e n o n i t o c i n g of f l i g h t i n s t r u m e n t s , and t h e & i l . u r e of t h e crew t o c a l l o u t d e s c e l r r a t e d u r i n g t h e l a s t i 5 seconds o f f l i g h g ,. I

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ILS approach. v i s u a l i l ? u s i o r . s , crew c o o r d i n a t i o n ,

T h i s document i s a v a i l a b l e

Identifier:

Virgir.ia

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11-707-3218 Accident

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FOREWORD -

On November 8, 1 9 7 4 . t h e National T r a n s p o r t a t i o n S a f z t y Board adopted and subsequently i s s u e d r e p o r t No. NTSB-AAR-74-15. This r e p o r t contained t h e f a c t s , circumstances, 3 r d conclusions t h a t were known a t t h a t time concerning t h e a - c i d e n t d c s c r i b e d herein. On Yay 6 , L976, t h e Ai; Line P i l o t s A s s o c i a t i o n p e t i t i o x d t h e S a f e t y Board t o r e c o n s i d e r t h e probable c a u w i n accordance wLth t h e Board's Procedural Regulation 49 CFN 831.36. As a r e s u l t 5f t h e p e t i t i o n , t h e Safnty Board reopcned t h e a c c i d e n t i n v e s t i g a t i o n because rf knowledge gained through o t h e r a c c i d e n t s a f t e r t h e o r i p i n a l i n v e s t i g a t i o n . The a i r c r a f t ' s f l i g h t d a t a r e c o r d e r d a t a , t h e cockpit v o i c e r e c o r d e r d a t e , and t h e a i ? c r a f t ' s engineering performance d a t 3 were r e e v a l u a t e d e x t e n s i v e l y t o determine more c o n c l u s i v e l y t h e e f f e c t of t h e e x i s t i n g environmental c o n d i t i o n s on t h e p i l o t s ' a b i l i t y t o s t a b i l i z e t h e a i r c r a f t ' s approach p r o f i l e .

The following r e p o r t r e f l e c t s the f i n d i n g s j f t h e Nztional T r a n s p o r t a t i o n S a f e t y Board's r e i n v e s t i g a t i o n . This 'report superceees and replaces MTSB AAR-74-15.

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TABLE OF CONTEE!TS Page

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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 1.17 1.17.1 1.17.2 1.17.3 1.17.4 1.18 2. 3. 3. I 3.2

4. 5.

Foreword Synoisis F a c i u a l Informarion H i s t o r y of t h e F l i g h t I n j u r i e s t o Persons D a ~ s g et o A i r c r a f t Other Damage Personnel Information Aircraft Infornation M c t e o r o l o g i c a l Information k i d s t o Navigation Communications Aerodrome 1nformat:Lon F l i g h r Xecorders Wreckage and Impact Informa,.:on Medical and P a t h o l o g i c a l Information Fire S u r v i v a l Aspects Tests and Research. A d d i t i o n a l Information Use of r l i g h t D i r e c t o r i n liir.dshear Conditions. R e s t r i c t e d Cargo Company Procedures A i r p o r t Q u a l i S i c n t i o n Progranrl"'n Xmt'ricnn. New l?vestig;ltio;i TechnLques Anal.ysis Conclusions Findings Probable Cause Safety Recorrmerdatilns ApJendires ApTenfix A - I n v e s t i g a t i o n and Hearing. Appendix B Ydrsonnel. Information. Appendix C A i r c r a f t Information Appendix D - Instrument Approzch Chart. Appendix C F l i g h t P r o t i l e F.ei;tionship w i t h Glj.de s l o p e and '.!AST hppeadix F - FM':; Kesponses t o Sa:L?t)r Recommendations.

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NAT1C)NAI TRA?JSPORTATIONSAFETY BOARD WASHINGTON', D.C. 20594 Adopted:

October 6 , 1977

PAN M R I C A N WORLll AIRWAYS, INC. BOEIXG 707-3218, N454PA PAGO PAGO, AMTR1C.U SAMOA

JANUARY 30, 1974

SYNOPSIS About 2341, American Sanoa s t a n d a r d t i n ? . on January 30, 1974, Pan American World Airways F l i g h t 806. crashed 3,965 feet P h o r t of runway 5 zt Pago Pago I n t e r n a t i o n a l A i r p o r t . l h . f l i g h t was mnking an 1LS approach a t n i g h t . O f tb.e 101 person. aboan' the a i r c r a f t , only 5 survived t h e a c c i d e n t . One m r v l v o r d i e d of i r l u r i e s 9 days a f t e r t h e a c c i d e n t . The a i r c r a f t was destroyed by impact acd f i r e .

The N a t i o n a l T r a n s p o r t a t i o n S n f e t y Board determines t h a t t h e probahie cause of t h e a c c i d e n t was t h e f l i g h t c r e w ' s l a t e r e c o g n i t i o n and failurz t o c o r r r c t i n a tioiely manner an e x c e s s i v e d e s c e n t rate which developed a s a r e s u l t of t h e a l r c r a f t ' s p e n e t r a t i o n through d e v t a b i l i z l n g wind changes. The winds c o n s i s t e d of h o r i z o n t a l and v e r t i c a l components produced by a heavy rains:onn and i n f l u e n c d by uneven t e r r a i n c l o s e t u t h e a i r c r a f t ' s approach r.ath. The c a p t a i n ' s r e c o g n i t i o n was hampers2 b y r e s t r i c t e d v i s i b i l i t y , t h e i l l u s o r y e f f e c t s of a " blackhole" approach, inadequate n o n i t o r i n g of f l i g h t instruiocnts, and t5e f a i l u r e of t h e crew t o c a l l o u t d e s c e n t r a t e d u r i n g t h e l a s t 15 seconds of f l i g h t .

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1. 1.1

FACllJhL I!IFORYATION

H i s t o r y of t h e F l i g h t On January 30, 1974, Pan American World Airways. In,:.,

Flight

806, a Roein?, 707-321B, N454PA. o p e r a t e d as a scheduled i n t e r u a t i o n a l passenger f l i g h t from A x k l a n d . !JewZealand, t o Los Angeles, C a l i f o r n i a .

En r o u t e s t o p s i n c l u d e d Pago Paso, American Samoa, and Honolulu, Hawaii.

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F l i g h t 306 d e p a r t e d Auckla.nd a t 2014 w i t h 9 1 passengers I t was c l e a r e d t o Pago Pago on an instrument and 10 crewmem5ers on board. f l i g h t r u l e s (IFK) f l i g h t plan. A t 2311:55, F l i g ' t t 806 c o n t e c t e d Pago Payo Approach Control and r e p o r t e d its p o s i t i o n 160 miles r.outh of the Pago Pago a i r p o r t . Approach c o n t r o l resp0ndr.d. " Clipper e i g h t z e r o six, r o g e r , and Pago weather, e s t i m a t e d c e i l f . n g one thousand six hundred broken, f o u r thousand broken, t h e v i s i b i l i t y - c o r r e c t i o n , one thousand o v e r c a s t . The v l s i b i l i t y one ze.ro, l i g h t r a i n shower. temperature seven e i g h t , wind three f i v e z e r o degrees, one f i v - . and altimeter's m o n i n e e i g h t f i v e . "

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A t 2313:04, Pago Pago Approach C o n t r o l c l e a r e d t h e f l i g h t t o t h e Pago Pago V0RTP.C. F l i g h t 806 r e p o r t e d l e a v i n g f l i g h t l e v e l (?X)330 a t 2316:58 and l e a v i n g FJ.-2CO a t 2324:40. Pa20 Pago Approach C c n t r o i c l e a r e d t h e f l i g h i a t 2324~49: Clipper e i g h t zero s i x , you're c l e a r e d f o r t h e ;LS DME runway f i v e approach ' 5 via t h e two zero mile arc south- southwest. Report :he arc, and l e a v i n g f i v e thousnnd." A t 2330:51, t h e f!.ight r e q u e s t e d t h e d i r e c t i o n and v e l o c i t y of t h e Pago Pago winds a n t was t o l d that they were 360' v a r i a b l e from 020" a t 10 t o 15 kuots.

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A i 2 3 3 4 5 6 , t h e f l i g h t r e p o r t e d o u t of 5,500 f e e t 3/ and t h a t they had i:ltcrcepLed t h e 226" r a d i a l of t h e PagJ Pago VOR. The approach control3.e.: responded, "Eight- oh s i x , r i g h t . Understand inbound on t h e l o c a l i z e u . Report about. t h r e e o u t . No o t h e r r e p o r t e < t r a f f i c . Winds z e r o onu zero d e g r e e s a t c,no f i v e g u s t i n g two zLro."

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All times h e r d L >are American Samoa s t a n d a r d , based on t h e 24-hour clock. 11,s ONE x n w a y 5 ;approach - an approach t o runway 5 on Pago Pago a i r p o r t , using t h e f.nntrunent landing system and t h e d i s t a n c e melsuring e q u i p m t of rhe VORTAC a s a i d s . A l l a l t i t u d e s a r e r e a n sea l e v e l u n l e s s o t h e r w i s e i n d i c a t e d .

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- 3 A t 2338:50, approach c o n t r o l s a i d , "C1.ipper e i g h t oh six, appears t h a t we've had pow,er f a i l u r e a t t h e a i r p o r t . " The f i r s t o f f i c e r r e p l i e d , "Eight oh s i x . we're s t i l l g e t t i n g your VOR, t h e I L S and t b e l i g h t s a r e showing." At 2339:05, approach c o n t r o l asked, "See t h e runway l i g h t s ? " The f l i g h t responded, ' " T h a t ' s Charl.ie." The approach we have a had r a i n showzr h e r e . I c n n ' t c o n t r o l l e r then s a i d , 'I. see them from my p o s i t i o n here." A t 2339:29, t h e f i r s t o f f i c e r said. "We're f i v e DME now and they s t i l l lobs b r i g h t . " ,lppmach Control replit-d, " ' b y , no o t h e r r e p o r t e d t r a f f i c . The wind is zero t h r e e zero d e g r e e s a t two zero, g u s t i n g two f i v e . Advisc c l e a r of t h e runway." A t 2339:41, t h e f l i g h t r e p l i e d , "Eight z e r o e i x , wflco." T h i s was t h e l a s t r a d i o t r a n s m i s s i o n from t h e f l i g h t .

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According t o t h e c o c k p i t v o l c e r e c o r d e r (COR), c o n v e r s a t t o n i n t h s c o c k p i t f o r t h e l a s t 59 second:. of t h e f l i g h t w:.s r o u t i n e . The c a p t a i n askcd t h e f i r s t o f f i c e r about .risual. r e f e r e n c e w i t h t h e runway, Windshield and t h e f i r s t o f f i c e r answered t h a t t h e runway was 7,isible. wipers were turned on and t h e f l a p s were s e t a t t h e SOo p o s i t i o n , whish completed t h e c h e c k l i s x f o r l a n d i n g . The f i r s t o f f i c e r s t a t e d dnring h i s p o s t a c c i d e n t i n t e r v i e w t h a t t h e only t h i n g he had n o t accomplished whtch :le should have vas t o change t h e No. 2 n a v i g a t i o n a l r e c e i v e r s e l e c t o r switch from the VOX frequency to t h e XLS frequeucy a t t h e f i n a l a2proach f i x .

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A t 2340:ZZ.S. t h e f i r s t o f f i c e r s t a t e d , "You're a l i t t l e high." Four seconds l.iter, a sound s i m i l a r t o e l e c t r i c s t a b i l i z e r trim a c t u a t i o n could be heard un t h e CVK.

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From 23$0:27.5 t o 2 3 i C : 3 L , t h e r a d i o a l c i m e t c r warning tone sounded twice. A L 23L?:33.5, t h e f i r s t o f f i c e r i n t e r r u p t e d chr second tL..nmg .. tone. with, "Y,~u'rea t mininu.ns."

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A t 2340:35, the f i r s t o f f i c e ; rcpc'rted. " Field i n s i g h t . " Seconds l a t d r , t h e f i . r s t G f f i c e r s r z . t e d , "Turn t o your r i g h t , " fnllowcci by "hundred and f o r t y knots." This h-as t h e l a s t communication recorded on t h e CVR. T h e r e h i bern no comnents made by e i t h e r t h e f l i g h t e n g i n e e r o r t h e p i l o t who occupied the jumpseat as t o a b n o r m a l i t i e s i n a i r s p e e d , . a l t i t u d e , or r a t e of d e s c e n t i n d i c a t i o n s . T k f i r s t o f f i c e r s t a t e d I n h i s p o s t a c c i d e n t i n t s r v i e w t h a t he d i d Got remember s e e i n g t h e VAS1 lights.

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A t 2340:$2. :I.e a i r c r a f t crashed i n t o trees a t an e l e v a t i o n of 113 f - e t , and about 3.ti6: fee: short of t h e runvay t h r e s h o l d . The f i r s t impact w i t h t h e ground wa5, about 236 f e e t f a r t h z r a l o n g t h e c r a s h path.

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The a i r c r a f t contlnurd through t h e jungle v e g e t a t i o n , s t r u c k a 3-foot-high l a v a I U C Z wal.l, and stopped about 3,096 5 e e t from t h e runway threshald. The a i r c r a f t vas dcstroyed by impact and t h e s L b s e q u w t fire. The a c c i d e n t uccurred d u r i n g t h e hours of dnrkncss a t 14' 29' 55" S l a t i r u d e znd 170' i 3 ' 55" W longitude. Thrre were no glound w i t n e s s e s t o the acciderlr.

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~ . . @ s J c a l l y i n t a c t on t h e aEt f u s e l a g e s t r u c t u r e . Fire damage was e v i d e n t on t h e 1cslf.r S U K f x r s of t h e Kigltt h o r i z o n t a i s t a b i l i z e r and e l e v a t o r . The e l e v a t o r s , e l e v a t o r t a b s , rudder, and rudder t a b were i n p l a c e and movable. The e l e v a t o r t a h s were in n e u t r a l , t h e rudder L:.b was d e f l e c t e d about 4 i n . co t h e I s f t , and t h e r u d d e r was i n n e u t r a l . The rudder t a b s e t t i n g rcrrraponded t o t h e s e t t i n g on t h e c o c k p i t trim wheel.

.The i n t e r i o r of the r e a r fwz&txfth.g-ce~aL p r e.s s u r e T C e ~ f a i S _ h t _ c p _ n t ~ l . c a t . s ~ ~ i~nr e ~ ! a b h>.~LC&+%. place and i n t e c t , The horizc.:tal s t a b i l i z e r a c t u a t o r v a s i n p l a c e , i n t a c t , and posiL'Jned a t t h r e e u n i t s a i r c r a f t nose up. There was no evidence of malfunction of t h e a i r c r a f t f l . i g h t c o n t r o l system before impact

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A m s se?aratc!d from ~hei~py~~bs~.aad.~h~ pylon had 'separated f r O ~ _ t h p l k ! i : ~ ~ The . t u r b i n e t h r u s t r e v e r s e r s were s e p n ~ i o m ~ ~ c i l g i n e s ' N o3 sanc . li. The t u r b i n e t h r u s t K e V C K S e r txlckets of t h e No. 1 engine were c l o s e & and t h e t r a n s l a t i n g s l e e v e was missing. P o r r i o n s of the f a n r e v e r s e r s remahne3 on each engine and were i n t h e stowed p o s i t i o n . The rim: and e.x@nd staj:? f a n b l a d e s on t h e f o u r engines were broken o f f a t t h e b l a d e platforms. The t h i r d s t a g e r o t o r b l a d e s on t h e four engines v e r e b e n t o p p o s i t e tho d i r e c t i o n of engine r o t a t i o n . Various amounts of f i n e l y chopped, f i b f r o u s r e s i d u e were found i n t h e bleed a i r passages of ehch of t h e engines.

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M ~ ? d i c a l _ a ~ n t h o l c g i ~Information aI

Post-mortem examination of t h e crewmesbers d i s c l o s e d -no evidence 1 o C i m - a a c _ i t a t i n g disease. Except f o r t h e t h i r d nff:lcer, who occupied t h e copil.ot seat, a i l f a t a l~. l y i n j u r e d persons d i e d of smoke i n h a l a A o n , massive f i r s t - . burns, and complications from t h o s e m s s i v e second- , and'~thi;d-;degrea ~-~ burns. ~

T o x i c o l o g i c a l examinations of the c a s u a l t i e s r e v e a l e d , i n each c3s.e. s i g n i f i c a n t l e v c i e of cnrbcn monoxide and.hydrogen cyamide. These g a s e s are natmal byproducto of aircract f i r e s . The t h i r d o f f i c e r , who s,;rvived t h e c r a s h bur 1att:r died of his i n j u r l e s , received t r a u m a t i c leg and ann i n j u r i e s and s e v e r e burns.

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Fire

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A small f i r e truck., manned bg two f i r c i l e n , was parked nexr t o t h e KUnWaF-a s t a n d a r d p r a c t i c e %hen a i r c r a f t arc schcduled t c land a t Pago Pago.

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A t 2343, t h e f i r e s t a t i o n received t h e f i r s t alarm. Response was delayed b k m e of sonf.Jsion as t o w h e t h e r _ a hnusr or an i r c r a f t was involver! i n t h e r e p o r t e d fire. Response t o t h e a c c i d e n t h a s f u r t h e r delayed by h e a q - r a i 3 and two c h a i n g a t e s across t h e a c c e s s road from t h e a i r p o r t i o t h e a c c i d e n t scece.

Access t o t h e f i r e vas l i m i t e d t o a one- lane road, and only one p i e c e of f i . r c f i g h t l n g equipment a t a t i m e & i i i I b ? p 5 6 a t h and f i g h t t h e f i r e . The d e p a r t n e n t ' s a c t i v i t i e s were l i m i t e d t o e x t i n g u i s h i n g t h e f i r e . No r e s c u e a c t i v i t i e s could ic carried o u t u n t i l a f t e r t h e f i r e was under control.

1.15

S u r v i v a l Aspects

- _ _ _ ~ ~ ~

This was a s u r v i_v _ a b l.e. a c ~.~ cident. ~~

PGssengers who survived t h e a c c i d e c t s a i d t h a t t h e impact f o r c e s wer&g@rlrmoteswere~ than a normal landing. No drmage t o t , k c a b i n i n t e r i o r was reported. Large f i r e s were seen O U I r i g h t side of t h e a i r c r a l t . One person opened an o v e w i n g e x i t on t h e r i g h t s i d e of t h e a i r c r a f t ; flames came i n through t h e e x i t , and he c l o s e d It. Other surv.tvors opened t h e l e f t owxwfng e x i t s , and all^ t h e s u r v i v o r s excep'. t h e f i r s t o f f i c e r escaped through those e x i t s . The f i r s t o f f i c e r was a s s i s t e d i n h i s escape by two o t h e r c3cI:pit crewmembers and l e f t the a i r c r a f t through a h o l e i n t h e c c c k p i t w a l l . The s u r v i v i n g passengers r e p o r t e d t h a t ~ m ~ a s s e n g rushed e ~ s t o w a _ r d w z e n t and rear of the^ c a b i n b e f o r e t h e a i r c r a f t sropped. The s u r v i v o r s d i d not hear i a s t r u c t f o n s r e g n r d h g escape from t h e a i r c r a f t a f t e r t h e e c c i d e n t . Most of t h e s u r v i v o r s s u f f e r e d burns and o t h e r i n j u r i e s a f t e r :hcy esc.aped from t h e cabin. l e d t h a t t h e forward and t h e P o , s ~ t a c c i ~ e n t ~ ~ n ~ s t i gxaetvi eDa n r e a r ~ g n t r ydoors wese not opened o r used f o r escape. The forward door was opened about 2 t o ~3 inches, b u c ~t h e a f t door was cloded. wreckage.

The forward g a l l e y s e r v i c e door could noc be i d e n t i f i e d in tlie The rear g a l l e y s e r v i c e door was found i n p l a c e and locked.

1.16

Tests

and R e s e a r s

F l i g h t R c - z d e r Data

- Airplane Perforr.;rnce Data Analysis

The measured v a l u e s of t!le f l i g h t d a t a re:order

parametc?rs

wOre annlyzed along w i t h t h e t h r u s t v a l u e s determined froa the S c n r a l E l e c t r i c Company's s p e c t r o g r a p h i c s t u d y of t h e c o c k p i t v o i c e r e c o r d e r

t a p e and t h e n a n u f a c t u r c r ' s d a t a on a i r p l a n e performance. Tht purpose of t h i s a n a l y s i s was t o d e t e r n i n e t h e magnitude o t the winds along t h e f l i g h t p a t h and t u c o n s t r u c t a f l i g h t p r o f i l e which would r e l a t e t h e a i r p l a n e ' s p o s i t i o n d u r i n g the f i n a l m i n u t e w i t h t h e ILS g l i d e s l o p e and t h e corresponding VAS1 i n d i c a t i o n .

-

12

--

( a ) Determination of winds encountered The a i r c r a f t ' s performance c a p a b i l i t y f o r a g i v m set of condit.ions ( i n c l u d i n g weight, c o n f i g u r a t i o n , t h r u s t , a i r s p e e d , and a l t i t u d e ) Is d e s c r i b e d by a s p e c i f i c p l o t of v e r t i c a l s p e e d s v e r s u s l o n g i t u d i n a l accel.erations. When tho val.ues f o r t h e a i r p l a n e ' s rate of a l t i t u d e change and r a t e of a i r s p e e d change a t a given i r i s t a n t were n o t compatible w i t h t h e calcu1a:ed t h e o r e t i c a l performance c a p a b i l i t y , t h e d i f f e r e n c e s were a t t r i b u t e d t o e x t e r n a l f o r c e s on t h e a i r p l m e which were produc.ed by changes i n t h e v e r t i c a l and h o r i z o n t a l components of t h e wind.

I i I

Although t h e t o t a l e f f e c t of t h e wind could be determined by these a n a l y s e s , t h e e x a c t combinations of v e r t i c a l and h o r i z o n t a l wind components which t h e a i r c r a f t encountered could n o t be determined p r e c i s e l y .

I

The d a t a showed t h a t t h e winds encountered by t h e a i r c r a f t were c h a r a c t e r i z e d as follows: From about 58 seconds b e f o r e Impact t o 51 seconds, v e r y l i t t l e wind e f f e c t ; from 51 seconds t o 47 seconds, a n i n c r e a s i n g headwind about: 5 knlsec., a n u p d r a f t of o v e r 4,000 fpm, some combination of i n c r e a s i n g headwind and u p d r a f t ; from 47 seconds t o 39 seconds. a d e c r e a s i n g headwind about 1 knlsec., a downdraft of about 1,000 fpm, some combination of d e c r e a s i n i hesdvind and downdraft; from 39 seconds t o 27 seconds, an i n c r e a s i n g heedwind v a r y i n g between ahout 1.5 knlsec. aad 3.5 k n l s e c . or an u o d r a f t v a r s i n a hetween about 1,200 fpm and 3,000 fpm, or some combination of i n c r e a s i n g headwird and u p d r a f t ; from 27 seconds t o 4 seconds, 1 i t : l e wind e f f e c t ranging from . 3 kn!scc. i n c r e a s i n g headwlnd t o .6 kn/sec d e c r e a s i n g headwind, from 300 fpm u p d r a f t t o 450 fpm downdraft, some combination of headwind change and v e r t i c a l wind change; f i n a l 4 seconds (from 1 2 5 " f e e t above t o ground), a d e c r e a s i n g headwind of about 2 knlsec., a downdraft of about 1,700 fpm, 0~ a combination of d e c r e a s i n g headwind and downdraft.

x

~-

,et:

The t h r u s t u h i c h would have been r e q u i r e d f o r t h e a i r c r a f t t o have achieved l e v e l f l i g h t w i t h a c w s t a n t indickrted a i r s p e e d was a l s o c a l c u l a t e d f o r each o f the envircnmental c o n d i t i o n s encountered. The t h r u s t r e q u i r e d f o r a l l c o n d i t i o n s except t h a t encountered d u r i n g t h e f i n a l 4 seconds was less t h a n t h e t h r u s t avaf.labible with takeoff power a p p l i z d (nominally zbout 57,000 poands). When encountering t h e c a l c u l a t e d wind change for t h e f i n a l L seconds of t h e f l i g h t , t h e t h r u s t which would have been r e q u i r e d t o m a i n t a i n u n a c c e l e r a t a d level f l i g h t woald have e x c t d e d t h e t h r u s t a v a i l a b l e a t cakeoff power. Ur!der t h e s e cur.ditions, l e v e l f l i g h t cou1.d have been maintained For a s h o r t time a i t h e s a c r i f i c c of a i r s p e e d . With continued exposure t o these wi.ltd changes. t h e a i r c r a f t wou:d. eventually, decelerate t o a s t a l l . These wind changes, however, were c a l c u l a t e d based on *:he a i r c r a f t ' s descent p r o f i l e . I f t h e winds during r:!e l a s t 4 seconds were v a r y i n g a s a f u n c t i o n of a l t i t u d e caused by rhe f r i c t i o r e f f e c t s assocj.atpd w i t h t h e i r ( t h e winds) c l c s e proximity t o t h e tcrrsi::, t h e y cc,uld have

-

1'3

-

1:een s i g c i f i c a n t l y d i f f e r e n t than thcwe c a l c u l a t e ? from t h e d e s c e n t p r o f i l e . I n wldch case, the a i r c r a f t , once l e v e l f l i g h t had been achieved, nay have encountered a more s t a b l e wl.nd v e l o c i t y . Under t h e r e condicions. t h e a v a i l a b l e t h r w t would have been s u f f l c i e n : t o a c c e l e r a t e t h e a i r c r a f t o r t o climb. The amoun: of a l t i t u d e which t h e a i r c r a f t would l o s e dur'ing a t r a n s i t i o n from a 1.500 f e e t p e r minute drxxent t o l e v e l f l i g h t following t h e p i l o t ' s i n i t i a l a c t i o n t o arrest t h e d e s c e n t i s dependent upon several v a r i a b l e s - - i n i t i a l a i r s p e e d , t h e caLe and amount of t h e p i l o t ' s c o n t r o l i n p u t , t h r u s t management, and w:r.d changes. This 1 3 a dynamic problem which would probably produce a range of r e s u l t s if exominfd in s i m u l a t i o n . A1:hough s i n l u l a t i o n was n o t conducted, t h e q u e s t i o n was analyzed based upon s p e c i f i c assumptions. These assumptions were: (1) t h a t t h e maneuver was i n i t i a t e d a t an a i r s p e e d of 148 kn; ( 2 ) t h a t t h e p i l o t introduced a c.ontro1 column i n p u t t o produce a load f a c t o - of 1.5g. o r a c t i v a t e t h e s t i c k s h a k e r whichever occurred f i r s t ; ( 3 ) t h a t t h e p i t c h rate was such t h a t maximum p i t c h channe was accomplished d u r i n g a 3-second p e r i o d ; ( 4 ) t h a t t h e r e was no s i g n i f i c a n t i n c r e a s e i n t h r u s t u n t i l t h e r i r c r a f t reached l e v e l f l i g h t ; and, (5) t k a t t h e wind was v a r y i n g only as a f u n c t i o n of t h e a!.rcraft's change of a l t i t u d e . Under t h e assumed c o n d i t i o n s , t h e a i r c r a f t would have l o s t about 55 f e e t i n completing t h e mane*mer. 'fie t o t a l change i n p i t c h a t t i t u d e would be from about nose l e v e l a t t h e inS:iatlon of t h e maneuver t o about 12O nose up a t t h e i n s t a n t l e v e l f l i g h t W.'B a t t a i n e d : . Thus, t h e r o t a t i o n rate t h e a i r c r a f t assumed was a b o u t 4'lsec, s l i g h t l y higher thar, t h e 3'Isec normally used i n a go-around maneuver. The a i r c r a f t would l o s e about 7 kn of a i r s p e e d i n completing t h e l e v e l o f f . Assuming t h a t , as the. d e s c e n t rate was arrested, t h e p i l o t lowered t h e nose of t h e a i r c r a f . t o m a i n t a i n l e v e l f l i g h t , the a i r c r a f t would have an i n i t i a l d e c e l e r a t i o n r a t e of about 1.5 k n l s e c and t h e i i n c r e a s i n g r a t e until She ellgil1CS bere d e c e l e r a t i o n would c m r i n u e a t m producing h i g h e r t h r u s t . The i n s t a n t a n e o u s a p p l i c a t i o n of t a k e o f f t h r u s t a t t h c i n i t i a t i m of t h e l e v e l o f f maneuver, even i g n o r i n g all allowance f o r engine a r r e l e r a t . i o n time, would have hat! no s i g n i f i c a n t e f f e c t on rhe t o t a l l o s s of a l t i t u d e .

The thrus-. which wculd b e r e q u i r e d t o m a i n t a i n , p o s i t i o n on a 3.2S0 g l i d e s l o p e in no wind c o n d i t i o n s f o r two c o n f i g u r a t i o n s Was S l S O c a l c u l a t e d . For a .LOo f l s p c o n f i g u r a t i o n , a t 150 kns, about 20.lf"l pounds 01 t h r u s t would be r e q u i r e d , A 50° f l a p ConfiRur~ltiOnwould r e q u i r e a t o u t 24.170 pounds of t h r u s t t o m a l n t a i n an approach a j ~ r s p e e d of 4 4 0 kns. (b)

k t e r m 5 n a t i c n of P l i g h t P r o f i l e am? R e l a t i o n n t l p ILS G l i d e Slo;>e nod VAS1 Indi$-gt.Lo2 1he Zli,cht p r o f i l e -~ of t h e a i r c r a f t . $:hat i s . i t s 31ti:ude v e r s u s discnnce f r m tile rc.WL'2.y t h r e s h o l d . was de-ermined f o r t h e l a , s t minute of L l i g h t usin[; air:;pc..d

--

..

.

- 14 -

.

and a l t i t u d e v a l u e s from t h e FDR. The v a l u e s were used u n c o r r e c t e d and c o r r e c t e d f o r che i p p a r e n t errors e v i d e n t from impact s i t e e l e v a t i o n and C'JR c a l l o u t s . T h e c r l c u l a t l o n s were performed assuming bot}, a 15-kn c o n s t a n t neadwind and a. hcnduin: which v a r i e d between z e r o and 35 kns (Che maximum wind speed i n d i c a t e d i n m e t e o r o l o g i c a l r e p o r t s ) i n accordanco W i t h t h e Wind a c c e l e r a t i o n s determined i n t.he d e s c r i b e d wind a n a l y s i s . The f l i s h t p r o f i l e s were compared w i t h t h e corresponding p o s i t i o n s of t h e ILS and VAS1 g l i d e nlopcs. Txe ILS g l i d e s l o p e e l e v a t i o n s were c a l c u l a t e d free a 3.25' .?lick s l o p e w i t h a t h r e s h o l d c r o s s i n g The V A S 1 i n d i c a t i o n s h e i g h t of 55 i t and a i r p o r t e l e v a t i o n of 30 E t . were determined Ear a s y s t e m I n s t a l l a t i o n and alignment as desc.ribed in FAA Document 6950.2, Handbook Visual Guidance L i g h t i n g Systems, October 16, 1974. (Thp r e s u l t s for a p l a u s i b l e so.: of assumptLnns--using

corrected

FDR a l t i t u d e and a i r s p e e d v a l u e s and headwinds v a r y i n g between z e r o and 35 kns- - are shown i n Append5.x E.) T k r e s u l t s i n d i c a t e that .he a i r c r a f t was b r a c k e t i n g , and w i t h i n 30 f e e t ? f . the g l i d e s l o p e w i t h a r e d / w h i t e VASi i t l 2 i c a t i o n p r e s e n t e d from 1 udnoLe u n t i ? 40 seconds b e f o r e i m p x t . ,It t h a t t i n e , t h e a i r c r a f t crossed the g l i d e sLope c e n t e r l i n e fxom iow t c h:gh. The a i r c r a f t continued t o d i v e r g e above t h e G l i d e s l o p e w!\ile a i r s p e e d i n c r c a s r d ahout 10 krm u n t i l , about 20 secorc's b e f o r e impact, i t reached a g l l u e :;lope d c v i a t l o n of 55 i t (one-dot displacement on raw data d i s p l a y ) . The V A S 1 would have p r e s e n t e d a' pink/white i n d i c . n t i o n during th?,t p e r i o d . About 16 seconds b e f o r e impact, the a i r c r a f t began t o r i . p I . i l y converge w i t h t h e g l i d e slo?e. The u i r c r r f t c r o s s e d t h e g l i d e . fit;pc Srom high Y O low between 11 and 12 seconds h e f o r e impnct and continded 10 d i v f 1 g e below t h e g l i d e s l o p e u l ? t i l impact. The VAS1 p r c s c n t a t i c n w0ul.l have changcd r n p i d i y goinc from pinklwhito t o r e d / w h i i e a b a u t 12 se.conds b f r o r e inpacc, t o r e d i p i n k ahout 8 seconds, and t o red/rc.3 abouc 6 secocds b e f o r e i n p a c t . The g l i d e !slope raw d z t a w w l d have shown .I f u l l scsle d e v i a t i o n f o r t h c f i n a l 6 crecoads. 1.17

A d d i t i o 2 a l Informntion &me

1.17.1

Uric of F l i g h t i l l r e c t o r i n Windshear Conditions

A n eagineerin:; f l i g h t s i m u l a t o r was used t ~ oo b s e r v e pilot and a i r c r a f t performan-e during passnde through windshear cnviromnents a s p a n o l t h e i i v e s t i g a t i o n of a n o t h e r nccldent. 21 Durinf: t h e s i m u l a t i o n , some p i l u t s m t e d t h a t t!13 s i n u l a t o r would c c n t i n u e t o d e s c e n t t u impact t h e gc?.wx\ w h i l e b c l o w g i i d c s l o p c , even though the f l . i g h t d i r e c . t o r

-5 /

-

I ' a s t c r n Air Lir,es, I.nc.. E - 7 2 7 , (!.ITSD-AAR-7(;-8.

.

Jamlica, ::ew Ycrk, June 2 4 , 1975

- 15 S t e e r i n g comands were n x l l e d . T h i s W ? J noted when p a s s i n g tb.rough programmed winds which c o n s i s t e d of r a p i d changes in both t h e h o r i z o n t a l and Vertical speeds. FOllOwing t h a t same a c c i d e n t , s i m u l a t e d windshear e n c o u n t e r s were condvcted a t t h e NASA Ames Research Center. During t h o s e tests, t h e p;tch a t t i t u d e r e q u i r e d t o s t o p t h e d e s c e n t r a t e o f t e n exceeded t h e f l i g h t d i r e c t o r p i t c h command limirs when t h e encountered wind caused a r a p i d and extrerte speed decay, or a f t e r a l a r g e g l i d e s l o p e e r r o r was allowed t o d e r e i o p as a r e s u l t uf slow p i l o t re-sponse t o i n i t i a l conuands, o r a f t e r a f l s g h t d i r e c t o r s t e p g a i n d e c r e a s e was i n i t i a t e d a t MM passage. R e s t r i c t e d Cargo

1.17.2

The a i r c r a f t WBS c a r r y i n g r e s t r i c t e d cargo. The c a r g o , listeZ a s a r t i c l e tiff. 727 by thz Intern.?l:ional Air Transport A s s o c i a t i o n (IATA) R e s t r i c t e d Articles Regulation, was e t h y l methyl ketone p e r o x i d e (.VK peroxide) IATA r e g u l a t i m s s p e c i f y t F 2 maximum q u a n t i t y t h a t nay b e packed i n any one o u t s i d e ccmtainer .ts 1/2 kilogra;? (1 pound) or 3.12 litre (1 p i n t ) . Compatible p l a s t i c tubes of n o t o v e r 5cc (116 f l u i d once) CaQaciry each, packed w i t h sufficient noncombustible c u s h i a n i n g an& absorbent m a t e r i a l which w i l l n o t r e a c t w i t h t h e c o n t e n t s and which w i l l prevent breakage or lee,kag?. s h a l l be packed i n iibe.rboard c o n t a i n e r s up t o a maximun n e t c[u;tntitl. oi 1 / 2 kilogram or 1 / 2 l i t r e . No more t h a n 24 of t h e s e c o n t a i n e r s ehould b c packed i n t o cne c o n t a i n e r ' . prcz-iiding t h e n e t quanti- v doe3 n o t cxceec. 1 k i l c g r a n ( 2 pcunds), o r 1 l i t r e p e r container. I

f

I !i

I

1

j

i

!

The r;lK p e r o x i d e ~ ( 3 sd i l u t e d t o 50.8 p e r c e n t peroxideowith hydroquinone. This i a h i b i t o r i n c r e a s e d t h e f l a h h p o i n t from 125 F t o 180' F, in a d d i t i o n t u i n h i b i t i c g i t chemically. The cnrpo consi.sted of 200 20cc b o t t l e s , w i t h 50 h o t t l e s p e r 1 g a l l o n [.in. "he b o t t l e s were placed i n p l a s t i c hags and then i n t h e t i n s . P e r l i t e was placed beneath, around, and above t h e bags. The fins-were sealed. ':?IF Iour t i n s were then placed i n a f i b e r b o a r d c x r t o o . The weight of t h e k : K peroxide i n t h e c . a r t w was 4 kiloglams. The shipper'. who was r e s p o n s i b l e f o r IdentiEyinS t h e material a s ha?.ardous, b e l i e v e d t h a t t h e f l a s h p o i n t of t h e material was the o n l y c r i t e r i o n for c l a s s i f y i n g m a t e r i a l a s hazardous. Consequer.tly. :he f r e i g h t forwarder and t h e c n r r i c r were not advised t h a t t h e n a t e r i a l was hazardous. F u r t h e r , s i n c e t h e f l i g h t d i s p a t c h ~ ; ~ D ~ xd si d n o t i d e n t i f y the. m a t e r i a l , t h e f l i g h t c r e w was unaware of t h e n a t u r e of t h e cargo.

.

1.17.3

C=anv

Procedures

foilowing procedures a r e extracteri from t h e Pan Aaerican Fliglkt O p e r a t i a m Vdnual.: The

11 . Conducting t h e Anproach and Laadirip

R e g s r d l c a j of t h e t y p e of approach. ,:!le a i r c r a f t should be on f i n a l approacn i n ;:lie landing c o n f l g u r a t i o n w i t h t h e

I

\

1 I

! !

i

-

16

-

Landing C h e c k l i s t complete, i n lMC, n o t lower than 1.000 f e e t A t t h i s point, the a i r c r a f t should be s t a b i l i z e 3 on t h e p l i d e p a t h , on Vprog, w i t h t h e proper s i n k r a t e 2nd trimmed fcr z e r o c o n t r o l f o r c e s .

AFE or, VMC, n o t lower t h a n 500 f e e t ATE.

I

During any approach, t h e p i l o t n o t f l y i n g i s t o c a l l - o u t r h e s i n k - r a t e when i t exceeds 800 FPM, ILS Approach Cal.1suJ:

During an I L S approach, t h e p i l o t no: foll.aw1r.g c a l l - o u t s :

f l y i n g is t o make t h e

1.

Outer Marker Outer marker, a l t i t u d e checks, i n s t r u m e n t s crosschecked.

2.

500 f e e t AFF 500 f e e t . i n s t r u m e n t s cross- checked.

3.

100 f e e t above Lii (Decision Height) 100 f e e t above m c i s i o n h e i g h t 2nd t h e a i r s p e e d .

4.

A t Dl1 A t d e c i s i o n hei.zht c a l l o u t 'Decislon h e i g h t , ' follcwed by ' v i s u a l c o l t t a c t ' or 'no c o n t a c t ' as app:dprlate.

"Approach Duties

T'le f l i g h t e n g i n e e r w i l l i n a d d i t i o n to h i s r e g u l a r d u t i e s : Monitor. c o m u n i c a t i o n s . Cros$--check i n s t r u m z n t s . B e {aware of c o r r e c t altimeter s e t t i n g and a i t i t u d e . Re .alert for missed rtpproach. Watch for v i s u a l cue$; approaching UH/MDP.. The Second/Third O f f i c e r w i l l :

.

Monitor cumnunications. Cross-check i n a t r u n e o t s . Use approach c h a r t s t o monitor nppronch. Confirm c o r r e c t fac..'l.ities tuned a n d i d e n t i f i e d . Be aware of correct. altimeter s e t t i n g end crosscheck a l t i t u d e . 'Jiltch f o r v l s u a l CUPS approaching DHIMDA. "Det?rnining -_

n:ill.mii

- Approaches

Other Than Cztegory I1

The i)ii or ?IDA f o r a n y appt:oaches o t h e r than a Category II

ILS i s determined by r e f e r e n c e t o t h e b a r o m e t r i c a l t i t u d e .

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.

L i m it&? It

Descent Rates Relow 2 , O C c W

The m&xFmum d e s c e n t rate recomended below 2,OGO Eeet above ground l e v e l (AGL! is 1,000 FPN."

1.17.1

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~ ~ o ~ ~ u n l i f i cProgram a t i o ~Pcn Americar,

Pan Amcrican World Airways usee a movie t o augu*wt their A i r p o r t 3 u a l i f i c n t i . o n Program. Ihe movie about t h e Pago P.igo A i r p o r t emphasizes t h e I',S/DXE procedure. The movie and n a r r a t i v e are d e s c r i p t i v e ; however, because of r e c e n t p h y s i c a l changes in t h e a i r p o r t and a change in t h e r e p o r t e d e l e v a t i o n of Logotala H i l l , t h e p o r t i o n s of t h e m 0 v i . r . which r e l a t e d t o t h e s e i t e m s were o u t d a t e d . The approach was a c c u r a t e l y d e s c r i b e d . The n a r r a t i v e also s t a t e d . when u p c r a t i n g VFR, "!he t o T e r r a i n , when landing on runway 5 , maintain 1,000 f e e t and d i s r e g a r d VAS1 u n t i l c r o s s h g Lima Oscar Gold YUB. A t t h i s p o i n t , VAS1 w i l l 1-ndicatr high."

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New Invest-n

Technique0

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PXALYSIS

General The a i r c r a f t was c e r t i f i c a t e d , equipped, 8r.d mainta.ined according t o requirements and Tegulations. The g r o s s weighr and c.g. ware w i t h i n y r e s c r i h e d limlts during t a k e o f f a t Auckland and t h s approach t o Pzgo Pago. I'he f1igl.t cremembera w E r e c e r t i f i c a t e d and q u a l i f i e d ir, accordance w i t h company and FAA r e g u l a t i o n s .

Based on t h e i n v e s t i g a t i o n , t h e t h i r d o f f i c e r ' s s t s t e n e n t . and t h e perfo=ance a n a l y s i s , t h e S a f e t y Board concludes t h a t t h e aircraft's powerplants, airframe, e l e c t r i c a l and p i t o t / s t a t i c instruments. f l i g h t c o n t r o l s , and h y d r a u l i c aud e l e c t r i c a l systems were not f a c t o r s in t h i s accident. Although t h e e t h y l methyl k e t m e peroxide was i n p r o p e r l y packaged, t h e r e i s no evidence t o i n d i c a t e t h a t i t c o n t r i b u t e d t o t h e cause of t h e accsdent o r t o t h e d e a t h of t h e passengers and crew. The Approach l'he CVR readout and t h e icterview w i t h t h e f i r s t o f f i c e r e s t a b l i s h e d t h a t t h u runway was in s i g h t when t h e a i r c r a E t was about 8 nmi from t h e runway t h r e s h o l d . The runway probably r w a i n e d i n s i g h t d u r i n z most of t h e approach. The f i r s t o f f i c e r c m e n t e d f i v e times d u r i n g t h e approach, afte?: t h e a i r c r a f t was v i t h i n 7.5 n n i of t h e runway t h r e s h o l d , t h a t he had t h e runway o r t h e runway l i g h t s in rigt:t. There was no i n d i c a t i o n t h a t any of t h e navigation&. a i d s o r t'.e a i r c r a f t instruments were faulty. The a l r c r n f t descended about 500 f t . below t h e published

minimum g l i d e s l o p e i n t e x e p t a l t i t u d e of 2,500 f t . b e f o r e t h e g l i d e s l o p e i n t e r c e p t p o i n t was roached. This placed t h e a i r c r a f t 180 f t . b e l o v t h e f i n a l approach f i x a l t i t u d e of 2,180 f t . These a l . t i t u d e s are confirmed by a CVR c c m e n t , "Tvo thousand", made abcut 1.5 seconds b e f o r e t h e FAF c a l l o u t . The S a f e t y Boar2 was unable t o determine t h e reason f o r thCs d e v i a t i o n from approach procedures.

A t FAF passage, t h e 7 nmi DKL f i x , t h e f i r s t o f f i c e r ' s navis e l e c t o r s w i t c h should have been changed ?om t h e VOR y o s i t i o r . tr, t h e -iLS p o s i t i s n ; hoxever, t h i s v a s n o t a c c m p l x s k e d . I f t h c change had been made, a s goo3 p r a c t i c e would d i c t a t e , t h e f i r s t o f f i c e r could have monitored t h e apprrach ~ o r de f i i c i c n t l y and his . I

9p.ationa1 r e c e i v e r

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n a v i g a t i o n a l d i s p l a y would have been ready f o r crosscheck by t h e c a p t a i n or crossover in c a s e of t h e f a i l u r e of t h e c a p t a i n ' s i n s t r m m t s .

As t h e a i r c r a f t approached t h e g l i d e s l o p e , i.t continued through and above i t a6 t.he c a p t a i n s t a r t e d h i a descent. The g l i d e Slope was iutcrcepred a s t h e a i r c r a f t passed through about 1.000 f t . "he airspeed during t h i s time v a r i e d a few 'mots above and below 160 b. From t h i s p o i n t on d u r i n g t h e approach, FDR. i n f o r c a t i o n shared t h a t t h e a i r c r a f t f l i g h t p a t h waa n o t c m p a t f t l i - with t h e a i r c r a f t performance which would b e expected i n E t a b l e a i r . The d i f f e r e n c e s can be a t t r i b u t e d t o e x t e r n a l f o r c e s a c t i n g upon t h e a i r c r a f t , c ~ c has wind changes or r a i n drag. Analysis has s h m t h a t a ma::mun d e n s i t y r a i n could produce an i n c r e a s e i n drag f o r c e s i h l c h would equate t o a -600 fpm change in descent r a t e ; however. s t a t e m e n t s by t h e f i r a t o f f i c e r and t h e s u r v i v i n g passengers refute any claim t h a t t h e a i r c r a f t encountered suc:l a heavy r a i n b e f o r e impact. Therefore. the d i f f e r e n c e between e x p e c t e d and recorded a i r c r a f t performance was more l i k e l y caused by t h e winds. An a n a l y s i s was conducted t,o determine t h e wind changes needed t o produce t h e recorded a i r c r a f t performance. The f l i g h t r e c o r d e r d a t a as recorded and c o r r e c t e d f o r an assumed 9-knot a i r s p e e d e r r o r . as i r d i c a t e d b:' t h e f i r s t o f f l . c e r ' s airE,pertd c a l l o u t s , were used in t h e a n s l y s i s , 'Ihc d i f f e r e n c e s produced b'y t h e 9-knot e t r o r w e r e . n o t considered t o be o i g n i f i c e n t i n t h e m a l y z e d wir.d.

This a n a l y s i s i n d i c a t e d t h a t t h e a i r c r a f t encountered gusty wind c o n d i t i o n s w i t h a pre.dom!.nmtly i n c r e a s i n g headwind and/or an % u p d r a f t about 50 seconds b e f o r e Impac,t. The i n f l u e n c e of t h i s wind c o n d i t i o n p e r s i s t e d f o r about 25 seccnds. The S a f e t y Boiird b e l i e v e s ' - t h a t t h e windshear was caused by t h e ouzflowing winds from t h e r s i n s t o r m Over t h e a i r p o r t a s they were a f f e c t e d by t h e upsloping t e r r a i n around Logotala Bill. The v i n d s h e s r was zvident by a s h a r p i n c r e a s e i n a i r s p e e d and a s h a l l o w i n g of t h e descent pzth. Consequently. t h e a i r c r a i t vrnt above t h e g l i d e slope. The a i r s p e e d a t chis time was s t i l l about 160 The sound spectogram showed t h a t . at t h i s time, t h e t h r u s t was reduced t o a p p a r e n t l y c o r r e c t t h e high and f a s t condition.

kn.

As t h e a i r c r a f t passed Logotala Hill, i t a p p a r e n t l y came o u t of t h e i n c r e a s i n g headwind or updraft, c o n d i t i o n and t h e p o s i t i v e performance e f f e c t was l o s t . I n f a c t , B wind which produced D small n e g a t i v e performance e f f e c t was probsbly encountered. The t h r u s t was v e i l below t h a t normally needed f o r a s t a b i l i z e d approach, and. about l m d s b e f o r e impact, t h e a i r c r a f t s t a r t e d a r a p i d descent. of about ~1.500 fpm. ~

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Isi n i t i a l e f Thus, t h e Board concludes t h a t t h e c a p t a i n recognized t h e f e c t of t h e windshear c o n d i t i o n and acted ta c o r r e c t t h e a i r c r a f t ' s f l i g h t p r o f i l e t y reducing t h r u s t , b u t h e d i d n o t reccgnize t h e second e f f e c t as ;he windshear c o n d i t i o n changed. Consequently, t h e a i r c r a f t , with low t h m s t , respondfd t o t h e changing wind by &velo p i n g a h i g h descent rste. The c a p t a i n had a t least 1 2 seccnds in which he could have taken a c t i o n t o arrest the. d e s c e n t i n time t o prevent thu accitient. During t h a t time, t h t t o t a l t h r u s t a v a i l a b l e exceeded t h a t r e q u i r e d t o maintain c,onstant a i r s p e e d in l e v e l f l i g h t . 'that t h e n e c e s s a r y p i t c h a t t i t u d e and t h r u s t changes were not a p p l i e d C M only i n d i c a t e t h a t t h e fii&h!xrerr was n o t aware of t h e high d e s c e n t rate and t h e inpending c r a s h . Evidence i n d i c a t e d t h a t , when the sink r a t e i n c r e a s e d , the c a p t a i n may have been looking o u t s i d e t h e a i r c r a f t and, t h e r e f o r e , .)as n o t f l y i n g by r e f e r e n c e t o t h e f l i g h t instruments. A t t h e time the sink rate i n c r e a s e d t o abaut 1,500 fpm, t h e aircraft war over an area dr:void of l i g h t s (knom as a " blackhole" ), a heavy t r o p i c a l r a i n s t o r m was over t h e a i r p q r t and moving toward the approach end of t h e runway, and t h e f i r s t o f f i c e r had c a l l e d t h e runway i n e i g h t .

The c i r c u n e t a n c e s of s e v s r a l o t h e r a c c i d e n t s which have. been invest,!.gnted by the Fr!*.r.! hevg i?..iicetz5 $52: : ! x$r?nsf.t.ion fr'r~u l n s t r u n e n t f i i g h t t o v l s u a l r e f e r e n c e f o r v e r t i c a l guidance is t h e most c r i t i c a l p o r t i o n of t h e approach, p a r t i c u l a r l y i f t h e t r a n s i t i o n i s i n i t i a t e d prematurely. DynaQic changes t o t h e a i r c r a f t ' n f l i g h t p r o f i l e are a p t t o go unrecognized. In t b i a a c c i d e n t , t h e heavy rainshower a h e a i of t h e a i r c r a f t probably caused v i s u a l cue8 t o d h i n i s h t.0 t h e e x t e n t t h a t t h e lncrea!?fd s i n k r a t e would have been extremely d i f f i c u l t . i f n o t impossible, t o recognize. An a result of previous s t u d i e s , t h e S a f e t y Board has endortied s t r o n g l y t h e i n s t a l l a t i o n of VASI as a v i s u a l a i d t o v e r t i c a l guidance and even n o r e so. t h e o p t i n i z s t i o n of 1nstrumer.t approach procr:durrs whi.ch would prevent the premature t r a n s i t i o n t o v i w a l r e f e r e n c e by t h e p i l o t c o n t r o l l i n g t h e a i r c r a f c . VASI was avsj.lable and o p e r a t i n g d u r i n g this approach, however, there was no way t o drr.ermine w i t h c e r t a i n t y t h a t t h e crew could have s e e n VAST c o n t i n u a l l y during t h e approach because of t h e heavy r a i n s t o m zh3t was moving a c r o s s t h e a i r p o r t . As t h e heav; r a i n a s s o c i a t e d w i t h t h e storm moved toward t h e a i r c r a f t ' s approach path f r o = t h e op2csitc end of runway 5 , the rain most l i k p l y would have obscured, p r o g r e s s i v e l y . each pair of russny edge 3.ights. This o b s c u r a t i o n would have progressed u n t i l t h e VASI disnypeared from t h e f l f g h t c r e w ' s s i g h t . A t t h j s p o i n t , 1 been contlnued because t h e app7oach 11&:3, t h e approach could ~ t i l . kave t& runway end i d r n t i f l . e r l i g h r s , and up t o 750 f t . of runvay edge l i g h t s could have bcen visib1.e t o t h e f l i g h t c r e w . The f a c t t h a t scme l i g h t s were - ~ i s i b l ct o t h e 3 i s v e r i f i e d 5y C t w repeated c a l l o u t s t o t h a t e f f e c t made by :he f i r s t d f f i c e r iluring :he approsch.

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- 21 The S a f e t y i)oard b e l i e v e s i t l i k e l y t h r t t h e f l i g h t c r e w d i d a t aome time d u r i n e t h e approach, p a r t i c u l a r l y after t h e f i r s t c f f i c e r ' s rt?port t h a t t h e a i r c r a f t was "...a littie :ligh." Even though t h e f i r s t o f f i c e r could n o t remember s e e i n g t h e !:GI, the most l i k e l y r e f e r e n c e fer h i s s t a t e m e n t of t h e aircrart's -,oaition relative t o t h e g l i d e s l o p e would have been VMI. becsuce he had not changed h i s No. 2 navi]:c~tional r e c e i v e r selectcr switch t o th- 11,s frequency. r h e r - f o r e , ILS i n f o r m a t i o n was no( dinplayed on h i s inetruments a?d t o o b t a i n t h i s information, o t h e r than v i s u a l l y . he would have hod t o look " cross- cockpit" a t t h e c a p t a i n ' s inotruments t o detexmine t h u t t h e a i r c r a f t was high. In t h e l a s t f e w s e c m d a , t h e f i r s t o i f i r a would have had t o look b.tck into t h e c o c k p i t t o a s c e r t a h tha: Lhr? a i r c r a f t was a t minimum a l t i t u d e and t h a t t h e a i r s p e e d was 140 kns and edviaed t h e c.aptain. I t is p o s s i t l e t h a t h e r o u l d n o t have seen t h e below g l i d e s l o p e i n d i c a t i o n s on t h e VASI under the152 circumatancea.

eet! and

u31? VXI

Even had tt.c c a p t a i n been observing VAS1 as t h e a l r c r n i t descended below g l i d e p a t h , h i 0 a t t e c t i o n t o t h e I n d i c a t i o n s and h i s r e a c t i o n t o an unsafe r e d l r e d s i g n a l would have had t o be r a p i d r a d d e c i e i v e i n o r d e t t o prevent impact. The a n a l y s i s of t h e VASI i n d i c a t i o r m . based 0.1 t h e f l i . g h t p r o f i l e d e r i v e d from f l i g h t r e c o r d e r data, showed t h a t , a t t h e time of t h e f i r s t o f f i c e r ' s c a l l o u t , t h e c a p t n i n , asawling t h a t t h e VAS1 wsa . r i s i b l e t o him, would have seen en nbove s l i d e s l o p e i n d i c a t i o n on t!re VASX. T h i s was about t h e s e w t!ee t h 2 h i g h ra:e of deace1.t s t a r r e ? . Without r e f e r e n c e t u h i s flight.. instrumento or a c ~ l from l one of t h e o t h e r crcmemhera in r e f e r e n c e t o t h e i n c r e a s e d r a t e of descent. t h e c a p t a i n would have had no i e a s o n t o .%-yply power a t t h i s timt. If he continued t o watch t h e VASI. he wo11ld hs-ve seen a n "on g i i d e slope" i n d i c a t i o n , then a " s l i g h t l y Icw on t h e g l i d e slope" i n d i c a i i o n ; stili no v i s u a l i n d i c a t i o n a l e r t e d hits t o t.he need f o r a power a p p i i c a t l o n . By t k e t i n e t h a t t h e VAS1 would have chahged t o an unsafe, IOU lndd by uneven t e r r a i n c l o s e to t h e a i r c r a f t ' s approach path. The c a p t a i r . ' ~ recognicion was h&mpered by r e s t r i c t e d v f s i tility. t h e illusory e f f e c t s of a " blackhole" approach, i c a d e q m t r moilitoring of f l i g h t i n s t r u m e n t s , and t h e f a j l u r t l of rhe crew t o c a l l out d e s c e n t rate during t h e l a s t 15 seconds of f l i g h t . I b e l i e v e wc! shculd look a t the whole p i c t u r e when determining F-obable cause. Our v i s i o n becomes too narrow when we adhere t o t h e "1ss;t p o s s i b l e chance t o prevent the a c c i d e n t " as t h e oc?y probable cause. I n t h i s case, t h e ccmplete reasoning should begin w i t h the f a c t t h a t t h e r e was a windsbear and then s t a t e t h e l a c k of proper r e a c t i o n under t h e circumstances.

/ s t KAY BAILEY Acting Chairman

October 6 , 1977

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APPENDIX A Investigat and Hearin&

1.

Invzsti~ation

The S a f e t y Board was n o t i i i e d of t h e accLdent a t about 0825 on Januarg 31, 1974. The i n v e s t i g a t i o n team went immediately t o t h e scene. Working groups were e s t a b l i s h e d f a r o p e r a t i o n s . witnesses. weather, human f a c t o r s , s t r u c t u r e s , maintenance r e c o r d s , powerplants, systems, f l i g h t d a t a r e c o r d e r , and cockpit v o i c e r e c o r d e r . P a r t i c i p a n t o i n t h e on-scene i n v e s t i g a t i o n h c l u d e d repres e n t a t i v e s of t h e F e d e r a l tivisition Administration, Pan hnerican World Airways, I n c . . .Air Line P i l o t s AsoocLation. F l i g h t Englueere I n t e r n a t i o n a l Aszociation. The lroeing Company, P r a t t 6 -&itney A i r c r a f t 2 i v i s i o n of United A i r c r a f t Corpol-ntion, and t h e Government of: American Samoa. 2.

Public H e a z h

A 3-day p u b l i c hearing WB? held a t t h e P r i n c e s s Kaiulani H o t e l , Honclulu. llawaii, beginning N w c h 19. 1974. Parties r e p r e s e n t e d a t t h e hearlr,g were: The Federill Av:Latit,!l A d m i n i s t r a t i o n . Pzn American World Airways, Inc.. Air L i n e P i l o t s A s s o c i ~ 2 t c n . and t h e FlfRht Enaineers Z n t e m a t i o n a l Association.

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- 32 APPENDIX B Personne!,%mmatioc CaFtai? Leroy A. Peterr= CapKaiiI L C K O )A~. Petersen, 5 2 , was employed by Pan American World Airways. I n c . , March 3 . 1951. He r e c e i v e d h i s i n i t i a l B707 t r a i n i n g a s a I k s e r v e Coyilot/Navig3tur Novmber 1, 1960. He WRS upgraded t o Master C o p i l o t c n t h e 11107 on J u l y 2 , 1965, m d t o 8707 c a p t a i n November 10, 196;'. Captain P e t e r s e n had 17,414 f l f g h t hours, of w,hich 7 , 4 1 6 hours were In t h e R 7 0 i .

~I

Captain P e t e r s e n h e l d Airlir:? Tranxrport P i l o t C e r t i f i c a t e No. ?E was t.ype n t e d in ?he DOcJglaS DC4, Boeing 337. 707/720. lie possessed r a d i o c e r r i f i c a c e No. 12507880 and n a v i g a t o r c e r t i f i c a t e No. 1225367, i s s u e d September 5 . 1951. Wia f l r s t class p h y s i c a l was taken Augrrst 9,'1973, wit.h no l i m i t a t i o n s .

7191-41. isstted July 2, 196s.

F i r s t 0 f f . i c e r R i c h a r d V. Gainaq

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F i r s t OEficcr (F/O) Richard \I. Gaines, 37, was employed by Fan American Norld Airuay>>, Inc., Augusc 7. 1964. His i n i t i a l 6707 Reserve Copilot/Navigator t r a i n i n g was completed October 20, 15\64, and he was upgl?ded t o Master CopIlot on J u n e 15, 1.967. He had 5,107 f l i g h t - h o u r s . a l l i n t h e U707. I n t h e c a s t 60 days h e had flown 117:14 hours 3n.I 5 6 : 4 4 In t h e p a s t 30 days. F/O Gaines h e l d A i r l i n e Trancport P i l v i C e r t i f i c a t e No. 3.578h52 d a t e d J u l y 14, 1967, with t y p e r a t i n g s .in t h e Boelng 707/720. He h e l d !radio c e r t i f i c a t e KO. P-3-12-17992 i s s u e d June 23, 1969,. and navigator c e r t i f i c a t e No. 1.62315s. d a t e d February 16, 1965. His f i . r s t c l a s s medical cxamination was tnken November 21, 1973, w i t h no waivers noted. F/O Gainas completed h i s "A" Phase t r a i n i n g 2an;iary 18, 1976. The s i m u l a t o r and a i r c r a f t p @ r t i o n s L f "8" Phase t r a i n i n g were completed J u l y 2 1 and 22, 1973. I n a d d i t i o n , he completed v o l u n t a r y s i m u l a t o r t r a i n i n g July 1, 1973. Mr. Gaines was observed by an FAA i n s p e c t o r March 20, 1973, during nn en m u t e i.nspection. Nauczrous r o u t i n g C c p i l o t T r i p r e p o r t s were reviewed from h i s f i l e , and no adverse c o m e n t s were noted

.

PI0 Gaines had flown i n t o Pago Pzav t u e l s ? times i n t h e y e a r preceding t h e a c c i d e n t .

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- 33 APPENDIX B

-Third

O f f i c e r Jam-s S. P h i l l i p s

T h i r d Officer James S. P h i l l i p s , 43, vas employed by Pan American World Airways, Inc., A p r i l 25, 1966. His i n i t i a l B707 t r a i n i n g as a Reserve Copilot/Navigator waa completed January 3, 1967. He had 5.208 f l i g h t hours, i n c l u d i n g 4.706 hours in t h e B7G7. I n t h e p a s t 60 days, h e had flown 119:07 houra, and in t h e l a s t 30 days h e had flown 56:07 hours. Between J u l y ' a n d December 1973. he recorded 199:33 hours of n i g h t f l y i n g .

Mr. F h i l l i p a h e l d C o m e r c 5 a l F i l o t r a t i n g Yo. 1498280 iasued May 16. 1961, H radio c e r t i f i c a t e i s s u e d Hay 23, 1966, a n d n a v i g a t o r c e r t i f i c a t e No. 172'1148, i s s u e d November 21, ?966. H i 6 f i r s t class medical exaninntion was taken Februarjr 5 , 1973, w i t h no waivers n'ted.

Mr. P h i l l i p s completed "A" Phose of t r a i n i n g November 1 4 , 1973. The followinp, comments were n o t e d by t h e t r a i n i n g c a p t a i n : "'A' Phase complete. Goo? work. Shcxld rate in s i x hours." The "8" Phase s i m u l a t o r t r a i n i n g was a c c m p l i s h e d Fay 7, 1973, and t h e a i . r c r a f t period completed t h e f o l l o w i n g day. After :he a i r c r e f t period. t h e t r a i n i n g c a p t a i n cmtment.ed: " A l l areas a t a good l e v e l of KC0 p r o f i c i e n c y Gk f o r l i n e Idg." T h i s s i r c r a f t period was observed by an FAA i n s p e c t o r . Mr. P h i l l i p s had flow. i n t o Pago Pago A i r p o r t aevcn times in t h e p a e t 7 months. Since Cctober 11. 1973, h e had made seven ttlkeofif! and n i n e landings. F l i g h t Engineer Gerry F l i g h t Engineer (F/E) Gerry W. Green, 37, was employed by Pan He r e c e i v e d h i s i n i t i a l Reserve Copilot/Navigstor B707 t r a i r d n g October 20. 1967, and h i s i n i t i a l B707 F l i g h t Engineer Q u a l i f i c l t i o n s J u l y 2, 1973. He had 2,299 f l i g h t hours of which 1,&44 hours were in tLe B707. In t h e p a s t 60 days he Lad flow1 R2:15 hours, and in t h e p a s t 30 days h e had f l o h 63:13 hours.

Amerlcm Woxld Airways, I n c . , A p r i l 24, 1967. !I

111

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FIE Green h e l d Connnerctsl P i l o t r a t i n e No. 1497654 i s s u e d Varch 2 7 , 1963. His r s d i o c e r t i f i c a t e was *.%sued Octoher 4 , 1966, and h i s n a v i g a t o r c e r t i f i c a t e ilo. 1771733 was dated J u l y 1 4 , 1967. He held F l i g h t Engineer c c r t i f i c a t e N e . 2677773. d a t e d March 11, 1571. liis second class medical cwamination was taken Aiiauat 3., l 9 i 3 , w i t h no waivers.

FIE Green c o n p l a t e d h i s "A" Phase t r a i n i n g Oecenber 7. 1'372. *r His l a s t f l i g h t c n g i n e e r I.ine check was completed J u l y 2 , 1373, and his Pkk 8707 q u a l i f i c a t i o n check was June 20, 1973.

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APPENDIX B

F l i g h t Attendants

Date oi Birth

Date of Hire

Ir&.rial TrAining

Last Recurrent Trainin2

9-28-13 9-12-39 6-6-48 7-22-48 3-19-45 4-10-50

7-1-66 3-16-66 2-14-72 5-8-72

7-14-66 3-30-66 3-6-72 5-30-72 5-14-69 3-6-73

6-20-73 1.-17-73 3-2-73 3-28-73 9-7-73 3-6-73

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Elizabeth Givens Gorda Rupp Glorla Olacz Patricia Reilly Kinuko Seko Yvonne Cotte

5-14!> 2-19-’73

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- 35 APPZNDIX C

.-Aircraft .

Informa-

A i r c r a f t N454PA. a Boeing 707-3215. serial No. 19376, vas ovned and operated by Pan American V x l d M r x a y s , Inc. It was manuf a c t u r e d Decerrber 2 0 , 1967, end d e l i v e r e d t o P w h r i c n n on t h a t d a t e . The l a s t r a j o r i n s p e c t i o n . a n a i r c r a f t i n s p e c t i o n l r e f u r b i a h a e n t wab performed A p r i l 22, 1973. in Plimi, F l o r i d a . A maintenance "8" check ?lad been a c c m p l i s h e d January 24. 1974, and a maintenance "A" check ha3 beer, a c c m p l i s h e d a t Auckland a i r p o r t j u s t b e f o r e t n k r o f f Januarf 30, 1974. Before t h e t a k e o f f from Auckjand, t h e a i r c r a f t had accumulatei( 21,625 hours f l i g h t time. The sreight and balance m a n i f e s t f o r t h i s f l i p h c i n d i c s t e d t h a t t h e s i r c r a f t had been v i t h i n i t a weisht and b a l a n c e l i m i t a t i o n s both a t t a k e o f f and a t t h e time of t h e a c c i d e c t .

&ere were 117,000 pounds cf j e t A-I f u e l aboard r b e t i r c r a f t frorr, Auckland. The plnnned f u e l burn- off f o r t h e f l i g h t t o Fsgo Pcgo was 48.500 pounds. The e s t i n n t e d g:oao weight, fuel rtmaining,and center of Gravity a t t h e t i n e ol t h e a c c i d e n t were 245.400

U F . Q ~d e p a r t u r e

pounds. 68,500 pounds, end 2 6 . 2 percezr, r e s p e c t i v c l y . The a 1 r c r . r f t vaa c d r r y i n g 37,900 pounds or .?tored fuel t n be use6 on a l a t e r !rig of t h e trip. According t o company records. a1.I a i r v o r t h i n e s e d i r e c t i v e s v r r c c6mpl:cd with.

f

- 36 APPENDIX C ENGINES

K O . 1 Engine SIN P645165

2/22/72

No. 2 Englne SIN P668155

4/11/73

18.769

6,181

KO. 3 Engine SIN 695684

4/19/73

9,370

7,171

SO.

4 Engine

S I N 645961

2

12:19/73

20.527

6,478

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1d

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1 I

Appendix E Flight Profile - Relationship with Glideslope & V.A.S.1.

!9,Ii

.i1? t

GLIDESLOPE

I

VISUAL APPROACH SLOPE IhDICI\TOR

Sea text (Section 1.16) for assurnptiocs used to derive this chart.

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- 39 APPENDIX F

DEPARTMENT OF TRANSPOiTATION FEDERU AVIATION ADMINISTRATION

WASHlNGTW 0.C

200190

Notation 1 3 6 5 December 18, 1974 Honorable John H. Reed. h a i r m a n National Transportation Safety B a r d Depar'ment of Transportation Washington. D. C. 20591.

D-r

Mr. Chiirrnm:

I h v e repiawed SLIoty Rceorrmrndation A-74-104 concerning the Bmyd'm investigation of the Pan American World Airways' (PAWA) Flight 806, B-707 accidmt 11e.r Pago Pago international Airport on January 31. A. you at*:* in your letter. Captain Peterrnos. after being off night status ior aome four months. did in fact accomy!ish all 01 the requrlification training for the B-707 nircraft required by Federal Av:ation fieplation.. In addition to simulator training ?xnder the auperviaion of I check airman. ground achool nessinnr and three actual tdceofIs and landings. he received 34 flying hour. a s pilotin-command p r i m to the accident. We very m u c h appreciate the sugEostion which you and your Board Mornbora have made thsl Section 121.439 of t h e Federal Aviation Regulations be amcndcd to require that a check nirnlrn suparvire the three tnkooffa and landings in the same n r a ~ e ri n which. by a r r e n t reyl.ation, the airnulator training i. supervised. And we note that if this w e r e to bo done. that same check airman would be Ires to require Iho pilot to pcrfcrm m y other rnaineuve~sdeemed ne. ~ s s a r y0: advisable.

Your recommendation is being given c1o.c and careful attention by the FAA staff and. through it, by appropriate organizations and indivlddala in the aviation community. 1 will advise you y r a c n r l l y of m y decistan. Sincerely,

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APPENDIX F

DEPARTMENT OF TRIINSPORTATION FEDERAL AVIATION ADMIHISTRITION

WASHINGTON. O.C.

20190

nu

DmcIw .D.l*8SmAIO.

JAN 1 4 1975 Notation 1365C

Sincerely,

- 41 APPENDIX F

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- 42 APPEIIDIX F

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43

APPENDIX F

DEPARTMENT OF TRANSWRTATIQN FEDERAL AVihTION ADMINI5TRAT:OR

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