I
PB-219 370
AIRCRAFT ACCIDENT REPORT. AMERICAN AIRLINES, INCORPORATED MCDONNELL DOUGLAS DC-10-10, N103AA NEAR WINDSOR, ONTARIO, CANADA, JUNE 12, 1972
Nation21 Transportation Safo'ty Bocrd Washington, D.'C: 28 February 1973 \
D\STk!BUTED BY:
Hational Tzchnical infomtioa Serfice U. S. DEPARTM€NT Of COWIMERCL 5285 For1 Royal Road, SprinpfyYa. 22151 < r\ F - 7 PB 219 370~- -1 C N A AIRCRAFT ACCIDENT REPORT L AMERICAN AIRLINES, INC. T MCDONNELL DOUGLAS DC-10-10, N103AA R I A NEAR WINDSOR, ONTARIO, CANADA N s 1 P JUNE 12, 1972 9 -0 Ri T A T I 0 N S
II I 1 AIRCRAFT ACCIDENT REPORT / AMERICAN AIRLINES, INC.
'" .... MCDONNELL DOUGLAS DC-10-10, N103AA
NEAR WINOSOR, ONTARIO, CANADA ".-.JUNE 12, 1972 ADOPTED: FEBRUARY 28.1973 / TECHNICAL REPORT STANDARD TITLE PAGE . Report No. 2.Government Accession No. ).Recipient's Catalog No. i'TSE-X\R-73-2 I '. Title and Subtitle Aircraft Accidcnc Keport. 5.Report Date Lmerican Airlines, Inc., McDonnell Douglas lK-lO-l@, Februnry 28, 1973 I103A.4, near Windsor, Ontario, Canada, June 12, 1972. 6.Performing Organization Code '. 'Author(s) 8.Performing Organizetion Report No.
I. Performing Organization Nam-and Address IO.Vork Unit No. iatio-1 Transportation Safety Board 3ureau of Aviation Safety I1.Contract or Grant Nc. lashington, 1). C. 20591 Period Covered 2.Sponsori.lg Agency Name and Address Aircraft Accident Report June U,1972 NATIOf4AL TRANSPORTATION SAFETY BOARD I Uashington. 0. C. 20591 14.Spo~soringAgency Code I 5.Supplementary Notes Chis reporc contains a0 ncw aircraft Safety Reconmendntions.
6.Abrtract American Mrlines. Inc.. McDonncll Douglas X-10-10, was damaged substantially rhrn the aft balk cargo compartment door separated from the aircraft in flight nt npproxiuntely 11,750 feet mean sea level. The separation caused rapid decorprcssion, rhlch, in turn, caused failure of the cnbin floor over the bulk cargo compartosnt.
Tha separated door caused minor damage to the fusclage above the door and sub- stantial damage to the leading cdge and upper surface of the left hori:.ontal stabilizer.
There were 56 passengers and a crew of 11 aboard the oircraft. Two atewardcsser and nine passengers receiv4 dnor injuries.
T%e National Transportation Safety Roard deternines that the probable cause of this accident was the iqroper engagement of thc latching mechanism for tho aft bulk :argo coqartment door dtrrity ?he preparation of the airplane for flight. The desigt: :i-arncteristice of the door latching mechanism pcrnitted the door to be apparently :lcsed when, in fact, the latches were not fully cngaged. and the latct. lockpinu --aerr not in place. 17. h?v UOrds 18.Distribution Statemcni 4ir,%x?- iccidcnt, Rapid Deconpression. In-Plight Release to public; Cr?x i:!,:.!, ~eoignDeficiency. distribution unlblted I - -- I?.Srcuriry Ciarrification 20,Security Clas?.iflcafion 21.No. of Pages 22.Prlce (Of this report) (of this page) 41 $ 3.w. - L!iCLASSiFIED UNCLASSIFIED P7L58 Form 1765.2 111/73; Li I. v-- .. .
TABLE OF CONTENTS
Synopsis ...... YrublblcCau ...... 1. Invcsti<.ttion ...... 1.1 History oi the Fllgkt ...... ,...... 1.2 InJuricr to I'crsons ...... 1.3 D~IIIA~Cto Aircraft .&...... 1.4 OtlIcr ~mnage.,Sa ...... 1.5 Crew Information ST ...... * * ...... 1.6 Aircrak Iniormatiun' : :?& ...... , ...... 1.7 Mctcoroklgicd Iniornvrriol; '4...... l.R . . . . , ...... , ...... 1.9 ...... 1.10 &...... 1.11 . , ...... 1.12 ...... , ...... 1.13 , ...... 1.14 ...... 1.15 Tests and Kcsearch. .@...... 2. Analysis and Conclusions.*...... 2. I AnJl~sis...... 2.2 Conclusions . . , . . . . . , ...... , ...... (a) find in^ ...... (1,) Probable C~usc...... , . . , ...... , . . , ...... 3. Kcroulmcndationr and Currestrvc Actinn ...... , ...... , ...... Apprndices Appendix A Invertipttion and tiearin!, ...... , ...... , ...... Appdlx I3 Crew InCorlrlation ...... , ...... Appendix C Aircraft lnfornlarion , ...... Appcndix L, Cockpit Vc,icc Kerder Transcript , ...... , . . , ...... Appcndlx E IX-10.1~CabinFloor I'lm . . . , ...... Appendix F Cargnthor ...... Appendix G NTSY Safcty Hrcorrrrrlcnd=rior* A.72.97 and YH tu the Fcdcral Avlatirm Adlninirtrrtor and I(csponr . . . , ...... 111 NATIONAL TKANSPOKTATION SAFETY HOAKI) W:\SIIINGTON. I). C. 20591 AIKCKAFT ACCIDENF I Adopted: Frhruarv 28. 1973 I -. -. - AMERICAN AIKLINES. INC. 1 i, McWNNELL IK)U(;LAS I~.lO-IO.N103AA NEAK WINDSOR. ONTAHIO. CANADA, JUNE 12, 1972 SYNOPSIS 1. INVESTIGATION 1.1 History of the Fligbt ;I American Airlinrs. lnc., Fli#ht96. a IX-10-10. I?,,!;'! N103AA. was a rchcdulrrl p;nssen;er flight from I, Ins Angelcs. California. to LaCuardia Airport. ,II Ncw York, with intcrmediatc stops at Dcrroit. ;;;i Michigan a~~d:3uff;llo. New York. Flight 96 dc- parted 1.0s A11ge1cs International Airport at hi ,I; ~ 1436 e.s.t..l on Junu 12, 1972. 46 minuter after pil its xl~cduleddeparture. The delay was a result pasrngcr traffic control. ~ of Ilandlirtg snd air ,/ill,1;!i I /. ~ Flight 96 arrived at !letroit at 1836. This sc~ CI t merit of the flight was without incident. p;: ; ,, Fuel. cargo. and paswngcrs were loaded ;;hrmrd ! ': the.lirpl:lne at 1)etroit and its takeoffgross weight 1 ,' ,,'$ w3s computed to he 300,888 pounds, well under .. thc maximum allowahlc. Thc last compartnlenc :/ to be secured prior to dispatch of the flight was ,, tltc aft hulk c.lrgo compartment. i The ramp service ;,gent who rrviced the aft/' cargo colnpartmcnt Itad difficulty clnsing the door. Flc stated that be closed the door elcc- trically. tie listened for the motor to stop rvn- ningand then attcntptcd to close the door handle. 'I'his handlc is designed to clmc the small vent-.-& dwr which is located on thc cargo door. to pusition a lockpin hchind a cam on each of the .. IAl: limo tuud hereat ate csrrcm%tmdard.hrsed w th.. 24-hour dmk. I L .. 1.5 Crew lnfor~~~ati~~n 4 3 , .. . ' , z of an adjustment to the dool-closing switch to 1.8 Aids to Navigation permit electric opcr:ktiun of thr latches. ." No Airworthiness Directive pert.~ining IC There were no reported malfunctims of the IX-IO cargo doors was in cficct at tlw time of nxvigational aids during the cnrcrgcncy. Run- the accidcnt. However. McDonnell Douglas WAY 03L. is equipped with a full instrument Service Uullrtitl 5?-?7.13C-10 SC 612. which pcr- Landinp, S)stcm. which was utilized by the crew rained to the electrical wiring to the latch actua- ior tbc approach. tor. had been issued on May 30, 1972. The modificarion recommended rcplacernent of thr Contrnunications cargo door latch actuator wiring with heavier 1.9 ?age wire. American Airlines had not complied All communications with Flight were with this bullctin at the time of the accident 91 routine and in accordance with established pro- nor was cornpliancc mandatory. The reason for cedures. Tl~crewere no reported diifirultics. the issuance of this bulletin was stated in the bulletin as: r 1.10 Aerodrome Ground Facilities "Heusow Detroit Metropolitan Wayne Coutrtv Airport Three operators have rcported failuro oi the is located approximately 17 statute miles south- e!cctrical latch actuators :o l~tclllunlarchthe west of Detroit. Michican. The gco~~.qhicloca- cargo doors. Latch ;Ictu.ltur failure is at- tion is 42O13.1' north latitude and 83c20.9'west I trihutcd to an cxccssive voltaec dro~rcducine '. lungitude, at a field clevxion of 135 lccr nwan the output torque to the actu:ttor. This con- sea level. Thc airport is operated continuously. dition may prevent electrical Iatchinglt~nlatcb- Runway 03 left is 10,500 feet in lengrh. and ing d the Imuks. Fadurc to provide adequatc 200 feet in width. of cwcretc construction. with 'i torque necessitates manual I;,tcl,inglull!;lrchil~g all.wcather ntarkinp. It is equipped with high- of the doorsresulting in tlisht delays. Increas- intensity runw.ly lights with ccntcrIi.,c lights ing tlw wire plgc hctwccn thr circuit breakers and high-intensit) approach lights. The approach and the actuators will rcJucc the voltagc drop lights arc equipped with wqucnce flashing lights. and pnrvide adequate In-que to operate the The runway i5 illso rquippcd with touchdown latch lnnuks uncb all anticiprcd conditions.'' " zone lights. Fircfightin~.and rcscue equipment availab!: ;1?1.7 Mrteorological infornlrtion wcrc as follows: 2-Ydnkec Walters. 2.500 gallon ta!:kers, The surface weathcr obrrvations at Detroit 1 --Yankee Waltcrs. 3.000 gallon tanker. Metropolitan Wayne County Airpurt, IJetrrrit. I .. 1)adgc Light Rcsr.ucTruc!i. 1.00Opoundr Mirhigan. for P period prim tu and inllowing dry chcmic:J. the acident wcrc. in part. as iollowr: 1 - 7511 gallon rumper. I -1)odge l 4 It is a digital recorder with an associated data. eitrth, were 3pproninlatCly 0.1875 of an incli zcquisition s~stenrof tlw cxpn~lcdprametrr from their fully closed positions. and thc lntcl~ typ~.The recording mudium is onr-qu;trtw inch mech.lnisnlr were 0.35 ofan inch irum the.'Lr over. nlapnctic tape. on which :tircr.tft >crformmcc center stop positions. information is recorJcJ serially in digital fornl Prclintionry cxaminetion of the scrcw-type or .four sequential tracks covering 25 hours of :lctuator which operates thex 1;lrchc.r indicated aircraft owration. that the length of the actuatorn~casurcdbctwccn The Jata recordrr was opcratiug normally up the cdntcr:incs o( its attach bolts was less than tu the time the door opcned. !nformation ob its normal cstcnded position. taiwd from it ronfirrncd thn crew's testimony The actuator wap rcmoved and taken to the that rhc incident occurred at an altitude of manuLcturer for cxamination and disassembly. 11.750 fret. However. the data recorded after I: was determined that the clcctrical extcnd limit the incident was largcly aberrant. and little use- switch was closcd. Thc gear train was operated (ut information was obtained Thc abcrrant manually until tlw cxtend limit switch opcncd. recording was che rcwlt of inadcquacics of the The fully cxtendrd acttlator n~casurcd11.777 installation in this particular data recorder which inciws,and the rctrxted mcasurcmenr was 9.997 cmxd accclrr~cionIds to affect the pcrform- inches. The actuator. as rcco\.errd. measurcd anct of tlw rccorder. 11.040 incltcs. Thc unit was given an clcccrical In addition to the flight data rrcordcr. tl~e load t.w which consistcd ol Ids of 1,500 aircraft was equipprd with a Fairchild Model poutxlr. 2.000 pounds, and 2.600 pounds. Volt- 100 cockpit voice recorder (CVK). The CVK agc readings varicd from 28 V I)(: to 13 V X. tape was recovered intact, and a transcript d the Whcn a lO~dof 1,500 pound? was applicd. the perrincnt communications is included in Appen- unit crcpr slnwly with a voltage of 13 V 1x3 and dix 0. a current d~awof 11 ampcrc. Whcn 2,000 pounds wcrc :~pplicJthe unit crept with a volt- 1.1 2 Airrraft Wrcckagc age of 13 V IX and a current of 13.5 ampere. With a lo~duf 2.600 poandr applicd. th: unit An cxamination of the airplane and of the aft crept with 18 V DC and I7 ampcre. The clutch argo door which llrd scparatcd in sc:ting was 2.900 pounds. All resting was per. conductcd. formed with ;I new cldcal mocor installcd. The carco door Ilinw. door frame. and thc .I ., Thc original motor had scparatrd fron~thc ac- four rollcrs on the durr sill, which CII~~?door tuator and was ncver rccowred. latches upon closing were basically undamaged. Exnnlination showed that a high-compression The rollers wcrc free to rotare and, except fix force wac transnlittcd from chc latches tlaromjh two rnlall goup marks on the second roller t11c irrcvcrsiblr latch linear n:ttlator to the door from rhc front. they \vert undanngcd. structurc. This was cvident from the I)rinelling Thc actuator gear Iwn was in plac~:how. durr of the trpper sidc oi the bushing on the actuator evcr. the motor had repmatcd from tl~cdoor and attxh log a1111 fran the damngc olwrvcd OD tlw was hanging by its clectric wires. The actuator actuator support brarks. 'rllis support bracket arm Iduparatrd and was not rccovereJ. The was ill pl:lcc on its bttach structltre: howcwr. door itxlf scparatrd front the fuxlagc in flight. tl~ctwo bolts which cwncctcd thc hrackct to thc lcaving approximately HO percent of itsexterior structure were shcnrrd. A part of one bolt was skin ill +LC on the door Iringc. still in tlrc door skin which was attached to the The Joor uas found with thc four latcl~cs rirplanc. Tltr l~olerin thc bracket and tl~catt:~cl~ ne.dv closcd. with the Iockpms not engaged, structurc wcrc about 0.375 of a#! inch out d with II~Cwnt dnw overtrrvrlrd lwyond tltc clprn .dignrnrnt at thc outboard side of rhc braclict. pcsitiun ,and with the dwr hanrllc in fhc btowcd c)thrr evidrncr of relative motion 1x.wcen thcrc pwitim. Thc latchrr. uhiclt wcre filled with parts WAS tl~ezuc.csiw chafernarks in tbc paint 5 of the support bracket whcre it fitted against ing systems. Although tl~cleft rudder pedal was the mount structure. These marks indicated a jnnmcd. the left brakc pedal 0pcra:c.d nornmlly. maximum relative motion betwecn the;e parts Operatiun of the various co~~trolsin tl~c cock- of 1.05 inches. pit revealed the following: The snlall Yent door on the aft cargo door, the door h:lndle. and tlte latch lockpins arc intcr- 1. The nosc steering system was positioned connected. The system is designed uo prevent approximately 10" left because of the left the door from closing and the handle lrom stow- rudder pet!;ll input signal. The system was ing if the lockpins arc not in place behind the operated from the control whccl with the closed latcl~cs. torque link dixonrected; this operated The link from the dor haltdle to the horizon- the nose stccring system normally. tar torque tubr w%ch controls iKewoor 2. The elevator system was operable through- ~~ ~ ~~~ -. and the lockpins had :ai!ed in tcnsion near it5 out itsrangc: however. the input loads were - ~_..__-- lowcr rnd; '7% fractured ciiiwerc separated higher than normal. .I-~~ by sevcra? inches and could not be pulled 3. The stabilizer trim switches on the control tosether. wheel operated normally: however, the The horizontal torque tube was bent slightly, position indicator was inoperative. and it was out of its bearing on thp forward en'. 4. The rudder trim control was opcrablc to the right; however. the trim would not The vent deor,which is attached to the torque position the rudder to the left. 1- tube, 1- irs ng rmalmosition and was ianlmed in vent door -~ place. The guard The collapsc of the cabin floor damaged a had failed ill t1.c downward direction. number of the engine and flight control system The linkage from the torque tube to the lock- cables which were rou:cd through thc floor pin mechanism was intact. except that the pivot beams ill that area. Thc following damage was point was brokcn on the bellcrank which con- obscrucd: verts vertical push-rod motion (from thc handle) to horizontal lock-tube motion. TIIC forward 1. lilewtor Control System cnd of the lock tube was bent outboard. The door frame was partially fractured in the area The right hand elevator cablcs (No. 5 of this bend. The lockrins were withdrawn and No. 6) wem preloadcd downward by beyond their normal unlocked positions. the collapscd cabin floor structure. The . &rlle cargo actu:ttiott and warning systcnls, elevators were operable: however, higher rhc hydraulic power rystcrn, the main wheel than normal control forces were required. brakes, thc nox steering system. the cmpennage Both left-hand elcvator cables were sepa- control, and the No. 2 engine control systems rated. Thc No. 4 cable pullcd out of thc wcre ex;amined. left tcnsion regulator. and chc No. 3 cable The cargo door warning light system was pu!led out of its swaged fitting to the clc- found opcrablc frnnl thc cockpit aft to the vator crank. connectnr plug on thc cargo door frame. None of the circuit hrcakcrs which cuntrol powcr to 2. RltdJer Corttml System the carp doors and warning systems was found tripycd. Thc v+ing to the door. the lock li~r~% The No. 3 ,right) rud& cable was warning switch, the closed limit switch. and the :.;retched t.mt by the collapsed floor struc- closcd limit warnlng su;itch werc xparatrd from cure and could not be moved. The rudder their attacllilcnrson thc ..ow structure. pedal mechanism had o>.ertravele.dits for- @o discrc~ancieswere found in the hp!r mlic ward position and was jannncd. The nose- power systems, or in the wl~eelbrakes or stccr- left stop and tl~elowcr crank (cable No. 1) 6 U ankls. Onc p.lsscugcr suffcrcd a dislocated finger and anuthcx p.tsscsISer a facial injury from bcins struck by a flo~r!latch during tlvidcconl- however, tllerc W;IS limited respomc to pression. All other inju:ies werr friction burns rudder trim in the rallgC iron1 neutral to sustained whcn the passcngcrs slid ~OWIIor cxitrd trailing edge right trim. the bottom of the ev.uIation sliJLs. The events frwn the time of decomprussion 3. Hori:o~fa/Stz16i/i:cr XIPI until e!ncrgency evacuatinn arc as follows: The horizont:l stabilizer could bc op- 711rl~','.,~,:t,,,~,s~ioll erated up and down by tl:c switches on either control \vhccI. There was no re. The decompression manifested itself to the sponse from the alternate electrical trim pmengcrs and flight attendants as a nlufflcd switches on the pcdcstal. explosive sound and a white gray fog which Rotl: left-hand manual trim suitcase fornlcd throughout thc cabin. The door to handle cables had failed, and both right- the cockpit and the door of the galley lift hand cables were preloaded. In ordcr to ~pened.and several ceiling panels in the ccnter trim thc stabilizer manually with tllese of the cabin fell down. A tloor hatch in the handlcs, both llandles must be functioning. aisle next to seat .4H flcw up and struck a The horizontal stsbilizcr position irdica- passenger in the facc. . ~ .~~.~-~ .. tor drivc_~rnkh~pjlswere slwG,.$~d. The chief flight atte~~dant.who was srand- the stabilizer position indicator cables ing in the forward service area, was thrown (No. 135 and Nm 136) had failed. from this area. The two flight attcldants seated at the two aft nitswere thrown to tl~c 4. .Yo. 2 fiuxiw Coutrols floor. which hdp.lrtially coll;tpsed into tl~c baggage conprtmcnt below. The circular The No. 2 engine throttle. fuel shutoff, standup lur on tlliscoilapscd tloor section was and firrwall shutoff cables had all failed. torll loost from the floor. The hydraulic, fire. and fuel firewall shut. Of the eight flisht attendants, fivc rcportcd off valves wcrc in their midpositions. that their first thought was to reach for oxygcn masks. The automatic release for thc wygcn system is prcsct tn operate at 14,000 fcct, 1.13 Fire and,aincc tllcairpl:tnc was hclow that altitude, There was no fire. thc system did not nctuatc. One flight a..tcnd. ant at Exit ?L obtained a \val\.-around oxygen bottle and callcd th.. cockpit on the intcrconl 1.14 Fur-rival Aspects system to tell the crew thar the damage was in tl~crear of the airplane. Thc chief flight The accident was survivable. attcndant adthe f?ig!tt nttc~~dantst;,ti,,ncd All crcwmembers and passcngcrs ,-sit*:d the at Exit 111, WCIIC to the cockpit for inst-lc. airplane throu$ six of its eight cmcrgc~vqexits. tions at various tinws. All escape slidcs for tl~cseexits ft!nctioncd nor- mally. 1''L 8 actualor linkages arc not overcenter. ‘rhus. rhr evidencr indicarcs that rlw Iatcll actuaror did nor crrcnd far enough to drive rl1e Iarchcs bryo~ld the overcenrer position, and rhat pr happzn. The same deflcction~rnichr have per- mitred the pilor indicaror switch 10 make con. tact. which. in this syrtenr. prevents tlium1n.trion ol the cockpit warning IIshr. Thus. rhe crew ha+. no warl1ll:g r‘nat the door nlecbanism was the pressurized bulk cargo cnmpartnwnt and rlle outside atmosphere during the clirnbour loadcd 9 ZI I, .. .. - ._ .. AI'PENIXX A INVESTICATION ANI) HEARING 1. Invr,tigatiun Tllcre was no public hearin& 3. Rclinlinary Kcport A preliminary rqmrt on this accident was issued by the Safety ktardun August 22, 1972. Preceding page blank 15 ..-.. .. '.'. I i ... , ...... 17 APPENDIX C AIRCKAFT IllSTORY The airplane was 1nanufa:tured bv McDonncll I)ouglas az a DC-10-10.The registration eumber was NIOJAA, rrrial nunlbcr 46503. It was received by American Airlines from the manufacturer on July 28. 1971. IC had accrued 2.142 huurs of flying time at the time of the accident. N103AA was powered by thrce (;enera1 Electric CF6-6D gas turbine engines. The No. 1 engine, serial nutnbcr 451208. was installed on February 17, 1972. nnd had a total time of 820 hours. The No. 2 cnginc. scrial number 451180. was installed on March 19, 1972, and had a total time of 920 hours. Thc No. 3 engine. scrial number 451298. was installed on May 19. 1972, and had a total time of 177 hours. The airplane records indicate that N103A.4 had been maintaincd in accordance with all company proccdures and FAA Directives. 18 APPENDIX D TRANSCKIPTION OF PERTINENT COMMUNICATIONS FROM COCKPIT VOICE RECORDER. DOUGLAS MODEL IX-10.10,N103AA, AMEKICAN AIRLINES FLIGHT 96 WINDSOR. CANADA. JUNE 12,1972 LEGEND CAM Cockpit area microphone voicc or sound source RDO Radio transmission from NlO3AA -1 Voice idcntificd as Gptain -2 Voice idcntificd as First Ofticcr -3 Voice identified as Second Officer -? Voice unidentified LC Local Control Detroit Metropolitan Airport DE Lkparturc Radar East Metropolitan Airport QGR Cleveland AKTC Center. WinZsor Radar Controller ARE Arrival Radar Fast Metropolitan Airport 1 Unintelligible word # Nonpcrcinent word % Break '3 continuity 0 Questionable text (( )) Editorial inscrrion 19 .I- .-I n ^. ,. . i. 7 f ?I IXTRACOCKPIT AIR GROUND- COMMUNICATIONS SOURCE SOURCE & TIME CONTENT -& TIME- CONTENT CAM-1 (Okay, thcr your forward gear has a long ways to go) 0020:11.5 LC American ninety-six maintain rvnway heading contact departure one eighteen four RW1 One eighteen four maintain runway heading American, eh, ninety-six CAM-? **** 0020:32.5 m-1 And American ninety-six, your frequency, we're off Detroit Metro N N DE American ninety-six Detroit departure radar con. tact climb and maintain six thousand 0020:42.0 RIM-1 Okay, you want us to climb and maintain six thousand, American, uh, ninety-six DE Roger American ninety-six turn heading zero six zero 0020:50.5 R w-1 Right to zero six Lcro, Anlaican ninety-six CAM-I Okay, you got 'em? % CAM-2 Yca h ti SOURCE &TIME SOURCE - CONTENT &TIME - CONTENT CAM-2 Flaps, up - CAM Sound of flap lever CAM-1 Zero nine zero, you got it? CAM-2 Slats. lip N w CAM Sound of click CAM-I CAM-2 CAM.? **** CAW3 Gear handle to * CAM Sound of click 0022:lS.O U L INTKACOCKPIT AIK GROUND COMMUNICATIONS SOURCE SOURCE &TIME ClNTENT-- & TlME CONTENT 0024:OS.O RDO-I Ah, correction was that two three zero? QGR Two three zero American ninety-six report reaching 0024:10.5 RW-I Okay, American ninety-six QGR Ninety * 0024;ZS.S CAM-1 (There) goes a big one up there 0024:3?.5 CAM Sound of high amplitude noisc CAM-? Ah, # 0024:35.0 CAM-I What the hell was it? (I wonder?) CAM-? Whirtle ((similar to human voice)) 00?4:35.5 CAM Sound of fire warning horn begins at % Same time with altitude warning horn W mz 0024:39.0 x0 CAh-I WcU pass the warning fue Q INTRA-COCKPIT AIR GROUND COMhlUNlCATlONS SOURCE SOURCE &TIME CONTENT &TIME CONTENT CAM-2 Which one? 0024:42.5 CAM-3 We’ve hit something CAM-2 We’ve lost ((pause)) lost an engine here 0024:46.5 CAM-I Ah. which one is it? CAM-3 Two N u CAM-I (Is pitch hold grabbing on?) CAM-3 Number one is still good CAM-3 And, ah, Caprin * we’ll have to * * * to check out this CAM-? Okay, we apparently ((pause)) Master Warning. this board’s got an engine fire over here. Yeah we got the engines, one and three CAM-2 Do we have, ah, hydraulics? E m’ CAM-1 No z E CAM-1 I’ve got full rudder here X c :r. ? i 'X INTRACOCKPIT AIR GROUND COMMUNICATIONS CONTENT CONTENT 0025:48.0 qcx American ninety&. ClevcLnd 0025:Sl.O KIM-2 WC got onc sewn zero heading sir and, ala. Ilyitl. taining twclve thousand 0025:54.5 N Nine six roger. type ofcmcrgency? U W,R RLX)-L Ycdh. ycs sir RDO-1 We have a control problem. wc bave nu rudder. gut full jam, WC'VC had x~mcthinghappen. I don't know what it is 0026:OCi.S WR American niuc six. understand ((puse)) clcarrd .- 10 maintak.al~,ninrr thouund. alrimcter IWO wner eight rvcn be. ah, radar vccr',r hack toward the ILS course runway thrcc. you want the quip > mcnt to bc standing by? 6- 0026:22.0 f" RDO-2 'Kay sir,ah,ah, YY again tbc heading and wc'll let down slowly to nincr thousand -" INTRACOCKPIT AIR GROUND COMMUNICATIONS SOURCE SOURCE --&TIME CONTENT 8. TIME COSTENT 0027:Zl.O RUO-1 Okay now. we've got. ah, problem I got a hole in the cabin, I think we've lost number two engine, we've got a jammed ruddcr full lcft rudder and we nccd to, ab. gct down and make an approach I guess Detroit Metro would be thc best and, ah. can you vector us around? 0027:42.5 QCR American nine six roger turn furthcr riKllt now hcading'll be two zero xro 0028:25.0 RDOl I haw no rudder control wlmsoever so our turns arc gonna haw to be very slow and c-.rtious 0028:31.0 QCR Understand 0028:33.0 CAM.2 Okay we've got full control on this though. how~.ver,so I gucss we're slow enough so we can probably use differ- entia1 directions with engines. thank good;lcss it's on: and two wc'vc got ((paua)) one and thrcc 0028:54.0 QCR Amcrion nine six continue descent to five rhousand feet say the altitude now INTRACOCKPII AIR GROUND COMMUNICATIONS SOURCE SOURCE &TIME CONTENT & TIME CONTENT 0028:58.5 m-2 Twclvc thousand to five 0029:57.0 QCR Nine six altitude now 0629:58.5 lux)-2 Ah, elem thound two hundred 0031:12.5 CAM. 1 Okay. Ciw me about fiftcen on thc flaps now. watch it carefully c" 0032:06.0 CAM.3 Wr'll be hdingabo.~ttwo hundred ninety two thouwnd 0032:45.0 RW-2 we're out of eight seven hundred for, ah five thousand right? G032:48.5 QGR American nine six cogcr turn back right now heading'll bc two cighr zero 0034:28.5 WR American ninctyaix now cleared to maintain chrcc thousand OU34:34.0 RW2 Three thousand INTRACOCKPlT AIR CTKNND COMMUNICATIONS SOURCE SOURCE & TIME - CONTENT &TIME - - CONTENT- 0035: 13.0 VCR American ninety-six Metro approach one two one five - one twenty-five fifteen go ahead 0035:18.5 RDO-2 Thank you one twentyfive one five 0036:08.5 CAM-:! We've got a nice rate of descent even if we have to touch down this way we're doing well *: Detroit Metro arrival east w N 0036:30.0 ARE American ninety-six, Detroit 0036:32.0 ". Loud and clear sir. and we're through five thousand five hundred four three 0036:45.5 ARE Ameriwn ninety-six, turn right heading three six =ro. descend and maintain three thousand vector to the ILS three left final approach courre, altim- eter two niner eight five. risibility one and one half. breaking. clear for all types ofaircraft m 0036:57.0 z$ Rm-2 1 think you heading now to three thousand a x 0 . t ...... INTRACOCKPIT AIR GROUND COM~hUNICATIONS SOURCE SOURCE &TIME CONTENT &TIME CONTENT 0038:40.0 CAM-1 Well gimme the gear 0039:39.0 CAM-1 Okay, Irere we're coming into the L.S. I'm gollnd start slowing her down, give me twenty-two on the flaps 0040:59.0 CAM-1 All right we got the green lizhts 0041:lO.O w ARE American ninety.six, you're two and a half lrilcs w from the marker. contact the tower one two one point one. good night 0041:15.0 RDO-2 Good night, sir 0042:23.5 LC American nincty-six cleared tu land 0042:26.5 RDO-2 American ninety-six cleared to lind 0042:42.0 CAM4 Give me thirty-five the flaps on % -0 004338.0 m Z CAM-1 I h-w no rudder to straighten it out E with when it hits x +J INTRACOCKPIT AIR GROUND COMMUNICATIONS SOURCE SOURCE -&TIME CONTENT -_6: TIME CONTENT-- 034353.5 c.4M-2 Okay, now ungintr off at )ow discretion 0044:55.0 CAM-1 SHUT 'EM DOWN w e , ... 35 .: APPENDIX F \ I I" \ \ . -. , APPENDIX G UNITED STATES OF AMERICA NATIONAL TRANSPORTATiON SAFETY BOARD WASHINGTON, D.C. ISSUED: July 6,1972 Adopted by the NATIONAL TRANSPORTATION SAFETY BOARD at its office in Washington, D. C. on the 23rd day of June 1972. FORWARDED TO: ) Honorable John Shdfer 1 H. ) Administrator 1 Federal Aviation Administration 1 Washington, D. C. 20591 ) SAFETY RECOMMENDATIONS A-72-97 & CS The N.ttional Transportation Safety Board is invesripting an accident involving an American Airlines McDot~nellDouglas Dc-10-10.N103AA, which occurred sllortly after takeoif from Iletroit Metropolitan-Wayne County Airport on June 12, 1972. Tl~uaft left-hand cargo door opened while the aircrlft was at approximately 12.000 feet. Tile cabin floor over this cargo conlpartment tlmfailed as a result of depressurization loading. and tlw floor 2roppcd partially into the cargo compartment. 'This displacement of the floor caused scrious disruption of the control cables wlticlt are routed tluouSll the floor beams to the ,:tnpcnn;tg control sysems and the ensine controls. With the exception ot' the right rudder pedal cable. all of the cable, on the left AIc of the fuselage brokc. The cable runs on the right side wurc also damaged-the cable guides tore fronk their attachnvmts to the floor beams, and the cablcs were &3lccted downward by the lloor structure. l'rclin~inary invcstl 37 However. tests conducted at Douglas Aircraft Company have Jenrunstr.ttcd that the vent door can be c!w4. and the handle stowed. without tl~elock -pins ongaged. Appren.ly. some combination of deflection of tl~operating mechanisms and tolerances pcrnlitted such opera- tion when a force of agproxim;tcly I20 pounds was applied to the operating i~audle. Lhring ther tests our investigator okscrwd bending of the sliding lock-tube which cacred the cap end of the tube to make contact with the pilot i~~dicatorswixh actuating arm. This arm nwves .through a very small arc to actuate the switch. and the hard helicws tl~ta similar contact on the accident aircraft dwr probably actuated the switch and give the pilotsa dour safe indica- tion on the annunciator light panel. Finally, the Board believer that iuddcn loss of pressure in this cargo compartnwnt for any reason should not jeopardize the safety of the night. In this case. tl~eloss of the doo: and resultant cabin floor failure caused an unwanted rudder input. mcvcrcly restricted the elevator control available to the crew and disrupted the No. 2 engine controls. Wc arc aware of the inspection proccdurcs currently in effect to ensure safety of operations of tlre DC-10 as well as .the:existing safety features of the door design. Nevcrtl~clcss.in order to preclude the recurrence of similar accidents. the Safety Board rccomnwnds that the Federal Aviation Administration: 1. ncquuca inodification to the DC-IO cargo door locking systcn, to make it pl~ysicnlly impossible to position the external locking handle and vent door to their nor~naldoor lockcd positions unless the locking pins arc fully rngaged. 2. Kequirc the installation of relief vents between the cabin and aft carp compartment to minimize the pressure loading on the cabin flooring in tl~cevent of sudden depres- suriwtion of the carso compartment. .- Members of our Burciu 'of A&tion Safety will be'availablc for Consultation in thc above matter if desired. &- APPENDIX C DEPARTMENT OF TRANSPORTATION FEDERAL AVIATION ADMINISTRATION 7 JUL 1972 Honorable John H. Reed Chairman. National Transportation Safety Board IJcpartrnent of Transportatioq Washington. D.C. 20591 Ckar Mr. Chairman: This is to acknowlcdge your Safety Kccomnwndationr A-72-97 and 98 issued on 6 July 1972 which included recommendations resulting from an inadvertent cargo door opening reported on a Doughs E-10.10airplane. All operators of DC-10-10airplanes arc currently performing 100 hour functional checks ,,n :he cargo door system and will incorporate necessary modifications in accordance wnll hlcDonnell Douglas ScrLice Bulletins 52-27 and A5335 within 300 hours. Tlrcsc lmdifications pertain to improvemenrs in the inspection and operation of lockingand vent mechanisms. Additional modifications to the cargo door locking and pressurization systcnls are being con. ridered as part of a continued invcstigation effort. Whi!c a preliminary investigation indicates that it may nor bc feasible to providc complete vcnting butween abin and cargo compartments. your reconlnlendations will he consided with respcct tu furtlwr action wken. Sincerely. /s/ J. H. Shdfcr Administrator . ..