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National Transportation Safety Board PB95-910406 NTSB/AAR-95/06 DCA95MA020 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT UNCONTROLLED COLLISION WITH TERRAIN AIR TRANSPORT INTERNATIONAL DOUGLAS DC-8-63, N782AL KANSAS CITY INTERNATIONAL AIRPORT KANSAS CITY, MISSOURI FEBRUARY 16,199s 6538/i The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Information about available publications may be obtained by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (202)382-6735 Safety Board publications may be purchased, by individual copy or by subscription, from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (703)487-4600 NTSBIAAR-95106 PB95-910406 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT UNCONTROLLED COLLISION WITH TERRAIN AIR TRANSPORT INTERNATIONAL DOUGLAS DC-8-63, N782AL KANSAS CITY INTERNATIONAL AIRPORT KANSAS CITY, MISSOURI FEBRUARY 16,1995 Adopted: August 30,1995 Notation 6538A Abstract: This report explains the accident involving an Air Transport International DC- 8-63, which was destroyed by ground impact and fire during an attempted takeoff at Kansas City International Airport, Kansas City, Missouri, on February 16, 1995. Safety issues in the report include three-engine takeoff training and procedures, flightcrew fatigue, company crew assignment decisionmaking, and Federal Aviation Administration oversight of the company. Safety recommendations concerning these issues were made to the Federal Aviation Administration and Air Transport International. 3 CONTENTS EXECUTIVE SUMMARY . vi 1. FACTUAL INFORMATION 1.1 History of Flight.................................................................................... 1 1.2 Injuries to Persons................................................................................. 25 1.3 Damage to Airplane .............................................................................. 25 1.4 Other Damage ....................................................................................... 25 1.5 Personnel Information........................................................................... 25 1.51 The Captain .......................................................................................... 25 1.52 The First Officer ................................................................................... 29 1.53 The Flight Engineer .............................................................................. 30 1.6 Airplane Information............................................................................. 31 1.6.1 General Maintenance History................................................................ 31 1.6.2 Powerplants .......................................................................................... 32 1.6.3 Rudder System Description................................................................... 32 1.7 Meteorological Information .................................................................. 32 1.8 Aids to Navigation ................................................................................ 33 1.9 Communications ................................................................................... 33 1.10 Aerodrome Information......................................................................... 33 1.11 Flight Recorders.................................................................................... 33 1.11.1 General ................................................................................................. 33 1.11.2 Sound Spectrum Analysis ..................................................................... 34 1.12 Wreckage and Impact Information ........................................................ 34 1.12.1 General Debris Field Description .......................................................... 34 1.12.2 Fuselage................................................................................................ 38 1.12.3 Wings ................................................................................................... 38 1.12.4 Empennage ........................................................................................... 38 1.125 Engines ................................................................................................. 39 1.12.5.1 Engine No. 2 ......................................................................................... 39 1.12.5.2 Engine No. 3 ......................................................................................... 39 1.12.5.3 Engine No. 4 ......................................................................................... 40 1.12.6 Fuel Samples......................................................................................... 40 1.12.7 Landing Gear ........................................................................................ 41 1.12.8 Hydraulic System................................................................................... 41 1.12.9 Rudder System...................................................................................... 41 1.12.10 Other Flight Control Systems ................................................................ 42 1.12.11 Cockpit Documentation ........................................................................ 42 . 111 1.13 Medical and Pathological Information .................................................. 43 1.13.1 General ................................................................................................. 43 1.13.2 Crew Rest Aspects ................................................................................ 44 1.14 Fire ....................................................................................................... 46 1.15 Survival Aspects ................................................................................... 46 1.16 Tests and Research ............................................................................... 46 1.16.1 Three-Engine Takeoff Procedural Comparison ..................................... 46 1.16.2 Simulator Experiment ........................................................................... 48 1.17 Organizational and Management Information ....................................... 49 1.17.1 General ................................................................................................. 49 1.17.2 Flightcrew Pairing................................................................................. 50 1.17.3 Captain Upgrade ................................................................................... 50 1.17.4 Company Authorization for Three-engine Takeoffs ............................. 50 1.17.5 Department of Defense (DOD) ............................................................. 51 1.17.6 FAA Oversight and Surveillance........................................................... 52 1.17.7 FAA National Aviation Safety Inspection Program (NASIP) ................ 54 1.17.8 Previous ATI Accidents ........................................................................ 55 1.18 Additional Information.......................................................................... 56 1.18.1 “V” Speeds and Vmcg Calculation........................................................ 56 2. ANALYSIS 2.1 General ................................................................................................. 59 2.2 Airplane Systems................................................................................... 60 2.2.1 Brakes, Landing Gear and Tires.............................................................. 60 2.2.2 Flight Controls......................................................................................... 60 2.3 ATI Operational Supervision ................................................................ 61 2.3.1 Flightcrew Background ......................................................................... 61 2.3 2 Flightcrew Assignment ......................................................................... 62 2.4 Flightcrew Performance ........................................................................ 63 2.4.1 Engine Start .......................................................................................... 63 2.4.2 Landing Curfew .................................................................................... 63 2.4.3 Performance Calculations ..................................................................... 64 2.4.4 Taxi and Takeoff................................................................................... 64 2.4.4.1 Three-Engine Takeoff Procedure .......................................................... 68 2.5 Flightcrew Training............................................................................... 70 2.5.1 Three-Engine Takeoff Training ............................................................. 70 2.5.2
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