NTSB Accident Report
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. e ,. , p~85-9,f,406 i , L, I \ NATIONAL WASHINGTON, D.C. 20594 . 9 AIRCRAFT AC-CIDENT F +W?T. --- . ‘\ ‘\ ‘i-c bORLD AIRWAYS, INC., FLIGHT 367% I-MCDONNELL DOUGLAS DC-10=30CF, i$ll3V’i; BOSTON-LOGAN INTERNATIONAL AIRP?RT BOSTON, MASSACHUSETTS ’ -si:i, JANUARY 23, 1982 I II NTSB/AAR-85106 (SUPERSEDES - - NTSB-AAR-82-15) UNITED STATES GOVERNMENT 4 ,I. .-’ ,/’ _---.-_x__I &__H _- -- _..-_ __c .-. ___.__._, .--:’ ‘iv.-. :;’ _.-._.’ . ------ ------ .- I . .-j _ ,, w r .---- at*.I 1 &G&q@:-~W fi+3Tg”;;AL REPORT DOCUMENTATION PAGE 2.Government Accession No. 'S.Recipient's Catalog No. .’ N%f57~?&5/06 PB85-910406 L 4 . Ti t 1 e and Subt i t 1 e Aircraft Accident Report-World S.Report Date Airways Inc., Flight 30H, McDonnell Douglas DC-lo-30CF, July 10, 1985 ’ N113WA, Boston-Logan International Airport, Boston, 6.Performing Organization Massachusetts, January 23, 1982 (Supersedes NTSB-AAR-82-l!5) Code 7. Author(s) 8,Performing Organization Report No. 9. Performing Organization Name and Address 10.W$ii3pi t No. National Transportation Safety Board Bureau of Accident Investigation ll.Contract or Grant No. Washington, D.C. 20594 cl 13.Type of Report and Period Covered 12,Sponsoring Agency Name and Address Aircraft Accident Report, January 23, 1982 NATIONAL TRANSPORTATION SAFETY BOARD Washington, D. C. 20594 14.Sponsoring Agency Code 15,Supilementary Notes 16.Abstract On January 23, 1982, World Airways, Inc., Flight 30H, a McDonnell Douglas DC-lo-30CF, was a regularly scheduled passenger flight from Oakland, California, to Boston, Massachusetts, with an en route stop at Newark, New Jersey. Following a nonprecision instrument approach to runway 15R at Boston-Logan International Airport, the airplane touched down about 2,800 feet beyond the displaced threshold of the 9,191-foot usable part of the runway. About 1936:40, the airplane veered to avoid the approach light pier at the departure end of the runway and slid into the shallow water of Boston Harbor. The nose section separated from the fuselage in the impact after the airplane dropped from the shore embankment. Of the 212 persons on board, 2 persons are missing and presumed dead. The other persons onboard evacuated the airplane safely, some with injuries. The weather was 800-foot overcast, 2 l/2-miles visibility, with light rain and fog. The temperature was 38’ with the wind from 165’ at 3 kns. The surface of runway 15R was covered with hard-packed snow and glaze ice overlaid with rainwater. Runway braking was reported by a ground vehicle 2 hours before the accident as “fair to poor++; subsequently, several pilots had reported braking as ++poor,+’ and one pilot had reported braking as ++poor to 18.Distribution Statement Won ronu)a)( Air-carrier, DC-lo: slippery ‘ice-covered This document is available mway, water-rescue capability, minimum(runwav lengthg to the public through the lot braking reports,(airport managemenfl measurement of National Technical nway slipperiness, airplanelsto ing distancej,& Information Service, 1c control)@utothrottle~~~i~-bar$[’ Springfield, Virginia wn. PP \I rcmfld- n4 9 22161 Security Classification 20.'Securi ty Classif ication 21.No. of Pages 22.Price h (of this report) (of this page) UNCLASSIFIED UNCLASSIFIED : 1 Form 1765.2 (Rev. Q/74) 135 ..- ,’ ‘/ fi I.- .I2 ,: . I:,.,’ airplane to land about 2,800 feet beyond the runway’s displaced threshold. “<*. _ Contributing to the accident were the inadequacy of the present system of reports to convey reliable braking effectiveness information and the absence of provisions in the Federal Aviation Regulations to require: (1) airport management to measure the slipperiness of the runways using-standardized procedures and to use standardized criteria in evaluating and reporting braking effectiveness and in making decisions to close runways, (2) operators to provide flightcrews and other personnel with information necessary to correlate braking effectiveness on contaminated runways with airplane stopping distances, and (3) extended minimum runway lengths for landing on runways which adequately take into consideration the reduction of braking effectivene3.s due to ice and snow. ii SYNOPSIS .......... l ..... ;....... .,-;.;.:,,;? ; .,f’ : 1 : ..... :: ....... .j ... i 1. FACTUAL INFORMATION ............. :’ .:.. ?r’. 2 1.1 History of Flight .. , ...................... 2“’ ‘,, 1.2 Injuries to Persons ...... .. ................ _. ... 1.__ 4:. 1.3 Damage to Aircraft .................... , ... 6 -... 1.4 Other Damage ........................ 6 1.5 Personnel Information ...... l .... l .... l .... 6 1.6 Aircraft Information ...................... 6 1.7 Meteorological Information. .................. 6 1.8 Aids to Navigation ...................... 9 1.9 Communications ....................... 10 1.10 Aerodrome Information .................... H ‘1,6., 1.11 Flight Recorders ....................... (‘I.2 1 1.12 Wreckage and Impact Information ................ ‘I$“;. 1.13 Medical and Pathological Information .............. k4’ 1.14 Fire ............................. 14 1.15 Survival Aspects ....................... 14._\$ 1.16 Tests and Research ...................... .17 ; 1.16.1 Correlation of Approach Profile, Touchdown, and Subsequent Events to the Airplane’s Position. .............. 9 17 1.16.2 Deceleration of Airplane During Landing Roll and Determination of Achieved Braking Coefficients ............... 19 1.16.3 Deceleration of Northwest Orient Flight 42, DC-IO-40 ....... 22 1.16.4 Theoretical Landing and Stopping Distances Based Upon Calculated and Estimated Braking Coefficients .............. 1.17 Additional Information. .................... 1.17.1 Certification Landing Distances and Approved Field Lengths .... 25 1.17.2 World Airways, Inc., Landing Procedures ............. 27 1.17.3 DC-10 Autothrottle/Speed Control System ............ 28 1.17.4 Antiskid System ....................... 29 1.17.5 Cornering Effect of Tires ................... 30 1.17.6 Timely -Information of Airport Conditions ............ 30 2. ANALYSIS. ......................... 31 2.1 The Flightcrew ........................ 31 2.2 The Aircraft ......................... 31 2.3 The Accident. ........................ 32 2.4 Survival Aspects ....................... 45 3. CONCLUSIONS. ....................... 47 3.1 Findings. .......................... 47 3.2 Probable Cause ........................ 50 RECOMMENDATIONS. .................... 50 APPENDIXES ........................ 53 Appendix A-Investigation and Hearing. ............. 53 Appendix B--Personnel Information ............... 54 Appendix C--Aircraft Information 55 Appendix D--Jeppesen Approach Ch&t’VbR DME *Runway i5R, Logan International, Boston, Massachusetts .. .... ........ 56 iii , go;<;!-:, , .I’ Appendix E--ATIS Information ltX-Rayll‘ . l . l l l w . l ii /: Appendix F--ATIS Field Condition Report No. 6. l l . l l l l . _‘. b Appendix G--Cockpit Voice Recorder Transcript . l . 60 Fy.. Appendix H--World 30H Runway 15R Stopping Performance . 79 Appendix I--World 30H, Descent Path - Altitude vs. Distance From Touchdown . ;. , . 81 Appendix J--World 30H Descent Path - Altitude vs. Distance From Touchdown (Enlarged) . 82 ,__ ___- ---.. “. Appendix K--World 30H Runway 15R Effective Braking Coefficients. 83 J Appendix L--Safety Board Recommendations A-82-24 and A-82-25 With Related Correspondence . 84 Appendix M--Safety Recommendations A-82-152 through -169. 93 .-- Appendix N--Know Your DC-lo. , 105 Appendix O--Safety Boar% Reply to Petition for Reconsideration Of Probable Cause and Findings . , . , . 109 I iv k-1 : ‘\ ‘; NATIONALTRANSPORTATIONSAPETYBOARD -i WASHINGTON,D.C. 20594 AIRCRAPTACCIDENTREPORT Adopted: July lo,1985 WORLDAIRWAYS,INC.,PLIGHT30H McDONNELLDOUGLASDC-1030 CP,N113WA, BOSTON-LOGANINTERNATIONALAIRPORT BOSTON, MASSACHUSETTS JANUARY 23,1982 SYNOPSIS On January 23, 1982, World Airways, Inc., Flight 30H, a McD:nnell Douglas DC-lo-30CF, was a regularly scheduled passenger flight from Oakland, California, to Boston, Massachusetts, with an en route stop at Newark, New Jersey. Following a nonprecision instrument approach to runway 15R at Boston-Logan International Airport, the airplane touched down about 2,800 feet beyond the displaced threshold of the 9,191-foot usable part of the runway. About 1936:40, the airplane veered to avoid the approach light pier at the departure end of the runway and slid into the shallow water of Boston Harbor. The nosersection separated from the fuselage in the impact after the airplane dropped from the shore embankment. Of the 212 persons on board, 2 persons are missing and presumed dead. The other persons onboard evacuated the airplane safely, some with injuries. The weather was 800-foot overcast, 2 l/2-miles visibility, with light rain and fog. The temperature was 38O with the wind from 165’ at 3 kns. The surface of runway 15R was covered with hard-packed snow and glaze ice overlaid with rainwater. Runway braking was reported by a ground vehicle 2 hours before the accident as “fair to poor”; subsequently, several pilots had reported braking as ‘1poor,11 and one pilot had reported braking as ‘poor to nil.” The National Transportation Safety Board determines that the probable cause of the accident was the minimal braking effectiveness on the ice-covered runway; the failure of the Boston-Logan International Air@ort management to exercise maximum efforts to ssess the ‘condition of the runway to assure continued safety of landing operations,4he failure of air traffic control to transmit the most recent pilot reports of braking action to the pilot, of Flight