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Aircraft Accident Report - ?An American World Airways, Inc., Being 707-3215, Nk54a, ?Ago Pago, American Samoa, January 30, 1974

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Aircraft Accident Report - ?An American World Airways, Inc., Being 707-3215, Nk54a, ?Ago Pago, American Samoa, January 30, 1974 . ,. ... , . ., ......... :. ..-. ... U.S. DEPARTMEHT OF COMMERCE Natiml Technical Informatin Smite .. NTlSUB/C/104-007 Aircraft Accident Report - ?an American World Airways, Inc., being 707-3215, Nk54A, ?ago Pago, American Samoa, January 30, 1974 National Transportation Safety Board, \bicshin(pton, D.C. 6 Od 77 . ....... ...... %/ ,, ;,' I- Report No. 9. Performing OGanization Name and Address tiationul Transportation Safety Board Uureau of Accident Investigation, I Waahingron; D.Q .--2UW I3.Type of Report and - Period Covered l2.Sponsoring Agency Name and Address Aircraft Accident Report N'4TTIOIIAL TRANS?ORTATION SAFETY BOARD January 30, 1974 Washington, 0. C. 20534 1b.Sponsoring Agency Code . The following report reflects the findings of the National Transportation Safety Board's reinvcstigatian. 'Illis report supercedes and rrplaces .- About :3:tl, American Samoa standard.time, on January 30. 1974, Pan American World Airways Flight 806 crashrJ 3,365 fcc? short of runway 5 at Pago Paso Tnternationnl Airport. 'lhe flight was making an 1LS approach at night. Of the 101 persons aboard the aircraft, only 5 survived the accident. One survivor died of injwics 9 days aftor the accident. The aircraft vas destruved by impact ar;d fire. The National Transpirtation Safety Board determines that the probable cause of the accident vas the flightcrew's late recognition md failure to correct i? a tinely manner an excessive descent rate wbic!? developed as a resnlt of the alrcrnft's penetratiun through dcstabillzing wind changes. The winds consisted of horizontal and vertical components produced by a heavy rsinrstoxm and infl-mced hy uneven terrain clanr LO the aircralt's approach pn;h. The captain's recogn'ltion was hampered by restricted visibiLi.ty, the illusory effecw of a "blackhole" approach, inadequate nonitocing of flight instruments, and the&il.ure of the crew to call out descelr rate during the last i5 seconds of flighg ,. I i ILS approach. visual il?usior.s, crew coordination, This document is available i' i Identifier: 11-707-3218 Accident Virgir.ia 22152 j I ... ... ...~ -FOREWORD- On November 8, 1974. the National Transportation Safzty Board adopted and subsequently issued report No. NTSB-AAR-74-15. This report contained the facts, circumstances, 3rd conclusions that were known at that time concerning the a-cident dcscribed herein. On Yay 6, L976, the Ai; Line Pilots Association petitioxd the Safety Board to reconsider the probable cauw in accordance wLth the Board's Procedural Regulation 49 CFN 831.36. As a result 5f the petition, the Safnty Board reopcned the accident investigation because rf knowledge gained through other accidents after the oripinal investigation. The aircraft's flight data recorder data, the cockpit voice recorder date, and the ai?craft's engineering performance dat3 were reevaluated extensively to determine more conclusively the effect of the existing environmental conditions on the pilots' ability to stabilize the aircraft's approach profile. The following report reflects the findings jf the Nztional Transportation Safety Board's reinvestigation. This 'report superceees and replaces MTSB AAR-74-15. ii ~....................... ........ ......, ............... "~_ j ............. ,..~ .-~,~ .~ .. ... .............. ......... ..... .... .. ...... -. TABLE OF CONTEE!TS Page Foreword ...................... Synoisis ...................... 1 1. Faciual Informarion ................ 2 1.1 History of the Flight ................ 5 1.2 Injuries to Persons ................ 4 1.3 Da~sgeto Aircraft ................ L 1.4 Other Damage ................... 4 1.5 Personnel Information ............... 6 1.6 Aircraft Infornation ............... 5 1.7 Mcteorological Information ............ 5 1.8 kids to Navigation ................ .6 1.9 Communications .................. 7 1.10 Aerodrome 1nformat:Lon ............... 7 1.11 Flighr Xecorders ................. 7 1.12 Wreckage and Impact Informa,.:on .......... 6 1.13 Medical and Pathological Information ....... 10 1.14 Fire ....................... 10 1.15 Survival Aspects ................. 11 1.16 Tests and Research. ................. 11 1.17 Additional Information ............... 14 1.17.1 Use of rlight Director in liir.dshear Conditions. 11 1.17.2 Restricted Cargo ................. 15 1.17.3 Company Procedures ................ 15 1.17.4 Airport QualiSicntion Progranrl"'n Xmt'ricnn. .... 17 1.18 New l?vestig;ltio;i TechnLques ........... 17 2. Anal.ysis ..................... 18 3. Conclusions .................... 25 3. I Findings ..................... 25 3.2 Probable Cause .................. 27 4. Safety Recorrmerdatilns .............. 27 5. ApJendires .................... 31 ApTenfix A - Investigation and Hearing. ...... 31 Appendix B - Ydrsonnel. Information. ........ 32 Appendix C - Aircraft Information ......... 35 Appendix D - Instrument Approzch Chart. ...... 37 Appendix C - Flight Protile F.ei;tionship with Glj.de slope and '.!AST ........ 38 hppeadix F - FM':; Kesponses to Sa:L?t)r Recommendations. .......... 39 i ii /' /' ..... .. .... .. .. NAT1C)NAI TRA?JSPORTATION SAFETY BOARD WASHINGTON', D.C. 20594 Adopted: October 6, 1977 PAN MRICAN WORLll AIRWAYS, INC. BOEIXG 707-3218, N454PA PAGO PAGO, AMTR1C.U SAMOA JANUARY 30, 1974 SYNOPSIS About 2341, American Sanoa standard tin?. on January 30, 1974, Pan American World Airways Flight 806. crashed 3,965 feet Phort of runway 5 zt Pago Pago International Airport. lh. flight was mnking an 1LS approach at night. Of tb.e 101 person. aboan' the aircraft, only 5 survived the accident. One mrvlvor died of irluries 9 days after the accident. The aircraft was destroyed by impact acd fire. The National Transportation Snfety Board determines that the probahie cause of the accident was the flightcrew's late recognition and failurz to corrrct in a tioiely manner an excessive descent rate which developed as a result of the alrcraft's penetration through devtabilizlng wind changes. The winds consisted of horizontal and vertical components produced by a heavy rains:onn and influencd by uneven terrain close tu the aircraft's approach r.ath. The captain's recognition was hampers2 by restricted visibility, the illusory effects of a "blackhole" approach, inadequate nonitoring of flight instruiocnts, and t5e failure of the crew to call out descent rate during the last 15 seconds of flight. .~ -2- 1. FACllJhL -I!IFORYATION 1.1 History of the Flight On January 30, 1974, Pan American World Airways. In,:., Flight 806, a Roein?, 707-321B, N454PA. operated as a scheduled interuational passenger flight from Axkland. !Jew Zealand, to Los Angeles, California. En route stops included Pago Paso, American Samoa, and Honolulu, Hawaii. Flight 306 departed Auckla.nd at 2014 1;' with 91 passengers and 10 crewmem5ers on board. It was cleared to Pago Pago on an instrument flight rules (IFK) flight plan. ! i At 2311:55, Flig'tt 806 contected Pago Payo Approach Control *j and reported its position 160 miles r.outh of the Pago Pago airport. ! I' Approach control resp0ndr.d. "Clipper eight zero six, roger, and Pago /I weather, estimated ceilf.ng one thousand six hundred broken, four thousand broken, the visibility-correction, one thousand overcast. The vlsibility iI one ze.ro, light rain shower. temperature seven eight, wind three five i ,( zero degrees, one fiv-. and altimeter's mo nine eight five." .. At 2313:04, Pago Pago Approach Control cleared the flight to the Pago Pago V0RTP.C. Flight 806 reported leaving flight level (?X)330 at 2316:58 and leaving FJ.-2CO at 2324:40. Pa20 Pago Approach Ccntroi cleared the flighi at 2324~49: .....Clipper eight zero six, you're cleared for the ;LS DME runway five approach 5' via the two zero mile arc south-southwest. Report :he arc, and leaving five thousnnd." At 2330:51, the f!.ight requested the direction and velocity of the Pago Pago winds ant was told that they were 360' variable from 020" at 10 to 15 kuots. Ai 233456, the flight reported out of 5,500 feet -3/ and that they had i:ltcrcepLed the 226" radial of the PagJ Pago VOR. The approach control3.e.: responded, "Eight- oh six, right. Understand inbound on the localizeu. Report about. three out. No other reporte< traffic. Winds zero onu zero degrees at c,no five gusting two zLro." -1/ All times herdL>are American Samoa standard, based on the 24-hour clock. -21 11,s ONE xnway 5 ;approach - an approach to runway 5 on Pago Pago airport, using the f.nntrunent landing system and the distance melsuring equipmt of rhe VORTAC as aids. -31 All altitudes are rean sea level unless otherwise indicated. ., .... ............................. .. ...... .. - .......... .. ._ . .- .. .. I- ,;/ -3- At 2338:50, approach control said, "C1.ipper eight oh six, appears that we've had pow,er failure at the airport." The first officer replied, "Eight oh six. we're still getting your VOR, the ILS and tbe lights are showing." At 2339:05, approach control asked, "See the runway lights?" The flight responded, '"That's Charl.ie." The approach controller then said, 'I. we have a had rain showzr here. I cnn't see them from my position here." At 2339:29, the first officer said. "We're five DME now and they still lobs bright." ,lppmach Control replit-d, "'by, no other reported traffic. The wind is zero three zero degrees at two zero, gusting two five. Advisc clear of the runway." At 2339:41, the flight replied, "Eight zero eix, wflco." This was the last radio transmission from the flight. According to the cockpit volce recorder (COR), conversatton in ths cockpit for the last 59 second:. of the flight w:.s routine. The captain askcd the first officer about .risual. reference with the runway, and the first officer answered that the runway was 7,isible. Windshield wipers were turned on and the flaps were set at the SOo position, whish completed the checklisx for landing. The first officer stated dnring ; his postaccident interview that the only thing he had not accomplished '.i. whtch :le should have vas to change the No. 2 navigational receiver selector switch from the VOX frequency to the XLS frequeucy at the final a2proach fix. At 2340:ZZ.S. the first officer stated, "You're a little ~ high." seconds l.iter, sound similar to electric stabilizer trim .. Four a actuation could be heard un the CVK.
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