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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 .
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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
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...... ~ -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.
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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
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/' /' ...... 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.
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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.
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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. I I 23$0:27.5 to 23iC:3L, the radio alcimetcr warning tone i From sounded twice. AL 23L?:33.5, the first officer interrupted chr second ! tL..nmg.. tone. with, "Y,~u'reat mininu.ns." i I At 2340:35, the first office; rcpc'rted. "Field in sight." I i Seconds latdr, the fi.rst Gfficer srz.ted, "Turn to your right," fnllowcci I. i by "hundred and forty knots." This h-as the last communication recorded .I on the CVR. There hi bern no comnents made by either the flight engineer 1 : ! or the pilot who occupied the jumpseat as to abnormalities in airspeed, i .altitude, or rate of descent indications. Tk first officer stated In I his postaccident intsrview that he did Got remember seeing the VAS1 i lights. 1. 1. , I ! At 2340:$2. :I.e aircraft crashed into trees at an elevation of ! 113 f-et, and about 3.ti6: fee: short of the runvay threshold. The first ._ impact with the ground wa5, about 236 feet farthzr along the crash path. i ! j The aircraft contlnurd through the jungle vegetation, struck a 3-foot-high lava IUCZ wal.l, and stopped about 3,096 5eet from the runway threshald. The aircraft vas dcstroyed by impact and the sLbsequwt fire.
The accident uccurred during the hours of dnrkncss at 14' 29' 55" S latirude znd 170' i3' 55" W longitude. Thrre were no glound witnesses to the acciderlr.
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TnjurLcs Crew I- __Passe- Others Fatal 10 86 0 Nonfatal -4f 0 5 0 None 0 0
Of the 101 occupants of the aircraft, 9 passengers and 1 crewnunbei aurvived the crash and fire. One passenger died the next day; tne crewmember adthree passengers died 3 Lays after the accident.
Damage to Aircraft 1.3 I ! The aircraft was destroyed.
1.4 Other Das?& The middle marker (MH) was destroyed.
1.5 Personnel Informat.Lq3
The four crewmembers wre certlfizated to serve as crewmembers on this flight. (See Appendix 3.)
The captain occt:picd the left sent and flew the aircraft from' Auckland. The thir?. officer acted as copilot because the first officer had laryngitis. The first officer occupied a jumpsrat,
The cp.pt.ain had be.en off flying statu6 from September 5, 1973, to January 15, 1974. for medical reasons. He vas released For flvlng by tho Pan American Medical kpartment on January 13, 1974. Captain Petersen underwent vo1u:ltnry simulator training on January 16, 1974, and the following coments were made by the training raptoin who monitored the period:
01 . . . we cov.2red heavy gross weight takeoff, dtparture procedures engine fire. holdir.8, he1 dbzping. ~teept.urns, stall series (clean-T.O,-Lc!g) and api)roaches particu1arl.y ILS apprraches. By the end of the priod Cnpratn Petersen was doing vc;y good work imluding 3 engine Flight Director ILS approaches to CAT 11 ninima."
The captain's "A" Phase check vas completed January 18. 1974, with the notations that he exhibited a Food knovledge of syscems and procedures nnd that the slr!ulator work was "very well done ttirollghout." In order to requalifv in :he B-707, he made three tak.eoffs and landings On January 19, 197&. In addititin he ccmplered a voluntary flight operaticns rwiew on December 11. 1973.
I- One paseenger nTcd sf his injuries 9 days aftcr 1:he accident. 49 CFR section 830.2, defines fatalities nttrihutable tc an accj.dcnt a8 those occurring vithin 7 days after the accident.
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This approach to Pago Pago wa:3 the first instrument approach the captain had flown in instrument meteorological conditions (IMQ since his return to flyi.ng status.
Before 1974, the captain's experience at Pngo Pago 1nV.ernatlonal Airport was limited to one landing-in May 1972. Before this t-rip, Which began on January 22, 1974, he sax. the Pan American movie on Pago Pago Airport to familiarize hiixself with the airport. Pan American policy and 14 CFR 121.fA7 required the movie. lie flew into Pago Pago Airport on t*a Eec@nr! leg of this trlp on January 23, 1974, but; available Information indicated the firrc officer landed the aircraft.
The captain had flown 38:34 hours from January 19. 1374, until the accideat--his total flight. time for the past 60 days. From Jamary mtil Decernber 1973, he had recorded 32:5:48 hours of night flying.
The captain accomplished his last line check on August 2, 1973, and the comment "good trip" was noted. He completed the noma1 "B" Phese check ,June 29, 1973, which consisted of simulator and aircraft training period.r. After completion of ehe simulztor period, the following comment was made: "All work well done. Good oral quiz. Smooth pilot. R.dpeated 3 ma. FD. TLS due out of limits at DH and GA. Sec0r.d very good." 'ihf comnents for the aircraft period the following drjy were: "Repeatgd 1 eng. inop. F/D app. to correct AIS control t.echn:.que ard GfS bracketing." He %as observed by FAA Air Carrier Inspectors during proficiency checks on June 29, 1973. and June 29, 1972.
1.6 Al.rcraf f Information
The aircraft was certificated, equipped, and inaintained in accordance with EM requirements. (See Appendix C.)
There were li7,OOO pounds of Jet A-1 fuel aboard the atrcraft upon departure from Auckland. The planni?d fuel burnoff for the flight to P8gO Pago wa6 48,000 pounds. The estimnted gross veighL, tt.e fcel remlnlng, and the center of gravity at the time of the accident were 245,400 pounds, mognds, and 26.2 percent, respective1.y.
1.7 Heteorological Informarlon
The terminal farecast for Paso Pago International Airport, issued by :he National Weather Sr-vice Forecast Office at Honnlulu, Ilnwaii, at 1700 on January 30, 15i4, and valiu for 24 hours beginning at 1900 was:
Wind 020°, 15-26 kn., visibilfty more than 5 nmi, 2/8 (Scattered) cumulus at 2,CW iect, 618 (b-oken) a1tocunc:us =t 8,000 feet, 6/8 cirrostratus at 25,000 feet. 1YOO to 07CO: temporary conditions--visibi.lity - 3 niles, 613 cumulus at 1,500 feet, 818 (overcast) alcoculnuius at 7,000 feet, 8/R cirrostratus at 25,000 feet. ..
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The official surface weather obser;atio,ns at Pago Pago International Airport near the tine of the accident cere as follows:
-2258 - es'lmnted ceiling - 1,690 feet broken, 4,000 broken, 11,000 feet overcast, viaibiljty - 10 miles, light rain shovers, temperature - 78"F., drwpoint - 7OoF., Wind - 320°, 15 kn, altimeter settirig - 29.85 in. 2339 - Special, estimated ceiling - 1,602 feet. broken, 4.000 feet broken, 11,000 feet overcast, vieibil!t-y - 1 mile, heavy rain showers, wind - OlrOo, 22 kn, altimeter setting - 29.85 in.
2345 - Special. ejtiaated ceiling - 1,700 feet broken, 4,000 feet overcast, visibility - 112 mile, heavy rain showers, wind - 020°, 13 kn, gusts - 35 kn, altimeter netting - 29.86 in.
The 2258 weat,ler observation wan the last received by the flight. The 2339 special observation vas not received by approach control in time to be transmitted to the flight.
Several persrm. who were waiting at. the alrpsrt tzminal for Flight R06. stated that ic was raining heavily when thcy saw the glow near the approach end cf runway 5 which later proved to be tlit? burning aircraft. At least one of these persons stated that he wacc!!ed the €tom as it moved across tne airport toward the approxh end of runvay 5.
According to the third officer, the flight had encountered rain, bur not heavy rain. before the crash.
Survivors stated that l.ights on the ground were clrarly visible and that there was little or no rain before the crash. They stated that there was heavy rain after the accident. lhe accident occurred in darknesc, below clouds, and in rain.
1.8 Aids to Navip-
A full ILS se'rves runway 5 at l'ngc Pn~o. h nondir*?ctional beacon and :E? are located, 1.7 and 0.5 nmi, Kespt~ctiVelY. from the runlray threshold. The ILS glidc slop' is. installed at a descent angle of 3* 15'. and is not usable below 138 feet because of the effects Of the irregular ccrrnin err signal reliabilitv. The ILS localizer is offset to the right and cro:;ses the extended ruc'doy centerline 3,000 feet iron '-he runway threshoLd. The decision heifiht for the approach Was 280 ft.; 250 ft. above field elevation. Postaccident flight and ground checks nf the ILS systc;n, which included the use uf .1 radio theodolite, showed no indication of 8 system malfunction or o!lt Of tolcrancP condition.
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Although the ILS approach procedure requires that DE; be nsed to establish t.he final approach fix (FAF), the DME iu not available on the ILS frequency. Th,aa, the flightcrew is required to monitor the 'IOR frequency on at lens1 one radio receiver until passage of the 7 mi LXE fix (FAF) position.
N9 communication difficulties were rePorted between the :1!g?.ccrew and the air traffic controllers.
1.10 Aerodrome Information
The Pago Pago International Airport is located cn the south- central coaat of the Island oi Tutuila, American Samoa. Rcnray 5 is 9.000 feet long and 150 feet vide. The runway is paved with asphalt. and the elevation at the touchdown ro:re in ?O feet.
The airport is equipped with high intensity runway ISghts, 2 aediwn intensity anproactB light system, runway alignment indic.ntor lighfs, and a vlsuz? apprJach slope indicator (VASI). Tbe VAS1 is a two-bar configuration located on the left slde of ruurray S. ?he hais are located 750 ft. and 1,500 ft.. respectively, f:om the apFroacl1 end of the runway.
According to wiirten statements and teotimny at the public hearing. thc runway lights and approach li.,htr wcre set a- step 3 and :O percent illunination. respectively. an required for nighttime uperations. and the VAS1 l'ghts were illumlnated. The first officer, according to the CVR. had thc runway lights in sight from about 8 ailzs w the ;i*raach.
Zle airport has no control tower. Flightcrews rely on advisories from the P.?go Pago CoEhir.ed Approach Cmtrol International 3taLion (CAPIS). The CAFIS is located about 2,000 feet norrhwest of the runway.
The approach to Pago Pago International Airport is cundurted over waL.pr until 3.25 miles from the nlnwav tl;reshl2. About 1.7 nmi frcm the runway threshold, the approach pr.h crosLea over Lcgotala Hill. which has an elevatisn of 309 feet. The terrain under the ayproach path slopes :ownhill from Logotala Hill LO the mlway. The terrain of the spyroach path in characterized by small. rolling hills. The area in spar.3ely inhabited acd covered with Lrees and jungle ve&etotf.on.
. ' 1.11 rlight Recorders
k Fairchild model A-100 c0ckpf.t voice recorder (CVt:), serial No. 1:'52. was ix5talied in the aFrcratt forward of the rear pressure bulkhfad in lavatory E. P.Jthoupn the recorder case was severely danaf;ed by fire and hcat, the caps WBB intact and a numa2 rendout was obtained. -8-
The tape was subjected to a sound spectroanalpsis, which was conducted by the Genera.1 Electric Company, to determioe the predominant frequencies of recorded. engine soun6s. These frequencies were compared with the known engine soucd characteristics to determine engine thrust values as a function of time.
The aircraft was also equipped with a Lockheed Aircraft Service Company model 1OYC tli.iht .lata recorder (PDR), serial No. 838. This unlt, which was installed in the fuselage aft of the rear pressure bulkhead, was found intact and undamaged. There w2s no rvlLtnce of exposure to heat or fire. The aluminum foil recording medium was examined and all recorded paramet.ers (altitude, airspeed, headirg, vertical acceleration, and WF radio transmission times) :rere legible. The values of these parameters were detexmlnet as a function of time for the final 6.5 minutes of the flight.
The FDR time base was correlated with the CVX time by a comparison of the common recording of VHF radio transmissions. The comparison showed that an initial vertical acceleration peak, 3 seconds before the recordings ceased, coincided closely with the first sound of impact.
Although ther: was no evidence of recorder malfunction or recorder abnormalities, a comparison of recorded altitude at the time of impact with the elrv'atinn of trees which were struck showed a difference of about 70 feet, the recorded value was high. Also, a camp.-rison of the recorded at-qpeed values at the times of the first officer's airspeed callouts disclosed a difference of 9 knots; zgain. the FDR values were high.
The FDR airspeed measurement, when corrected to agree with the CVR airspeed ieferences, shows that the aircraft was indicating ahout 160 knots when at an altitude of 1,100 feet about. 1 minute before iTpact. The airspeed increased to a maximum of about 175 knots before decreasing to about 140 knots at_imaas, The sound spectroanalysis for rhrust values showed that thrl~stvaried between about 17.000 pounds and 13.800 pounds during th: last minute of flight. Thrust was increasing at impact. W 1.12 -Wreck.age and Impact Information The aircraft cm\e to rest about 3.090 feet~fromtba a;rprcach end of runway 5 at Pngo Pago International Airport, American SmOa. The . wreckage path was about 775 feet long and about 150 feet wide. -. _-.~~ -~-.~ .~ ~ . The aircraft first conacted trees 25 feet above the ground and 3,865 feet shart of the threshold of runway 5. The grlwnd elevation at this point is 86 feet.
Tne-first vssible signs of ground contact^ were located.3,629- feet from the rcnway threshold. i'ieces of forward nose fuselage strU~:~.re Were fCmd embedde4 in rocks; radome material was recovered iron the same area. -9-
The aircraft cict a swath through the trees, jungle vegetation, and a 3-toot-hi,$ la-;; rock wall before ctoppiag. TJe &award angle of t-.Llu%JEs and iungle vegetation. was abou:u. The- Ewath path was somewhat left of the runway centerline ald slightly lower on the right side at frtitial jmpact with the trees. During the last part of tha ground slide, the aircr&ft's right wing Lit and destroyed the MM trancnitter located 3,090 feet from the runway threshold.
There was progressive destruction of the aircraft during its travel through the vegeta:lon and as it slid over the ground. The landtng gear, the outer wing panels, the outboard ailerons, parts of the main and fillet wiv: flaps, all four engines, and the No. 3 pylon wparated From Lhr aircraft. The lower fuselage structure from the nose to just forward of the rear pressurc bulkhead was severely darcaged. A portion of the c2nter section keel beam was found at the lava rock wall.
The fuselage, including the empennage, the left wing outboard to about wing station (OS) 733, and the right wing outbuard to US 5.20, came to rest over a shallow gulley and partially on a senice road to the MM site. ! eTident AuLi.ng the 3Ut2f- the xreckage I last I pattern. The aircral :: fust!lage frsm the aft presslce bulkhead forward throug3 the cockpit area was gutted by fire. Froo the wing trailing l edge forward, the toy of the fusel.age and the. fuselage sidewalls were II consumed down to a point about 4 feet above the window line. The passenger I cabin floor and conet!nts were consumed from the aft pressure bulkhead forward to the cockpit. I.I I he cockpit darpaged by fire. Many of the ilrea~wcts.cxteosively~ ~ ~ ~ ~~~~ i instrument.;L-.- and- Instxument panels were melted, 2nd no valid informacfon was obtalned from chem. I Both wings and '111 fuel tanks which remained with the aircraft ' * were burned and melted. The upper skin was melted on the Nos. 1, 2, and i1 3 main fuel tanks and both stub sections of the <:enter wing tanks. The < main wing tank had ruptured and was damaged extcnsively by fire. No. 4 $i: There was no evidence of fire or explosion a: the wirg tip tank vents. I' .d There was evidence of in-flight...+ stuLcror~a,J_failure, fire, .: explosion. All structural fracturcs were typical of those.~causedby 3 or .. ~~~ __ ~~ --- overload. 4 Examination of the wing flaps and >andir!g -orients revealed that the Llqs were. extended t2.a setting of 20: and that the landing gears were extended at the~~ . ~~time of impact.~- -~
Host of the aircraft system.: were destroyed. The spoilers were in the retractcd position. The! speed !,rake handle in the cqckpit was in the fuli forward position (d~wn)and locked. The recovered wing 1rnJing edge devic. actuatvrs wprr in the fullv extended position.
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- 10 - '€h~e!!c~>~..@sJcally__ intact on the aEt fuselage structure. Fire damage was evident on the 1cslf.r SUKfxrs of the Kigltt horizontai stabilizer and elevator. The elevators, elevator tabs, rudder, and rudder tab were in place and movable. The elevator tahs were in neutral, the rudder L:.b was deflected about 4 in. co the Isft, and the rudder was in neutral. The rudder tab setting rcrrraponded to the setting on the cockpit trim wheel.
.The interior of the rear fwz&txfth.g-ce~aL pressure. kL%!ab~h>.LC&+%. TCe~faiS_ht_cp_nt~l.cat.s~~~re~in place and intect, The horizc.:tal stabilizer actuator vas in place, intact, and posiL'Jned at three units aircraft nose up. There was no evidence of malfunction of the aircraft fl.ight control system before impact .
Amsse?aratc!d from ~hei~py~~bs~.aad.~h~ pylon had 'separated frO~_thplk!i:~~.The turbine thrust reversers were sepn~iom~~cilgines'Nos.3 anc li. The turbine thrust KeVCKSer txlckets of the No. 1 engine were close& and the translating sleeve was missing. Porrions of the fan reversers remahne3 on each engine and were in the stowed position.
The rim: and e.x@nd staj:? fan blades on the four engines were broken off at the blade platforms. The third stage rotor blades on the four engines vere bent opposite tho direction of engine rotation. Various amounts of finely chopped, fibfrous residue were found in the bleed air passages of ehch of the engines.
1.13 M~?dical_a~ntholcgi~aIInformation Post-mortem examination of the crewmesbers disclosed --no evidence oCim-aac_itating disease. 1-
Except for the third nff:lcer, who occupied the copil.ot seat, ail fatally~. injured persons died of smoke inhalaAon, massive first-. second-, and'~thi;d-;degrea burns, and complications from those mssive ~-~~ burns.
Toxicological examinations of the casualties revealed, in each c3s.e. significant levcie of cnrbcn monoxide and.hydrogen cyamide. These gases are natmal byproducto of aircract fires.
The third officer, who s,;rvived the crash bur 1att:r died of his.. injurles, received traumatic leg and ann injuries and severe burns. 1.14 Fire I
A small fire truck., manned bg two fircilen, was parked nexr to the KUnWaF-a standard practice %hen aircraft arc schcduled tc land at Pago Pago.
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At 2343, the fire station received the first alarm. Response was delayed bkme of sonf.Jsion as to whether_ a hnusr or an ircraft was involver! in the reported fire. Response to the accident has further delayed by heaq- rai3 and two chain gates across the access road from the airport io the accident scece.
Access to the fire vas limited to a one-lane road, and only one piece of fi.rcfightlng equipment at a time&iiiIb?p56ath and fight the fire. The departnent's activities were limited to extinguishing the fire. No rescue activities could ic carried out until after the fire was under control.
1.15 Survival Aspects
This was a survivable accident. -___~~~__ .. ~.~~~ PGssengers who survived the accidect said that the impact forces wer&g@rlrmoteswere~ than a normal landing. No drmage to t,kcabin interior was reported. Large fires were seen OUI- right side of the aircralt. One person opened an ovewing exit on the right side of the aircraft; flames came in through the exit, and he closed It. Other surv.tvors opened the left owxwfng exits, and all^ the survivors excep'. the first officer escaped through those exits. The first officer was assisted in his escape by two other c3cI:pit crewmembers and left the aircraft through a hole in the ccckpit wall.
The surviving passengers reported that~m~assenge~srushed towa_rdwzent and rear of the^ cabin before the aircraft sropped. The survivors did not hear iastructfons regnrdhg escape from the aircraft after the eccident. Most of the survivors suffered burns and other injuries after :hcy esc.aped from the cabin.
Po,s~tacci~ent~~n~stigatiDnxevealed that the forward and the rear~gntrydoors wese not opened or used for escape. The forward door was opened about 2 to ~3 inches, buc~the aft door was cloded.
The forward galley service door could noc be identified in tlie wreckage. The rear galley service door was found in place and locked.
1.16 -Tests and Resears Flight Rc-zder Data - Airplane Perforr.;rnce Data Analysis
The measured values of t!le flight data re:order parametc?rs wOre annlyzed along with the thrust values determined froa the Scnral Electric Company's spectrographic study of the cockpit voice recorder tape and the nanufacturcr's data on airplane performance. Tht purpose of this analysis was to deternine the magnitude ot the winds along the flightpath and tu construct a flight profile which would relate the airplane's position during the final minute with the ILS glide slope and the corresponding VAS1 indication. - 12 - (a) Determination of winds encountered -- The aircraft's performance capability for a givm set of condit.ions (including weight, configuration, thrust, airspeed, and altitude) Is described by a specific plot of vertical speeds versus longitudinal accel.erations. When tho val.ues for the airplane's rate of altitude change and rate of airspeed change at a given iristant were not compatible with the calcu1a:ed theoretical performance capability, the differences were attributed to external forces on the airplme which were produc.ed by changes in the vertical and horizontal components of the wind.
Although the total effect of the wind could be determined by these analyses, the exact combinations of vertical and horizontal wind components which the aircraft encountered could not be determined precisely. I i The data showed that the winds encountered by the aircraft I were characterized as follows:
From about 58 seconds before Impact to 51 seconds, very little wind effect; from 51 seconds to 47 seconds, an increasing headwind about: 5 knlsec., an updraft of over 4,000 fpm, x some combination of increasing headwind and updraft; from 47 seconds to 39 seconds. a decreasing headwind about 1 knlsec., a downdraft of about 1,000 fpm, some combination of decreasini hesdvind and downdraft; from 39 seconds to 27 seconds, an increasing heedwind varying between ahout 1.5 knlsec. aad 3.5 knlsec. or an uodraft varsina~- hetween about 1,200 fpm and 3,000 fpm, or some combination of increasing headwird and updraft; from 27 seconds to 4 seconds, 1it:le wind effect ranging from .3 kn!scc. increasing headwlnd to .6 kn/sec decreasing headwind, from 300 fpm updraft to 450 fpm
downdraft, ,et: some combination of headwind change and vertical wind change; final 4 seconds (from 125"feet above to ground), a decreasing headwind of about 2 knlsec., a downdraft of about 1,700 fpm, 0~ a combination of decreasing headwind and downdraft. The thrust uhich would have been required for the aircraft to have achieved level flight with a cwstant indickrted airspeed was also calculated for each of the envircnmental conditions encountered. The thrust required for all conditions except that encountered during the final 4 seconds was less than the thrust avaf.labible with takeoff power applizd (nominally zbout 57,000 poands). When encountering the calculated wind change for the final L seconds of the flight, the thrust which would have been required to maintain unacceleratad level flight woald have exctded the thrust available at cakeoff power. Ur!der these cur.ditions, level flight cou1.d have been maintained For a short time ai the sacrificc of airspeed. With continued exposure to these wi.ltd changes. the aircraft wou:d. eventually, decelerate to a stall.
These wind changes, however, were calculated based on *:he aircraft's descent profile. If the winds during r:!e last 4 seconds were varying as a function of altitude caused by rhe frictior effects assocj.atpd with their (the winds) clcse proximity to the tcrrsi::, they cc,uld have - 1'3 -
1:een sigcificantly different than thcwe calculate? from the descent profile. In wldch case, the aircraft, once level flight had been achieved, nay have encountered a more stable wl.nd velocity. Under there condicions. the available thrwt would have been sufflcien: to accelerate the aircraft or to climb.
The amoun: of altitude which the aircraft would lose dur'ing a transition from a 1.500 feet per minute drxxent to level flight following the pilot's initial action to arrest the descent is dependent upon several variables--initial airspeed, the caLe and amount of the pilot's control input, thrust management, and w:r.d changes. This 13 a dynamic problem which would probably produce a range of results if exominfd in simulation. A1:hough sinlulation was not conducted, the question was analyzed based upon specific assumptions. These assumptions were: (1) that the maneuver was initiated at an airspeed of 148 kn; (2) that the pilot introduced a c.ontro1 column input to produce a load facto- of 1.5g. or activate the stick shaker whichever occurred first; (3) that the pitch rate was such that maximum pitch channe was accomplished during a 3-second period; (4) that there was no significant increase in thrust until the rircraft reached level flight; and, (5) tkat the wind was varying only as a function of the a!.rcraft's change of altitude.
Under the assumed conditions, the aircraft would have lost about 55 feet in completing the mane*mer. 'fie total change in pitch attitude would be from about nose level at the inS:iatlon of the maneuver to about 12O nose up at the instant level flight W.'B attained:. Thus, the rotation rate the aircraft assumed was about 4'lsec, slightly higher thar, the 3'Isec normally used in a go-around maneuver. The aircraft would lose about 7 kn of airspeed in completing the leveloff.
Assuming that, as the. descent rate was arrested, the pilot lowered the nose of the aircraf. to maintain level flight, the aircraft would have an initial deceleration rate of about 1.5 knlsec and the deceleration would cmrinue at im increasing rate until She ellgil1CS bere producing higher thrust. The instantaneous application of takeoff thrust at thc initiatim of the leveloff maneuver, even ignoring all allowance for engine arrelerat.ion time, would have hat! no significant effect on rhe total loss of altitude.
The thrus-. which wculd be required to maintain,position on a 3.2S0 glide slope in no wind conditions for two configurations Was SlSO calculated. For a .LOo flsp configuration, at 150 kns, about 20.lf"l pounds 01 thrust would be required, A 50° flap ConfiRur~ltiOnwould require atout 24.170 pounds of thrust to malntain an approach aj~rspeed of 440 kns.
(b) kterm5naticn of Plight Profile am? Relationntlp -~ILS Glide Slo;>e nod VAS1 Indi$-gt.Lo2 -- 1he Zli,cht profile of the aircraft. $:hat is. its 31ti:ude versus discnnce frm tile rc.WL'2.y threshold. was de-ermined for the la,st minute of Llight usin[; air:;pc..d
.. .. - 14 - and altitude values from the FDR. The values were used uncorrected and corrected for che ipparent errors evident from impact site elevation and C'JR callouts. The crlculatlons were performed assuming bot}, a 15-kn constant neadwind and a. hcnduin: which varied between zero and 35 kns (Che maximum wind speed indicated in meteorological reports) in accordanco With the Wind accelerations determined in t.he described wind analysis.
The flisht profiles were compared with the corresponding positions of the ILS and VAS1 glide nlopcs. Txe ILS glide slope elevations were calculated free a 3.25' .?lick slope with a threshold crossing height of 55 it and airport elevation of 30 Et. The VAS1 indications were determined Ear a system Installation and alignment as desc.ribed in FAA Document 6950.2, Handbook Visual Guidance Lighting Systems, October 16, 1974.
(Thp results for a plausible so.: of assumptLnns--using corrected FDR altitude and airspeed values and headwinds varying between zero and 35 kns--are shown in Append5.x E.)
Tk results indicate that .he aircraft was bracketing, and within 30 feet ?f. the glide slope with a red/white VASi itl2ication presented from 1 udnoLe unti? 40 seconds before impxt. ,It that tine, the aircraft crossed the glide sLope centerline fxom iow tc h:gh. The aircraft continued to diverge above the Glide slope w!\ile airspeed incrcasrd ahout 10 krm until, about 20 secorc's before impact, it reached a gllue :;lope dcviatlon of 55 it (one-dot displacement on raw data display). The VAS1 would have presented a' pink/white indic.ntion during th?,t period. About 16 seconds before impact, the aircraft began to ri.pI.ily converge with the glide slo?e. The uircrrft crossed the glide . fit;pc Srom high YO low between 11 and 12 seconds hefore impnct and continded 10 divf1ge below the glide slope ul?til impact. The VAS1 prcscntaticn w0ul.l have changcd rnpidiy goinc from pinklwhito to red/whiie abaut 12 se.conds bfrore inpacc, to redipink ahout 8 seconds, and to red/rc.3 abouc 6 secocds before inpact. The glide !slope raw dzta wwld have shown .I full scsle deviation for thc final 6 crecoads.
1.17 Additio2al Informntion
&me
1.17.1 Uric of Flight illrector in Windshear Conditions
An eagineerin:; flight simulator was used t~oobserve pilot and aircraft performan-e during passnde through windshear cnviromnents as pan ol the iivestigation of another nccldent. 21 Durinf: the simulation, some piluts mted that t!13 sinulator would ccntinue to descent tu impact the gc?.wx\ while bclow giidc slopc, even though the fl.ight direc.tor
- -5/ I'astcrn Air Lir,es, I.nc.. E-727, Jamlica, ::ew Ycrk, June 24, 1975 (!.ITSD-AAR-7(;-8. . - 15 - f Steering comands were nxlled. This W?J noted when passing tb.rough programmed winds which consisted of rapid changes in both the horizontal and Vertical speeds. FOllOwing that same accident, simulated windshear I encounters were condvcted at the NASA Ames Research Center. During ! those tests, the p;tch attitude required to stop the descent rate often i exceeded the flight director pitch command limirs when the encountered wind caused a rapid and extrerte speed decay, or after a large glide slope error was allowed to dereiop as a result uf slow pilot re-sponse to I initial conuands, or after a flsght director step gain decrease was initiated at MM passage.
1.17.2 Restricted Cargo 1
The aircraft WBS carrying restricted cargo. The cargo, listeZ as article tiff. 727 by thz Intern.?l:ional Air Transport Association (IATA) Restricted Articles Regulation, was ethyl methyl ketone peroxide j (.VK i peroxide) I IATA regulatims specify tF 2 maximum quantity that nay be ! packed in any one outside ccmtainer .ts 1/2 kilogra;? (1 pound) or 3.12 litre (1 pint). Compatible plastic tubes of not over 5cc (116 fluid once) CaQaciry each, packed with sufficient noncombustible cushianing an& absorbent material which will not react with the contents and which will prevent breakage or lee,kag?. shall be packed in iibe.rboard containers up to a maximun net c[u;tntitl. oi 1/2 kilogram or 1/2 litre. No more than 24 of these containers ehould bc packed into cne container'. prcz-iiding the net quanti-v doe3 not cxceec. 1 kilcgran (2 pcunds), or 1 litre per container.
The r;lK peroxide ~(3sdiluted to 50.8 percent peroxideowith hydroquinone. This iahibitor increased the flahhpoint from 125 F to 180' F, in addition tu inhibiticg it chemically. The cnrpo consi.sted of 200 20cc bottles, with 50 hottles per 1 gallon [.in. "he bottles were placed in plastic hags and then in the tins. Perlite was placed beneath, around, and above the bags. The fins-were sealed. ':?IF Iour tins were then placed in a fiberboard cxrtoo. The weight of the k:K peroxide in the c.artw was 4 kiloglams.
The shipper'. who was responsible for IdentiEyinS the material as ha?.ardous, believed that the flashpoint of the material was the only criterion for classifying material as hazardous. Consequer.tly. :he I freight forwarder and the cnrricr were not advised that the naterial was \ 1 hazardous. Further, since the flight dispatch ~;~D~xsdid not identify the. material, the flightcrew was unaware of the nature of the cargo. I ! 1.17.3 C=anv Procedures ! .. The foilowing procedures are extracteri from the Pan Aaerican i Fliglkt Operatiam Vdnual.:
11 . Conducting the Anproach and Laadirip
Regsrdlcaj of the type of approach. ,:!le aircraft should be on final approacn in ;:lie landing conflguration with the - 16 -
Landing Checklist complete, in lMC, not lower than 1.000 feet AFE or, VMC, not lower than 500 feet ATE. At this point, the aircraft should be stabilize3 on the plidepath, on Vprog, with the proper sink rate 2nd trimmed fcr zero control forces. I During any approach, the pilot not flying is to call-out rhe sink-rate when it exceeds 800 FPM,
ILS Approach Cal.1suJ:
During an ILS approach, the pilot no: flying is to make the foll.aw1r.g call-outs:
1. Outer Marker Outer marker, altitude checks, instruments cross- checked.
2. 500 feet AFF 500 feet. instruments cross-checked.
3. 100 feet above Lii (Decision Height) 100 feet above mcision height 2nd the airspeed.
4. At Dl1 At decision hei.zht call out 'Decislon height,' follcwed by 'visual colttact' or 'no contact' as app:dprlate.
"Approach Duties
T'le flight engineer will in addition to his regular duties:
Monitor. comunications. Cros$--check instrumznts. Be {aware of correct altimeter setting and aititude. Re .alert for missed rtpproach. Watch for visual cue$; approaching UH/MDP..
The Second/Third Officer will:
Monitor cumnunications. Cross-check inatruneots. Use approach charts to monitor nppronch. Confirm correct fac..'l.ities tuned and identified. Be aware of correct. altimeter setting end cross- . check altitude. 'Jiltch for vlsual CUPS approaching DHIMDA. -_"Det?rnining n:ill.mii - Approaches Other Than Cztegory I1 The i)ii or ?IDA for any appt:oaches other than a Category II ILS is determined by reference to the barometric altitude. .. - 17 - -It Limit&?- Descent Rates Relow 2,OCcW The m&xFmum descent rate recomended below 2,OGO Eeet above ground level (AGL! is 1,000 FPN." 1.17.1 ~~o~~unlificatio~Program - Pcn Americar,
Pan Amcrican World Airways usee a movie to augu*wt their Airport 3ualificnti.on Program. Ihe movie about the Pago P.igo Airport emphasizes the I',S/DXE procedure. The movie and narrative are descriptive; however, because of recent physical changes in the airport and a change in the reported elevation of Logotala Hill, the portions of the m0vi.r. which related to these items were outdated. The approach was accurately described. The narrative also stated. when upcrating VFR, "!he to Terrain, when landing on runway 5, maintain 1,000 feet and disregard VAS1 until crosshg Lima Oscar Gold YUB. At this point, VAS1 will 1-ndicatr high."
I.. 1s New Invest-n Technique0
Nonc
i
! ...... l______.____-._._ .~..~~.~---~-_-1__111_ . . . .. 1
- 18 -
2. PXALYSIS
General
The aircraft was certificated, equipped, 8r.d mainta.ined according I1 to requirements and Tegulations. The gross weighr and c.g. ware within I yrescrihed limlts during takeoff at Auckland and ths approach to Pzgo ! Pago.
I'he f1igl.t cremembera wEre certificated and qualified ir, accordance with company and FAA regulations.
Based on the investigation, the third officer's ststenent. and the perfo=ance analysis, the Safety Board concludes that the aircraft's powerplants, airframe, electrical and pitot/static instruments. flight controls, and hydraulic aud electrical systems were not factors in this accident.
Although the ethyl methyl ketme peroxide was inproperly packaged, there is no evidence to indicate that it contributed to the cause of the accsdent or to the death of the passengers and crew.
The Approach
l'he CVR readout and the icterview with the first officer established that thu runway was in sight when the aircraEt was about 8 nmi from the runway threshold. The runway probably rwained in sight durinz most of the approach.
The first officer cmented five times during the approach, afte?: the aircraft was vithin 7.5 nni of the runway threshold, that he had the runway or the runway lights in rigt:t. There was no indication that any of the navigation&. aids or t'.e aircraft instruments were faulty.
The alrcrnft descended about 500 ft. below the published minimum glide slope intexept altitude of 2,500 ft. before the glide slope intercept point was roached. This placed the aircraft 180 ft. belov the final approach fix altitude of 2,180 ft. These al.titudes are confirmed by a CVR ccment, "Tvo thousand", made abcut 1.5 seconds before the FAF callout. The Safety Boar2 was unable to determine the reason for thCs deviation from approach procedures.
.I At FAF passage, the 7 nmi DKL fix, the first officer's navi- 9p.ationa1 receiver selector switch should have been changed ?om the VOR yositior. tr, the -iLS positisn; hoxever, this vas not accmplxsked. If thc change had been made, as goo3 practice would dictate, the first officer could have monitored the apprrach ~ordefiicicntly and his \\ - 19 -
navigational display would have been ready for crosscheck by the captain or crossover in case of the failure of the captain's instrmmts.
As the aircraft approached the glide slope, i.t continued through and above it a6 t.he captain started hia descent. The glide Slope was iutcrcepred as the aircraft passed through about 1.000 ft. "he airspeed during this time varied a few 'mots above and below 160 b.
From this point on during the approach, FDR. inforcation shared that the aircraft flightpath waa not cmpatftli- with the aircraft per- formance which would be expected in Etable air. The differences can be attributed to external forces acting upon the aircraft, c~chas wind changes or rain drag. Analysis has shm that a ma::mun density rain could produce an increase in drag forces ihlch would equate to a -600 fpm change in descent rate; however. statements by the firat officer and the surviving passengers refute any claim that the aircraft encountered suc:l a heavy rain before impact. Therefore. the difference between expected and recorded aircraft performance was more likely caused by the winds.
An analysis was conducted t,o determine the wind changes needed to produce the recorded aircraft performance. The flight recorder data as recorded and corrected for an assumed 9-knot airspeed error. as irdicated b:' the first offl.cer's airE,pertd callouts, were used in the anslysis, 'Ihc differences produced b'y the 9-knot etror were.not considered to be oignificent in the malyzed wir.d.
This analysis indicated that the aircraft encountered gusty wind conditions with a pre.dom!.nmtly increasing headwind and/or an %updraft about 50 seconds before Impac,t. The influence of this wind condition persisted for about 25 seccnds. The Safety Boiird believes '-that the windshear was caused by the ouzflowing winds from the rsinstorm Over the airport as they were affected by the upsloping terrain around Logotala Bill. The vindshesr was zvident by a sharp increase in airspeed and a shallowing of the descent pzth. Consequently. the aircrait vrnt above the glide slope. The airspeed at chis time was still about 160 kn. The sound spectogram showed that. at this time, the thrust was reduced to apparently correct the high and fast condition.
As the aircraft passed Logotala Hill, it apparently came out of the increasing headwind or updraft, condition and the positive per- formance effect was lost. In fact, B wind which produced D small negative performance effect was probsbly encountered. The thrust was veil below that normally needed for a stabilized approach, and. about lmds before impact, the aircraft started a rapid descent. of about ~1.500 fpm. ~ =--~__ -~~~ . - - 20 -
Thus, the Board concludes that the captain recognized the Is initial effect of the windshear condition and acted ta correct the aircraft's flight profile ty reducing thrust, but he did not reccgnize the second effect as ;he windshear condition changed. Consequently, the aircraft, with low thmst, respondfd to the changing wind by &vel- oping a high descent rste. The captain had at least 12 seccnds in which he could have taken action to arrest the. descent in time to prevent thu accitient. During that time, tht total thrust available exceeded that required to maintain c,onstant airspeed in level flight. 'that the necessary pitch attitude and thrust changes were not applied CM only indicate that the fii&h!xrerr was not aware of the high descent rate and the inpending crash. !
Evidence indicated that, when the sink rate increased, the ., captain may have been looking outside the aircraft and, therefore, .)as not flying by reference to the flight instruments. At the time the sink rate increased to abaut 1,500 fpm, the aircraft war over an area dr:void of lights (knom as a "blackhole"), a heavy tropical rainstorm was over the airpqrt and moving toward the approach end of the runway, and the first officer had called the runway in eight.
The circunetances of sevsral other accidents which have. been invest,!.gnted by the Fr!*.r.! hevg i?..iicetz5 $52: :!x $r?nsf.t.ion fr'r~u lnstrunent fiight to vlsual reference for vertical guidance is the most critical portion of the approach, particularly if the transition is initiated prematurely. DynaQic changes to the aircraft'n flight profile are apt to go unrecognized. In tbia accident, the heavy rainshower aheai of the aircraft probably caused visual cue8 to dhinish t.0 the extent that the lncrea!?fd sink rate would have been extremely difficult. if not impossible, to recognize. An a result of previous studies, the Safety Board has endortied strongly the installation of VASI as a visual aid to vertical guidance and even nore so. the optinizstion of 1nstrumer.t approach procr:durrs whi.ch would prevent the premature transition to viwal reference by the pilot controlling the aircrafc. , VASI was avsj.lable and operating during this approach, however, there was no way to drr.ermine with certainty that the crew could have seen VAST continually during the approach because of the heavy rainstom zh3t was moving across the airport. As the heav; rain associated with the storm moved toward the aircraft's approach path fro= the op2csitc end of runway 5, the rain most likply would have obscured, progressively. each pair of russny edge 3.ights. This obscuration would have progressed until the VASI disnypeared from the flfghtcrew's sight. At thjs point, the approach could ~til.1kave been contlnued because the app7oach 11&:3, t& runway end idrntifl.er lighrs, and up to 750 ft. of runvay edge lights could have bcen visib1.e to the flightcrew. The fact that scme lights were -~isiblcto the3 is verified 5y Ctw repeated callouts to that effect made by :he first dfficer iluring :he approsch. - 21 -
The Safety i)oard believes it likely thrt the flightcrew did eet! and u31? VXI at aome time durine the approach, particularly after the first cfficer's rt?port that the aircraft was "...a littie :ligh." Even though the first officer could not remember seeing the !:GI, the most likely reference fer his statement of the aircrart's -,oaition relative to the glide slope would have been VMI. becsuce he had not changed his No. 2 navi]:c~tional receiver selectcr switch to th- 11,s frequency. rher-fore, ILS information was no( dinplayed on his in- etruments a?d to obtain this information, other than visually. he would have hod to look "cross-cockpit" at the captain's inotruments to detexmine thut the aircraft was high. In the last few secmda, the first oifira would have had to look b.tck into the cockpit to ascertah tha: Lhr? aircraft was at minimum altitude and that the airspeed was 140 kns and edviaed the c.aptain. It is possitle that he rould not have seen the below glide slope indications on the VASI under the152 circumatancea.
Even had tt.c captain been observing VAS1 as the alrcrnit descended below glidepath, hi0 attection to the Indications and his reaction to an unsafe redlred signal would have had to be rapid rad decieive in ordet to prevent impact.
The analysis of the VASI indicatiorm. based 0.1 the fli.ght profile derived from flight recorder data, showed that, at the time of the first officer's callout, the captnin, asawling that the VAS1 wsa .risible to him, would have seen en nbove slide slope indication on t!re VASX. This was about the sew t!ee th2 high ra:e of deace1.t starre?. Without reference tu his flight.. instrumento or a c~llfrom one of the other crcmemhera in reference to the increased rate of descent. the captain would have had no ieason to .%-yply power at this timt. If he continued to watch the VASI. he wo11ld hs-ve seen an "on giide slope" indication, then a "slightly Icw on the glide slope" indicaiion; stili no visual indication alerted hits to t.he need for a power appiicatlon. By tke tine that the VAS1 would have chahged to an unsafe, IOU lnd The flight profile analysis showed chat the bircrnft wad about 173 fret ebove the trees when the red,'red \'AS1 should h&vc been seen by the crew. At that tize the aircraft wn3 debcending st 25 :eet/eecond. Thus, allowin8 1 second for the captain to intrcduce a control novcmen~ afwr recognizing the necessity to do so. the atrcraft vnuld rhen have loat about 80 feet of nltitude before the '2escer.t wa& arresred. This assuses a very posltive leveloff rmeuver l-here the alrcrnft is rotated at 4"/sec. to a l..;~lmd factor. Thereiore, the captain crcu1.d have . .. - 22 - had to recognize and start responding to the situation within about 2.5 seconds of the rdred VSI presentatioc in order to limit the total altitude loss to 133 feet and to miss the trees with about 35 feet of pargin. Slower recrgnition time or a less pcsitive leveloff maneuver would have resultrd in inpact with the trees. The Safety Board believes th3t 2.5 seconds is marginal foc the perception of the change in VAS1 indications and the initiation of appropriate response. by the captain. Performacce iukalysis shared also that the aircraft could not maintain flight without further loss of airspeed after the leveloff even with maximum thrust if the decreasing headwind condition encountered within 120 feet of the trees persisted. Emever, the Board believes it likely that the windshear encountered by the accldr-nt aircraft as it approached the ground was a result of the wind vi.riation with altitude camofi when in close proximity to the terrain. If so, the aircraft's performance would not be degraded once level iligh: was achieved. Accelerated level flight or a climb should have been achievable aftcr thrtwt attairmenc. Thc Safety ]:card considered another factor which could have i added to or have sup;)orted the captain's visual indications that he need nct apply powci to rectch the runway or to arrest a high rate of descent. ., I f The heavy rainstorm which. was moving toward the aircraft could have caused n short.ening of the pilot's visual segment-that diqtance along the svrracr visible ttr the pilot over the nose of the aircraft. This can produce the iliusion ;hat the horizon is moving lower and, as a result, is often misinterpreted as an aircraft pitch change in the nose up direction. :'he u(iL'bu.__ ---' -sponse by the pilot wodd be to lover the nose or to decrease, nct increase, pow?r. While conceding that the environmental circumstances at the tlne of this accident wer? mllex;rab?e. the Safety Board must conclude -,that the accident cou1.d have >een avoided had the crew recognized, frm ~~~ ~ ~~~~~~~~~~~~ ~~ all available sourcen, the onset of ths high descent rate and taken timely action. The Board is, therefore, concerned about crew procedures relative to zltitude awa~messand required callouts. If the crew was conpletsly aware of the aircraft's altitude, they should not have accepted a glide slope intercept altitude 500 ft. lower thaa the published altitude; they should not hwe accepte6 m.eltitude 150 ft. lower than that altitude presicribed for the FAF cl'ossing; and the pilots-not-fl.ying should hare made altitude warning crillouts. The firs: officer did make an altlmeter c.heck abcut 2.4 minutes before impact, bu: he said nothing about actual altitude. About 3 seconds alter the first officer's i comment, the captain made an unSnreSli,glSle cornat which nay have he.en a rqcognitiun of the aircraft's lower-thm-prescri5ed altitude because, I 5 seconds later, the sound of a power increase could be heard m the CVR. '. 1 . . ,. ... . , . 23 - - .. The CVK tape contained a few other unintelligible comments that may have been altitucle or warn2-g callouts. However, if these COments were altitude or warning callouts, it is difficult. to understand why they went unhezded by the captain. Perhapa even more important than altitude awareness in this accident wts awareness of increasing sink rate. Pan American procedures I required that the pilot not flying the aircraft cail out sink rate when it exceeded 800 fpm a*.ld recommended that the sink rate below 2,000 ft.. should not exceed 1,1100 fpm. An annlyiis of the approach to Pago Pago showed thnt the 3.25' glide slope would require a descent rate. slightly less than 800 fpm with an indicated airspeed of 135 kns in zero wind conditions. In this case, 135 kns was the reference speed (Vref) for the approach. Usiug the company procedure of adding only half the I steady wind velocity to Vr,f, thz required descent rate would be less than that rate required for zero wind since the groundspeed would be affected by the total val.ue of +he steady wind velocity. Any addftionol I speed margin to compensate for wind gust velocity would have had the effect of incrersing the groundspeed and thereby Increasing the required descent rate; however, cuch rates wol;ld still be less than 1,000 fpm even with a 35-knot gutit margin. I me captain of Flight 806 was atteP:pLing to maintain an approach I speed of 150 kno. If the anticipated headwind dissipated to zero, the ~ descent rate required to maintain positIan on the glide slope would have 1 been 880 fpn, still less than the 1.090 fpm mximun. Nevertheless, I according to procedures, a csllout ahould have been made whicn ma57 have alertad the captain that the actual winds differed from those reported. ! The FUR data showed that the aircrsft's rate of descent increased I about 1.500 fpm at least'15 seconds before impb2t. Again, there were no i callouts and the evidence indicated that the captain.did not recognize I or react to this increased sink rate in a timely manner. The Safety i Board believes that, had he done so 3s a result of a cailour by one of the nonilying crewmembern, the accident could hsve peen avoided. i The Sefety Board also believes that flight instruments are I more reltatie indicators than the senges of the pilots, especially I ? durlrg that portion of the approach wler. the aircraft is close to the ! i :1 ground and when the visual cues reaparse or diminishing. In undocu- mented windshear encounter tests contucted at NASA, it was determined that t.he flight directo;. steering cmmands ere adequate except when the i windshear rescited in wry rapid Speed decay, when initial steering commands were not followed by tne pilot, or after the flight director gainwhange was initiated at MM passase. Therefore, to manage such i conditions the flight director uiilst be used in combination with other i flight instruments such as the raw data indications. i - 24 - In the final 15 seconds of this approach, the rate of descent mst have avryaged considerably more than the 1,000 fpm reccmended maximum and the raw data glide slope needle must have shovn that the aircraft p~.s~edthrough, then below, t5e glidz slope. The glide slope WRS noted musable below 138 ft., but the aixraft departed the glidepath well above that altitude. Any indication thst the aircrart was below the glide slope at an altitude lower than 30C ft. should have been .. ,treated with suspicion. the note about glide slope unusability notwith- stmding. especially if the VAS1 WRS not in sight or was obscured. Survivab- -- was.~rnriintainedthrou~I~~+~~_~~n~--The only traumatic ;;juries were those to the first officer. _TEie survival problems stmmed frm postcrash factors. ~~~ ~~~~~ ~~ .- .~~~ Three major postcrssh survival problems were: (i) The cabit1 I crew did not cpen the primary emergency ~eats*(2) twe5ict~igns to the crash, and (3) Fas.zettent&fenes&to_ the pretakeoff briefing ~~ . ~ and the passenger information pamphlet. ~~ ~ ~~~ ~-~ ~~~ .._ ~ -~ ~~ - . It could 110: be deternhed why the primary emergency exits were not opened o khcbksldeof-Cho aircraft. The de the aircraft------* on t e L&ht side or the press of passengers n-hy the doors on the r_islt~- s1de were-_ not opensd. The doors un the Left s1.de of the aircraft may have beeti dm.=.gcd during the rrash. In thjs event, the flight artexdents wuuld be expected to redirect the passengers to other exits. The survivir'g een,gezs-were sll,&escLnrar..the dddl.cef,the~ aireraft and_dg~noc hear instructions yiven by flight attendants after tlie-c+ Since none of the f1ightattsT;dakXs- received traiGtic~njii~Ie6in the crash, it is pos3fble that thy ~errovercame by smoke or that~~they~LKjRd to open the cxits and did not redirect passenEe~5~~alterna~.rexlts. It is also possible that: the pssengers-cr-wd-ed against the doorp, and for that reason, the il,i&h~attcndants .~irere unable to-open the -exLts. ~~~~ It is u-kall of the passengcrccould have esceued from the nireraft t+traug'kfing exits. Fiowcver. 11-19 pessihle that there would have been more surviv.oLE.had the passengers acted~accordiTlg +u prefl.i&t~_ins~~uc&ionsand proc-ee*d to the nearest eat. instzad~of-~ox!zx toward the main exits through whch-~theTho:l originall,, entered. ~- - .~~ ~ ~._/ I - 25 - All the syvivors rerroxted at th~llEten*ld_ta_:hep;etakeoff bridi--mthu ~m2hlet..~~~ ~~~ These actions prepared them for the evacuation hy stressing the location of the nearest: exit and the procedures to be fol.lcved in an emergency. The movement of mast of the passengers. including many of the peseengers in the averwing area of the alrcraft, to the front and rear exi:s indicates that ti-cy either dtb- riot ca~prehend~~the~Fretakeoffbriefing or thesreacte! to the emergency without thin.king. ~ ~- -Fire and Rescue Fire and rescue to reach the crash site and to of the fire department was s across the responsem, and the uncertainty~ofwhe~~er_th~w~s~sm~an qircraft or~~~ a house. It is doubtful that any _cf~tbe~oc~~ants~~remaining~!.n the aircraft -.-ere~atill+Li*uhen-rhe~ fire personnel arrived at and res~~~~~ tbe~~scene. The fire and rescue pzrsonnel experienced considerable difficulty in fighting the fire. Tne greatest problem was tbe linited access to the wreckage. The 0ne-Wprecluded more than one vehicle from fighting the fire at a, tine. AI1 approaches to the fire h-d to be made from the front of the aircraft: therefore.total crverzge of the fire vas not possible. Had all fire vehicles beel able to approach the fire simuitanenusly, fire dmage to the aircraft may not have been so extecsive. 3. coscLusxoE;s 3.i I_Find!= -31. There vas no evidence of preimpact structural failure, fire, or flight concrol or powerplnnt mnlfuuction. 2>2. Flight 806 was conducting an 1l.SfiXE approach to runway 5 at Pago Pagn 1nternatior.al Airport; the cap:ain vas 2 flying the aircraft: the third officer wak perfuming first officer duties and was qualified to do 60. -,3. All conlponcnts of the ILS and visual guidance 1iGhting systems were operating properly...... , - 26 - -34. '&ken Flight 806 was approximately 3 mi from the eirport, it encountered an increasing headwisd and updraft vhich caused the aircraft to gain airspeed and deviate above the glide slope. The wind condition was associated with a heavy rain shower which was moving down the runway toward the ap- proach end. The pilot obsenred the airspeed and glide slope deviations caused Ly the inltial windshear eacounter and responded -1 by reducing thrust. I Whm Flight 806 was approximately from the 1.25 mi + airport, the positive performance. effect of the windshear j diminished and the airplane. because the reduced of i thrust, began r'eecend!.ng st a rate- of 1,500 fpm. i The 1,500-fpm Gcsccnt rate was not corrected for 15 I secondti until 5ust before impact, although power WRB increased -lur.lng the last 4 seconds. i I. 9. The flightcrei- had at least sane of the runway lights in sight during the last 2 minutes 50 seconds of the flight. 10. The LXghtcrew pro\ably did not recognize the development of the increasing descent rate and the deviation below glide slope because of their reliance on visual referenceb: /7 althou3h VAS1 vas available and operating, the lights lcay have been obscured by rain. ! 11. A v,lsual assessmeyt of vertical guidnnce would have been difficult because of an absence oE visual cues and the "blark.hole" approach phenomena. Althouah the first officer monitored and called cut airspeeds and minkaum sltitude. during the final seconds of the flight, there were no rate of descent callouts by any of the nonflying crew although the descent rate exzeeded the 1,000 fprrcomended maxfnum for at lcasr 15 seconds. ,' The No. 2 nev receiver was tuned to the VOR frequency to provide DME information and the first officer had not switched to dlsplay the ILS information on his instruments; I consequmtly, the glide slope raw data and flight director steering cornrnands were displayed only on the captein's instrmcnt panel. - 27 '- 14. The iupact was... survivable. Fglati.~t?yminor crash forcee were involved, occupant res:-aint GE!&+T&-i-riiaXe~- occupiable area'of the aircrxit was cct comprom.Csed. 15. The injuries sustained by the fatall? injured passengers as well as the surviving passeneers ..>ere a direct result of the postcraah fire. .~ - .~~ - 16. All surviving passengers reported thaLlhey listened to thLp.~reri- the pas@_engerinformation pamphlets. 17. Fire and rescue res;.onse time was delayed by rain. barriers acrosa the response route, terrain, and cor.fusion OV& what was burnirii;~-~---- ~ 18. Restrictions in the approach to the fire hamperet! fire- fighting effectiveness. 3.2 Probable Cause The National Transportation Safety Board determines that thc cause of the accident was the flightcrew's late recobmition and to correct in d timely manner an excessive descent rate w1,ich j failure 1 developed as a resul: of the aircraft's penetration Llirough destabilizing ,' 1 wind changes. The wlrds consisted of horizontal an2 vertical cmponents by a hesvy rainstcrm and influenced by uneven terrain cXose to the aircraft's approach path. The captain's recognition was hsmpered by restricted visibility, the illusory effcces of a "blackhole" approach, hadequat2 monitoring of flight instroinents. and the failure of tL1e crew to call rp.w. dcacent rate during the last 15 deconds of flight. 4. SAFETY RECCWFXDATIONS As a result of its invcstigimton of this accident, the Naticnal Trarisportation Safely Doard has reconlnended that the Federal hviation Administration: - "Ammd 14 CFR 121.439 to require tlrat R check airman (1) observe a pilot ns he performs the three takecifs and thrce I landings specified for recent experience, snd (2) cortlfy that the pil.ot is qualified and proficient to retxrn to his assiped atatus, In addition, the check airman should require a pilot to perfom any maneuvers n<-:cecsary to certiEy pcrfom.ance.." . A-74-104 "Rquirc Air Carriw Operstions ~nr;pecror.; to reviev nr~! evaluate airpor: and route qualification proqams to insure r ...... ~..~..,.I ...... ".*.-., ...... I^..- ~,,...... - ...... -I.. "llll..., ~. .,.,'~ .) ------.-.- ...... __ .---___I__I^_...... 4 1 i .. that all information is up to date, that company proredures nre consistlmt with the publibh.id FAA procedures, and that !'! obsolete procedural material is not included." A-74-11R I),. ii , ') "Amend 14 CFR 139.55(b)(,:) to prescribe mintnun levels of nedicai service provisions simLlnr to those provSded for in ,. Advisory Circular 150/5210.2 to insure that mass ,?asualties ., resulting from an aircraft accident cm be adequately handled ! and satisfactorily treated." (A-75-1) For EM'S responses to these xecmendations see App-mdix F. 'V .".%.X - 29 - ., /s/ FRANCIS H. ElcAUAMS . Member i I I /:z/ WILLIAM R. HALEY Member KAY BAILEY, Acting Chairman, filed rhe following dissent: I disagree with the probable ca'lse in the majority decision. I think wfl?dshear should be stated as a major faccor in the cause of the accident. ?:he probable cause should read: I Re Ilational Transportation Safety Board dctermines thai the probable cause of the accident was the aircraft's penetration throueh destabilizing wind changes and the flightcrew's late recognition and feilure to correct in a timely mannc-r the resulting excessive descent rate. Tne winds consisted of horlzoctal and vertical c0mponent.s proauced by a heavy rainstorm and infl:lenct>d by uneven terrain close to the aircraft's approach path. The captair.'~ recognicion was h&mpered by restricted vfsi- tility. the illusory effects of a "blackhole" approach, icadeqmtr moilitoring of flight instruments, and the fajlurtl of rhe crew to call out descent rate during the last 15 seconds of flight. I believe wc! shculd look at the whole picture when determining F-obable cause. Our vision becomes too narrow when we adhere to the "1ss;t possible chance to prevent the accident" as the oc?y probable cause. In this case, the ccmplete reasoning should begin with the fact that there was a windsbear and then state the lack of proper reaction under the circumstances. /st KAY BAILEY Acting Chairman October 6, 1977 .. . ., I"' -31 - APPENDIX A Investigat 1. Invzsti~ation The Safety Board was notiiied of the accLdent at about 0825 on Januarg 31, 1974. The investigation team went immediately to the scene. Working groups were established far operations. witnesses. weather, human factors, structures, maintenance records, powerplants, systems, flight data recorder, and cockpit voice recorder. Participanto in the on-scene investigation hcluded repre- sentatives of the Federal tivisition Administration, Pan hnerican World Airways, Inc.. .Air Line Pilots AsoocLation. Flight Englueere International Aszociation. The lroeing Company, Pratt 6 -&itney Aircraft 2ivision of United Aircraft Corpol-ntion, and the Government of: American Samoa. 2. Public Heazh A 3-day public hearing WB? held at the Princess Kaiulani Hotel, Honclulu. llawaii, beginning Nwch 19. 1974. Parties represented at the hearlr,g were: The Federill Av:Latit,!l Administration. Pzn American World Airways, Inc.. Air Line Pilots Associ~2tcn. and the FlfRht Enaineers i Zntemational Association. Preceding page hiank ! - 32 - APPENDIX B Personne!,%mmatioc CaFtai? Leroy A. Peterr= CapKaiiI LCKO)~A. Petersen, 52, was employed by Pan American World Airways. Inc., March 3. 1951. He received his initial B707 training as a Ikserve Coyilot/Navig3tur Novmber 1, 1960. He WRS upgraded to Master Copilot cn the 11107 on July 2, 1965, md to 8707 captain November 10, ~I196;'. Captain Petersen had 17,414 flfght hours, of w,hich 7,416 hours were In the R70i. Captain Petersen held Airlir:? Tranxrport Pilot Certificate No. 7191-41. isstted July 2, 196s. ?E was t.ype nted in ?he DOcJglaS DC4, Boeing 337. 707/720. lie possessed radio cerrificace No. 12507880 and navigator certificate No. 1225367, issued September 5. 1951. Wia flrst- class physical was taken Augrrst 9,'1973, wit.h no limitations. First 0ff.icer Richard V. Gainaq -----I__ First OEficcr (F/O) Richard \I. Gaines, 37, was employed by Fan American Norld Airuay>>, Inc., Augusc 7. 1964. His initial 6707 Reserve Copilot/Navigator training was completed October 20, 15\64, and he was upgl?ded to Master CopIlot on June 15, 1.967. He had 5,107 flight-hours. all in the U707. In the cast 60 days he had flown 117:14 hours 3n.I 56:44 In the past 30 days. F/O Gaines held Airline Trancport Pilvi Certificate No. 3.578h52 dated July 14, 1967, with type ratings .in the Boelng 707/720. He held !radio certificate KO. P-3-12-17992 issued June 23, 1969,. and navigator certificate No. 1.62315s. dated February 16, 1965. His fi.rst class medical cxamination was tnken November 21, 1973, with no waivers noted. F/O Gainas completed his "A" Phase training 2an;iary 18, 1976. The simulator and aircraft p@rtions Lf "8" Phase training were completed July 21 and 22, 1973. In addition, he completed voluntary simulator training July 1, 1973. Mr. Gaines was observed by an FAA inspector March 20, 1973, during nn en mute i.nspection. Nauczrous routing Ccpilot Trip reports were reviewed from his file, and no adverse coments were noted . PI0 Gaines had flown into Pago Pzav tuels? times in the year preceding the accident. I I ! - 33 - APPENDIX B -Third Officer Jam-s S. Phillips Third Officer James S. Phillips, 43, vas employed by Pan American World Airways, Inc., April 25, 1966. His initial B707 training as a Reserve Copilot/Navigator waa completed January 3, 1967. He had 5.208 flight hours, including 4.706 hours in the B7G7. In the past 60 days, he had flown 119:07 houra, and in the last 30 days he had flown 56:07 hours. Between July'and December 1973. he recorded 199:33 hours of night flying. Mr. Fhillipa held Comerc5al Filot rating Yo. 1498280 iasued May 16. 1961, H radio certificate issued Hay 23, 1966, and navigator certificate No. 172'1148, issued November 21, ?966. Hi6 first class medical exaninntion was taken Februarjr 5, 1973, with no waivers n'ted. Mr. Phillips completed "A" Phose of training November 14, 1973. The followinp, comments were noted by the training captain: "'A' Phase complete. Goo? work. Shcxld rate in six hours." The "8" Phase simulator training was accmplished Fay 7, 1973, and the ai.rcraft period completed the following day. After :he aircreft period. the training captain cmtment.ed: "All areas at a good level of KC0 proficiency Gk for line Idg." This sircraft period was observed by an FAA inspector. Mr. Phillips had flow. into Pago Pago Airport aevcn times in the paet 7 months. Since Cctober 11. 1973, he had made seven ttlkeofif! and nine landings. Flight Engineer Gerry Flight Engineer (F/E) Gerry W. Green, 37, was employed by Pan Amerlcm Woxld Airways, Inc., April 24, 1967. He received his initial 111!I Reserve Copilot/Navigstor B707 trairdng October 20. 1967, and his initial I B707 Flight Engineer Qualificltions July 2, 1973. He had 2,299 flight hours of which 1,&44 hours were in tLe B707. In the past 60 days he Lad flow1 R2:15 hours, and in the past 30 days he had floh 63:13 hours. FIE Green held Connnerctsl Pilot ratine No. 1497654 issued Varch 27, 1963. His rsdio certificate was *.%sued Octoher 4, 1966, and his navigator certificate ilo. 1771733 was dated July 14, 1967. He held Flight Engineer ccrtificate Ne. 2677773. dated March 11, 1571. liis second class medical cwamination was taken Aiiauat 3., l9i3, with no waivers. *r FIE Green conplated his "A" Phase training Oecenber 7. 1'372. His last flight cngineer I.ine check was completed July 2, 1373, and his Pkk 8707 qualification check was June 20, 1973. ‘r-,. . APPENDIX B Flight Attendants Last Date oi Date of Ir&.rial Recurrent -Birth -Hire TrAining -Trainin2 Elizabeth Givens 9-28-13 7-1-66 7-14-66 Gorda Rupp 6-20-73 9-12-39 3-16-66 3-30-66 1.-17-73 Glorla Olacz 6-6-48 2-14-72 3-6-72 3-2-73 Patricia Reilly 7-22-48 5-8-72 5-30-72 Kinuko 3-28-73 Seko 3-19-45 5-14!> 5-14-69 9-7-73 Yvonne Cotte 4-10-50 2-19-’73 3-6-73 3-6-73 .. .. . - 35 - APPZNDIX C .-Aircraft . Informa- Aircraft N454PA. a Boeing 707-3215. serial No. 19376, vas ovned and operated by Pan American Vxld Mrxays, Inc. It was manu- factured Decerrber 20, 1967, end delivered to Pw hricnn on that date. The last rajor inspection. an aircraft inspectionlrefurbiah- aent wab performed April 22, 1973. in Plimi, Florida. A maintenance "8" check ?lad been accmplished January 24. 1974, and a maintenance "A" check ha3 beer, accmplished at Auckland airport just before tnkroff Januarf 30, 1974. Before the takeoff from Auckjand, the aircraft had accumulatei( 21,625 hours flight time. The sreight and balance manifest for this fliphc indicsted that the sircraft had been vithin ita weisht and balance limitations both at takeoff and at the time of the accidect. &ere were 117,000 pounds cf jet A-I fuel aboard rbe tircraft UF.Q~departure frorr, Auckland. The plnnned fuel burn-off for the flight to Fsgo Pcgo was 48.500 pounds. The estinnted g:oao weight, fuel rtmaining,and center of Gravity at the tine ol the accident were 245.400 pounds. 68,500 pounds, end 26.2 percezr, respectivcly. The a1rcr.rft vaa cdrrying 37,900 pounds or .?tored fuel tn be use6 on a later !rig of the trip. According to company records. a1.I airvorthinese directives vrrc c6mpl:cd with. f - 36 - APPENDIX C ENGINES KO. 1 Engine 2/22/72 SIN P645165 No. 2 Englne 4/11/73 SIN P668155 18.769 6,181 KO. 3 Engine 4/19/73 SIN 695684 9,370 7,171 SO. 4 Engine 12:19/73 20.527 SIN 645961 6,478 2 i I ! - 38 - 1 3 d? Appendix E !i9,I ~j Flight Profile - Relationship with Glideslope & V.A.S.1. .1i? : 1. 1 t I GLIDESLOPE I VISUAL APPROACH SLOPE IhDICI\TOR Sea text (Section 1.16) for assurnptiocs used to derive this chart. .. - 39 - APPENDIX F DEPARTMENT OF TRANSPOiTATION FEDERU AVIATION ADMINISTRATION WASHlNGTW 0.C 200190 Notation 136 5 December 18, 1974 Honorable John H. Reed. hairman National Transportation Safety Bard Depar'ment of Transportation Washington. D. C. 20591. D-r Mr. Chiirrnm: I I hve 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 re- qurlification 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. as pilot- in-command prim to the accident. We very much appreciate the sugEostion which you and your Board Mornbora have made thsl Section 121.439 of the Federal Aviation Regulations be amcndcd to require that a check nirnlrn suparvire the three tnkooffa and landings in the same nra~erin which. by arrent reyl.ation, the airnulator training i. supervised. And we note that if this were to bo done. that same check airman would be Ires to require Iho pilot to pcrfcrm my other rnaineuve~sdeemed ne. ~ssary0: advisable. Your recommendation is being given c1o.c and careful attention by the FAA staff and. through it, by appropriate organizations and in- divlddala in the aviation community. 1 will advise you yracnrlly of my decistan. Sincerely, :, 1 , .. . .I...... - 40 - APPENDIX F DEPARTMENT OF TRIINSPORTATION FEDERAL AVIATION ADMIHISTRITION - WASHINGTON. O.C. 20190 DmcIw nu .D.l*8SmAIO. JAN 1 4 1975 Notation 1365C Sincerely, - 41 - APPENDIX F /. '\ I i - 42 - APPEIIDIX F . - 43 - APPENDIX F DEPARTMENT OF TRANSWRTATIQN FEDERAL AVihTION ADMINI5TRAT:OR ! !