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Uncontrolled Impact with Terrain, Fine Airlines Flight 101, Douglas DC-8-61, N27UA, Miami, Florida, August 7, 1997

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Uncontrolled Impact with Terrain, Fine Airlines Flight 101, Douglas DC-8-61, N27UA, Miami, Florida, August 7, 1997 { PB98-910402 NTSB/AAR-98/02 DCA97MA059 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT UNCONTROLLED IMPACT WITH TERRAIN FINE AIRLINES FLIGHT 101 DOUGLAS DC-8-61, N27UA MIAMI, FLORIDA AUGUST 7, 1997 6927A ——— — / The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Information about available publications may be obtained by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (202)382-6735 (800)877-6799 Safety Board publications may be purchased, by individual copy or by subscription, from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (703)487-4600 NTSB/AAR-98/02 PB98-910402 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT UNCONTROLLED IMPACT WITH TERRAIN FINE AIRLINES FLIGHT 101 DOUGLAS DC-8-61, N27UA MIAMI, FLORIDA AUGUST 7, 1997 Adopted: June 16, 1998 Notation 6927A Abstract: This report explains the accident involving Fine Airlines flight 101, a Douglas DC-8-61, which crashed after takeoff from runway 27R at Miami International Airport, Miami, Florida, on August 7, 1997. Safety issues in the report include the effects of improper cargo loading on airplane performance and handling, operator oversight of cargo loading and training of cargo loading personnel, the loss of critical flight data recorder information, and FAA surveillance of cargo carrier operations. CONTENTS ABBREVIATIONS ...................................................................................................................... vi EXECUTIVE SUMMARY........................................................................................................viii 1. FACTUAL INFORMATION.................................................................................................. 1 1.1 History of Flight .................................................................................................................... 1 1.1.1 Statements of Witnesses............................................................................................................3 1.1.2 Cargo Weight Distribution Procedures .....................................................................................4 1.1.2.1 Cargo Handling System ..................................................................................................................... 6 1.1.3 Cargo Loading...........................................................................................................................6 1.1.4 Weight and Balance.................................................................................................................10 1.2 Injuries to Persons ............................................................................................................... 11 1.3 Damage to Airplane............................................................................................................. 11 1.4 Other Damage...................................................................................................................... 11 1.5 Personnel Information ......................................................................................................... 11 1.5.1 The Captain ..............................................................................................................................11 1.5.2 The First Officer.......................................................................................................................12 1.5.3 The Flight Engineer..................................................................................................................12 1.5.4 Cargo Loading Personnel ........................................................................................................13 1.6 Airplane Information........................................................................................................... 13 1.6.1 General ....................................................................................................................................13 1.6.2 Engines ....................................................................................................................................14 1.7 Meteorological Information ................................................................................................ 15 1.8 Aids to Navigation .............................................................................................................. 15 1.9 Communications ................................................................................................................. 15 1.10 Airport Information ........................................................................................................... 15 1.10.1 Emergency Response.............................................................................................................15 1.11 Flight Recorders ................................................................................................................ 16 1.11.1 Flight Data Recorder .............................................................................................................16 1.11.2 Cockpit Voice Recorder............................................................................................... 17 1.12 Wreckage and Impact Information.................................................................................... 17 1.12.1 Pallet Lock Configuration, Cargo Flooring, and Pallets .......................................................19 1.13 Medical and Pathological Information.............................................................................. 20 1.14 Fire .................................................................................................................................... 20 1.15 Survival Aspects................................................................................................................ 20 1.16 Tests and Research............................................................................................................ 20 1.16.1 Weight and Balance Scenarios..............................................................................................20 1.16.2 Airplane Performance and CVR Sound Spectrum Studies ...................................................21 1.16.3 Lock Assembly Load and Fracture Tests .............................................................................24 1.16.4 Tail Skid Examination...........................................................................................................25 1.17 Organizational and Management Information................................................................... 25 1.17.1 Fine Air..................................................................................................................................25 1.17.2 Wet Lease Agreement Between Fine Air and Aeromar........................................................26 1.17.3 Department of Defense Inspections of Fine Air....................................................................27 1.17.4 FAA Oversight of Fine Air....................................................................................................28 iii 1.17.4.1 Preaccident RASIP and NASIP Inspections........................................................................29 1.17.4.2 Postaccident FAA RASIP Inspection............................................................................................. 30 1.17.4.3 FAA Management Reaction to Postaccident Inspection Findings ................................................. 33 1.17.5 Consent Agreement ...............................................................................................................34 1.18 Additional Information...................................................................................................... 35 1.18.1 Postaccident FAA Inspector Guidance for Surveillance of Cargo Operations .....................35 1.18.2 Previous Fine Air Pitch-up Incident......................................................................................36 1.18.3 Recent FAA Enforcement Actions Against Cargo Carriers..................................................37 1.18.4 Fine Air Cargo Inspection Procedures ..................................................................................38 1.18.4.1 Fine Air Outstation Load Planning and Inspection Procedures .................................................... 39 1.18.5 Cockpit Verification of Weight and Balance ........................................................................40 1.18.6 Job Descriptions for Aeromar Loading and Security Personnel ...........................................40 1.18.7 Fine Air Job Descriptions for Ramp Supervisors and Cargo Loaders ..................................41 1.18.8 Postaccident Changes in Fine Air Cargo Loader Training....................................................43
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