Sa-439 File No. 1-0011 Aircraft Accident Report Delta Air Lines, Inc
Total Page：16
File Type：pdf, Size：1020Kb
SA-439 FILE NO. 1-0011 AIRCRAFT ACCIDENT REPORT DELTA AIR LINES, INC. DOUGLAS DC-9-31, N975NE BOSTON, MASSACHUSETTS JULY 31, 1973 ADOPTED: MARCH 7, 1974 NATIONAL TRANSPORTATION SAFETY BOAR0 Washington, D.G. 20591 REPORT NUMBER: NTSB-AAR-74-3 TECHNICAL REPORT STANDARD TITLE PAGE 1. Report No. 2.Government Accession No. 3.Recipient's Catalog No. NTSB-AAR-74-3 '4. Title and Subtitle Aircraft Accident Report 5.Report Date lelta Air Lines, Inc., qC-9-31. N975NE March 7, 1974 1. Boston, Maasachusetts. July 31, 1973 6.Performing Organization 1.1 Code 7. Author(s1 8.Performlng Organization 1.2 Report No. 1.3 1.4 9. Performing Organization Name and Address IO.Work Unit No. 1.5 National Transportation Safety Board 11624 1.6 Bureau of Aviation Safety 1i.Contract or Grant No. 1.7 Washington, D. C. 20591 1.8 13.Tvpe of Report and I 1.9 Period Covered 1.10 12.Sponsoring Agency Name and Address I 1.11 Aircraft Accident Report 1.12 July 31, 1973 NATIONAL TRANSPORTATION SAFETY BOARD 1.13 Washington, D. C. 20591 1.14 1.15 I 1.16 15.Suppiementary Notes 1.16.: 1.16.: This report contains Aviation Safety Reconmendation A-74-19. 1.16.: ~~ ~~~ 1.17 I6.Abstract 1.17.1 Delta Air Lines Flight 723, a DC-9-31, crashed at 1108 eastern daylight time on July 31, 1973, while executing an instrument landing system approach to ruraray 4R on 1.17.; the Logan International Airport, in Boston, Massachusetts. There were 83 passengers, 1.17.: 5 crevmembers, and a cockpit observer on board. All occupants, except one passenger, 1.17.: were killed in the crash. The lone survivor, who had been injured critically, died 1.17.4 later. The aircraft struck a seawall about 165 feet to the right of the extended run 1.17.5 way centerline and about 3,000 feet short of the runway displaced threshold. The air 1.17.f craft was destroyed. 2. The National Transportation Safety Board determines that the probable cause of 2.1 the accident was the failure of the flightcrew to monitor altitude and to recognize 2.2 passage of the aircraft through the approach decision height during an unstabilized precision approach conducted in rapidly changing meteorological conditions. The un- stabilized nature of the approach was due initially to the aircraft's passing the outer marker above the glide slope at an excessive airspeed and thereafter compounded 3. by the flightcrew's preoccupation with the questionable information presented by the flight director system. The poor positioning of the flight for the approach was in part the result of nonstandard air traffic control services. As a result of this accident, the Safety Board has made several recommendations to the Administrator of the Federal Aviation Administration. 17.. Kev, Words~~~~ Ii8.Dlstribution Statement Intercept angle, final approach, localizer, glide slope, This document is available approach control, monitoring, aircraft instruments, to the public through the altimeter, flight director system. fog, displaced National Technical Informa- threshold, runway visual range, approach lighting tion Service, Springfield, system, decision height, airport environment. Va. 22151 19.Security Classification 20.Security Classification 2i.No. of Pages 22.Price (of this report) (of this page) UNCLASSIFIED UNCLASSI.FIED 72 NTSB Form 1765.2 (11/70) ii TABLE OP CONTENTS . synopsis ...................... 1 1. Investigation ................... 2 1.1 History of the Flight ................ 2 1.2 Injuries to Persons ................ 5 1.3 Damage to Aircraft ................. 5 1.4 Other Damage .................... 5 1.5 Crew Information .................. 6 1.6 Aircraft Information ................ 6 1.7 Meteorological Information ............. 6 1.8 Aids to Navigation ................. 7 1.9 Comnications ................... 7 1.10 Aerodrome and Ground Facilities .......... 7 1.11 Flight Recorders .................. 8 1.12 Aircraft Wreckage ................. 9 1.13 Medical and Pathological Examination ........ 10 1.14 Fire ........................ 11 1.15 Survival Aspects .................. 11 1.16 Test and Research ................. 12 1.16.1 Altimeter System Test ............... 12 1.16.2 Flight Track Presentation ............. 13 1.16.3 Simulator Tests .................. 13 1.17 Other Information ................. 14 1.17.1 The Delta Air Lines IC-9 Modification Program ... 14 1.17.2 Flight Director History .............. 15 1.17.3 Operation of Sperry Flight Director ........ 16 1.17.3.1 Comparison of Sperry and Collins Mode ....... 17 1.17.4 FAA Terminal Air Traffic Control Handbook 7110.8C. 19 1.17.5 FAA Advisory Circular 61-49 ............ 19 1.17.6 Delta Air Lines Operating Manual ........... 20 2 . Analysis and Conclusions .............. 20 2.1 Analysis ...................... 20 2.2 Conclusions .................... 28 (a) Findings ................. 28 @) Probable Cause .............. 29 3 . Reconnoendations .................. 29 Appendices Appendix A Investigation and Hearing .... 31 Appendix B Crew Information ......... 32 Appendix C Aircraft Information ....... 35 Appendix D Jeppeson Approach Chart ..... 36 Appendix E Flight Data Recorder Graph .... 37 Appendix F Cockpit Voice Recording ..... 39 Appendix G Flight Track Presentation .... 59 Appendix H Wreckage Distribution Chart ... 61 Appendix I NTSB Safety Reconmendations ... 63 iii cc- --- SA-439 File No. 1-0011 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D. C. 20591 AIRCRAFT ACCIDENT REPORT Adopted: March 7, 1974 DELTA AIR LINES, INC. DOUGLAS DC-9-31, N975NE BOSTON, MASSACHUSETTS JULY 31, 1973 SYNOPSIS About 1108 e.d.t. on July 31, 1973, De.lta Air Lines Flight 723, a DC-9-31, crashed into a seawall while executing an instrument landing sys- tem (ILS) approach to runway 4R on the Logan International Airport, Boston, Massachusetts. There were 83 passengers, 5 crewmembers, and a cockpit observer on board. All occupants, except one passenger, were killed in the crash. The lone survivor, who had been injured critically, died on December 11, 1973. The aircraft struck the seawall about 165 feet to the right of the extended runway centerline and about 3,000 feet short of the runway dis- placed threshold. The aircraft was destroyed. The accident occurred during daylight hours. The weather was charac- terized by lowering ceilings and visibilities; sea fog of increasing density was moving across the airport from an easterly direction. The National Transportation Safety Board determines that the probable cause of the accident was the failure of the flightcrew to monitor alti- tude and to recognize passage of the aircraft through the approach deci- sion height during an unstabilized precision approach conducted in rapidly changing meteorological conditions. The unstabilized nature of the ap- proach was due initially to the aircraft's passing the outer marker above the glide slope at an excessive airspeed and thereafter compounded by the flightcrew's preoccupation with the questionable information presented by the flight director system. The poor positioning of the flight for the approach was in part the result of nonstandard air traffic control ser- vices. As a result of this accident, the Safety Board has made several rec- omendations to the Administrator of the Federal Aviation Administration (FAA). -2- 1. INVESTIGATION At two twc 1.1 History of the Flight FI On July 31, 1973, Delta Air Lines, Inc., Flight 723, a Douglas challer DC-9-31 (N975NE), was a scheduled passenger flight from Burlington, Vennont, to Logan International Airport @OS), in Boston, Massachusetts. Fr An unscheduled stop was made at Manchester, New Hampshire, to pick up and the passengers who were stranded because an earlier.flight had been canceled because of weather. Flight 723 was a continuation of Flight 524, which At had originated at BOS earlier the same day. heading inbound The flight departed the airport gate at Manchester, New Hampshire, AR-1. at 0957, IJ with 83 passengers, 5 crewmembers, and a cockpit observer on cept.. board. After several delays, due to weather conditions at BOS, the flight was cleared to BOS on an instrument flight rules flight plan, and Ab departed at 1050. From takeoff at Manchester until the time of the stated, crash, the first officer in the right seat piloted the aircraft, and the two tho captain handled air-to-ground communications. down." At 1051:22, Boston Approach Control (AR-1) cleared the flight to the At Lawrence, Mass., VOR 21 advising, 'I. no delays, plan vectors ILS 31 for ILS four right, the Boston altimeter is three zero one one. Weather is for the partial obscuration, estimated four hundred overcast, mile and a half and fog." Ac' was ini Flight 723 acknowledged the clearance from AR-1 at 1051:32, and localiz climbed to an assigned altitude of 4,000 feet. 41 During the climb, the cockpit obaerver 21 called out the after-takeof? checklist challenges, Th, and the captain responded. the air1 called, At 1054:25, the flight advised BOS AR-1, "Delta seven two three was fol' approaching Lawrence," after which AR-1 told the flight, "Seven two three and qual roger, fly heading now one eight zero, radar vectors ILSfour right.'' The checklic flight acknowledged the clearance and complied. when thl At 1055:57, the cockpit observer began calling out the challenges Bel in the descent checklist. between At 1056:24, BOS AR-1 cleared the flight to descend to 3,000 feet. 11( The flight acknowledged the request and complied. CAI All times herein are eastern daylight, based on the 24-hour clock. VOR - Very high frequency onmi-directional radio range. 11c ILS - Instrument landing system. All altitudes herein are mean sea level unless otherwise indicated. w A former Northeast Airlines, Inc., captain, in the process of re- qualification after he was grounded for an extensive period of time 116 because of illness. -3- At 1057:36, BOS AR-1 requested, "Delta seven two three, fly heading two two zero.ll The flight complied. From 1058:50 until 1100:17, the cockpit observer called out the challenges in the approach checklist; .the captain responded.