Crash Short, Downeast Airlines, Inc., Dehavilland DHC-6-200, N68DE, Rockland, Maine, May 30, 1979
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Crash short, Downeast Airlines, Inc., DeHavilland DHC-6-200, N68DE, Rockland, Maine, May 30, 1979 Micro-summary: This DeHavilland DHC-6-200 crashed during a non-precision approach (the Nance crash) Event Date: 1979-05-30 at 2055 EDT Investigative Body: National Transportation Safety Board (NTSB), USA Investigative Body's Web Site: http://www.ntsb.gov/ Cautions: 1. Accident reports can be and sometimes are revised. Be sure to consult the investigative agency for the latest version before basing anything significant on content (e.g., thesis, research, etc). 2. Readers are advised that each report is a glimpse of events at specific points in time. While broad themes permeate the causal events leading up to crashes, and we can learn from those, the specific regulatory and technological environments can and do change. Your company's flight operations manual is the final authority as to the safe operation of your aircraft! 3. Reports may or may not represent reality. Many many non-scientific factors go into an investigation, including the magnitude of the event, the experience of the investigator, the political climate, relationship with the regulatory authority, technological and recovery capabilities, etc. It is recommended that the reader review all reports analytically. Even a "bad" report can be a very useful launching point for learning. 4. Contact us before reproducing or redistributing a report from this anthology. Individual countries have very differing views on copyright! We can advise you on the steps to follow. Aircraft Accident Reports on DVD, Copyright © 2006 by Flight Simulation Systems, LLC All rights reserved. www.fss.aero CONTENTS SYNOPSIS .......................... 1 1. FACTUAL INFORMATION .................. 1 1.1 History of the Flight .................... 1 1.2 Injuries to Persons ..................... 3 1.3 Damage to Aircraft ..................... 3 1.4 Other Damage ....................... 3 1.5 Personnel Information .................... 4 1.6 Aircraft Information .................... 5 1.7 Meteorological Information .................. 6 1.8 Aids to Navigation ..................... 7 1.9 Communications ...................... 8 1.10 Aerodrome Information ................... 8 1.11 Flight Recorders ...................... 8 1.12 Wreckage and Impact Information ............... 8 1.13 Medical and Pathological Information ............. 12 1.14 Fire ........................... 12 1.15 Survival Aspects ...................... 13 1.16 Tests and Research ..................... 15 1.16.1 Aircraft Flight Test Results ................. 15 1.16.2 Bleed-air Valve Test Results ................. 16 1.16.3 In-flight Observations .................... 16 1.17 Other Information ...................... 16 1.17.1 Company Procedures .................... 16 1.17.2 Crew Training ....................... 17 1.17.3 Company Chief Pilot Responsibilities ............. 17 1.17.4 Alleged Company Unsafe Practices .............. 18 1.17.5 Federal Aviation Administration Surveillance .......... 20 1.18 New Investigative Techniques ................. 21 2 . ANALYSIS ......................... 21 2.1 The Accident ........................ 21 2.2 The Captain's Role ..................... 23 2.3 The First Officer's Role ................... 24 2.4 Management Practices .................... 25 2.5 Survival Aspects ...................... 26 2.6 Flight Recorders ...................... 27 2.7 FAA Surveillance ...................... 28 3 . CONCLUSIONS ....................... 28 3.1 Findings .......................... 28 3.2 Probable Cause ....................... 29 4 . SAFETY RECOMMENDATIONS ................ 30 5 . APPENDIXES ....................... 33 Appendix A -Investigation and Hearing ............ 33 Appendix B -Personnel Information ............. 34 Appendix C -Aircraft Information .............. 35 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT Adopted: May 12, 1980 DOWNEAST AIRLINES, INC. DeHAVILLAND DHC-6-200, N68DE ROCKLAND, MAINE MAY 30, 1979 SYNOPSIS About 2055 e.d.t., on May 30, 1979, Downeast Airlines, Inc., Flight 46 crashed into a heavily wooded area about 1.2 mi south-southwest of the Knox County Regional ~ir~ort,Rockland, Maine. The crash occurred during a nonprecision instrument approach to runway 3 in instrument meteorological conditions. Of the 16 passengers and 2 crewmembers aboard, only 1 passenger survived the accident. The aircraft was destroyed. The National Transportation Safety Board determines that the probable cause of the accident was the failure of the flightcrew to arrest the aircraft's descent at the minimum descent altitude for the nonprecision approach, without the runway environment in sight, for unknown reasons. Although the Safety Board was unable to determine conclusively the reason(s) for the flightcrew's deviation from standard instrument approach procedures, it is believed that inordinate management pressures, the first officer's marginal instrument proficiency, the captain's inadequate supervision of the flight, inadequate crew training and procedures, and the captain's chronic fatigue were all factors in the accident. 1. FACTUAL INFORMATION 1.1 History of the Flight On May 30, 1979, Downeast Airlines, Inc., Flight 46, a deHaviUand DHC-6-200 (N68DE), was a scheduled flight from Logan International Airport, Boston, Massachusetts, to Knox County Regional Airport, Rockland, Maine. The flight was scheduled to depart Boston at 1850; I/ however, because of adverse weather encountered en route by Flight 45, theearlier flight from Rockland to Boston, Flight 46's departure from Boston was delayed. Both flights were flown by the same flightcrew. -I/ All times herein are eastern standard, based on the 24-hour clock. About 1900, the captain of Flight 46 contacted the company's certified weather observer 2/ at Rockland by telephone and obtained the current weather at the Rockland airport. The observer reported the weather at that time to be: indefinite ceiling~700ft, sky obscured; visibility~3mi in fog. At 1930, the captain obtained a weather briefing by telephone from the National Weather Service {NWS) in Boston on the actual and forecast weather for Maine; however, there was no terminal forecast for Rockland. During the investigation of the accident and during the public hearing, a company ramp agent in Boston stated that there were other telephone conversations between the flightcrew of Flight 46 and company officials in Rockland before the flight departed Boston. Reportedly, these discussions concerned the possible cancellation of the flight because of the weather at Rockland, the flightcrew's concerns about attempting to land at Rockland, and aircraft vibrations allegedly caused by the right power plant. Company officials denied knowledge of these telephone conversations, however. At 1955, Flight 46 departed Boston on an instrument flight rules {IFR) flight plan. There were 16 passengers and 2 crewmembers aboard. After takeoff, Logan Departure Control vectored the flight to a heading of 010° advised the flight that the Portland, Maine VORTAC was out of service, and told the flight to expect radar vectors to the Kennebunk, Maine VORTAC. Subsequently, the flight was given a heading of 030'. At 2006, Logan Departure Control advised the flight to contact Boston Air Route Traffic Control Center (ARTCC). The flight complied with the request. At 2026:27, Boston ARTCC requested that Flight 46 contact Navy Brunswick Approach Control~the con trolling facility for the Rockland area. The flight complied with this request, reporting its altitude to Navy Brunswick as 7,000 f t. 3/ Between 2026:50 and 2033:40, Flight 46 requested and received the following weather information from Navy Brunswick: Brunswick -4/ - 800 ft scattered, 1,500 ft broken, 8,000 ft broken, 20,000 ft broken; visibility--6 mi in fog. Rocklan d indefinite ceiling, 300 f t, sky obscured; visibility--3/4 mi in fog; wind~light and variable; altimeter~30.05 inHg; conditions deteriorating. -2/ Certain company personnel were certified by the National Weather Service to make weat her observations. -3/ All altitudes are mean sea level unless otherwise indicated. -4/ Navy Brunswick is located about 39 nmi west-southwest of Rockland. Portland -5/ - indefinite ceiling, 200 ft, sky obscured; visibility--1/4 mi in fog; conditions deteriorating rapidly. Augusta 61 800 ft scattered, estimated 1,200 ft overcast; visibility--10 mi. At 2034:58, Navy Brunswick cleared Flight 46 to descend to 3,000 ft at the captain's discretion. At 2038:16, the flight reported leaving 7,000 ft. At 2042:40, Flight 46 received further clearance from Navy Brunswick to cruise at 3,000 ft for an approach into Knox County Regional Airport. At the same time, the flight was advised that it was to report when it wanted to cancel its IFR flight plan, that radar service was terminated 14 nmi southwest of the Sprucehead nondirectional radiobeacon (NDB), and that the flight could switch its radio frequency to the Rockland Unicorn. -7/ At 205223, Navy Brunswick radar showed the flight's position about 1 nmi south of Sprucehead NDB at an altitude of 1,500 ft. This was the last radar position recorded. At 2054:25, Flight 46 told Navy Brunswick 'I. looks like we're probably going to have to miss the approach here at Rockland. We're going down but maybe you can pull us out a clearance for Augusta." At 2054:38, Navy Brunswick replied that the clearance was "on request." According to testimony at the public hearing, the flight made a radio transmission to the company facility at the