PB97-910405 NTSB/AAR-97/05 DCA97MA016 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT UNCONTROLLED FLIGHT INTO TERRAIN ABX AIR (AIRBORNE EXPRESS) DOUGLAS DC-8-63, N827AX NARROWS, VIRGINIA DECEMBER 22, 1996 F 6822A I 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-97/05 PB97-910405 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT UNCONTROLLED FLIGHT INTO TERRAIN ABX AIR (AIRBORNE EXPRESS) DOUGLAS DC-8-63, N827AX NARROWS, VIRGINIA DECEMBER 22, 1996 Adopted: July 15,1997 Notation 6822A CONTENTS EXECUTIVE SUMMARY.......................................................................................................... v 1. FACTUAL INFORMATION..................................................................................................1 1.1 History of Flight....................................................................................................................1 1.2 Injuries to Persons.................................................................................................................4 1.3 Damage to Airplane...............................................................................................................4 1.4 Other Damage........................................................................................................................4 1.5 Personnel Information...........................................................................................................4 1.5.1 The Pilot Not Flying (PNF)........................................................................................................4 1.5.2 The Pilot Flying (PF)..................................................................................................................5 1.5.3 Flight Engineer...........................................................................................................................5 1.5.4 FEF Experience of the Accident Pilots......................................................................................6 1.5.5 Flightcrew’s 72-hour History Before the Accident....................................................................6 1.6 Airplane Information.............................................................................................................7 1.6.1 N827AX Overhaul and Modification Maintenance Work.........................................................7 1.6.2 Stall Warning System Checks....................................................................................................8 1.6.3 Maintenance Discrepancies Listed on the First FEF..................................................................8 1.6.4 Weight and Balance....................................................................................................................8 1.6.5 Airplane Performance Calculations............................................................................................9 1.6.6 Operating Authority to Conduct the Accident Flight.................................................................9 1.7 Meteorological Information................................................................................................10 1.8 Aids to Navigation..............................................................................................................10 1.9 Communications.................................................................................................................10 1.10 Airport Information...........................................................................................................11 1.11 Flight Recorders................................................................................................................11 1.11.1 FDR Data During Stall Entry and Subsequent Loss of Control.............................................12 1.12 Wreckage and Impact Information....................................................................................13 1.13 Medical and Pathological Information..............................................................................14 1.14 Fire....................................................................................................................................14 1.15 Survival Aspects................................................................................................................14 1.16 Tests and Research............................................................................................................14 1.16.1 Douglas DC-8 Certification and Simulation Data..................................................................14 1.17 Organizational and Management Information...................................................................15 1.17.1 Selection and Workload of Management Pilots.....................................................................15 1.17.2 Crew Resource Management (CRM) Program......................................................................17 1.17.3 ABX’s FEF Program..............................................................................................................17 1.17.4 ABX Management Communication with the Accident Flightcrew.......................................18 1.17.5 ABX Scheduling Requirements and Plans for the Accident Airplane...................................19 1.17.6 Department of Defense Inspection of ABX...........................................................................19 1.17.7 FAA Oversight of ABX Operations.......................................................................................20 1.17.8 ABX Safety Program..............................................................................................................20 1.18 Additional Information......................................................................................................21 1.18.1 Previous DC-8 Loss of Control Incident at ABX...................................................................21 1.18.2 Survey of Evaluation Flight Procedures.................................................................................22 iii 1.18.3 Survey of Stall Recovery Procedures.....................................................................................23 1.18.4 Previous Nonroutine Operation DC-8 Accident.....................................................................26 1.18.5 Previous Safety Board Recommendation on Angle of Attack Indicators ..............................27 1.18.6 Safety Board Recommendations on Unusual Attitude Recovery Training............................28 2. ANALYSIS.............................................................................................................................. 30 2.1 General ................................................................................................................................ 30 2.2 Flightcrew Performance During the Accident Sequence .................................................... 30 2.2.1 Execution of the Stall Recovery...............................................................................................30 2.2.2 Buffet Onset and Stall Speeds..................................................................................................32 2.2.3 Flightcrew’s Mis-trim of the Airplane .....................................................................................34 2.2.4 Monitoring and Challenging by the PNF .................................................................................34 2.3 Cues Presented to the Flightcrew ........................................................................................ 36 2.3.1 Stall Warning System...............................................................................................................36 2.3.2 Angle of Attack Instrumentation ..............................................................................................38 2.3.3 Engine Compressor Surges.......................................................................................................38 2.3.4 Ambient Lighting, Visibility, and Cloud Clearance.................................................................39 2.4 Simulator Fidelity and Training for Stall Recovery Procedures ......................................... 40 2.5 ABX Organizational Structure and Function ...................................................................... 41 2.5.1 Failure of ABX to Use Revised FEF Stall Recovery Procedures ............................................41