Crash of a Boeing 747-228B in Rio de Janeiro

Date & Time: Dec 2, 1985 at 0634 LT
Type of aircraft:
Operator:
Registration:
F-GCBC
Survivors:
Yes
Schedule:
Paris – Rio de Janeiro – Buenos Aires – Santiago de Chile
MSN:
22427
YOM:
1980
Flight number:
AF091
Country:
Crew on board:
17
Crew fatalities:
Pax on board:
265
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16139
Captain / Total hours on type:
979.00
Copilot / Total flying hours:
6148
Copilot / Total hours on type:
513
Aircraft flight hours:
22762
Circumstances:
Air France flight 091 was involved in runway excursion accident at Rio de Janeiro-Galeão International Airport, Brazil. The aircraft, a Boeing 747-200, took off from Paris-Charles de Gaulle Airport, France at 21:30 UTC on a flight to Santiago, Chile with en route stops at Rio de Janeiro and Buenos Aires, Argentina. The flight to Rio de Janeiro took about eleven hours and was uneventful. At 08:34 UTC the aircraft touched down on runway 14, 400 meters from the threshold. After reversers were set, the aircraft deviated from the runway heading and at 2,000 meters from the threshold it veered off the right side of the runway. The aircraft ran over the grass for 765 meters, until passing over a drainage ditch and the load apron concrete step, where the landing gears folded aft with the left wing gear completely separating. On the load apron concrete the aircraft spun around for 275 meters until stopping, after the left outboard wing section struck an illumination stand. For a few seconds engines 2, 3 and 4 kept running at maximum reverse thrust, while engine number one run operated at full forward thrust. After the engines were shut down, the passengers evacuated using three of the aircraft's left hand side escape slides. The fire that started on the area near engines number 2 and 3 was extinguished by the airport fire fighters. It appeared that the n°1 engine throttle cable had broken, making it impossible for the flight crew to control engine power. The engine had accelerated to an unusually high level of (forward) thrust (above takeoff power).
Probable cause:
The following findings were reported:
(1) Human Factor:
Physiological Aspect - The crewmembers physical conditions (fatigue) might have contributed to their delay in perceiving the engine failure and to the inadequate reactions during the emergency.
(2) Material Factor:
a) The hydraulic pump ripple of the CF6-50E engine caused considerable vibration on the pulley support region, which worked as a dynamic source to produce cable oscillation and relative movement between cable and pulley.
b) Pulley bracket design deficiency, possibly related to the reduced contact area between cable and pulley, allowing for the wearing of these components in the presence of abrasive agents, in association with the vibration on that area, knowing that there is localized contact between both (at the same points) in an almost permanent way (93% of the engine operating time in cruise range).
c) The tests performed by the Manufacturer confirmed the existing relative movement between cable and pulley, even after the introduction of modifications.
(3) Maintenance Deficiency:
a) The use of an aluminum pulley, not authorized by the manufacturer as a substitution to the recommended phenolic pulley, made possible the formation of the abrasive agent (alumina).
b) The inadequate fixation of the pulley bracket due to the use, by the operator, of a screw of insufficient length for an additional washer, left loose the support side brace, allowing for the increase of the relative movement. already existing at that region, between cable and pulley.
(4) Flight Manual Deficiency:
a) The B747 AFM instructions allow the pilot flying to apply reverse thrust before knowing the effective transit of reversers.
b) The B747 AFM has no instruction regarding a failure of reverser deployment associated with an engine runaway forward thrust. The lack of instructions on this specific kind of abnormality, contributed to the crew not noticing that the failure had occurred.
(5) Training Requirement Deficiency:
a) The lack of simulator training requirement for this type of emergency contributed to the control loss.
(6) Crewmember Factor due to Operational Error:
a) The captain did not observe the AFM instructions about the reverse levers and manual brake use.
b) The FIE did not observe the AFM instructions about the correct engine instrument monitoring during the reverse operation.
Final Report:

Crash of a Boeing 747SR-46 on Mt Osutaka: 520 killed

Date & Time: Aug 12, 1985 at 1856 LT
Type of aircraft:
Operator:
Registration:
JA8119
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Tokyo - Osaka
MSN:
20783
YOM:
1974
Flight number:
JL123
Country:
Region:
Crew on board:
15
Crew fatalities:
Pax on board:
509
Pax fatalities:
Other fatalities:
Total fatalities:
520
Captain / Total flying hours:
12423
Captain / Total hours on type:
4842.00
Copilot / Total flying hours:
3963
Copilot / Total hours on type:
2665
Aircraft flight hours:
25030
Aircraft flight cycles:
18835
Circumstances:
JA8119 was a Japan Air Lines Boeing 747SR, a short range variant of the Boeing 747 Series 100. The was aircraft specifically configured for domestic flights with a high density seating arrangement. On June 2, 1978 the aircraft operated on a flight to Osaka (ITM). It floated after touchdown and on the second touchdown the tail struck the runway. The aircraft sustained substantial damage to the rear underside of the fuselage. The rear pressure bulkhead was cracked as well. The aircraft was repaired by Boeing. Engineers replaced the lower part of the rear fuselage and a portion of the lower half of the bulkhead. Seven years later, on August 12, 1985, JA8119 had completed four domestic flights when it landed at Tokyo-Haneda (HND) at 17:17. The next flight was to be flight 123 to Osaka (ITM). The aircraft took off from Tokyo-Haneda at 18:12. Twelve minutes later, while climbing through 23900 feet at a speed of 300 knots, an unusual vibration occurred. An impact force raised the nose of the aircraft and control problems were experienced. A decompression had occurred and the crew got indications of problems with the R5 door. In fact, the rear pressure bulkhead had ruptured, causing serious damage to the rear of the plane. A portion of its vertical fin, measuring 5 m together with the section of the tail cone containing the auxiliary power unit (APU) were ripped off the plane. Due to the damage, the hydraulic pressure dropped and ailerons, elevators and yaw damper became inoperative. Controlling the plane was very difficult as the airplane experienced dutch rolls and phugoid oscillations (unusual movement in which altitude and speed change significantly in a 20-100 seconds cycle without change of angle of attack). The aircraft started to descend to 6600 feet while the crew tried to control the aircraft by using engine thrust. Upon reaching 6600 feet the airspeed had dropped to 108 knots. The aircraft then climbed with a 39 degree pitch-up to a maximum of approx. 13400 feet and started to descend again. At 18:56 JAL123 finally brushed against a tree covered ridge, continued and struck the Osutaka Ridge, bursting into flames. A stewardess, one female passenger and two little girl survived while 520 other occupants were killed.
Probable cause:
It is estimated that this accident was caused by deterioration of flying quality and loss of primary flight control functions due to rupture of the aft pressure bulkhead of the aircraft, and the subsequent ruptures of a part of the fuselage tail, vertical fin and hydraulic flight control systems. The reason why the aft pressure bulkhead was ruptured in flight is estimated to be that the strength of the said bulkhead was reduced due to fatigue cracks propagating at the spliced portion of the bulkhead's webs to the extent that it became unable to endure the cabin pressure in flight at that time. The initiation and propagation of the fatigue cracks are attributable to the improper repairs of the said bulkhead conducted in 1978, and it is estimated that the fatigue cracks having not be found in the later maintenance inspection is contributive to their propagation leading to the rupture of the said bulkhead.
Final Report:

Crash of a Boeing 747-237B in the Atlantic Ocean: 329 killed

Date & Time: Jun 23, 1985 at 0715 LT
Type of aircraft:
Operator:
Registration:
VT-EFO
Flight Phase:
Survivors:
No
Schedule:
Vancouver – Toronto – Montreal – London – New Delhi – Bombay
MSN:
21473
YOM:
1978
Flight number:
AI182
Country:
Region:
Crew on board:
22
Crew fatalities:
Pax on board:
307
Pax fatalities:
Other fatalities:
Total fatalities:
329
Captain / Total flying hours:
20379
Captain / Total hours on type:
6488.00
Copilot / Total flying hours:
7489
Copilot / Total hours on type:
2469
Aircraft flight hours:
23634
Aircraft flight cycles:
7525
Circumstances:
On the morning of 23rd June, 1985 Air India's Boeing 747 aircraft VT-EFO (Kanishka) was on a scheduled passenger flight (AI182) from Montreal and was proceeding to London enroute to Delhi and Bombay. It was being monitored at Shannon on the radar scope. At about 0714 GMT it suddenly disappeared from the radar scope and the aircraft, which had been flying at an altitude of approximately 31,000 feet, plunged into the Atlantic Ocean off the southwest coast of Ireland at position latitude 51° 3.6' N and longitude 12° 49' W. This was one of the worst air disasters wherein all the 307 passengers plus 22 crew members perished. The fact that emergency had arisen was first by Shannon Upper Area Control (UAC) after the aircraft had disappeared from the radar scope. The control gave a number of calls to the aircraft but there was obviously no response. Thereafter various messages were transmitted and that is how the rest of the world came to know of the accident. Shannon Control at 0730 hours advised the Marine Rescue Coordination Center (MRCC) about the situation which appeared to have arisen. MRCC, in turn, explained the situation to Valencia Coast Station and requested for a Pan Broadcast. Thereafter ships started converging on the scene of the accident and they commenced search and rescue operations.
Probable cause:
The following findings were reported:
- The aircraft was subjected to a sudden event at an altitude of 31,000 feet resulting in its crash into the sea and the death of all on board,
- The forward and aft cargo compartments ruptured before water impact,
- The section aft of the wings of the aircraft separated from the forward portion before water impact.
- There is no evidence to indicate that structural failure of the aircraft was the lead event in this occurrence.
- There is considerable circumstantial and other evidence to indicate that the initial event was an explosion occurring in the forward cargo compartment. This evidence is not conclusive. However, the evidence does not support any other conclusion.
Final Report:

Crash of a Boeing 747-283B in Madrid: 181 killed

Date & Time: Nov 27, 1983 at 0106 LT
Type of aircraft:
Operator:
Registration:
HK-2910
Survivors:
Yes
Schedule:
Frankfurt – Paris – Madrid – Caracas – Bogotá
MSN:
21381
YOM:
1977
Flight number:
AV011
Country:
Region:
Crew on board:
19
Crew fatalities:
Pax on board:
173
Pax fatalities:
Other fatalities:
Total fatalities:
181
Captain / Total flying hours:
23215
Captain / Total hours on type:
2432.00
Copilot / Total flying hours:
4384
Copilot / Total hours on type:
875
Aircraft flight hours:
20811
Aircraft flight cycles:
5800
Circumstances:
Following an uneventful flight from Paris-Roissy-CDG Airport, the crew was cleared to descent to Madrid-Barajas Airport runway 33. Once the altitude of 9,000 feet reached on descent, the crew was cleared to continue. At 0103LT, he was cleared to land on runway 33 and should complete a turn to the right. Following several errors on approach, the crew initiated a right turn prior to pass over the VOR, causing the aircraft to descent below the MDA. At an altitude of 2,247 feet and at a speed of 142 knots, the right main gear struck the top of a hill. Upon impact, the right main gear and the engine n°4 were torn off. Three seconds later, while in a 4,9° nose-up attitude, at a speed of 135 knots, the aircraft struck the top of a second hill. Then, six seconds later, the right wing struck the ground. The aircraft overturned and crashed upside down, bursting into flames. The wreckage was found 12 km from the runway threshold in an olive plantation. Eleven passengers (among them four members of the same family, father, mother and both children) were injured while 181 other occupants were killed, among them the Peruvian writer Manuel Scorza.
Probable cause:
Following a series of omissions and navigation errors on descent, the crew adopted a wrong approach configuration, causing the aircraft to descend below the MDA without proper visual contact with the runway until initial and final impact with the ground. The following contributing factors were reported:
_ Inaccurate navigation by the crew, which placed them in an incorrect position for initiating the approach manoeuvre,
- Failure of the crew to take corrective action after the GPWS alarm sounded in the cockpit,
- Poor crew coordination,
- Crew fatigue,
- Lack of ATC assistance during the last portion of the flight,
- Misinterpretation of ATC instructions on part of the flying crew,
- Lack of visibility due to the night.

Crash of a Boeing 747-230B off Sakhaline Island: 269 killed

Date & Time: Sep 1, 1983 at 0535 LT
Type of aircraft:
Operator:
Registration:
HL7442
Flight Phase:
Survivors:
No
Schedule:
New York - Anchorage - Seoul
MSN:
20559
YOM:
1972
Flight number:
KE007
Country:
Region:
Crew on board:
23
Crew fatalities:
Pax on board:
246
Pax fatalities:
Other fatalities:
Total fatalities:
269
Circumstances:
On 31 August 1983, a Korean Air Lines (KAL) Boeing 747, designated KE 007, departed John F. Kennedy International Airport, New York, United States, on a one-stop scheduled flight for Kimpo International Airport, Seoul, Republic of Korea. The en-route stop occurred at Anchorage International Airport, Alaska, United States. At Anchorage, the aircraft was refuelled and serviced for the remainder of the flight to Seoul and, in accordance with company practice, the flight and cabin crews were changed. The flight departed at the planned time of departure which, in keeping with Korean Air Lines' procedure, was calculated for each KE 007 flight. The departure from Anchorage was flexible to ensure arrival in Seoul at the scheduled arrival time of 21:00 hours* (06:00 hours local time). The actual departure time of 13:00 hours on 31 August would have resulted in an on-time arrival of KE 007 in Seoul, had the flight been completed in accordance with its flight plan. On departing Anchorage, the flight had 269 persons on board consisting of 240 passengers, 3 flight crew members, 20 cabin attendants, and 6 crew members of KAL being repositioned to Seoul. Soon after departure from Anchorage, KE 007 deviated to the right (north) of its direct track to Bethel. This deviation resulted in a progressively greater lateral displacement to the right of its planned route which, ultimately, resulted in its penetration of adjacent high seas airspace in flight information regions (FIR_s) operated by the Union of Soviet Socialist Republics (USSR), as well as of sovereign USSR airspace overlying Kamchatka Peninsula and Sakhalin Island and their surrounding territorial waters. No evidence was found during the investigation to indicate that the flight crew of KE 007 was, at any time, aware of the flight's deviation from its planned route in spite of the fact that it continued for over five hours. According to representatives of the United States, military radar installations in Alaska were not aware in real time that the aircraft was proceeding west with an increasing northerly deviation from the recognized airways system. The military radar installations of the Japanese Defence Agency were aware that an aircraft was tracking in USSR airspace over Sakhalin Island. According to representatives of Japan, they were not a\vare that it was a civil aircraft off its intended track. Approximately between 16:40 and 17:08 hours military aircraft operated by the USSR attempted to intercept KE 007 over Kamchatka Peninsula. The interception attempts were unsuccessful. From about 18:00 hours when KE 007 was approaching Sakhalin Island, USSR, the flight was intercepted by USSR military aircraft. At 18:26:02 hours the aircraft was hit by at least one of t\\'o air-to-air missiles fired by the pilot of one of the USSR interceptor aircraft who had been directed, by his ground command and control units, to shoot down an aircraft which they assumed to be a United States RC-135. As a result of the attack, KE 007 collided with the sea and sank off the southwest coast of Sakhalin Island. There were no survivors. The flight recorders, fragmentary pieces of the aircraft and a small number of items of personal property were salvaged by divers from the USSR during a two month period following the accident. In addition, some flotsam from the aircraft was dispersed by tidal currents and recovered later. The cockpit voice recorder (CVR) and the digital flight data recorder (DFDR) tapes were recovered by the USSR in 1983 and were handed over to ICAO in January 1993 by the representatives of the Russian Federation. They also made available recordings and transcripts of the communications between the pilots of the intercepting fighter aircraft and their ground controllers as well as the communications between the command centres. The representatives of the United States made available certified copies and transcripts of the Anchorage ATC tapes, and the representatives of Japan made available the Tokyo ATC tape. In the course of the investigation, all practical steps were taken to confirm the authenticity of the communications tapes. A comprehensive assessment of the physical characteristics of the CVR and the DFDR tapes and the information recorded thereon was made to ensure that they contained authentic records. The material on the communications tapes and the CVR and DFDR tapes showed no evidence of contradiction with known information and correlated well with other sources of data. There was no evidence to suggest that the crew of flight KE 007 was aware that their aircraft was flying to the north of its planned route or that they knew of the presence of the intercepting fighter aircraft. The DFDR record established that flight KE 007 maintained a constant magnetic heading from soon after departure from Anchorage until the attack by the fighter aircraft. The maintenance of the constant magnetic heading was so accurate it could only have resulted from the autopilot controlling the aircraft. The CVR and the DFDR records also established that the aircraft did not sustain an extensive avionics or navigation systems failure or malfunction prior to the attack by the USSR fighter aircraft. The evidence obtained supported the first hypothesis of those listed in the 1983 ICAO report, Le. that the crew inadvertently flew virtually the entire flight on a constant magnetic heading. The maintenance of a constant magnetic heading and the resulting track deviation was due to the KE 007 crew's failure to note that the autopilot had either been left in heading mode or had been switched to INS when the aircraft was beyond the range (7.5 NM) for the INS to capture the desired track.
Concerning the interception and associated identification, signalling and communications the investigation found the following:

1) Interceptions of KE 007 were attempted by USSR military aircraft over Kamchatka Peninsula and made in the vicinity of Sakhalin Island.

2) The USSR command centre personnel assumed that KE 007 was a United States RC-135 aircraft. KE 007's climb from FL 330 to FL350 during the time of the interception over Sakhalin Island was interpreted as being an evasive action, thus further contributing to the USSR presumption that it was an RC-135 aircraft.

3) No attempt was made by the USSR to contact the crew of KE 007 by radio on the distress frequency 121.5 MHz or on any other VHF or HF frequency. However, the interceptor pilot was instructed by his ground control to attempt to attract the attention of the crew of the intruding aircraft by firing his aircraft's cannon and flashing its navigation lights. It was not possible to assess the distance of the interceptor aircraft from the intruder nor their relative positions when the interceptor's lights were flashed and the cannon fired.

4) The USSR command centre personnel on Sakhalin Island were concerned with the position of the intruder aircraft in relation to USSR sovereign airspace as well as its identity. The time factor became paramount as the intruder aircraft was .about to coast out from Sakhalin Island. Therefore, exhaustive efforts to identify the intruder aircraft were not made, although apparently some doubt remained regarding its identity. .5) It was not possible to determine the position of KE 007 at the time of the missile attack in relation to USSR sovereign airspace.
Probable cause:
1. The considerable lateral deviation of the B-747 aeroplane on Flight KAL-007 from the assigned airway R20 was a result of the crew using an air navigation method based on maintaining a constant magnetic heading immediately after take-off (three minutes after the aeroplane lifted oft) and throughout the whole of the subsequent flight. This basically contradicts the generally accepted standards and rules of air navigation, including the regulated documents of Korean Air Lines. Disregarding the need for multiple corrections of the magnetic heading, which were prescribed by the computer flight plan, as well as the resulting current information from the aeroplane's navigation systems when reaching the intermediate waypoints, cannot be explained by an insufficient professional level of crew training, inattention or even negligence, since in this case what one is talking about is the complete refusal of the crew to comply with all the rules and procedures for the performance of the flight prescribed by the airline's instructions, including those in the event of possible abnormalities in the operation of the equipment. A probable explanation for the situation which developed may be the intentional following of the route which was actually taken. The following facts attest to this:
- in accordance with the ATS plan, the crew informed the Anchorage and Tokyo ATC units of their position with respect to the compulsory reporting points. However, the information did not correspond to the actual position of the aeroplane indicated by the airborne navigation systems;

- when reporting with respect to NABIE and NEEVA, the crew did not ask the ATS units about the serviceability of the NDB and DME on St. Paul Island and that of the VOR and elements of the DME/TACAN .0n "Shemya Island, despite the absence of signals from these radio navigation aids, since,possibly, they knew that they were out of coverage;

- having determined their position with respect to NEEVA, the crew, according to the DFDR data, did not make any attempts to contact the Anchorage ARTCC on communications channel VHF-2,

- the recording, of the radio exchanges (CVR) of the crew of Flight KAL-007 with the crew of Flight KAL-015, which was following it at an interval of approximately 4 minutes, indicates the complete lack of alertness on the part of the crew of KAL-007 with regard to the basic differences in wind force and direction according to the data of these two aeroplanes;

- long before entering Japan's ATS radar area, the crew set on the SSR code selector the code 1300, which refers to the phase of exit from this area prior to entry into the Korean area TAEGU, instead of the prescribed code 2000. The flight path of Flight KAL-007, obtained on the basis of the results of modelling taking into account the data from the radar tracking stations of the United States, the USSR and Japan, essentially coincides over a considerable extent (Anchorage-abeam NIPPI) with a great circle flight path Anchorage - FIR Seoul (the deviations do not exceed ± 15 NM. This is determined by the accuracy of the calculations made). If one assumes that a route along the great circle VOR Anchorage - FIR Seoul was programmed on one of the three INS and that the flight was performed according to this programme, then in this case the crew's actions can be logically explained. However, the investigation materials do not 'contain exhaustive evidence confirming this assumption. Thus, the Commission could not determine the reasons which prompted the crew to decide to follow from Anchorage to Seoul the route which was actually taken and which was close to the great circle.

2. The actions of the USSR Air Defence Forces on the territory of Kamchatka Peninsula and Sakhalin Island were based on the conviction that 'a military intruder aeroplane had entered USSR airspace. The absence of civil aircraft, according to the reports of the USSR ATC units, in the airspace monitored by them and the impossibility of visual recognition of the intruder aeroplane type as a civil aircraft under night flying conditions confirmed the certainty of its military affiliation. Given these circumstances, the rules of interception for civil aircraft, recommended by ICAO and established in the USSR AlP, were not applied by the USSR Air Defence Forces. The USSR Air Defence units were guided by the rules regulating the actions of the Air Defence Forces in the event of violation of the USSR State border by military aeroplanes. This led to the stopping of the flight at 1826 hours. As was shown by an analysis of the objective information on the actions of the Air Defence units in intercepting the intruder aeroplane, all available measures were taken to identify and determine the type and State affiliation of this aeroplane. Further evidence of this is the fact that the flight was stopped not when it flew over Kamchatka Peninsula and not when it again violated the USSR State border in the area of Sakhalin Island, but immediately before the intruder aeroplane exited USSR airspace.
Final Report:

Crash of a Boeing 747-2B5B in Seoul: 14 killed

Date & Time: Nov 18, 1980 at 0725 LT
Type of aircraft:
Operator:
Registration:
HL7445
Survivors:
Yes
Schedule:
Los Angeles – Anchorage – Seoul
MSN:
21773
YOM:
1979
Flight number:
KE015
Country:
Region:
Crew on board:
13
Crew fatalities:
Pax on board:
213
Pax fatalities:
Other fatalities:
Total fatalities:
14
Circumstances:
Following an uneventful flight from Los Angeles via Anchorage, the crew started the approach to Seoul-Gimpo Airport in the early morning, just after sunset. On final to runway 14, with a limited visibility of 1,000 meters due to patches of fog, the crew failed to realize his altitude was insufficient when the airplane landed 90 meters short of runway threshold. Then the aircraft struck a concrete wall, causing all main gears to be torn off or to pushed back in their respective wheel well, except the nose gear which remained intact. The airplane slid on its belly for about 1,200 metres before coming to rest in flames on the left side of the runway. 14 occupants escaped uninjured while 198 others were injured. Unfortunately, eight passengers and six crew members, among them both pilots, were killed. The aircraft was destroyed by a fire that probably ignited in a cargo compartment.
Probable cause:
Wrong approach configuration on part of the flying crew who continued the approach below the glide without any visual contact with the ground until the airplane struck the ground short of runway.

Crash of a Boeing 747-237B off Mumbai: 213 killed

Date & Time: Jan 1, 1978 at 2041 LT
Type of aircraft:
Operator:
Registration:
VT-EBD
Flight Phase:
Survivors:
No
Schedule:
Bombay - Dubaï
MSN:
19959
YOM:
1971
Flight number:
AI855
Country:
Region:
Crew on board:
23
Crew fatalities:
Pax on board:
190
Pax fatalities:
Other fatalities:
Total fatalities:
213
Circumstances:
After takeoff from Bombay-Santa Cruz Airport runway 27, while climbing by night at an altitude of 2,400 feet, the captain contacted ATC and wished a Happy New Year. He was cleared to climb to 8,000 feet and initiated a turn to the right according to departure procedures. Once the turn was finished and the aircraft was leveling, the captain realized his Attitude Director Indicator (ADI) was still showing a right-bank indication. The copilot confirmed his ADI was correct and the flight engineer noticed the difference between the captain's ADI and the third ADI system. Despite these two confirmation, the captain started a turn to the left as he thought the aircraft was still in a right-bank attitude. The airplane entered a left turn to an angle of 40° then until an excessive angle of 108° when control was lost. From an altitude of 2,000 feet, the airplane entered a dive and crashed into the Arabian Sea. The airplane disintegrated on impact and all 213 occupants were killed. Most of the debris were found in shallow water about 3 km offshore. Control was lost as the pilot-in-command was flying over the sea by night without any visual references with the ground.
Probable cause:
The probable cause of this accident was due to the irrational control wheel inputs given by the captain following complete unawareness of the attitude of the aircraft on his part after Attitude Director Indicator (ADI) had malfunctioned. The crew failed to gain control based on the other flight instruments. He had failed to determine the attitude of the aircraft with the associated flight instruments including Standby Horizon Indicator. The co-pilot had failed to monitor the flight instruments and did not render any assistance to the captain in ascertaining the attitude of the aircraft.

Crash of a Boeing 747-206B in Tenerife: 248 killed

Date & Time: Mar 27, 1977 at 1706 LT
Type of aircraft:
Operator:
Registration:
PH-BUF
Flight Phase:
Survivors:
No
Schedule:
Tenerife - Las Palmas
MSN:
20400
YOM:
1971
Flight number:
KL4805
Country:
Region:
Crew on board:
14
Crew fatalities:
Pax on board:
234
Pax fatalities:
Other fatalities:
Total fatalities:
248
Captain / Total flying hours:
11700
Captain / Total hours on type:
1545.00
Copilot / Total flying hours:
9200
Copilot / Total hours on type:
95
Aircraft flight hours:
21195
Aircraft flight cycles:
5202
Circumstances:
The KLM Boeing 747, registration PH-BUF, took off from Schipol Airport (Amsterdam) at 0900 hours on 27 March 1977, en route to Las Palmas de Gran Canaria. This flight was part of the Charter Series KL4805/4806 Amsterdam-Las Palmas (Canary Islands) - Amsterdam operated by KLM on behalf of the Holland International Travel Group (H.I.N.T.), Rijswijk-Z.H. The Boeing 747 registration N736PA, flight number 1736, left Los Angeles International Airport, California, United States, on 26 March 1977, local date, at 0129Z hours, arriving at John F. Kennedy International Airport at 0617Z hours. After the aeroplane was refuelled and a crew change effected, it took off for Las Palmas de Gran Canaria (Spain) at 0742Z. While the aeroplanes were en route to Las Palmas, a bomb exploded in the airport passenger terminal. On account of this incident and of a warning regarding a possible second bomb, the airport was closed. Therefore, KLM 4805 was diverted to Los Rodeos (Tenerife) Airport, arriving at 1338Z on 27 March 1977. For the same reason, PAA1736 proceeded to the same airport, which was its alternate, landing at 1415. At first the KLM passengers were not allowed to leave the aeroplane, but after about twenty minutes they were all transported to the terminal building by bus. On alighting from the bus, they received cards identifying them as passengers in transit on Flight KL 4805. Later, all the passengers boarded KLM 4805 expect the H.I.N.T. Company guide, who remained in Tenerife. When Las Palmas Airport was opened to traffic once more, the PAA 1736 crew prepared to proceed to Las Palmas, which was the flight's planned destination. When they attempted to taxi on the taxiway leading to runway 12, where they had been parked with four other aeroplanes on account of the congestion caused by the number of flights diverted to Tenerife, they discovered that it was blocked by KLM Boeing 747, Flight 4805, which was located between PAA 1736 and the entrance to the active runway. The first officer and the flight engineer left the aeroplane and measured the clearance left by the KLM aircraft, reaching the conclusion that it was insufficient to allow PAA 1736 to pass by, obliging them to writ until the former had started to taxi. The passengers of PAA 1736 did not leave the aeroplane during the whole time that it remained in the airport. KLM 4805 called the tower at 1656 requesting permission to taxi. It was authorized to do so and at 1658 requested to backtrack on runway 12 for take-off on runway 30. The tower controller first cleared the KLM flight to taxi to the holding position for runway 30 by taxiing down the main runway and leaving it by the (third) taxiway to its left. KLM 4805 acknowledged receipt of this message from the tower, stating that it was at that moment taxiing on the runway, which it would leave by the first taxiway in order to proceed to the approach end of runway 30. The tower controller immediately issued an amended clearance, instructing it to continue to taxi to the end of the runway, where it should proceed to backtrack. The KLM flight confirmed that it had received the message, that it would backtrack, and that it was taxiing down tile main runway. The tower signalled its approval, whereupon KLM 4805 immediately asked the tower again if what they had asked it to do was to turn left on taxiway one. The tower replied in the negative and repeated that it should continue on to the end of the runway and there backtrack. Finally, at 1659, KLM 4805 replied, "O.K., sir." At 1702, the PAA aeroplane called the tower to request confirmation that it should taxi down the runway. The tower controller confirmed this, also adding that they should leave the runway by the third taxiway to their left. At 1703:00, in reply to the tower controller's query to KLM 4805 as to how many runway exits they had passed, the latter confirmed that at that moment they were passing by taxiway C4. The tower controller told KLM 4805, "O.K., at the end of the runway make one eighty and report ready for ATC clearance ." In response to a query from KLM 4805, the tower controller advised both aeroplanes - KLM 4805 and PAA 1736 - that the runway centre line lights were out of service. The controller also reiterated to PAA 1736 that they were to leave the main runway via the third taxiway to their left and that they should report leaving the runway. At the times indicated, the following conversations took place between the tower and the KLM 4805 and PAA 1736 aeroplanes. Times taken from KLM CVR.
1705:44.6 KLM 4805: The KLM four eight zero five is now ready for take-off and we are waiting for our ATC clearance. (1705:50.77).
1705:53.41 Tower: KLM eight seven zero five you are cleared to the Papa Beacon, climb to and maintain flight level nine zero, right turn after take-off, proceed with heading four zero until intercepting the three two five radial from Las Palmas VOR. (1706 :08.09).
1706:09.61 KLM 4805: Ah - Roger, sir, we are cleared to the Papa Beacon, flight level nine zero until intercepting the three two five. We are now (at take-off). (1706:17.79).
1706:18.19 Tower : O.K..... Stand by for take-off, I will call you. (1706: 21.79).
Note: A squeal starts at: 1706:19.39 The squeal ends at: 1706:22.06
1706:21.92 PAA 1736: Clipper one seven three six. (1706 : 23.39).
1706:25.47 Tower: Ah - Papa Alpha one seven three six report the runway clear. (1706: 28.89).
1706:29.59 PAA 1736: O.K., will report when we're clear. (1706:30.69).
1706:31.69 Tower: Thank you.
Subsequently, KLM 4805, which had released its brakes to start take-off run 20 seconds before this communication took place, collided with the PAA aeroplane. The control tower received no further communications from PAA 1736, nor from KLM 4805. There were no eyewitnesses to the collision. All 248 occupants on board the KLM 747 were killed. Among the 396 people on board the Pan Am 747, 335 were killed (among them nine crew members) and 61 others were injured.
Probable cause:
The KLM aircraft had taken off without take-off clearance, in the absolute conviction that this clearance had been obtained, which was the result of a misunderstanding between the tower and the KLM aircraft. This misunderstanding had arisen from the mutual use of usual terminology which, however, gave rise to misinterpretation. In combination with a number of other coinciding circumstances, the premature take-off of the KLM aircraft resulted in a collision with the Pan Am aircraft, because the latter was still on the runway since it had missed the correct intersection.
Final Report: