Douglas DC-10

Operator:

Registration:

HL7339

Flight Phase:

Flight Type:

Cargo

Survivors:

Site:

Anchorage-Ted Stevens Intl

Schedule:

Seoul - Anchorage - Los Angeles

MSN:

46960

YOM:

1977

Flight number:

KE084

Location:

Alaska

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

12562

Captain / Total hours on type:

6471.00

Copilot / Total flying hours:

8157

Copilot / Total hours on type:

2995

Circumstances:

While taxiing out in fog, the KAL crew became disoriented and ended up on the wrong runway. During the takeoff run, the aircraft collided head-on with South Central Air Flight 59, a Piper PA-31 which was taking off from runway 06L-24R for a flight to Kenai. The 9 occupants of N35206 were injured. The DC-10 overran the runway by 1434 feet and came to rest 40 feet right of the extended centreline.

Probable cause:

The failure of the pilot of Korean Air Lines Flight 084 to follow accepted procedures during taxi, which caused him to become disoriented while selecting the runway; the failure of the pilot to use the compass to confirm his position; and the decision of the pilot to take off when he was unsure that the aircraft was positioned on the correct runway. Contributing to the accident was the fog, which reduced visibility to a point that the pilot could not ascertain his position visually and the control tower personnel could not assist the pilot. Also contributing to the accident was a lack of legible taxiway and runway signs at several intersections passed by Flight 084 while it was taxiing.

Final Report:

Crash of a Douglas DC-10-30CF in Málaga: 50 killed

Date & Time: Sep 13, 1982 at 1200 LT

Type of aircraft:

Operator:

Registration:

EC-DEG

Flight Phase:

Charter/Taxi (Non Scheduled Revenue Flight)

Flight Type:

Survivors:

Site:

Schedule:

Madrid – Málaga – New York

MSN:

46962

YOM:

1977

Flight number:

BX995

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

381

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

16129

Captain / Total hours on type:

2119.00

Copilot / Total flying hours:

6840

Copilot / Total hours on type:

2165

Aircraft flight hours:

15364

Aircraft flight cycles:

4008

Circumstances:

Takeoff acceleration was normal, failure was not detected on engines, systems or structures. The crew registered a strong vibration at or close to V1. The captain felt how this vibration was highly increased as he began rotation, consequently rejecting the takeoff at a speed between VR and V2. Physical evidence shows how detachment of the tread of a tire of the nose gear, retreated, began before the aircraft had reached V1. The reject of takeoff began where there were another 1,295 meters (4,250 feet) of runway left. The aircraft crossed the runway end at a speed slightly over 110 knots, colliding with an ILS concrete building, breaking the metal fencing of the airport, crossing a highway, causing damage to three vehicles on the same, colliding then with farming construction. Engine number three detached after impact with the ILS building. Approximately three quarters of the right wing as well as the right horizontal stabilizer were detached as a result of the impact with the afore mentioned farming construction. The fuselage also ran over the construction with which the right wing collided. The aircraft stopped 450 meters (1,475 feet) away from the end of runway 14, and approximately 40 meters (130 feet) off to the left from the centerline. Neither the passenger department nor the cockpit showed damage that could impede survival when the aircraft stopped. Fuel was spilled off the right wing, from the time it collided with the farming construction, and the fire began in the rear of the fuselage. The fire destroyed the aircraft completely. There were 381 passengers and 13 crew members on board. 333 passengers and 10 crew survived, and as a result of the fire subsequent to the impact, 47 passengers and three assistant crew members died.

Probable cause:

The Commission determines the cause of the accident to be the fractional detachment of the retread of the right wheel of the nose gear, originating a strong vibration which could not be identified by the captain, leading him into the belief that the aircraft would become uncontrollable in flight, and thus deciding to abandon the take-off over VR. The decision of aborting the take-off, though not in accordance with the standard operation procedure, is in this case considered reasonable, on the base of the irregular circumstances that the crew had to face, the short period of time available to take the decision, the lack of training in case of wheel failure and the absence of take-off procedures when failure other than that of the engines occurs.

Final Report:

Crash of a Douglas DC-10-30CF in Boston: 2 killed

Date & Time: Jan 23, 1982 at 1936 LT

Type of aircraft:

Landing (descent or approach)

Operator:

Registration:

N113WA

Flight Phase:

Flight Type:

Survivors:

Site:

Lake, Sea, Ocean, River

Schedule:

Oakland - Newark - Boston

MSN:

47821/320

YOM:

1980

Flight number:

WO30H

Location:

Boston-Logan

Massachusetts

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

200

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

18091

Captain / Total hours on type:

1969.00

Copilot / Total flying hours:

8600

Aircraft flight hours:

6327

Circumstances:

Following a non-precision instrument approach to runway 15R at Boston-Logan International Airport, the airplane touched down about 2,800 feet beyond the displaced threshold of the 9,191-foot usable part of the runway. About 1936:40, the airplane veered to avoid the approach light pier at the departure end of the runway and slid into the shallow water of Boston Harbor. The nose section separated from the fuselage in the impact after the airplane dropped from the shore embankment. Of the 212 persons on board, 2 persons are missing and presumed dead. The other persons onboard evacuated the airplane safely, some with injuries.

Probable cause:

The minimal braking effectiveness on the ice-covered runway; the failure of the Boston-Logan International Airport management to exercise maximum efforts to assess the condition of the runway to assure continued safety of landing operations; the failure of air traffic control to transmit the most recent pilot reports of braking action to the pilot of Flight 30H; and the captain's decision to accept and maintain an excessive airspeed derived from the auto throttle speed control system during the landing approach which caused the aircraft to land about 2,800 feet beyond the runway's displaced threshold. Contributing to the accident were the inadequacy of the present system of reports to convey reliable braking effectiveness information and the absence of provisions in the Federal Aviation Regulations to require:
- Airport management to measure the slipperiness of the runways using standardized procedures and to use standardized criteria in evaluating and reporting braking effectiveness and in making decisions to close runways.
- Operators to provide flight crews and other personnel with information necessary to correlate braking effectiveness on contaminated runways with aircraft stopping distances, and
- Extended minimum runway lengths for landing on runways which adequately take into consideration the reduction of braking effectiveness due to ice and snow.

Final Report:

Crash of a Douglas DC-10-30 on Ross Island: 257 killed

Date & Time: Nov 28, 1979 at 1250 LT

Type of aircraft:

Charter/Taxi (Non Scheduled Revenue Flight)

Operator:

Registration:

ZK-NZP

Flight Phase:

Flight

Flight Type:

Survivors:

Site:

Mountains

Schedule:

Auckland - Christchurch

MSN:

46910/182

YOM:

1974

Flight number:

NZ901

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

237

Pax fatalities:

Other fatalities:

Total fatalities:

257

Captain / Total flying hours:

11151

Captain / Total hours on type:

2872.00

Copilot / Total flying hours:

7934

Copilot / Total hours on type:

1361

Aircraft flight hours:

20763

Circumstances:

In preparation for Flight TE901 two of the pilots attended a route qualification briefing. This briefing consisted of an audio visual presentation, a review of a printed briefing sheet and a subsequent 45 minute flight in a DC 10 flight simulator for each pilot to familiarise him with the grid navigation procedures applicable to the portion of the flight south of 60o south latitude and the visual meteorological conditions (VMC) letdown procedure at McMurdo. This briefing was completed 19 days prior to the scheduled departure date. The briefing gave details of the instrument flight rules (IFR) route to McMurdo which passed almost directly over Mt Erebus, a 12450 ft high active volcano, some 20 nm prior to the most southerly turning point, Williams Field. It also stated that the minimum instrument meteorological conditions (IMC) altitude was 16000 ft and the minimum altitude after passing overhead McMurdo was 6000 ft providing conditions were better than certain specified minima well in excess of the standard VMC in New Zealand. On the day of the flight the crew participated in a normal pre-flight dispatch planning. At 1917 hours (Z) on 27 November 1979 Air New Zealand Flight TE 901, a DC10-30 (ZKNZP) departed from Auckland Airport on a non-scheduled domestic scenic flight which was planned to proceed via South Island New Zealand, Auckland Islands, Baleny Island, and Cape Hallett to McMurdo, Antarctica then returning via Cape Hallett and Campbell Island to Christchurch its first intended landing point. The flight was dispatched on an IFR computer stored flight plan route. The flight deck crew consisted of the captain, two first officers and two flight engineers. Beside the fifteen cabin crew there was an official flight commentator on the flight who was experienced in Antarctic exploration. The passenger load was reduced by 21 from the normal passenger seating capacity as a deliberate policy to facilitate movement about the cabin to allow passengers to view the Antarctic scenery. In a discussion with the McMurdo meteorological office at 0018 hours (Z) the aircraft crew was advised that Ross Island was under a low overcast with a base of 2000 ft and with some light snow and a visibility of 40 miles and clear areas approximately 75 to 100 nm northwest of McMurdo. At approximately 0043 hours (Z) Scott Base advised the aircraft that the dry valley area was clear and that area would be a better prospect for sightseeing than Ross Island. In response to the message that the area over the Wright and Taylor Valleys was clear the captain asked the commentator if he could guide them over that way. The commentator said that would be no trouble and asked if the captain wished to head for that area at the time. The captain replied he “would prefer here first”. The US Navy Air Traffic Control Centre (ATCC) “Mac Centre” suggested that the aircraft crew take advantage of the surveillance radar to let down to 1500 feet during the aircraft’s approach to McMurdo and the crew indicated their acceptance of this offer. In the event however the aircraft was not located by the radar equipment prior to initiating its descent (or at any other time). The aircraft crew also experienced difficulty in their attempts to make contact on the very high frequency (VHF) radio telephone (R/T)and the distance measuring equipment (DME) did not lock onto the McMurdo Tactical Air Navigation System (TACAN) for any useful period. The aircraft was relying primarily on high frequency (HF) R/T during the latter part of its flight for communication with the ATCC. The area which was approved by the operator for VMC descents below 16000 feet was obscured by cloud while ZK-NZP was approaching the area, and the crew elected to descend in a clear area to the north of Ross Island in two descending orbits the first to the right and the second to the left. Although they requested and were granted a clearance from “Mac Centre” to descend from 10000 to 2000 feet VMC, on a heading of 180 grid (013oT) and proceed “visually” to McMurdo, the aircraft only descended to 8600 feet before it completed a 180° left turn to 375°G (190°T) during which it descended to 5,700 feet. The aircraft’s descent was then continued to 1500 feet on the flight planned track back toward Ross Island. Shortly after the completion of the final descent the aircraft collided with Ross Island. The aircraft’s ground proximity warning system (GWPS) operated correctly prior to impact and the crew responded to this equipment’s warning by the engineer calling off two heights above ground level, 500 and 400 feet, and the captain calling for “go round power”. The aircraft’s engines were at a high power setting and the aircraft had rotated upwards in pitch immediately prior to impact. The aircraft collided with an ice slope on Ross Island and immediately started to break up. A fire was initiated on impact and a persistent fire raged in the fuselage cabin area after that section came to rest. The accident occurred in daylight at 0050 hours (Z) at a position of 77° 25’30” S and 167° 27’30” E and at an elevation of 1467 feet AMSL. The cockpit voice recorder (CVR) and digital flight data recorder (DFDR) established that the aircraft was operating satisfactorily and the crew were not incapacitated prior to the accident.

Probable cause:

The probable cause of this accident was the decision of the captain to continue the flight at low level toward an area of poor surface and horizon definition when the crew was not certain of their position and the subsequent inability to detect the rising terrain which intercepted the aircraft’s flight path. The following findings were reported:
- The flight planned route entered in the company’s base computer was varied after the crew’s briefing in that the position for McMurdo on the computer printout used at the briefing was incorrect by over 2 degrees of longitude and was subsequently corrected prior to this flight.
- The system of checking the detailed flight plan entries into the base computer was inadequate in that an error of 2° of longitude persisted in a flight plan for some 14 months,
- Some diagrams and maps issued at the route qualification briefing could have been misleading in that they depicted a track which passed to the true west of Ross Island over a sea level ice shelf, whereas the flight planned track passed to the east over high ground reaching to 12,450 feet AMSL,
- The briefing conducted by Air New Zealand Limited contained omissions and inaccuracies which had not been detected by either earlier participating aircrews or the supervising Airline Inspectors,
- The crew were not aware of the VHF R/T callsigns in use in the area and these are not published in the briefing notes, the NZAIP, or the US Department of Defence documents which were available to the crew. They were however specified in US Navy instruction CNSFA INST 3722.1, a copy of which was held by Operation Deep Freeze Headquarters,
- The question of making a landing near McMurdo on either the ice runway or the skiways at Williams Field and the type of emergencies which might require such a diversion was not discussed at the company’s briefing,
- The Civil Aviation Division Airline Inspectors had formally approved the audio visual stage of the route qualification briefing for the flight and one had witnessed a typical audio visual segment of the briefing for an Antarctic flight, twice, without requiring any amendments or detecting the errors contained in the briefing. They had also confirmed that it was no longer necessary for captains to carry out a supervised flight as required in the Operations Specifications in view of these briefings and the flight simulator detail,
- Civil Aviation Regulation 77 1(a) had not been complied with,
- The operator departed from the stated undertaking to carry two captains on each flight and substituted an additional first officer in lieu of the second captain,
- Of the flight deck crew only one engineer had flown to the Antarctic previously,
- The crew were not monitoring their actual position in relation to the topography adequately even though a continuous readout of the aircraft’s latitude and longitude and distance to run to the next waypoint was continuously available to them from the AINS,
-The crew did not observe the transition level in use in the McMurdo air traffic control area for resetting this aircraft’s altimeters and this procedure was not published in either the briefing notes or the US Department of Defence documents which were made available to the crew. The procedure used was that prescribed in US Federal Aviation Regulation 91.81 which required the QNH to be set basically at FL 180 during descent but this was modified in low pressure areas,
- The captain’s altimeter was not set to the correct QNH until the aircraft reached 3,500 feet,
- The captain initiated a descent to an altitude below both the IMC (16000 feet) and VMC (6000 feet) minima for the area in a cloud free area but in contravention of the operator’s briefing and outside the sector approved for the descent to 6000 feet by the DCA and the Company,
- The co-pilot was devoting a significant proportion of his time in an endeavour to establish VHF contact with the McMurdo ground stations and did not monitor the decisions of the pilot in command adequately in that he did not offer any criticism of the intention to descend below MSA in contravention of company restrictions and basic good airmanship,
- The descent was intentionally continued below the VMC limit specified by CAD and Air New Zealand Limited, of 6000 feet to an indicated 1500 feet,
- The crew were distracted but not preoccupied by their failure to raise the Ice Tower or any local ground station on VHF, the failure of the DME to lock on to the TACAN and the lack of any identification of the aircraft on radar,
- The company deleted an earlier requirement for VMC descents to be monitored by radar and substituted the alternative procedure of contacting the radar controller for co-ordination of the descent,
- The failure of the aircraft’s systems to establish satisfactory VHF contactor to “lock on” to the McMurdo TACAN was probably due to the aircraft’s low altitude in conjunction with significant high ground between the aircraft and the ground equipment,
- The flight engineers endeavoured to monitor the progress of the flight and expressed their dissatisfaction with the descent toward a cloud covered area,
- Although the route selected by Air New Zealand for the approach to McMurdo crossed almost directly over a 12450 ft active volcano just 20 miles from destination in preference to the normal approach path of military aircraft which was across the sea level ice shelf the Air New Zealand route was safe provided the crew observed the minimum altitudes stipulated for the flight and no extraordinary activity occurred in the volcano,
- Despite the shortcomings of some aspects of the route qualification briefing, this flight and Antarctic flights in general were not unacceptably hazardous, if they had been conducted strictly in accordance with the route qualification briefing as presented,
- The CAD procedure of reapproving Antarctic flights each season on the condition that they complied with the constraints of the previous season’s flights led to some items being discontinued without formal notification or agreement, e.g. the carriage of 2 captains on each flight, and the requirement for a briefing by ODF Headquarters,
- The on board navigation and flight guidance system operated normally during the latter stages of the flight,
- The aircraft’s GPWS operated in accordance with its design specifications,
- CAD had not implemented effectively the section of the ICAO standard detailed in Annex 6 of the convention which requires appropriate life-sustaining equipment to be carried on flights across land areas which have been designated by the State concerned as areas in which search and rescue would be especially difficult. Although the Commander of the USN Antarctic Support Force stated that “limited SAR capability existed over land and very little over water”, this may not constitute “designation of the area” as being especially difficult for search and rescue activities by the State concerned,
- Although some notes on Antarctic survival were given to the Chief Purser immediately before this flight no additional life-sustaining equipment was carried or training given to the crew members to facilitate survival following an emergency landing on the ice or in the polar waters of Antarctica,
- Neither the passengers nor the crew were expecting the collision and all received fatal injuries on impact with the ice,
- The search and rescue organisation was mobilised and co-ordinated in a competent manner despite the difficult environment and the aircraft was located as soon as practicable, (11 hours) after the collision occurred,
- The aircraft was not fitted with a self activated ELT but such equipment is not at present required,
- The aircraft’s CVR and DFDR operated as intended and provided an excellent record for the investigators of this accident. The CVR system however could be significantly improved as discussed in recommendation 8.
- The aircraft’s radar would have depicted the mountainous terrain ahead.

Final Report:

Crash of a Douglas DC-10-10 in Mexico City: 73 killed

Date & Time: Oct 31, 1979 at 0542 LT

Type of aircraft:

Landing (descent or approach)

Operator:

Registration:

N903WA

Flight Phase:

Flight Type:

Survivors:

Site:

Mexico City-Benito Juarez

Schedule:

Los Angeles - Mexico City

MSN:

46929/107

YOM:

1973

Flight number:

WA2605

Location:

Federal District of Mexico City

Country:

Mexico

Region:

Central America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

31500

Captain / Total hours on type:

2248.00

Copilot / Total hours on type:

354

Aircraft flight hours:

24614

Aircraft flight cycles:

7345

Circumstances:

The airplane had taken off from Los Angeles International Airport, California, for Mexico City, at 0140LT on 31 October 1979. The Mexico centre had cleared the crew to approach Mexico City via Tepexpan, subsequently instructing the aircraft crew to change frequency to the control tower. The tower operator informed the crew that the runway in use was 23 Right and provided the crew with information on the weather conditions prevailing at Mexico City International Airport, and landing data. When the aircraft was on final approach, the control tower operator repeated that the runway in use was 23 Right and drew the attention of the pilot to the fact that he was left of the flight path he should be following to land on the runway in use. The pilot acknowledged the information and the fact that he was slightly to the left. The transcription of the magnetic tape which contains the communications between the control tower operator and the crew of aircraft N-903WA reveals that et one point the control tower operator asked the pilot whether he could see the approach lights on his left, to which the pilot replied "negative". The data obtained from the aircraft's flight recorder shows that the crew was making an instrument approach. The instrument landing procedure authorized in the aeronautical information publication (AIP) for Runway 23 Left with transition to 23 Right specifies that if the pilot does not have the runway in sight at 600 ft during an instrument landing approach, he must break off the approach and climb to 8 500 ft. In this case the crew continued with the landing procedure, ignoring the requirement to call out the altitude values and the decision minimum, and descended until the landing gear touched down off-centre of Runway 23 Left, which was closed to all operations. On the transcription of the cockpit voice recorder the pilot-in-command is heard to have said that he was on the flight path to Runway 23 Left, just before the left landing gear wheels touched down on the grass to the left of Runway 23 Left and the right landing gear wheels on the runway shoulder. The aircraft did not enter the runway until it had travelled some 100 m. According to the flight recorder data and the wheel traces at the site of the accident, the crew re-applied power for the go-around procedure and lifted the aircraft nose by 100-210. Now airborne, the aircraft's right landing gear collided with a truck located on the left shoulder of the runway which was closed for repairs. The impact left a distinct mark in the left-hand side of the vehicle's bonnet corresponding exactly to the shape and size of the aircraft's wheel. The collision with the truck, which was loaded with 10 tonnes of earth, removed the right landing gear leg with part or sections of the main gear beam to which it is attached, bursting three of the four tires. The two front tires came off the wheels, whose hubs disintegrated, scattering pieces away from the aircraft. The horizontal shaft which carries the two front wheels and the associated brake units also broke off and were projected forward over a distance of over 400 m. After breaking off, the right landing gear leg struck the right tailplane and elevator, severing the two almost completely. This caused the landing gear leg complete with the two rear tires, wheels and brake units to be thrown about 70 m beyond the point of collision with the truck. The left side panel of the truck's dumper body, the only part to break off, was thrown to the left of the runway; this panel bore traces of tires about halfway along its top edge. The inner right-hand section of the wing flaps also struck the dumper body, which removed the complete section; this was found to the right of the aircraft's flight path some 40 m beyond the final location of the dumper body. The underside of the flap was full of earth and the fractures in the structure contained earth from the truck. The right-hand side panel of the dumper body also bore evidence of having been struck by a metal object. The truck broke up completely and parts of it were scattered over a considerable distance on and off the runway, the area covered being some 400 m long by 100 m wide. Three seconds before the collision with the truck the engine throttles were opened. The collision occurred under these conditions and in spite of the violence of the impact the aircraft remained airborne and flew on, although lift was precarious due to the loss on the right side of the tailplane complete with elevator and the inner section of the wing flap. The aircraft was banked to the right and this inclination increased so much that when the aircraft was approximately 1 500 m from the threshold of Runway 23 Left, the outer section of the right wing flap struck the cab of an excavator which was parked parallel to the right-hand edge of Runway 23 Left. The impact completely destroyed the cab and parts of the trailing edge of the wing flap were found embedded in the twisted framework of the excavator. The aircraft continued, veering to the right and increasing its bank angle towards that side until the right wing tip was scraping Taxiway "A", leaving a deep score in the pavement, damaging a telephone manhole and destroying some taxiway edge lights. A severed section of the right wing was found deeply embedded in the ground at this point and the first signs of the fire which burned the nearby grass were also in this area. The distance from the marks left by the landing gear in the grass and on the runway shoulder 167 m from the threshold of Runway 23 Left, to the score made in Taxiway "A" by the right wing tip, is approximately 2 500 m, and over this entire distance the aircraft left no mark or trace on the ground, except a few metres beyond the excavator. From this point a score of constant depth and width had been made in the grass over a distance of about 70 m, possibly by something suspended underneath the aircraft. Small fragments of glass fibre, the material used for the trailing edges of the aircraft's control surfaces, were found along this score. The evidence above proves that the aircraft had remained airborne from the time it collided with the truck until reaching Taxiway "A", as confirmed by the flight recorder data. After the traces left by the right wing tip on Taxiway "A", scores of varying depths were made in Taxiway "Ptt by the aileron and the outer section of the right flap. A few metres further on the right wing collided with the corner of the PCV repair hangar, knocking down a pillar, a cross tie and part of the roof corner. Various aircraft components were found inside the hangar, e.g. the flap guides and hinges, sections of the leading edge of the right aileron, etc., besides the fuel which was spilled from the fractured wing onto a PCV under repair and on parked cars and vans. The collision of the right wing with the PCV repair hangar hardly interrupted the aircraft along its flight path and it finally crashed against the front of a building, which was demolished by the impact. This was the main impact, during which the tail fin complete with rudder and engine No. 2, the tail unit and the left tailplane with its elevator broke off, together with what remained of the right tailplane and elevator removed earlier by the right landing gear leg. The left wing was also severed at its attachment to the centre section and was thrown more than 200 m, turning over in the process and falling on a house outside the airport; part of this house was burned out. Engines No. 1 and 3 broke away from the wings and were destroyed by the impact and fire. 16 people were injured while 72 occupants, including nine crew members were killed as well as one people in the building.

Probable cause:

The accident was the consequence of the combination of the following factors:
- Non-compliance with the meteorological minima for the approach procedure, as cleared,
- Failure to comply with the aircraft's operating procedures during the approach phase,
- Landing on a runway closed to traffic,
- During the final approach to the runway assigned and having reached a height of 800 feet above the ground, the aircraft flew into a fog bank which concealed it from the control tower operator,
- The aircraft's crew did not comply with the procedural minima for the approach for which it had been cleared, in that the crew descended below the minima without reporting the runway in sight or initiating a go-around procedure,
- The crew never reported to the control tower operator that the runway was in sight and no landing clearance was therefore given,
- The data obtained from the cockpit voice recorder revealed that the crew did not comply with the operational procedures laid down in the relevant manuals, in particular the requirement to call out the altimeter readings during the final approach phase.

Final Report:

Crash of a Douglas DC-10-10 in Chicago: 273 killed

Date & Time: May 25, 1979 at 1504 LT

Type of aircraft:

Operator:

Registration:

N110AA

Flight Phase:

Flight Type:

Survivors:

Site:

Schedule:

Chicago - Los Angeles

MSN:

46510/22

YOM:

1971

Flight number:

AA191

Location:

Chicago-O'Hare

Illinois

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

258

Pax fatalities:

Other fatalities:

Total fatalities:

273

Captain / Total flying hours:

22500

Captain / Total hours on type:

3000.00

Copilot / Total flying hours:

9275

Copilot / Total hours on type:

1200

Aircraft flight hours:

19871

Circumstances:

American Airlines Flight 191, a McDonnell-Douglas DC-10-10, crashed on takeoff from Chicago-O'Hare International Airport, Illinois, USA. The aircraft was destroyed and all 271 occupants were killed. Additionally, two persons on the ground sustained fatal injuries. At 14:59 hours local time Flight 191 taxied from the gate at O'Hare Airport. The flight was bound for Los Angeles, California, with 258 passengers and 13 crew members on board. Maintenance personnel who monitored the flight's engine start, push-back, and start of taxi did not observe anything out of the ordinary. The weather at the time of departure was clear, and the reported surface wind was 020° at 22 kts. Flight 191 was cleared to taxi to runway 32R for takeoff. The company's Takeoff Data Card showed that the stabilizer trim setting was 5° aircraft nose up, the takeoff flap setting was 10°, and the takeoff gross weight was 379,000 lbs. The target low pressure compressor (N1) rpm setting was 99.4 percent, critical engine failure speed (V1) was 139 kts indicated airspeed (KIAS), rotation speed (VR) was 145 KIAS, and takeoff safety speed (V2) was 153 KIAS. Flight 191 was cleared to taxi into position on runway 32R and hold. At 15:02:38, the flight was cleared for takeoff, and at 15:02:46 the captain acknowledged, "American one ninety-one under way." The takeoff roll was normal until just before rotation at which time sections of the No.1 (left) engine pylon structure came off the aircraft. Witnesses saw white smoke or vapor coming from the vicinity of the No. 1 engine pylon. During rotation the entire No. 1 engine and pylon separated from the aircraft, went over the top of the wing, and fell to the runway. Flight 191 lifted off about 6,000 ft down runway 32R, climbed out in a wings-level attitude. About nine seconds after liftoff, the airplane had accelerated to 172 knots and reached 140 feet of altitude. As the climb continued, the airplane began to decelerate at a rate of about one knot per second, and at 20 seconds after liftoff, and an altitude of 325 feet, airspeed had been reduced to 159 knots. At this point, the airplane began to roll to the left, countered by rudder and aileron inputs. The airplane continued to roll until impact, 31 seconds after liftoff, and in a 112-degree left roll, and 21-degree nose down pitch attitude. At 15:04 Flight 191 crashed in an open field and trailer park about 4,600 ft northwest of the departure end of runway 32R. The aircraft was demolished during the impact, explosion, and ground fire. The No.1 engine pylon failure during takeoff was determined to have been caused by unintended structural damage which occurred during engine/pylon reinstallation using a forklift. The engine/pylon removal and reinstallation were being conducted to implement two DC-10 Service Bulletins. Both required that the pylons be removed, and recommended that this be accomplished with the engines removed. The Service Bulletin instructions assumed that engines and pylons would be removed separately, and did not provide instructions to remove the engine and pylon as a unit. Additionally, removal of the engines and pylons as a unit was not an approved Maintenance Manual procedure. The lack of precision associated with the use of the forklift, essentially an inability to perform the fine manipulations necessary to accomplish reinstallation of the engine/strut assembly, in combination with the tight clearances between the pylon flange and the wing clevis resulted in damage to the same part that had just been inspected. Inspections of other DC-10 pylon mounts following the accident resulted in nine additional cracked mounts being identified.

Probable cause:

The asymmetrical stall and the ensuing roll of the aircraft because of the uncommanded retraction of the left wing outboard leading edge slats and the loss of stall warning and slat disagreement indication systems resulting from maintenance-induced damage leading to the separation of the no.1 engine and pylon assembly procedures which led to failure of the pylon structure. Contributing to the cause of the accident were the vulnerability of the design of the pylon attach points to maintenance damage; the vulnerability of the design of the leading edge slat system to the damage which produced asymmetry; deficiencies in FAA surveillance and reporting systems which failed to detect and prevent the use of improper maintenance procedures; deficiencies in the practices and communications among the operators, the manufacturer, and the FAA which failed to determine and disseminate the particulars regarding previous maintenance damage incidents; and the intolerance of prescribed operational procedures to this unique emergency.

Final Report:

Crash of a Douglas DC-10-10 in Los Angeles: 2 killed

Date & Time: Mar 1, 1978 at 0925 LT

Type of aircraft:

Operator:

Registration:

N68045

Flight Phase:

Flight Type:

Survivors:

Site:

Schedule:

Los Angeles - Honolulu

MSN:

46904

YOM:

1972

Flight number:

CO603

Location:

Los Angeles

California

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

186

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

29000

Captain / Total hours on type:

2911.00

Copilot / Total flying hours:

10000

Copilot / Total hours on type:

1249

Aircraft flight hours:

21358

Circumstances:

On March 1, 1978, Continental Air Lines, Inc., Flight 603, a McDonnell Douglas DC-10-10 (N68045), was a scheduled flight from Los Angeles International Airport, California, to Honolulu, Hawaii. At 0857:18, Flight 603 called Los Angeles clearance delivery and was cleared for the route of flight which was to have been flown. About 2 min later, the flight received permission from Los Angeles ground control to push back from the gate. At 0901:37, Flight 603 was cleared by ground control to taxi to runway 6R. The runway was wet, but there was no standing water. At 0922:29, Los Angeles local control cleared Flight 603 to taxi into position on runway 6R and hold. At 0923:17, local control cleared Flight 603 for takeoff; however, the flightcrew did not acknowledge the instructions and did not comply with them. At 0923:57, local acknowledged the instructions. The captain stated that he delayed control, again, cleared the flight for takeoff. This time the flightcrew acknowledgment of the takeoff clearance because he believed that he had initially been given the clearance too soon after a heavy jet aircraft had made its takeoff. The flightcrew stated that acceleration was normal and that all engine instruments were in the normal range for takeoff. As the airspeed approached the V1 speed of 156 kns, the captain heard a loud "metallic bang" which was followed immediately by "a kind of quivering of the plane." The flightcrew noticed that the left wing dropped slightly. A rejected takeoff was begun immediately; however, according to the digital flight data recorder (DFDR), the airspeed continued to increase to about 159 kns as the rejected takeoff procedures were begun. The captain stated that he applied full brake pressure while simultaneously bringing the thrust levers back to idle power. Reverse thrust levers were actuated and full reverse thrust was used. The flightcrew stated that they noted good reverse thrust. First, the aircraft moved to the left of the runway centerline and appeared tb the flightcrew to be decelerating normally. With about of deceleration had decreased, and they believed that the aircraft would 2,000 ft of runway remaining, the flightcrew became aware that the rate not be able to stop on the runway surface. The captain stated that he maintained maximum brake pedal force and full reverse thrust as he steered the aircraft to the right of the runway centerline in an effort "to go beside the stanchions holding the runway lights" immediately off of the departure end of runway 6R. He stated further that he encountered no problems with directional control of the aircraft throughout the rejected takeoff maneuver. The aircraft departed the right corner of the departure end of runway 6R. About 100 ft beyond the runway, the left main landing gear broke through the nonload-bearing tar-macadam (tarmac) surface and failed rearward. Fire erupted immediately from this area. The aircraft dropped onto the left wing and the No. 1 (left) engine and rotated to the left as it continued its slide along the surface. It stopped between two of the approach light stanchions for runway 24L about 664 ft from the departure end of runway 6R and about 40 ft to the right of the runway 6R extended centerline; it came to rest on a heading of 008°, in an 11° left wing low, 1.3° noseup attitude. When the aircraft came to a stop, the evacuation was begun immediately. Two passengers were killed while all other occupants were evacuated, some of them with serious injuries.

Probable cause:

The National Transportation Safety Board determined that the probable cause of the accident was the sequential failure of two tires on the left main landing gear and the resultant failure of another tire on the same landing gear at a critical time during the takeoff roll. These failures resulted in the captain's decision to reject the takeoff. Contributing to the accident was the cumulative effect of the partial loss of aircraft braking because of the failed tires and the reduced braking friction achievable on the wet runway surface which increased the accelerate-stop distance to a value greater than the available runway length. These factors prevented the captain from stopping the aircraft within the runway confines. The failure of the left main landing gear and the consequent rupture of the left wing fuel tanks resulted in an intense fire which added to the severity of the accident.

Final Report:

Crash of a Douglas DC-10-30CF in Istanbul

Date & Time: Jan 2, 1976 at 0636 LT

Type of aircraft:

Landing (descent or approach)

Operator:

Registration:

N1031F

Flight Phase:

Flight Type:

Charter/Taxi (Non Scheduled Revenue Flight)

Survivors:

Site:

Marmara Region (Marmara Bölgesi)

Schedule:

Jeddah - Ankara

MSN:

46825

YOM:

1973

Flight number:

SV5130

Location:

Istanbul-Yeşilköy

Country:

Turkey

Region:

Asia

Crew on board:

Crew fatalities:

Pax on board:

364

Pax fatalities:

Other fatalities:

Total fatalities:

Aircraft flight hours:

9848

Circumstances:

Leased by Saudi Arabian Airlines, the aircraft was completing a charter flight (hajj flight) from Jeddah to Ankara. En route, the crew was informed about poor weather conditions in Ankara (limited visibility due to foggy conditions) and was instructed to divert to Istanbul-Yeşilköy Airport. On approach to runway 24, the copilot informed the captain that one of the VASI's light was red and that their altitude was insufficient. The captain increased engine power but the aircraft continued to descent until it struck the ground eight meters short of the concrete runway. On impact, the left engine (n°1) was torn off and both left main gear and central gear were also torn off when the airplane struck the shoulder of the first runway's concrete block. The aircraft slid on its belly for few hundred meters, veered to the left and came to rest in flames in a grassy area. All 376 occupants were quickly evacuated, among them 10 were slightly injured. The aircraft was damaged beyond repair.

Probable cause:

The crew reported the runway in sight while passing the local NDB about 600 feet below the published minimums. The descent was completed below the glide slope. There were strong evidences that the first officer's altitude callouts were from the radio-altimeter, which was considered as a contributing factor.

Final Report:

Crash of a Douglas DC-10-30C in New York

Date & Time: Nov 12, 1975 at 1310 LT

Type of aircraft:

Operator:

Registration:

N1032F

Flight Phase:

Flight Type:

Positioning

Survivors:

Site:

Schedule:

New York - Frankfurt - Jeddah

MSN:

46826

YOM:

1974

Flight number:

OV032

Location:

New York-JFK

New York

Country:

Region: