Douglas DC-8

The following findings were reported:
- Poor weather conditions with heavy rain falls,
- Limited visibility,
- The runway 05 was wet and the braking action was reduced,
- The aircraft suffered aquaplaning,
- The reverse thrust systems were unserviceable on engine n°2 and 4,
- The crew completed the landing without the spoilers being armed,
- The aircraft was not airworthy,
- The crew failed to follow the approach checklist.

Wrong approach configuration on part of the crew who landed at an excessive speed of 135 knots in marginal weather conditions. The following contributing factors were reported:
- The runway surface was wet,
- The braking action was poor,
- The crew failed to take corrective actions in time,
- Possible aquaplaning,
- The crew failed to use all available brake systems.

The accident was the consequence of the following factors:
- The loss of directional control by the pilot in command during the takeoff roll, and his decision to continue the takeoff and initiate a rotation below the computed rotation airspeed, resulting in a premature liftoff, further loss of control and collision with the terrain.
- The flightcrew's lack of understanding of the three-engine takeoff procedures, and their decision to modify those procedures.
- The failure of the company to ensure that the flightcrew had adequate experience, training, and rest to conduct the nonroutine flight. Contributing to the accident was the inadequacy of Federal Aviation Administration oversight of air transport international and federal aviation administration flight and duty time regulations that permitted a substantially reduced flightcrew rest period when conducting a non revenue ferry flight under 14 code of federal regulations part 91.

The impaired judgement, decision-making, and flying abilities of the captain and flight crew due to the effects of fatigue; the captain's failure to properly assess the conditions for landing and maintaining vigilant situational awareness of the airplane while manoeuvring onto final approach; his failure to prevent the loss of airspeed and avoid a stall while in the steep bank turn; and his failure to execute immediate action to recover from a stall. Additional factors contributing to the cause were the inadequacy of the flight and duty time regulations applied to 14 CFR, Part 121, Supplemental Air Carrier, international operations, and the circumstances that resulted in the extended flight/duty hours and fatigue of the flight crew members. Also contributing were the inadequate crew resource management training and the inadequate training and guidance by American International Airways, Inc., to the flight crew for operations at special airports such as Guantanamo Bay; and the Navy's failure to provide a system that would assure that local tower controller was aware of the inoperative strobe light so as to provide the flight crew with such information.

Loss of directional control upon landing for unknown reasons.

Failure of the nose gear due to the fracture of the upper cap of the nose gear shock strut which in turn led to the failure of the control arms of the down lock safety mechanism.

The failure of the flight crew to properly recognize or recover in a timely manner from the unusual aircraft attitude that resulted from the captain's apparent spatial disorientation, resulting from physiological factors and/or a failed attitude director.

The following findings were reported:
1. The organisational structure for the deployment team was ill-defined and fragmented.
2. Deployment maintenance personnel were not qualified or authorised to perform the function of releasing the aircraft as being fit to fly.
3. The release of the aircraft as being fit to fly was delegated to non-practising Aircraft Maintenance Engineers whose primary function was to operate the aircraft as flight crew members.
4. The aircraft was signed-off as fit for flight, in an unairworthy condition, by the operating flight engineer who had no involvement in the aircraft servicing.
5. The #2 and #4 tyre pressures were below the minimum for flight dispatch. Other tyres may also have been below minimum pressures.
6. Maintenance personnel were aware of the low tyre pressures but failed to rectify the faults.
7. The mechanic altered the only record of the actual low pressures, measured by the avionics specialist on 7 July, four days before the accident.
8. There was no evidence that the tyre pressures had been checked, using a tyre pressure gauge, after 7 July.
9. The lead mechanic was aware of the low tyre pressures.
10. The persons who were aware of the low pressures had insufficient knowledge of the hazards of operating at low tyre pressures.
11. The project manager was aware of a low tyre pressure but was not qualified to assess its importance.
12. The project manager was responsible for the aircraft schedule and directed that the aircraft depart without servicing the tyre.
13. The lead mechanic who was aware of the requirement for, and had requested nitrogen for tyre servicing, did not countermand the decision of the project manager.
14. There was no evidence to indicate that this flight crew were ever informed of the low tyre pressures.
15. The aircraft departed the ramp in an unairworthy condition.
16. During the taxi from the ramp to the runway, the transfer of the load from the under-inflated #2 tyre to #1 tyre on the same axle, resulted in over deflection, over-heating and structural weakening of the #1 tyre.
17. The #1 tyre failed very early on the take-off roll due to degeneration of the structure, caused by over-deflection.
18. The #2 tyre failed almost immediately after #1 due to over-deflection and rapid overheating when the load was transferred from the #1 tyre.
19. The #2 wheel stopped rotating for reasons not established. Friction between the wheel/brake assembly and the runway generated sufficient heat to raise the temperature of tyre remnants above that required for a tyre fire to be self-sustaining. Rubber remnants ignited during the take-off roll.
20. Numbers 1 and 2 wheels were severely damaged and at least one piece of #1 wheel rim struck the airframe, becoming embedded in the left flap.
21. The crew were aware of unusual symptoms early and throughout the takeoff roll; the captain continued the take-off.
22. The aircraft was not equipped with warning systems which would have provided the flight crew with adequate information on which to make a decision to reject the take-off after tyre(s) failure.
23. The captain did not receive sufficient cues to convince him that a rejected take-off was warranted.
24. The crew retracted the gear, consistent with company procedures, and burning rubber was brought into close proximity with hydraulic and electrical system components.
25. The evidence indicates that the wheel well fire involved tyres, hydraulic fluid, magnesium alloy and fuel. The fuel was probably introduced as a result of "burn through" of the centre fuel tank.
26. Fire within the wheel wells spread and intensified until the cabin floor was breached and control systems were disabled.
27. The fuel increased the intensity of the fire until, shortly before impact, airframe structural integrity was lost.
28. Tyre characteristics and performance are not adequately addressed during training and licensing of both flight crews and technical personnel.
29. The aircraft operator's tyre inflation pressures did not accurately reflect what was contained in the aircraft manufacturer's maintenance manual.
30. The operator's maintenance and operating documentation for the DC-8 does not contain adequate information for the proper maintenance and operation of aircraft tyres.