Crash of a Douglas DC-9-32 in Banjarmasin

Date & Time: Jan 13, 1980
Type of aircraft:
Operator:
Registration:
PK-GND
Survivors:
Yes
Schedule:
Jakarta - Banjarmasin
MSN:
47463
YOM:
1971
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
121
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
For unknown reasons, the airplane christened 'Brantas' landed hard at Banjarmasin-Syamsudin Noor Airport. All 126 occupants escaped, six of them were slightly injured. The aircraft was written off.

Crash of a Douglas DC-9-32 near Sarroch: 31 killed

Date & Time: Sep 14, 1979 at 0047 LT
Type of aircraft:
Operator:
Registration:
I-ATJC
Survivors:
No
Site:
Schedule:
Alghero - Cagliari
MSN:
47667/776
YOM:
1975
Flight number:
BM012
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
27
Pax fatalities:
Other fatalities:
Total fatalities:
31
Aircraft flight hours:
10000
Circumstances:
The airplane departed Alghero Airport at 0010LT on a short schedule service (BM012) to Cagliari-Elmas Airport, carrying 27 passengers and a crew of four. While descending to Cagliari, the crew was informed that runway 14 was in use with thunderstorm activity and rain falls south of the airport. After contacting the Cagliari Tower controller at 0026LT, the flight was cleared to descend to the transition altitude of 6,000 feet. Having in front of them a consistent formation of Cumulonimbus clouds, the first officer radioed their intention to make a 360° turn to further lower the altitude and thus avoid the cloud formations. The controller, not having traffic in the area, authorized the manoeuvre, and first officer then announced the intention to leave at 7,500 feet for 3,000 feet. The controller then asked the flight if they had visual contact with the ground, but this was not the case. The clearance was amended to go down to 6,000 feet instead of 3,000 feet. At 0030LT the flight reported that it was in visual contact with the ground, and that it was about to leave 6,000 ft for 3,000 ft. The controller confirmed this, adding that it had started to rain at the airport in the meantime. The aircraft however did not complete the planned 360° turn, thus finding itself with a different heading from that initially planned. After reaching 3,000 feet, the flight was cleared for the approach. The first officer confirmed this and announced that they would start the final approach with a slight deviation to the right of the beacon. At 0034LT the first officer asked the controller to confirm that the ILS system was inoperative, which it was. At this stage of the flight the crew became unaware of their position. The captain believed he was flying over the sea, further south than the actual position of the aircraft, while the first officer rightly believed he was flying over the mountainous terrain of southern Sardinia. In the last minute and a half of the flight, the captain asked the first officer to lower the undercarriage and continued the descent. At an altitude of 2,000 feet (610 m) the DC-9 hit the rocky mountainside of Conca d'Oru with the lower part of the fuselage, causing the aircraft to break up. A fire erupted. The point of impact was 18 km south-west of the airport. All 31 occupants were killed.
Source: ASN
Probable cause:
The accident was the consequence of a controlled flight into terrain caused by a wrong approach configuration on part of the flying crew and a misinterpretation of ATC instructions.

Crash of a Douglas DC-9-14 in Dade-Collier

Date & Time: Feb 9, 1979 at 1712 LT
Type of aircraft:
Operator:
Registration:
N8910E
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Dade-Collier - Dade-Collier
MSN:
45771/58
YOM:
1966
Crew on board:
4
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12898
Captain / Total hours on type:
1959.00
Circumstances:
The airplane was dispatched at Dade-Collier Airport for a local training flight, carrying one instructor and four pilots under supervision. During the takeoff roll on runway 09/27, the pilot-in-command started the rotation when the instructor shut down the left engine to simulate an engine failure. The airplane rolled to the left, causing the left wing to struck the ground then nosed down and struck the runway surface. The nose gear was torn off and the aircraft nose and cockpit section was almost destroyed. All five occupants were injured, two of them seriously.
Probable cause:
Loss of control during initial climb due to improper operation of flight controls. The following contributing factors were reported:
- lack of familiarity with aircraft,
- Inadequate supervision of flight,
- Simulated conditions,
- First officer trainee upgrade training flight,
- Check captain adm simulated left engine failure at liftoff.
Final Report:

Crash of a Douglas DC-9-32 off Palermo: 108 killed

Date & Time: Dec 23, 1978 at 0039 LT
Type of aircraft:
Operator:
Registration:
I-DIKQ
Survivors:
Yes
Schedule:
Rome - Palermo
MSN:
47227
YOM:
1968
Flight number:
AZ4128
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
124
Pax fatalities:
Other fatalities:
Total fatalities:
108
Captain / Total hours on type:
418.00
Copilot / Total hours on type:
173
Circumstances:
Following an uneventful flight from Rome-Fiumicino, the crew started the descent to Palermo-Punta Raisi Airport by night and good visibility (up to 10 km). Following a 'normal' VOR/DME approach, the crew continued the descent down to 150 feet over the sea when, at 3 km from the shore, the pilot-in-command (the copilot in this case) initiated a slight turn to the left to join runway 21. At a speed of 150 knots, the left wing tip struck the water surface and the aircraft crashed into the sea. All five crew members and 103 passengers were killed while 21 others were rescued by fishermen.
Probable cause:
It was determined that the last portion of the approach was completed in visual mode with a relative low rate of descent. The approach was started prematurely and the crew descended below the minimum descent altitude after several points of the approach checklist have been missed. It is possible that the crew have been misled by the malfunction of one or more altimeters due to an erroneous indication of the warning flag. Douglas and Collins informed Alitalia in 1975 already about the possible malfunction of those altimeters and their respective warning flag systems.

Crash of a Douglas DC-9-32 in Toronto: 2 killed

Date & Time: Jun 26, 1978 at 0808 LT
Type of aircraft:
Operator:
Registration:
CF-TLV
Flight Phase:
Survivors:
Yes
Schedule:
Ottawa - Toronto - Winnipeg - Vancouver
MSN:
47197
YOM:
1968
Flight number:
AC189
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
102
Pax fatalities:
Other fatalities:
Total fatalities:
2
Aircraft flight hours:
25476
Circumstances:
During the takeoff roll on runway 23L, at a speed of 145 knots, the crew heard a thumping noise and felt vibrations. In a meantime, the right engine power dropped and a warning light coupled to the right main gear illuminated. The copilot informed the captain about the fact that the right main gear was unsafe. At a speed of 149 knots, the captain decided to abandon the takeoff procedure and initiated an emergency braking maneuver. He deployed the spoilers and activated the thrust reversers systems. The airplane was unable to stop within the 1,219 meters remaining, overran at a speed of 70 knots, rolled on a distance of 139 meters then went down a 15 meters high embankment and eventually came to rest, broken in three. Two passengers were killed while 55 others were injured and 50 unhurt.
Probable cause:
It was determined that the tire n°3 located on the right main gear burst during takeoff, probably due to wear. Few rubber debris damaged various elements of the main gear while other rubber debris were thrown into the right engine, causing it to lose power and the thrust reverser system to malfunction. The decision of the captain to abandon the takeoff procedure was correct but taken too late, more than four seconds after the warning light illuminated in the cockpit. A lack of crew training in emergency situations and a lack of increased monitoring of tire wear were considered as contributing factors. It was also determined that a period of 65,7 seconds elapsed between the brake release and the immobilization of the aircraft.

Crash of a Douglas DC-9-31 in New Hope: 72 killed

Date & Time: Apr 4, 1977 at 1619 LT
Type of aircraft:
Operator:
Registration:
N1335U
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Muscle Shoals - Huntsville - Atlanta
MSN:
47393
YOM:
1970
Flight number:
SO242
Crew on board:
4
Crew fatalities:
Pax on board:
81
Pax fatalities:
Other fatalities:
Total fatalities:
72
Captain / Total flying hours:
19380
Captain / Total hours on type:
3205.00
Copilot / Total flying hours:
3878
Copilot / Total hours on type:
235
Aircraft flight hours:
15405
Circumstances:
Southern Airways Flight 242, a DC-9-31, operated as a scheduled passenger flight from Muscle Shoals, Alabama, to Atlanta, Georgia, with an intermediate stop at Huntsville, Alabama. Flight 242 departed Muscle Shoals at 15:21 and landed at Huntsville about 15:44. About 15:54, Flight 242 departed Huntsville on an instrument flight rules (IFR) flight plan for the Hartsfield-Atlanta International Airport; there were 81 passengers and 4 crew members aboard. The flight's route was direct to the Rome VOR and then a Rome runway 26 profile descent to Atlanta. Its estimated time en route was 25 min and its requested en route altitude was 17,000 ft. At 15:56, the controller told Flight 242 that his radarscope was showing heavy precipitation and that the echos were about 5 nmi ahead of the flight. At 15:57:36, the controller said, "...you're in what appears to be about the heaviest part of it now, what are your flight conditions." Flight 242 replied, "...we're getting a little light turbulence and...I'd say moderate rain." At 15:57:47, the controller acknowledged Flight 242's report and told the flight to contact Memphis Center. The Memphis Center controller advised the flight that a SIGMET was current for the area. He then told Flight 242 to contact Atlanta Center. At 16:03:20, Flight 242 switched to another sector of Atlanta Center, established communications on the new frequency and reported being level at FL170. As the aircraft entered an area of rain, the flight crew began discussing the weather depicted on their radar. Based on information from the airborne radar, the captain initially decided that the storms just west of the Rome VOR were too severe to penetrate. Shortly after his initial assessment of the storm system, the captain decided to penetrate the storm area near the Rome VOR. At 16:06:41 Atlanta Center cleared Flight 242 to descend to and maintain 14,000 ft. Shortly afterwards the aircraft entered an area of heavy hail or rain, which continued for at least one minute. The ingestion of intense rain and hail into the engines caused the rotational speed of both engines to decrease below the engine-driven electrical generator operating speeds, and resulted in normal electrical power interruption for 36 seconds. The flight crew likely advanced one or both thrust levers, restoring its generator to operation and provide normal electrical power. After establishing contact with Atlanta Center again, the flight was told to maintain 15,000 ft. At 16:09:15, Flight 242 reported to Atlanta Center, "Okay...we just got our windshield busted and... we'll try to get it back up to 15, we're 14." After reported that the left engine had flamed out, the flight was cleared to descend to 13,000 ft. Meanwhile both engines' high-pressure compressors began to stall severely due to ingestion of massive quantities of water. The severe compressor stalls produced an overpressure surge which deflected the compressor blades forward in the sixth stage of the low-pressure compressors; these blades clashed against the fifth-stage stator vanes and broke pieces from the blades and vanes. Pieces of blades and stator vanes were then ingested into the high-pressure compressors and damaged them severely. Continued high thrust settings following the severe damage to the high-pressure compressors probably caused severe overheating in the turbine sections of both engines, and the engines ceased to function. Shortly before normal electrical power was again, the flight crew radioed that both engines had failed. Atlanta Center told the crew to contact approach control for vectors to Dobbins Air Force Base. Power was then lost for 2 min 4 sec until the APU-driven generator restored electrical power. After establishing contact with Atlanta Approach Control the flight was told they were 20 miles from Dobbins. As the flight was descending, the captain began to doubt their ability to reach Dobbins. Cartersville was closer at 15 miles, so the controller gave vectors for Cartersville. Unable to make it to Cartersville, the crew began looking for a clear field or highway for an emergency landing. At 16:18:02, Flight 242's last transmission to Approach Control was recorded: "... we're putting it on the highway, we're down to nothing." The aircraft's outboard left wing section first contacted two trees near State Spur Highway 92 south-southwest of the community of New Hope. About 0.8 miles farther north-northeast, the left wing again contacted a tree alongside the highway within the community of New Hope. The left and right wings continued to strike trees and utility poles on both sides of the highway, and 570 ft after striking the first tree in New Hope, the aircraft's left main gear contacted the highway to the left of the centerline. Almost simultaneously, the outer structure of the left wing struck an embankment, and the aircraft veered to the left and off the highway. The aircraft traveled another 1,260 ft before it came to rest. As it traveled, the aircraft struck road signs, utility poles, fences, trees, shrubs, gasoline pumps at a gas station-store, five automobiles, and a truck. Of the 85 persons aboard Flight 242, 62 were killed, 21 were seriously injured, and 1 was slightly injured. Additionally, eight persons on the ground were killed. Within a month of the accident, one of the surviving passengers and one person on the ground both died of their injuries.
Probable cause:
Total and unique loss of thrust from both engines while the aircraft was penetrating an area of severe thunderstorms. The loss of thrust was caused by the ingestion of massive amounts of water and hail which, in combination with thrust lever movement, induced severe stalling in and major damage to the engine compressors. Major contributing factors include the failure of the company's dispatching system to provide the flight crew with up-to-date severe weather information pertaining to the aircraft's intended route of flight, the captain's reliance on airborne weather radar for penetration of thunderstorm areas, and limitations in the FAA's ATC system which precluded the timely dissemination of real-time hazardous weather information to the flight crew.
Final Report:

Crash of a Douglas DC-9-14 in Denver

Date & Time: Nov 16, 1976 at 1729 LT
Type of aircraft:
Operator:
Registration:
N9104
Flight Phase:
Survivors:
Yes
Schedule:
Salt Lake City - Denver - Houston
MSN:
47081/155
YOM:
1967
Flight number:
TI987
Crew on board:
5
Crew fatalities:
Pax on board:
81
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15000
Captain / Total hours on type:
651.00
Copilot / Total flying hours:
8400
Copilot / Total hours on type:
4000
Aircraft flight hours:
24333
Circumstances:
On November 16, 1976, Texas International Flight 987, a McDonnell Douglas DC-9-14, N9104, operated as a scheduled passenger flight from Salt Lake City, Utah, to Houston, Texas, with an intermediate stop at Denver, Colorado. The flight was routine to Stapleton International Airport, Denver, Colorado. The flight left the gate at Stapleton International Airport with 81 passengers and 5 crew members aboard. When Flight 987 was cleared to taxi to runway 8R for takeoff, the weather was clear, the wind was from 130° at 7 kns, and the temperature was 40° F. At 1726:33, the tower cleared the flight to take the runway and to hold while two light: aircraft took off from a nearby intersection. At 1729:13, Flight 987 was cleared for takeoff, and at 1729: 15 the flight reported "rolling." The first officer was making the takeoff and, upon receipt of the clearance, he advanced the throttles to a position commanding 1.4 EPR and released the brakes. After the engines stabilized at 1.4 EPR, the first officer advanced the throttles to the takeoff thrust position. Upon reaching this position, he relinquished control of the throttles and placed his left hand on the control yoke. The captain guarded the throttles until rotation speed (VR) was reached. The pilots described the takeoff roll to rotation as "normal." The captain monitored the engine instruments and noted no abnormal readings. He said he called out 100 KIAS, 130 KIAS, V1, VR, V2; the cockpit voice recorder (CVR) readout corroborated his statement. The first officer stated that when the captain called VR, he checked his airspeed indicator before he moved his control column aft and saw 149 or 150 KIAS either at, or just before, he began to rotate the aircraft. He stated that he rotated the aircraft at a normal rate to a target pitch angle of 10° which he determined from his attitude indicator; he estimated that this took about 3 to 4 seconds. About halfway through the rotation--about a 5° pitch angle--the stall warning system's stickshaker activated. The first officer stated that once it began it was continuous. He said he continued the rotation to what he believed to be about 10° and the stickshaker continued to operate. He saw that although the airspeed was beyond 150 KIAS, the aircraft did not lift off. Since it had accelerated to a speed greater than V1, the first officer said that he tried to get it airborne. He could not recall how long he maintained the pitch angle, but he believed it was adequate to get the aircraft off the runway. When he concluded that the aircraft was not going to fly, he rejected the takeoff. The captain stated that rotation was normal and that as rotation was begun there were a couple of "clacks" from the stickshaker. As the rotation continued, the stickshaker began to operate continuously. He saw about 10° pitch angle on his attitude indicator and 152 KIAS on the airspeed indicator. All other instrument indications were normal. The stickshaker continued to operate and he believed that the aircraft would not lift off. At this point, with the airspeed well past V2, he decided to reject the takeoff. His actions to reject the takeoff were simultaneous with those of the first officer. When the first officer began to abort the takeoff, he reached over and, in what he described as one continuous motion, pulled the throttles to idle and applied full reverse thrust. Almost simultaneous with his initiation of the power reduction, he felt the captain's hand on top of his. He said that he had already started to apply forward pressure on the yoke to lower the nose. on his, he realized that the captain was assuming control of the aircraft and he removed his own hand from the thrust levers and placed it on the yoke. He described the lowering of the nosewheel to the runway as rapid, and once it was on the ground he pushed the yoke forward to hold the nosewheel there and applied brakes. The stickshaker had stopped, but neither pilot could recall exactly when. When he felt the captain's hand When the nose was lowered, full reverse thrust and maximum wheel braking were applied; however, the ground spoilers were not deployed. The captain estimated that there was 2,500 to 3,000 ft of runway remaining when the takeoff was rejected. He later noted that they were in the amber lighted area of the runway when the abort began. The first officer said that all he could see were the amber runway edge lights when the nose was lowered. The amber coded runway edge lights on 8R begin 2,000 feet from the eastern threshold of the runway. The captain stated that he steered the aircraft toward the right side of the runway to avoid the approach light stanchions for runway 26L. The aircraft left the runway, continued another 1,050 ft, traversed two drainage ditches, struck approach light stanchions, turned left, and stopped headed in a northerly direction. After the aircraft stopped, the captain ordered the first officer to proceed into the cabin and assist the flight attendants with the passenger evacuation. The captain then cleaned up the cockpit and carried out the emergency engine shutdown procedures. The engines were shut down, the fuel shutoff valves were closed, the engine fire handles were pulled, the fire extinguishing agent was discharged, and battery and ignition switches were turned off. All 86 occupants were evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
A malfunction of the stall warning system, for undetermined reasons, which resulted in a false stall warning and an unsuccessful attempt to reject the take-off after the aircraft had accelerated beyond refusal and rotation speed. The decision to reject the take-off although not consistent with standard operating procedures and training, was reasonable in this instant case, based upon the unusual circumstances in which the crew found themselves, the minimal time available for decision, and the crew's judgment concerning a potentially catastrophic situation.
Final Report:

Crash of a Douglas DC-9-32 in Vrbovec: 113 killed

Date & Time: Sep 10, 1976 at 1114 LT
Type of aircraft:
Operator:
Registration:
YU-AJR
Flight Phase:
Survivors:
No
Schedule:
Split - Cologne
MSN:
47649/741
YOM:
1974
Flight number:
JP550
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
108
Pax fatalities:
Other fatalities:
Total fatalities:
113
Captain / Total flying hours:
10157
Captain / Total hours on type:
3250.00
Copilot / Total flying hours:
2951
Copilot / Total hours on type:
1583
Aircraft flight hours:
1345
Aircraft flight cycles:
990
Circumstances:
Hawker Siddeley HS-121 Trident 3B operated by British Airways as flight BE476 and a McDonnell Douglas DC-9-32, operated by Inex-Adria Aviopromet, were destroyed when both aircraft crashed near Vrobec following a mid-air collision. All 176 on board both aircraft were killed. The Trident was on a scheduled flight from London-Heathrow Airport in England to Istanbul-Yesilköy Airport in Turkey, carrying 54 passengers and a crew of 9. The aircraft took off at 08:32 GMT and the flight proceeded normally. First contact with the Zagreb Area Control Centre was established on the Upper Sector frequency 134,45 MHz at 10:04 GMT. The flight was requested to report passing the Zagreb VOR at flight level 330. The aircraft flew along the centreline of airway UB5 with slight side deviation 1-2 km to the right due to wind. At 2 minutes and 50 seconds before the collision, the aircraft changed heading to 115° to head back towards the airway centreline. Airspeed was 295 Kts. The DC-9 departed Split Airport at 09:48 GMT to fly 108 West German tourists back to Cologne. Flight JP550 was issued instructions to climb to FL180. At 09:54 the flight, on passing flight level 130, switched to the Zagreb Area Control Centre lower sector east frequency of 124.6 MHz, receiving clearance to climb to FL240 and later to FL260. At 10:03 the crew switched to the frequency of the middle sector controller, responsible for safety and regulation of traffic between flight levels 250 and 310. This controller cleared to flight to FL350. The aircraft assumed a heading of 353° and a speed of 273 Kts as it passed a beam and to the west of the KOS NDB, approximately 2-3 km from the airway centreline. While heading towards the Zagreb VOR, the flight crew radioed the Upper Sector controller on frequency 134,45 MHz at 10:14:04 GMT and reported that they were climbing through FL325. The controller then requested, in Serbo-Croatian, flight JP550 to maintain their present altitude and report passing the Zagreb VOR. The controller stated that an aircraft was in front passing from left to right at FL335, while in fact BE476 was at FL330. At 10:14:38 the crew replied, also in Serbo-Croatian, that they where maintaining FL330. Three seconds later both aircraft collided. The outer five meters of the DC-9's left wing cut through the Trident's cockpit. Due to the sudden decompression, the forward part of the Trident's fuselage disintegrated. The remaining part of the fuselage struck the ground tail-first. With it's left wing torn off, the DC-9 tumbled down and hit the ground right-wing first.
Probable cause:
Direct cause of the accident was the struck of the DC-9 wing into the middle side of the Trident 3B fuselage which occurred at the height of 33.000 feet above Zagreb VOR so that both aircraft became uncontrollable and fell on the ground.
- Improper ATC operation,
- Non-compliance with regulations on continuous listening to the appropriate radio frequency of ATC,
- Non-performance of look-out duty from the cockpits of either aircraft.
Final Report:

Crash of a Douglas DC-9-15 in León

Date & Time: Sep 2, 1976 at 0730 LT
Type of aircraft:
Operator:
Registration:
XA-SOF
Survivors:
Yes
Schedule:
Mexico City - León
MSN:
47124/254
YOM:
1968
Flight number:
AM152
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at León-Guanajuato del Bajio Airport, the airplane was unable to stop within the remaining distance, overran and came to rest. All 24 occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Douglas DC-9-31 in Philadelphia

Date & Time: Jun 23, 1976 at 1712 LT
Type of aircraft:
Operator:
Registration:
N994VJ
Survivors:
Yes
Schedule:
Providence – Windsor Locks – Philadelphia – Nashville – Memphis
MSN:
47333/481
YOM:
1969
Flight number:
AL121
Crew on board:
4
Crew fatalities:
Pax on board:
102
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
25000
Captain / Total hours on type:
6000.00
Copilot / Total flying hours:
11000
Copilot / Total hours on type:
6000
Aircraft flight hours:
21320
Circumstances:
Allegheny Airlines Flight 121, a Douglas DC-9-31, suffered a landing accident on the Philadelphia International Airport, Pennsylvania. Of the 106 persons onboard, 86 persons were injured; there were no fatalities. The captain of Flight 121 had conducted an instrument approach to runway 27R in visual conditions as a thunderstorm passed over the airport in a north-northeasterly direction. When near the threshold the captain initiated a go-around from a low altitude and entered rain of increasing intensity. Shortly thereafter the aircraft was seen descending in a nose-up attitude with the landing gear retracted. After striking tail first on a taxiway about 4,000 feet beyond the threshold of runway 27, the aircraft slid about 2,000 feet and stopped. The wreckage came to rest about 6,000 feet beyond the threshold and about 350 feet to the right of the centerline of runway 27R.
Probable cause:
The aircraft's encounter with severe horizontal and vertical wind shears near the ground as a result of the captain's continued approach into a clearly marginal severe weather condition. The aircraft's ability to cope under these conditions was borderline when flown according to standard operating procedures; however, if the aircraft's full aerodynamic and power capability had been used, the wind shear could probably have been flown through successfully. Contributing to the accident was the tower controller's failure to provide timely below-minimum RVR information.
Final Report: