United States of America

The pilot was cleared for a localizer approach by Atlanta Center and told to maintain 5,000 feet until crossing the final approach fix (FAF). Normal altitude at the FAF was 2,700 feet. The pilot was unable to land from this approach and performed a missed approach. He was handed off to Chattanooga Approach, then was cleared to cross the FAF at 3,000 feet and perform another localizer approach. About one mile from the FAF, the pilot was told to change to the airport advisory frequency. The pilot acknowledged, then there was no further communication with the aircraft. A short time later, witnesses heard the aircraft crash near the approach end of the runway. Examination of the crash site showed the aircraft had touched down in a grass area about 1,100 feet from the end of the runway, while on the localizer. Propeller slash marks showed both engines were operating at approach power and the aircraft was at approach speed. No evidence of precrash mechanical failure or malfunction of the aircraft structure, flight controls, systems, engines, or propellers was found. The 0621 weather was in part: 300 feet overcast and 1/2 mile visibility with fog. Minimum descent altitude (MDA) for the localizer approach was 1,180 feet msl; airport elevation was 710 feet. The pilot had flown 8 flight hours, was on duty for 13.6 hours the day before the accident, was off duty for about 6 hrs, and had about 4 hours of sleep before the accident flight.

The Beech 1900C cargo aircraft was loaded with more than 4,962 pounds of cargo during an approximate 20 minute period. No scale was available at the aircraft, forcing loaders to rely on tallying either waybill weights or estimates of total cargo weight and center of gravity (CG) during the brief loading period. Additionally, a strike had shut down a major cargo competitor at the time with substantial cargo overflow to the operator. Post-crash examination determined the cargo load was 656 pounds greater than that documented on the pilot's load manifest, and the CG was between 6.8 and 11.3 inches aft of the aft limit. The airplane behaved normally, according to the pilot, until he initiated full flaps for landing approaching the threshold of runway 34L at the Seattle-Tacoma International airport. At this time, the aircraft's airspeed began to decay rapidly and a high sink rate developed as the aircraft entered into a stall/mush condition. The aircraft then landed hard, overloading the nose and left-main landing gear which collapsed. A post-impact fuel system leak during the ground slide led to a post-crash fire.

The flight was part of a pre-buy inspection of the airplane. Witnesses reported the airplane did not climb more than 200 feet above ground level (agl) after takeoff. The airplane entered a shallow left turn and completed about 210 degrees of heading change before it impacted a flat field near the approach end of runway 26. Witnesses reported that the landing gear were retracted and that the engines sounded like they running at high power, but the airplane did not accelerate or climb normally. The airspeed was slow and 'mushy.' The engines' gas generator sections exhibited strong rotational scoring. The engines' power sections exhibited light rotational signatures. The left and right propellers exhibited minimal leading edge damage. Both propellers exhibited high blade angles. The secondary low pitch stops (SLPS) had been installed on the aircraft four days prior to the accident. A ground check, but no flight check, had been conducted. The SLPS sensors were found in the full aft position on the mounting bracket, not in the normal mid-range position. The SLPS control box installed on the aircraft was an updated box and was incompatible with the existing wiring.

Fine Air Flight 101 was originally scheduled to depart Miami for Santo Domingo at 09:15 using another DC-8 airplane, N30UA, to carry cargo for Aeromar. Due to a delay of the inbound aircraft, Fine Air substituted N27UA for N30UA and rescheduled the departure for 12:00. N27UA arrived at Miami at 09:31 from San Juan, Puerto Rico, and was parked at the Fine Air hangar ramp. The security guard was not aware of the airplane change, and he instructed Aeromar loaders to load the airplane in accordance with the weight distribution form he possessed for N30UA. The first cargo pallet for flight 101 was loaded onto N27UA at 10:30 and the last pallet was loaded at 12:06. The resulting center of gravity (CG) of the accident airplane was near or even aft of the airplane’s aft CG limit. After the three crew members and the security guard had boarded the plane, the cabin door `was closed at 12:22. Eleven minutes later the flight obtained taxi clearance for runway 27R. The Miami tower controller cleared flight 101 for takeoff at 12:34. Takeoff power was selected and the DC-8 moved down the runway. The flightcrew performed an elevator check at 80 knots. Fourteen seconds later the sound of a thump was heard. Just after calling V1 a second thump was heard. Two seconds later the airplane rotated. Immediately after takeoff the airplane pitched nose-up and entered a stall. The DC-8 recovered briefly from the stall, and stalled again. The airplane impacted terrain in a tail first, right wing down attitude. it slid west across a road (72nd Avenue) and into the International Airport Center at 28th Street and burst into flames. Investigation showed that the center of gravity resulted in the airplane’s trim being mis-set by at least 1.5 units airplane nose up, which presented the flightcrew with a pitch control problem on takeoff.

After touching down to scoop another load of water, the pilot added power and the aircraft pitched forward. The pilot heard a pop and felt a sudden decelerative force. When the nose began to bowsuck, he applied more back pressure but the aircraft did not respond. The floor split open and water began rushing into the cockpit. The left nose gear door locking pin was found separated from its hydraulic actuator. It displayed a bend that corresponded to its retracted position in the pin guide. The deformation prevented investigators from reinserting the damaged pin back through the guide. The left mycarta block remained attached to the door and did not exhibit any damage.

The aircraft crashed while landing on runway 22R at Newark International Airport (EWR), Newark, New Jersey. The regularly scheduled cargo flight originated in Singapore on July 30 with intermediate stops in Penang, Malaysia; Taipei, Taiwan; and Anchorage, Alaska. The flight from Anchorage International Airport (ANC), Anchorage, Alaska, to EWR was conducted on an instrument flight rules flight plan and operated under provisions of 14 Code of Federal Regulations (CFR) Part 121. On board were the captain and first officer, who had taken over the flight in Anchorage for the final leg to EWR, one jumpseat passenger, and two cabin passengers. All five occupants received minor injuries in the crash and during subsequent egress through a cockpit window. The airplane was destroyed by impact and a post crash fire. According to flight plan and release documents, the airplane was dispatched to ANC with the No. 1 (left engine) thrust reverser inoperative. The flight plan time from ANC to EWR was 5 hours and 51 minutes—47 minutes shorter than the scheduled time of 6 hours and 38 minutes because of 45-knot tailwinds en route. The flight crew stated that at flight level (FL) 330 (about 33,000 feet mean sea level [msl]), the flight from ANC to EWR was routine and uneventful. At 0102:11, a Federal Aviation Administration (FAA) Boston Air Route Traffic Control Center air traffic controller instructed flight 14 to descend and maintain FL180, according to the airplane’s cockpit voice recorder (CVR). About 0103, the captain and first officer discussed the approach and landing to runway 22R and the airplane’s landing performance. Using the airport performance laptop computer (APLC), the first officer determined that the airplane’s runway stopping distance would be approximately 6,080 feet using medium (MED) autobrakes. According to the CVR, at 0103:33, the flight crew then compared the APLC approximate landing distance for MED braking (6,080 feet) to the after-glideslope touchdown distance (6,860 feet) provided on the instrument approach plate. Based on the flight crew's calculation (6,860 – 6,080), MED braking provided a 780-foot margin after stopping. The flight crew then compared the APLC approximate landing distance for maximum (MAX) braking (5,030 feet) to the same 6,860-foot after-glideslope touchdown distance provided on the instrument approach plate. Based on the flight crew's calculation (6,860 – 5,030), MAX braking provided a 1,830-foot margin after stopping. On the basis of these calculations, the first officer suggested using MAX autobrakes. The captain agreed, stating “we got a lot of stuff going against us here so we’ll…start with max.” The first officer added, “I mean…I mean if we don’t have the reverser.” At 0114:22, the captain asked the first officer to advise the passengers that “we’re gonna have a pretty abrupt stop because of those brakes and the thrust reversers and all that stuff.” Twice during the approach, the captain asked the first officer to remind him to only use the No. 2 and No. 3 thrust reversers. At 0116:16, the captain noted that the left landing light was inoperative, adding “… just the right’s working.” The EWR tower controller cleared flight 14 to land at 0129:45 and advised the flight crew “winds two five zero at five.” At 0130:02, the first officer stated “max brakes” during the before-landing checklist. The captain replied “max brakes will be fine,” and the first officer responded “if they work.” At 0130:34, the captain stated “[landing gear] down in four green” and called for “flaps fifty.” At 0130:45, the captain disengaged the autopilot at an altitude of 1,200 feet during the approach and “hand flew” the airplane to touchdown. The autothrottles were engaged, as recommended by McDonnell Douglas and FedEx procedures. According to information from the airplane’s flight data recorder (FDR), the approach was flown on the glideslope and localizer until touchdown, and the airplane’s approach airspeed was about 158 knots until the flare. According to the CVR, the pilots had selected an approach reference speed of 157 knots, or Vref plus 5 knots. Altitude callouts were made by the on board central aural warning system (CAWS) at 1,000 feet and 500 feet, and the first officer called out minimums (211 feet) at 0132:03. At 0132:09, the first officer stated “brakes on max,” and CAWS callouts followed for 100, 50, 40, 30, 20, and 10 feet until the sound of initial touchdown at 0132:18.75. One-half second later, the CVR recorded an expletive by the captain. At 0132:20.26, the CVR recorded increasing high-frequency tones consistent with engine spool-up (accelerating engine rpms), and at 0132:21.06, the CVR recorded a decrease in high-frequency tones consistent with engine spool-down. The sound of a “loud thump” consistent with another touchdown was recorded at 0132:21.62. A series of expletives by the captain and first officer followed until sounds of “metallic breakup” were recorded at 0132:27. FDR data indicated that after the airplane’s initial touchdown, it became airborne and rolled to the right as it touched down again (see section 1.1.1 for a detailed description of the airplane’s performance during the landing sequence). The airplane continued to roll as it slid down the runway, coming to rest inverted about 5,126 feet beyond the runway threshold and about 580 feet to the right of the runway centerline. The accident occurred during the hours of darkness. Visual meteorological conditions prevailed at the time of the accident.

The pilot and passengers departed the Spirit of St. Louis Airport and flew to Springfield Regional Airport, a 50 to 60 minute flight. The fuel on board was about 25 to 30 gallons in the left wing tanks, and 75 to 80 gallons in the right wing tanks. Each engine burned about 25 to 30 gallons per hour. The airplane was not fueled prior to the return flight. About five minutes after takeoff, the airplane had reached 4,300 feet msl (3,033 feet agl) and began a 402 fpm descent. The airplane continued the descent away from the airport for about 7 nm before turning 180 degrees to the left. The airplane had descended to 2,200 feet msl (933 feet agl) and was 10 miles from the airport. The pilot reported to the controller that he had a '...partial engine failure on the left side.' The airplane impacted the ground in an inverted, vertical nose down attitude. The landing gear were down at impact. Neither propeller was feathered. The right wing, right engine, fuselage, and empennage received extensive fire damage. The left wing was consumed by fire between the nacelle and the wing root. The remaining left wing, left nacelle, and engine were not destroyed by fire. Examination of the engines and airframe did not reveal any pre-existing anomalies that prevented normal operation. The Airplane Flight Manual did not contain procedures which explained fuel cross feeding procedures in case of fuel exhaustion to a wing's fuel tanks.

Witnesses near the airport saw the flight approach on a left base to runway 4, touchdown on the runway, and takeoff again. One witness, a pilot, said the airplane turned onto final to the 'south' (right) of the runway centerline.' The airplane made a 'sharp' turn to the left to realign with the runway center, slightly overshot the runway to the left, turned to the right 'sharply,' and touched down on the runway. The witness further stated, '...by the time the pilot was on the runway he had wasted approximately 1,200 to 1,500 feet of runway 4, they hit reverse thrusters [sic] and were on full bore till they crossed runway 27 and 9.' The witness saw heat come out of both engine thrust reversers, the nose gear touched down and then came up again. He then saw the airplane come off the ground about 30 to 40 feet, wobble left and right at a 'slow airspeed,' crossover a highway at a low altitude, right wing low, strike some wires, go into a field, and catch fire. The pilot said, when he touched down on the runway, the airplane seemed to 'lurch' to the side. He said at this point his airspeed was 126 knots. He elected to abort the landing, and applied full power. He said the engines would not develop thrust and he elected to land in a field less than 1/4 mile in front of him. Examination of the left thrust reverser revealed that the translator was in the deployed position, with the blocker doors fully open. Both the left and right pneumatic latches were found in the unlocked position. Examination of the right thrust reverser revealed that the translator was in the deployed position, with the blocker doors fully closed. The left pneumatic latch was found in the locked position. The right pneumatic latch was found in the unlocked position. The inboard sequence latches were found about 2 inches forward of full aft travel. The thrust reverser switch was found in the 'NORMAL' position. According to Gates Lear Jet Airworthiness Directive (AD) 79-08-01, '...to preclude inadvertent thrust reverser deployment and possible loss of aircraft control....,' the following limitations apply to all gates Lear Jet Model 35, 36, 35A, 36A, aircraft equipped with Aeronca Thrust reversers. According to the AD, Section I-LIMITATION; '....Thrust Reversers must not be operated prior to takeoff...Thrust Reversers must not be used for touch and go landings...After Thrust Reversers have been deployed, a visual check of proper door stowing must be made prior to takeoff...Operational Procedures in this Thrust Reverser Supplement are mandatory.' According to Lear Jet and FlightSafety International, the procedures that are taught to Lear Jet pilots in the use of thrust reverse and spoilers during landings are; '...pilots [are] to use thrust reverse only on full stop Lear Jet landings. Pilot are trained not to deploy spoilers or thrust reverse during touch and go's or during balked landings.' The pilot-in-command of N19LH at the time of the accident, told the NTSB investigator-in-charge (IIC) that he was 'aware' of the limitations on the Aeronca Thrust Reverser and he knew that once the Thrust Reverser was deployed that he was 'committed' to land. The pilot told the IIC that he knew of the limitations and that he was committed to land.

The pilot boarded the 4 passengers and cargo (unsecured) for a chartered flight to a fishing lodge. The floatplane departed uneventfully. About 45 min. later, while cruising about 1,700 feet above rugged terrain and a river, the engine began to lose power and the floatplane descended. The pilot attempted a forced landing in a small lake that was 1,200 ft. in length and located about 1 mile west of the river. During the approach to landing, the airplane stalled and impacted swampy terrain at the lake's edge in a steep nose down attitude. An examination of the wreckage revealed that the no.1 engine exhaust pushrod had failed in fatigue just below the top (valve) ball end. Examination of the pushrod revealed that material had been pushed away from the rod during installation of the ball end. The fatigue crack may have initiated from a score mark produced by the installation. Pushrod life is reduced due to surface scratches. The life of the failed pushrod could not be determined. Insufficient information exists in the overhaul manual regarding pushrod life/inspection.

On approach to White Plains-Westchester County Airport, the crew noted a left main gear unsafe light. The gear was recycled and the crew agreed with ATC to perform a low pass to check the gear. Few minutes later, upon landing, the left main gear collapsed. All four occupants escaped uninjured while the aircraft was damaged beyond repair.