Loss of Pitch Control on Takeoff Emery Worldwide Airlines, Flight 17 McDonnell Douglas DC-8-71F

124 Pages·2003·1.29 MB·English

Loss of Pitch Control on Takeoff
Emery Worldwide Airlines, Flight 17
McDonnell Douglas DC-8-71F, N8079U
Rancho Cordova, California
February 16, 2000
Aircraft Accident Report
NTSB/AAR-03/02
PB2003-910402
Notation 7299A
National
Transportation
Safety Board
Washington, D.C.

Aircraft Accident Report
Loss of Pitch Control on Takeoff
Emery Worldwide Airlines, Flight 17
McDonnell Douglas DC-8-71F, N8079U
Rancho Cordova, California
February 16, 2000
ATION AL TRE PLUARIBUNS UNUSM PORTATIO
NTSB/AAR-03/02 NS AFETYBO AR DN
PB2003-910402 National Transportation Safety Board
Notation 7299A 490 L(cid:146)Enfant Plaza, S.W.
Adopted August 5, 2003 Washington, D.C. 20594
National Transportation Safety Board. 2003. Loss of Pitch Control on Takeoff, Emery
Worldwide Airlines, Flight 17, McDonnell Douglas DC-8-71F, N8079U, Rancho Cordova, California,
February 16, 2000. Aircraft Accident Report NTSB/AAR-03/02. Washington, D.C.
Abstract: This report explains the accident involving Emery Worldwide Airlines flight 17, a
McDonnell Douglas DC-8-71F, which crashed in an automobile salvage yard shortly after takeoff,
while attempting to return to Sacramento Mather Airport, Rancho Cordova, California, for an
emergency landing. Safety issues discussed in this report include DC-8 elevator position indicator
installation and usage, adequacy of DC-8 maintenance work cards (required inspection items),
and DC-8 elevator control tab design. Safety recommendations are addressed to the Federal
Aviation Administration.
The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,
pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board
Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study
transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board
makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and
statistical reviews.
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Public Inquiries Section, RE-51
490 L(cid:146)Enfant Plaza, S.W.
Washington, D.C. 20594
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purchase this publication, order report number PB2003-910402 from:
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The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports
related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.
iii Aircraft Accident Report
Contents
Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii
1.Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Injuries to Persons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.3 Damage to Aircraft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.4 Other Damage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.5 Personnel Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.5.1 The Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.5.2 The First Officer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.5.3 The Flight Engineer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.6 Airplane Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.6.1 Cargo Load Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.6.2 DC-8 Longitudinal Flight Control System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.6.3 Maintenance Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1.7 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
1.8 Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
1.9 Communications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
1.10 Airport Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
1.11 Flight Recorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
1.11.1 Cockpit Voice Recorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
1.11.2 Flight Data Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
1.12 Wreckage Recovery and Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
1.12.1 Longitudinal Flight Control Surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
1.13 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
1.13.1 Flight Crew Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
1.13.2 Cargo Handlers(cid:151)Postaccident Drug and Alcohol Testing. . . . . . . . . . . . . . . . . . . 41
1.14 Fire/Explosion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
1.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
1.16 Tests and Research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
1.16.1 DC-8 Elevator Flight Control Tests. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
1.16.2 Airplane Performance Studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
1.17 Operational and Management Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
1.17.1 Emery Worldwide Airlines, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
1.17.2 Tennessee Technical Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
1.17.3 FAA Oversight of Emery Worldwide Airlines(cid:146) Certificate. . . . . . . . . . . . . . . . . . . 59
1.18 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
1.18.1 Design and Certification of DC-8 Elevator System. . . . . . . . . . . . . . . . . . . . . . . . . 62
1.18.2 Party Submissions Regarding Contact/Possible Contact with the Bolt. . . . . . . . . . 63
Contents iv Aircraft Accident Report
2. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
2.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
2.2 The Accident Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
2.2.1 Disconnection of the Right Elevator Control Tab. . . . . . . . . . . . . . . . . . . . . . . . . . 66
2.3 Role of Aircraft Maintenance in the Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
2.4 Preflight Inspection and Flight Control/EPI Checks . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
2.4.1 Preflight Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
2.4.2 Elevator Checks/Use of the EPI Gauge. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
2.5 Elevator Design Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
2.5.1 Elevator Geared Tab Crank Arm Fractures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
2.6 Emery(cid:146)s DC-8 Maintenance Documents and Guidance. . . . . . . . . . . . . . . . . . . . . . . . . 73
2.6.1 Required Inspection Items. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
2.6.2 Emery(cid:146)s B-2 Inspection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
2.6.3 DC-8 MM Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
2.7 FDR-Related Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
2.8 Drug and Alcohol Testing of Ground Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
3.Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
3.1 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
3.2 Probable Cause. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
4.Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
5.Appendixes
A: Investigation and Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
B: Cockpit Voice Recorder Transcript . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
v AircraftAccidentReport
Figures
1. The airplane(cid:146)s ground track, with selected CVR comments, during the accident flight. . . . . . . . . . . . 7
2. A diagram of the elevator control tab installation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
3. A photograph of an EPI gauge similar to the gauge installed on the accident airplane . . . . . . . . . . . 14
4. EPI installation on the lower left side of the first officer(cid:146)s instrument panel
(shown by the yellow arrow), similar to that on the accident airplane. . . . . . . . . . . . . . . . . . . . . . . . 15
5. Photograph showing the elevator damper(cid:146)s location on the right elevator of a DC-8 . . . . . . . . . . . . 24
6. Elevator, pitch, and control column plots recorded by the accident airplane(cid:146)s FDR
during ground operations before the accident flight. The first 20 seconds of data
were recorded while the gust lock was engaged. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
7. Pitch attitude, control column position, and (corrected) elevator position FDR
data from the accident flight. About the first 20 seconds of data were recorded
while the gust lock was engaged. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
8. Pitch attitude, control column position, and (corrected) elevator position FDR
data for the previous takeoff from RNO. About the first 1 minute 20 seconds
of data were recorded while the gust lock was engaged. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
9. A photograph of the accident airplane(cid:146)s right elevator control tab crank
fitting. Note damage on forward face of control tab crank fitting lugs . . . . . . . . . . . . . . . . . . . . . . . 40
10. Photograph of the test airplane(cid:146)s right elevator control tab pushrod contacting
the crank fitting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
11. Photograph of the test airplane(cid:146)s disconnected right elevator control tab
pushrod centered between the lugs of the crank fitting with the control
tab rotated 3” to 4” in the TEU direction after the attachment bolt was removed. . . . . . . . . . . . . . . . 45
12. The control column position required for the left elevator control tab to
reach its TEU physical stop (for the recorded elevator position) and the
actual recorded control column position for the accident flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
13. Plots of the control column and corrected elevator position recorded
by the accident FDR during the accident takeoff roll and the previous takeoff roll (from RNO) . . . 50
vi AircraftAccidentReport
Abbreviations
AC advisory circular
AD airworthiness directive
ALPA Air Line Pilots Association
AND airplane nose down
ANU airplane nose up
AOM aircraft operating manual
ASB alert service bulletin
ASOS automated surface observation system
ATC air traffic control
ATP airline transport pilot
c.g. center of gravity
CAR Civil Aviation Regulations
CFR Code of Federal Regulations
CVR cockpit voice recorder
DAY James M. Cox Dayton International Airport
DFR digital flight recorder
EPI elevator position indicator
FAA Federal Aviation Administration
FAR Federal Aviation Regulations
FCD fleet campaign directive
FDR flight data recorder
FOB flight operations bulletin
FSB field service bulletins
FSDO flight standards district office
GPWS ground proximity warning system
Abbreviations vii AircraftAccidentReport
HBAW flight standards handbook bulletin for airworthiness
IFR instrument flight rules
IPC Illustrated Parts Catalog
MAC mean aerodynamic chord
MEL minimum equipment list
MHR Sacramento Mather Airport
MM maintenance manual
MPPM maintenance policies and procedures manual
msl mean sea level
NASIP National Aviation Safety Inspection Program
OHM overhaul manual
P/N part number
PMI principal maintenance inspector
POI principal operations inspector
PTC pitch trim compensator
RASIP Regional Aviation Safety Inspection Program
RNO Reno/Tahoe International Airport
S/N serial number
SB service bulletin
SDR service difficulty reports
STC supplemental type certificate
TED trailing edge down
TEU trailing edge up
TRACON terminal radar approach control
TTS Tennessee Technical Services
ULD unit loading device
viii AircraftAccidentReport
Executive Summary
On February 16, 2000, about 1951 Pacific standard time, Emery Worldwide
Airlines, Inc., (Emery) flight 17, a McDonnell Douglas DC-8-71F (DC-8), N8079U,
crashed in an automobile salvage yard shortly after takeoff, while attempting to return to
Sacramento Mather Airport (MHR), Rancho Cordova, California, for an emergency
landing. Emery flight 17 was operating under the provisions of 14 Code of Federal
Regulations (CFR) Part 121 as a scheduled cargo flight from MHR to James M. Cox
Dayton International Airport (DAY), Dayton, Ohio. The flight departed MHR about
1949, with two pilots and a flight engineer on board. The three flight crewmembers were
killed, and the airplane was destroyed. Night visual meteorological conditions prevailed
for the flight, which operated on an instrument flight rules flight plan.
The National Transportation Safety Board determined that the probable cause of
the accident was a loss of pitch control resulting from the disconnection of the right
elevator control tab. The disconnection was caused by the failure to properly secure and
inspect the attachment bolt.
The safety issues discussed in this report include DC-8 elevator position indicator
installation and usage, adequacy of DC-8 maintenance work cards (required inspection
items), and DC-8 elevator control tab design. Safety recommendations are addressed to
the Federal Aviation Administration.