~ ~~~~~~

N A T

I 0 N

L

T R A N S P

A AIRCRAFT i

lune 22, 1971

McDONNELL DOUGLAS E-9-31, N982NE NORTHEAST AIRLINES, INC.

MARTHA'S VINEYARD, MAssAcwsms JUNE 22, 1971

TABLE OF CONTENTS

Page

Synopsis . . . . . . . . . . . . . . . . . . . 1

Investigation . . . . . . . . . . . . . . . . . 3

Analysis and Findings . . . . . . . . . . . . . 7

Probable Cause . . . . . . . . . . . . . . . . 7

Recommendations . . . . . . . . . . . . . . . . 8

Appendices . . . . . . . . . . . . . . . . Appendix A - Investigation and Hearing

Appendix B - Crew Information

Appendix C - Aircraf t History

Appendix D - Safety Recommendation

iii

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NATIONAL TRANSPORTAT.lON SAFETY BOARD O f f i c e o f General Manager

Washington, D. C. 20591 Acc iden t I n q u i r i e s 8 Records S e c t i o n

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F i l e No. 4-0001

NATIONAL TRANSPORTATION SAFETY BOARD Washington, D. C. 20591

AIRCRAFT INCIDENT REPORT

Adopted: December 29, 191

McDONNELL DOUGUS X-9-31> N982NE NORTHECLST AIRLINES I N C .

MARTHA'S VDihVlRE , MASSACHUSETTS JUNE 22, 1971

I SYNOPSIS

I I c N982Wt, was a regularly scheduled passenger f l i g h t operating from ! .. John F. Kennedy Internat ional Airport, New York, t o Martha's Vineyard, I ':." ;Massachusetts, with an intermediate stop i n New Bedford, Massachusetts.

he f l i g h t from New York t o New Bedford was without reported incident. l igh t 938 departed from New Bedford at 0822 eastern daylight time and

- Northeast Air l ines , Inc. , Flight 938, a McDonnell Douglas, E-9-31,

~

1 " ; r proceeded d i r ec t t o Martha's Vineyard. While on a VOR final approach t o / the a i rport , i n instrument f l i g h t conditions, the a i r c r a f t struck the water, received minor damage but remained airborne. The incident occurred

Vineyard. The captain then flew the a i r c r a f t t o Logan Internat ional a t 0830 e.d.t. approximately 3 miles from the end of Runway 24 a t Martha's

Airport at Boston, Massachusetts, where he made a normal landing. None of the f ive crewmembers and three passengers were injured.

I

1 ! -7

I the a l t i t ude during the performance of a nonprecision instrument approach, I

i

I

i I r The National Transportation Safety Board determines that the probable cause of this incident was the lack of crew coordination i n monitoring

the misreading of the a l t imeter by the captain, and a lack of a l t i t u d e 1 ' awareness on the par t of both p i lo t s . I /

l .- investigation of similar accidents and incidents. O u r most recent corre- The Board has previously made several recommendations following the

'',\ spondence t o the Administrator, Federal Aviation Administration, i s attached as Appendix D.

The Board noted during t h i s investigation that N982NE was not equipped with a radio o r radar alt imeter.

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Therefore t he Board recommends that:

1. The Administrator require a l l air ca r r i e r a i r c r a f t t o be

t o barometric alt imeters equipped with a ground proximity warning device, i n addition

2. The Administrator es tab l i sh appropriate operating procedures for such equipment.

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INVESTIGATION

Northeast Airl ines Inc.. FlJ&hL,938,a McDonnell Douglas E-9-31, N982NE was a scheduled domestic passenger flight from J a ~ 7 T E E u & y International Airport, New York, t o Martha's Vineyard, Mass,achusests, w i L . n intermediate s top i n New Bedford, Mass,agh@et.ts. ...

~~~~

Flight 938 departed from New Bedford a t 0822 e.d.t. 1./ on an i n s t m e n t f l i g h t rules clearance ~ c t _ t a - t G i h ! s vi-ney%rd VOR a t 3,000 f e e t m.s.1. 9 Approximately 2 minutes after takeoff, t-

and t o des.cend- t o 1,700 f ee t . This was a radar vector f o r a s t ra igh t- in f l i g h t was advised by Otis Approach Control t o tu rn t o a heading of 110"

VOR approach

~. . ..~ .- . .

_..-- - .~ ~ .~ .. ~. . 24. .. .

def in i te ce i l ing 300 fee t ; sky obscured; v i s i b i l i t y 1 mile and fog; O ~ a ~ 5 - i C i o t s ; ~ and the Otis a l t imeter 29.81. The control ler then lnstructed FTl'ght 938 t o t u rn r igh t t o 140" and then k t h e r right t o

% 240". Fl ight 938 was then advised that it was 8 miles northeast of the VOR. The control ler again inst ructed the f l i g h t t o tu rn right t o a head- ing of 240" and cleared it,-for. .& .VOR .approach t o the Martha'-s-V.neyard A.*rport

T h e wea-r given by the control ler f o r Martha's Vineyard was: in- ~~

.

-_

and the before-landing checklists were completed. The captain and first The captain called &..b-d-i.ng~ gear down and f laps 25": The descent

officer each cross-checked both altimeters and both instruments indicated the same a l t i tude .

--- ~ ~~. .

The captain checked the r a t e of descent as the a i r c r a f t was leaving

windshield. shor t ly after this time and saw water d i r ec t ly below. He 1,100 fee t and intended t o l eve l off a t 540 f ee t . He looked out the

immediately applied full power and rotated the airplane t o a climbing at t i tude; however, the a i rc ra f t continued t o descend until it struck the water.

during o w approach," and " -. . I may have misread my altimeter." The captain then advised the passengers: "We have struck the water

the water'the a l t imeter indicated 900 fee t and the a i r c r a f t was climbing. The first efficer. estimated that 40 seconds a f t e r t he afrcraft s t ruck

The .&&r&J.q&~fi.o~' t o Bpkon: with the landing ge$'~extended and landed S t h o u t fur ther incident.

~. ~~ i - -- . ..

A l l times herein a r e eastern daylight, based on the 2bhour clock.

Very high frequency omnidirectional radio range.

A l l a l t i tudes expressed i n feet , mean sea level , unless otherwise indicated.

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i

ing a l t i t udes be cal led out during nonprecision instnrment approaches: Northeast Air l ines Fl ight Operations Manual required that the follow-

\ 1. "1,000 f ee t above MDA." \

2. "500 f ee t above MDA"; "100 f ee t above KDA''; and "50 fee t above MDA . "

3 Callout, "Minimum a l t i t ude ." During the approach, the first o f f i ce r .~d id not @e .these required

ca l l s . A t t he time the calls ;-h==<e been made, he was tm>in t h e low frequency radL.g.beacpn and, on the captain's~.iastruc~ons.. , .at temp%~g t o c m ~ ~ € ~ ! & - ~ o m m ~ -on_the..ra!iiLto...obtain the-. laksLweather report f r& .. .. Martha's Vi-rd .

. ... .~

. .., ~~.~ -

', The Jeppesen Approach C h a r t used by the captain for the Martha's ' Vineyard apprmch was dated February 26, 1971. The landing minima on

and a minimum descent a l t i t u d e of 540 feet when the radio beacon was t h i s VOR approach t o Runway 24 were three-quarters of a mile v i s i b i l i t y

inoperative and 460 f e e t when the beacon was operating. The beacon was operating during this approach and the MDA of 460 feet applied.

Both the flight data recorder (FDR) and the cockpit voice recorder (CVR) tapes were examined i n the Board's Washington office.

The FDR data was plotted, and the graph shared an elapsed time of 9 minutes 48 seconds from takeoff a t New Bedford t o impact with the water. One minute 26 seconds a f t e r the a l t i t ude t r ace indicated a departure

minute, t he t r ace moved rapidly f r o m plus I25 feet t o minus 250 f ee t . from 1,570 f e e t with a rate of descent of approximately 1,090 feet per

A t t he beginning of this descent, t he heading was 174" magnetic. The t r ace showed a r e l a t i ve ly continuous r igh t t u rn until the a i r c r a f t s t ruck the water on a heading of 272'. The indicated airspeed a t the start of the descent was 135 knots, and it increased t o 157 knots at impact, a t which point, a l l f o u r traces: acceleration; airspeed; heading; and a l t i t u d e shared sudden large deviations f o r a period of about 7 seconds. The acceleration t race shared addit ional a c t i v i t y f o r another 5 seconds.

spool and no information was available regarding this incident. The Microdot CVR tape was found broken and wound around the takeup

The cowling of the lower segment of both engines was buckled, wrinkled, and torn, with a sect ion of cowl skin and frame missing. The lower half of the No. 1 engine thrust reverser was pushed aft , and the

41 Minimum descent a l t i t ude .

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i skin fa i r ing was to rn and missing. The lower half of the No. 2 engine thrust reverser was torn, buckled, and wrinkled.

The a i r c r a f t was cer t i f ica ted and registered as required by Federal regulations. (For de t a i l s see Appendix C. ) The a i rc ra f t records disclosed no maintenance discrepancies which could be re la ted t o this incident.

materials were found i n the system and no air leaks were detected. The P i to t s t a t i c system was tes ted. No water or other foreign

Bzth altimeters w e r e t es ted i n t he a i rcraf t with the s t a t i c system in tac t .>fi€he ~ captain 's a l t imeter was- checked without an air data

error of 50 f e e t was recorded. The al t imeter was then removed and tes ted 4 computer correction and with t he instrument vibrator "off," a f r i c t i o n

i n an overhaul f a c i l i t y . It was reported t o be operating within the estab- lished accuracy limits.

The copi lot ' s a l t imeter i s not connected t o the air data computer s o it was tes ted with t he instrument vibrator "off" and a f r i c t i o n e r ro r of 50 fee t was recorded. DtIring the examination of this al t imeter at the overhaul f a c i l i t y , a barometric s e t t i n g e r ro r of 20 f e e t was found. T h i s

tude 20 f ee t lower than the a i r c r a f t ' s ac tua l a l t i t ude . error would have resul ted i n the a l t imeter displaying an indicated a l t i -

The air.cra-fi_EJas.mt-.equi- . either.radio~~altimeters or an a.ltitude' a l e r t i ng system. ~. ~.. .~ -~

The air data computer had an e r ro r of 30 fee t i n the a l t i t ude reference

the ac tua l a l t i t ude of the a i r c r a f t . The computer was approximately 15 fee t synchro. Th i s e r ro r a l s o would have caused the a l t imeter t o read lower than

out of tolerance at 1,000 fee t , bu t a l l other outputs were normal.

I Both p i lo t s were properly cer t i f ica ted and had met the requirements of 1 the Federal and company regulations t o perform t h e i r duties. (See Appendix B e )

physical examination on June 20, 1971. The findings of this examination were the same as his previous examination dated December 24, 1970. The near-vision portion of the most recent examination disclosed that his:

The captain received a f i r s t- c l a s s medical ce r t i f i ca t e after taking a

r i gh t eye tes ted t o 20/60 corrected t o 20/20 with corrective lenses ;

l e f t eye tes ted t o 20/60 corrected t o 20/20; and

both eyes tes ted t o 20/60 corrected t o 20/20.

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lenses f o r near vis ion while he was flying; however, he was n e L u i r e d t o wear them. He had his glasses i n his possession, but he was not wearing them during the flight.

The captain 's medical c e r t i f i c a t e required that he possess corrective

for near vision. The findings of this t e s t ( a t 30 inches) were as follows: A t t h e Board's request the captain was reexamined on November 8, 1971,

Right Eye 20/60 corrected t o 20/30

Left Eye 20/60 corrected t o 20/30

Both Eyes 20/60 corrected t o 20/30

I n response t o t he Board's request, the captain submitted a statement regarding the l igh t ing conditions during the accident f l i gh t . I n par t he s ta ted:

fi;". "Just p r ior t o executing the approach while cruising a t 3000' and on a heading of llOo,,,_we were f ly ing

existed u n t i l we entered the over cast during the descent phase of t he approach. After entering the o v e r b b . a d d . es.t~tuat.e. that. t K e Z e X s B @ . ' '

s m . . i ~ a very bri,ght.'~+ze approxi- .. -~ ~ .. ._ , .

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j r e @ & L m . . i n n u t s ~ l i g h t . .. . "During the e n t i r e approach the florescent l i gh t s under the glare shield were a l l on full bright . They were -i- turned on by means of the thunder storm l i g h t switch

.. on the overhead panel. These l i gh t s were on pr ior t o leaving New Bedford Airport. '7 .>

"Neither the F i r s t Officer nor I were wearing sun-glasses

2 during the approach."

The FAA-designated aviat ion medical examiner. who examined the caotain. ~~

s t a t ed that under-the external and in t e rna l l igh t ing conditions, " . . .a t s n g e i n l ight ing."~~~~~----- .

&hs.-.cc$ain's eyes approximately one t o two minutes t o adjust

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ANALYSIS AND FINDINGS

Investigation of the a i r c r a f t , engines, sys tem, and a i r c r a f t records indicated that there were no . m e ~ ~ . c a ~ ~ l f u n c t i o n s _ e r ~ l ~ . e s of t he a i r c r a f t that could be re la ted t o the cause of this incident.

t o Fl ight 938, and there was no evidence of equipment or navigational f a c i l i t y malfunction.

Air Traffic Control functions were properly executed as they r e l a t e --...

. .. . --

ce i l ing of 300 f e e t with the sky obscured. The reported v i s i b i l i t y was l m i l e with fog. There was an indef in i te

that the probable a l t imeter e r ro r a t sea level , air data computer on, The t e s t s of the s t a t i c pressure system and the a l t i m e t e r s p t e -_-~-

during a slow descent, was no more than @nus =feet. This e r ro r would have been i n favor of t he p i lo t ; i.e., the a l t imeter would have read 30 f ee t lower than the ac tua l a l t i t ude of the a i r c r a f t . *

During his announcement t o the passengers and l a t e r during an in t e r- view, the captain s t a t ed that he may have misread the alt imeter. The

alt imeters during the f l i g h t and both instruments indicated the same captain and the first of f icer both s ta ted that they had cross-checked t h e i r

a l t i t ude . The f irst of f icer estimated that 40 seconds elapsed from the time the a i r c r a f t s t ruck the water until his al t imeter read 900 f e e t which indicates a r a t e of climb of approximately 1,350 feet per minute. . .//

/' I ',, acuity could have been contributing factors i n his misreading of the

The ex is t ing l igh t ing conditions and the captain 's reduced visual

,!alt imeter. Under the external and in t e rna l l igh t ing i n this case, it 1 could have taken the captain 's eyes approximately 1~2~ . .@u&es -b .~&mk : t o the change i n l igh t ing when he descended i n t o the fog."

T h i s incident could have been prevented if the crew had followed the a l t i t u d e cal lout and coordination procedures required by the Northeast AirlineS' f l i g h t manual.

PROBABLE CAUSE

cause of this incident was the lack of crew coordination i n monitoring the The National Transportation Safety Board determines that the probable

misre_ading~ nf.altimeter_hg.~.khc . cp t a in , and a ~ c k . Q P - - ~ l t i t u a e a ~ ~ ~ e . s s a l t i t ude during the performance of a nonprecision i n s t m e n t approach, %

on . the par t of both p i lo t s e

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,

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FXCOMMENDATIONS

The Board has previously made several recornendations following the investigation of similar accidents and incidents. O u r most recent corre- spondence t o the Administrator, Federal. Aviation Administration, i s attached as Appendix D.

with a radio o r radar alt imeter. The Board noted during this investigation that ~ 9 8 2 x 3 was not equipped

Therefore the Board recommends that:

1. The Administrator require a l l air carrier a i r c r a f t t o be equipped

barometric alt imeters. with a functional ~ Q m d . p & q ~ t y warning device, i n addit ion t o

~ . ..

2. The Administrator es tabl ish appropriate operating procedures for such equipment.

’. The Board has been advised that the Federal Aviation Administration i s pr&sently examining the need f o r intermediate vision requirements for p i lo t s . The Board encourages t h i s program and, i f addit ional vision requirements are ident i f ied, w i l l provide i ts c m e n t s on any rulemaking the FAA may i n i t i a t e .

BY THE NATIONAL TRANSPORTATION SAFETY BOARD:

December 29, 1971

JOHN H. REED Chairman

OSCAR M. LAUREL Member

FRANCIS H. McADAMS Member

LOUIS M. THAYER Member

Member ISABEL A. BURGESS

1. Invest

June 22, 1 The E

the scene .Kennedy I n D. C. Wor Cockpit Vc of Operati

Inter

Ai rc ra f t C Federal Av

2. Hearin

There

3. Prelim

An in t he first

- 9 - Appendix A

INVESTIGATION AND HEARING

1. Investigation

June 22, 1971. The invest igator i n charge m s dispatched immediately t o the scene from the Safety Board's New York City Field Office a t John F. .Kennedy International Ai rpor t with technical assistance from Washington, D. C. Working groups were established for: Systems, Fl ight Recorder, Cockpit Voice Recorder, Human Factors, and a combined group consisting of Operations, Weather and A i r Traff ic Control.

The Board received not i f ica t ion of t h i s incident about 0 9 0 e.d.t. on

Federal Aviation Administration, Northeast Air l ines , McDonnell Douglas Aircrafi Corporation, and the A i r Line P i lo t s Association.

$?. Hearing

Interested par t ies par t ic ipat ing i n the investigation included the

4 There was no public hearing.

3. Preliminary Reports

An interim report of investigation summarizing the f ac t s disclosed by the first phase of t he investigation was pu%lished on August 4, 1971.

- 10 - Appendix B

CRFW INFORMATION

Cert i f icate No. 1030174. His l a t e s t Federal Aviation Administration f i r s t - c l a s s medical ce r t i f i ca t e was dated June 20, 1971, with the

near vision while exercising the privileges of his ce r t i f i ca t e . He holds l imi ta t ion that he shall have i n his possession corrective glasses f o r

a i r c r a f t type ra t ings f o r the E-3, 6, 7, and 9 -- FH 27/227. He success- f u l l y completed t r ans i t i on t ra in ing and checkout as captain on the E-9- type a i r c r a f t on June 12, 1967.

Captain Paul Donoghue, aged 46, holds Air l ine Transport P i lo t

Captain Donoghue had accumulated 17,344 hours 'as of May 31, 1971, of which 3,050 hours were as captain i n the E-9. He had flown 1.33 hours during this f l i g h t with a 4-day r e s t period before the f l i g h t . H i s last en route check was conducted on September 28, 1970, and his l a s t proficiency check was conducted on Apri l 19, 1971.

, F i r s t Officer Rudolph C . Milhalik, aged 31, holds Commercial P i lo t Ckr t i f ica te No. 1609095 fo r single-engine land with an instrument ce r t i - f i ca t e . His l a t e s t Federal Aviation Administration first .- class medical c e r t i f i c a t e was dated November 18, 1970, with no l imita t ion. He had accumulated a t o t a l of 2,933 hours as of May 31, 1971, of which 2,001 hours were i n the DC-9. He had flown 1.33 hours during t h i s f l i g h t with a 4-day r e s t period before the f l i gh t . His i n i t i a l f i r s t - o f f i ce r proficiency check was conducted on November 26, 1967, with his l a t e s t proficiency check on November 23, 1970.

was c

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Serit

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Hour:

- 11 - Appendix C

NRCRAFT HISTORY

~ 9 8 2 ~ ~ was a McDonnell Douglas E-9- 31 model a i r c r a f t . Manufacture was completed i n January 1968.

The a i r c r a f t had been flown a t o t a l of 8,907:15 hours since manu- facture and had flown 1,046:20 hours since the last inspection.

N982NE was equipped with two P r a t t & Whitney JT8D-7 engines.

Engine No. 1 Engine No. 2

h t e of Manufacture 8/16/67 10/12/67

Ser ia l Number 654614 654707

T o t a l Time (hours ) 7720:21 8169:20

Hours Since Las t Overhaul. 7720:21 8169:20

The Boar

- 1 2 - Appendix D

RECOMMENDATIONS

*d f inds tha .t a l t i t u d e a l e r t i n g equipment now ins ta l l ed on qir ca r r i e r aircraf ' t i s not used as a ground proximity warning device W c h has been previously recommended and, therefore, the Board recommends that the Federal Aviation Administration:

1. Develop a ground proximity warning system f o r use i n the approach and landing phases of operation which will warn flightcrews of excessive ra tes of descent, unmted/ inad- vertent descent below M i n i m u a Descent Alti tudes, o r descent through Decision Height. It would be desirable if the equipment now ins ta l l ed could meet this need; and

2. Develop and implement appropriate operational procedures t o provide this type of warning t o flightcrews f o r use during the approach and landing phase of flight.

DEPAR' FEDERAI -

1 5 NO'J

Bonors chairm Safe

Depart Washir

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DEPARTMENT OF TRANSPORTATION FEDERAL AVIATION ADMINISTRATION - 13 -

1 5 NO\/ 1971

Honorable John X. Reed Chairman, National Transportation

Department of Transportation Washington, D. C. 20591

Safety Board

THE ADMINISTRATOR OFFICE OF

Desr Mr. Chairman:

This is in response to the recomeadations contained in Report Number

*,Airways DC-9 at Gulfport, Mississippi, on 17 February 1971 and referred NTSB-AAR-71-14, an aircraft accident report concerning a Southern

&to in your letter dated 3 November 1971.

With respect to the recommendation to develop a ground proximity warning system for use during approach and landing, we believe the present

supposes proper cockpit disciplines are maintained. On this flight instrumentation and procedures are safe and adequate. This pre-

at 300 feet. The voice recorder transcript shows the Captain the Captain stated that during the approach he read the altimeter

called 150 feet and advised the copilot who was flying the aircraft to "bring it up.Ir The report brings out that the radar altimeter was set for 400 feet and the yellow warning light was observed by the pilot. We believe the pilot was well aware that he was below the Minimum Descent Altitude (MDA). We fail to see how a ground proximity warning could have contributed further to what we believe was already known.

We are, however, reassessing our system requirements for nonprecision

assistance to the pilot in the form of accurate position information straight-in-approach systems with a view to providing additional

which will make his evaluation of the visual approach segment less susceptible to human error.

With respect to the recornendation to have operational procedures to provide ground proximity warning, the agency has, for many years, had an altitude awareness program. Operators develop and publish in their manuals company procedures to insure altitude awareness during approaches. Southern Airways did have such a procedure, but it was not followed during the approach in question. Additionally, as the nonprecision straight-in-approach systeq is revised we will consider new or additional procedures to implement the system.

, i ; I

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With respect to the recormendstion to commission the ful l ILS at Gulfport, grading needed to solve the siting problem is being accomplished by the sponsor. We expect the system to be codssioned in early 1972.

Sincerely,

NTSB Northeast Airlines, Inc. AAR 72-4

McDonnell Douglas DC9

c.2

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