NATIONAL TRANSPORTATION SAFETY
BOARD
Public Meeting of August 5,
2003
(Information subject to
editing)
Report of Aviation Accident
Emery Worldwide Airlines,
Inc.,
McDonnell Douglas
DC-8-71F
Rancho Cordova,
California, February 16, 2000
NTSB/3/03
This is a synopsis from the Safety Board's report and does not include the Board's rationale for the conclusions, probable cause, and safety recommendations. Safety Board staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted. The final report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible. The attached information is subject to further review and editing.
On February 16, 2000, about 1951 Pacific standard time, Emery Worldwide Airlines, Inc. (Emery) flight 17, a McDonnell Douglas DC-8-71F, 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 Part 121 as a scheduled cargo flight from MHR to James M. Cox Dayton International Airport, 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.
1. The captain, first officer, and flight engineer were properly certificated and qualified and had received the training and off-duty time prescribed by Federal regulations and company requirements. No evidence indicated any preexisting medical or behavioral conditions that might have adversely affected the flight crew's performance during the accident flight.
2. The accident airplane was certificated, equipped, and dispatched in accordance with applicable regulations and industry practices.
3. Cargo loading for the accident flight was routine, and the airplane was operating within prescribed center of gravity limits.
4. Weather and air traffic control were not factors in this accident.
5. At some time after the previous takeoff (from Reno, Nevada) and before the accident takeoff roll, the bolt connecting the right elevator control tab crank fitting to the pushrod migrated out of the fitting, allowing the control tab to disengage from its pushrod and shift to a trailing edge down position.
6. When the aerodynamic forces increased as the airplane accelerated during the takeoff roll, the right elevator control tab crank fitting contacted the disconnected pushrod, restricting that control tab's further trailing edge up movement and leaving it in an extreme trailing edge down deflection.
7. As a result of the right elevator control tab's extreme trailing edge down deflection, the accident airplane's elevator surfaces were driven to command an extreme airplane nose-up pitch attitude; despite the large nose-down forces the pilots applied to the control columns, the pilots were unable to overcome the effects of the restricted right elevator control tab.
8. The bolt attaching the accident airplane's right elevator control tab crank fitting to the pushrod was improperly secured and inspected, either during the most recent D inspection or subsequent maintenance; however, the Board was unable to determine when this improper securement and inspection occurred.
9. DC-8 operators' procedures and training should more clearly emphasize that DC-8 flight crewmembers need to verify symmetry between the right and left side elevators, control tabs, and geared tabs during the preflight inspection.
10. DC-8 operators, including Emery, do not use the elevator position indicator (EPI) to confirm elevator movement indications above and below the neutral range during the 80-knot elevator check and, thus, do not take full advantage of the EPI's capabilities to provide pilots with an indication of an abnormal elevator condition.
11. The elevator position indicator needs to be periodically calibrated to ensure that it provides the most accurate information possible to the pilots.
12. The elevator position indicator gauge should be readily visible to both pilots.
13. The circumstances of the Emery flight 17 accident show that the current DC-8 design does not preclude a catastrophic result from a disconnection or failure of the existing control tab crank fitting to pushrod attachment.
14. There may be airplanes that were certificated to Civil Aviation Regulations 4b standards other than the DC-8 on which the disconnection of a critical flight control could have catastrophic results.
15. Replacement of the DC-8 aluminum elevator geared tab crank arms on DC-8 airplanes with stainless steel elevator geared tab crank arms would likely eliminate the possibility of a jam resulting from fractured geared tab crank arms.
16. DC-8 elevator rigging procedures should be fully addressed in a separate work card that specifically lists required inspection items, including verifying the security of elevator control tab attachments after the rigging is completed.
17. All DC-8 work cards related to critical flight controls should identify required inspection items as discrete tasks with individual inspection signoff requirements.
18. The use of a single airplane's flight data recorder (FDR) parameter correlation for all airplanes of the same type is inadequate to ensure accurate correlations for older airplanes that have been retrofitted to record additional FDR parameters.
19. Loral Fairchild Model F-800 flight data recorders with unaddressed or unidentified track switching anomalies may currently be in operation.
20. The current regulatory definition of safety-sensitive functions is too narrow for the issue of postaccident testing because it does not include cargo handlers, load planners, and ramp supervisors, all of whom have a demonstrated potential to affect the safety of a flight.
PROBABLE CAUSE
The National Transportation Safety Board determines 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.
SAFETY RECOMMENDATIONS
To the Federal Aviation Administration:
1. Require all DC-8 operators to train DC-8 flight crewmembers to look for symmetry between the right and left side elevators, control tabs, and geared tabs during preflight inspection, consistent with Boeing's June 2001 flight operations bulletin guidance. (A-03-XX)
2. Require the development of DC-8 80-knot elevator check procedures that will ensure that pilots are clearly made aware of whether the elevator is functioning properly before the airplane lifts off, then require all DC-8 operators to incorporate these procedures into their training and normal operations. The procedures should contain specific guidance regarding an expected range of elevator position indicator (EPI) needle movement (including EPI needle movement well below the neutral mark with forward control column movement), and specific criteria for aborting a takeoff as a result of an inadequate elevator movement indication. (A-03-XX)
3. Require all DC-8 operators to incorporate periodic elevator position indicator (EPI) calibration inspections into their maintenance programs to ensure that the EPI indications observed by pilots accurately represent the condition of the elevator. (A-03-XX)
4. Require DC-8 elevator position indicators to be located and sized so that they are visible and usable for both the captain and first officer. (A-03-XX)
5. Require Boeing to redesign DC-8 elevator control tab installations and require all DC-8 operators to then retrofit these installations such that pilots are able to safely operate the airplane if the control tab becomes disconnected from the pushrod. (A-03-XX)
6. Evaluate other airplanes certificated to Civil Aviation Regulations 4b standards to evaluate whether disconnection or failure of critical flight control systems could have catastrophic results and, if so, require that they also be redesigned and retrofitted and/or equipped with dual-locking devices to preclude such catastrophic results. (A_03-XX)
7. Require all DC-8 operators to replace all DC-8 aluminum elevator geared tab crank arms on their DC-8 airplanes with stainless steel elevator geared tab crank arms. (A-03-XX)
8. Require all DC-8 operators to create or revise DC-8 work cards to ensure they specifically include a postrigging inspection of the elevator assembly, including verifying the security of elevator control tab attachments. (A-03-XX)
9. Require all DC-8 operators to review their work cards related to critical flight controls, and revise them as necessary to ensure that appropriate tasks are identified as discrete tasks with individual inspection signoff requirements. (A-03-XX)
10. Require all Part 121 air carrier operators to revise their task documents/work cards to describe explicitly the process to be followed in accomplishing maintenance tasks. (A-03-XX)
11. Require all Part 121 air carrier operators to either: 1) provide maintenance personnel with the manufacturer's current pertinent installation drawings, update those installation drawings as needed, and require use of those drawings during installation and/or assembly of that airplane's components; or 2) list the illustrated parts catalog (IPC) on that operator's operation specifications, provide maintenance personnel with up-to-date IPCs for reference, continue to update those IPCs as needed, and require maintenance personnel to use the pertinent updated IPCs during installation and/or assembly of an airplane's components. (A-03-XX)
12. Require operators of airplanes manufactured before August 18, 2000, that have been retrofitted with additional flight data recorder (FDR) parameters in compliance with Federal requirements and for which an operator maintains a common correlation document for that airplane type to conduct a full correlation of all such airplanes' FDR parameters at the airplanes' next required FDR maintenance inspection to verify accurate FDR system documentation and sensor function. (A-03-XX)
13. Require all operators of airplanes equipped with Loral Fairchild Model F-800 flight data recorders to comply with Loral Fairchild Field Service Bulletins digital flight recorder (DFR) 011 and DFR 027 for recorders with applicable part numbers and installed component numbers. (A-03-XX)
14. Require overhaul facilities that service Loral Fairchild Model F-800 flight data recorders to monitor those recorders to determine whether abnormal track switching is occurring and to report any such findings to the Federal Aviation Administration and the manufacturer. (A-03-XX)
15. Modify the list of safety-sensitive functions described in 14 Code of Federal Regulations Part 121, Appendixes I and J, to include all personnel with direct access to the airplane and a direct role in the handling of the flight, including cargo handlers, load planners, and ramp supervisors. (A-03-XX)