Last revised: September 06, 2013
ATC - 25 Best Years -
(1958-83)
Album #
9.
(1977)
(Midair
Collision)
-Tenerife, Canary Islands
THE 2nd WORST AVIATION DISASTER IN HISTORY! |
![]() Less experienced flight crew members were encouraged to challenge their captains when they believed something was not correct, and captains were instructed to listen to their crew and evaluate all decisions in light of crew concerns. This concept was expanded into what is known as Crew Resource Management (CRM). CRM is a procedure and training system where human error can have devastating effects and is used primarily for improving air safety. CRM focuses on interpersonal communication, leadership, and decision making in the cockpit. CRM training is now mandatory for all airline pilots. The training
covers a wide range of knowledge, skills and attitudes including
communications, situational awareness, problem solving, decision making,
and teamwork. CRM is a management system which makes optimum use of all
available resources: equipment, procedures and people to promote safety
and enhance the efficiency of operations. |
The DC-9 crew was advised of the presence of embedded thunderstorms and possible tornadoes along the flight route, but they were not subsequently told that the cells had since formed a squall line. As the DC-9 descended from 17,000' to 14,000' it entered a thunderstorm cell with massive amount of water and hail. The hail was intense enough to break the jet's windshield, and due to the ingestion of both water and hail, both engines were damaged and underwent flameout. The crew were unable to restart the engines and gliding down unpowered, trying to find an emergency landing field within range. As the jet ran out of altitude and options, gliding with a broken windshield and no power the crew made visual contact with the ground and found a straight section of rural highway. They executed an unpowered forced landing, but during the rollout, the DC-9 collided with a gas station/grocery store and other structures. The NTSB determined the probable cause of the crash was the total and unique loss of thrust from both engines while the jet was penetrating an area of severe thunderstorms. Also the failure of Southern Airways dispatch to provide the crew with up-to-date severe weather information, and the FAA's air traffic control system which did not provide timely dissemination of real time hazardous weather information to the flight crew. A dissenting opinion: The probable cause was the captain's decision to penetrate rather than avoid an area of severe weather, the failure to obtain all the available weather information despite having knowledge of the severity of the storm system, and the reliance of airborne weather radar for penetration rather than avoidance of the storm. 63 people on the aircraft (including the flight crew) and 9 people on
the ground died; 20 passengers and two flight attendants survived.
(63 Fatalities)
|
![]() The FAA also began providing enhanced dissemination of SIGMETs and Severe Thunderstorm Watch Bulletins and Tornado Watch Bulletins. En route and tower controllers will make broadcasts on receipt of all SIGMETs. Additionally, the FAA plans to display emergency airports with approved
approaches on radar screens. These airports, not required for normal
operations, will be displayed on a separate filter key in emergency
situations. |
![]() ![]() 1977 - President Jimmy Carter selected an expert in aviation law, Langhorne M. Bond, as the 7th FAA Administrator. |
(1978)
The NTSB determined the probable cause of this accident was the sequential failure of two tires on the left main landing gear and the resultant failure of another tire on the same landing gear at a critical time during the takeoff roll. Also the partial loss of aircraft braking because of the failed tires and the reduced braking friction achievable on the wet runway surface.
The failure of the left main landing gear and the consequent rupture of
the left wing fuel tanks resulted in an intense fire which added to the
severity of the accident. |
![]() Additionally the FAA
requires that pilot training programs include information regarding
optimum rejected takeoff procedures at maximum weights, on wet and dry
runways, and at speeds at or near V1, and for rejected takeoffs which must
be initiated as a result of engine or tire failures. |
They landed at Denver airport to take on more fuel for Cuba. While
waiting for the fuel, the cockpit crew jumped from the cockpit to escape
the hijacker who then surrendered to the FBI within minutes of the crews
escape. No fatalities, but the 3 cockpit crew members suffered fractures
and torn cartilage from the unassisted 2-story jump. |
The ILS for runway 16 had been out of service since January for runway reconstruction. However, a non-precision approach to runway 25 was available instead. While established on the approach, the first officer neglected to make altitude and approach fix call outs. The ground proximity alarm sounded and the first officer checked his altimeter. He read it as 1,500' and turned off the alarm. The flight data recorder showed the actual altitude was only 500'. The flight crew may have been distracted by the alarm and failed to realize they passed through the minimum descent altitude. Shortly after they impacted Escambia Bay, barge traffic in the area assisted in the evacuation. 3 passengers drowned attempting to exit the B-727. (3 Fatalities) Probable Causes: The flight crew had information that a VASI light system for runway 25 was available and operational, but the crew was unaware of this alternate approach aid. Also contributing to the crash was an error of the radar controller. The controller misjudged the jet's distance and turned it to final inside the recommended distance, resulting in the jet being on final approach vector for about 4.5 nmi, close to half the distance of a normal approach. The NTSB concludes the controller "created a situation that would make it impossible for the captain to configure his jet in the manner specified in the flight manual." Also, a
reluctance to declare a missed approach pervaded the descent. Radar
controller, captain, first officer and flight engineer all had indications
of an "out of the ordinary" approach, producing a rushed and busy
environment. The captain failed to lower the landing gear immediately
after lowering the flaps to 25 degrees, because he "wanted to avoid
placing a simultaneous demand on the hydraulic system while the flaps were
in transit." Also the first officer never made the required 1,000'
callout. The lack of crew communication and a "no problem here" attitude
resulted in false awareness of altitude and descent rate on the part of
all involved. |
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![]() The cost for each successful participant had averaged $370,000. The
House Appropriations Committee report suggested that controllers who had
been incapacitated on the job should seek rehabilitation services under
Worker's Compensation. |
(Midair
Collision)
-San Diego, CA
The weather was clear with 10 miles visibility, and the PSA crew was alerted by the approach controller about a small Cessna aircraft nearby. The Cessna-172 was being flown by two licensed pilots. One with a single-engine, multi-engine and instrument flight ratings, as well as a commercial certificate and an instrument flight instructor certificate. The other pilot, a U.S. Marine Corps sergeant had single and multi-engine ratings and a commercial certificate, and at the time of the accident practicing ILS approaches under the instruction of the 1st pilot in pursuit of his instrument rating. The 2nd pilot was wearing a "hood" to limit his field of vision straight ahead to the cockpit panel in normal IFR training.
The B-727 crashed after a midair collision with a Cessna-172 while on a downwind leg at San Diego. The PSA's flight crew was cited at fault for failing to maintain visual separation with the Cessna after reporting it in sight. The Cessna was directly in front of and below the B-727 which was descending and rapidly closing in on the small pane, which had taken a right turn to the east, deviating from the assigned course. The B-727 crew never explicitly alerted the tower that they had lost sight of the Cessna. Moreover, if the Cessna had maintained the heading of 70 degrees assigned by ATC instead of turning to 90 degrees, they would have missed each other by about 1000'. The aircraft collided at 2,600'.
The PSA B-727 struck the ground 3 miles northeast of Lindbergh field. It impacted in a high-speed, nose-down attitude while banked 50 degrees to the right. The largest piece of the Cessna impacted about 2 blocks away.
Probable Cause: The failure of the PSA flight crew to follow proper
ATC procedures to "keep visual separation from the Cessna traffic", and did
not alert ATC that they had lost sight of it. Errors on the part of ATC
were also named including the use of visual separation procedures when
radar clearances were available. Also the Cessna did not maintain their
assigned heading after completing a practice instrument approach, nor did
they notify ATC of their course change. |
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Additionally, a review of policies regarding the use of visual separation
in terminal areas will be completed as soon as possible. |
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October 24, 1978 - The Civil Aeronautics Board passed a new law - the Airline Deregulation Act - which permitted the commuter airline industry and air taxis to employ bigger aircraft and made them eligible for the FAA equipment loan-guarantee program. It also created a highly competitive airline industry. The act also allowed for immediate fare reductions of up to 70% without CAB approval, and the automatic entry of new airlines into routes not protected by other carriers. 22 airline reps submitted applications for dormant airline routes and the CAB awarded 248 new routes to smaller communities which were guaranteed essential air services for 10 years with a government subsidy if necessary. The act also provided equipment loan guarantees to commuter airlines.
When airline deregulation became law, the air traffic control system
required enhancement to keep pace with the increased volumes of traffic
resulting from the new deregulated environment. |
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NTSB determined that the probable cause was the failure of the captain to monitor properly the aircraft's fuel state and to respond to the low fuel problem. He also didn't respond to the other crewmember's advisories regarding the fuel gauges resulting in fuel exhaustion to all 4 engines.
Contributing to the accident was the failure of the other two flight crew members, either to fully comprehend the criticality of the fuel state or to successfully communicate their concern to the captain who was inattentive because of the landing gear malfunction and preparations for a possible landing emergency.
A total of 189 occupants were on the jet, and 10 lost
their lives (8 passengers, the flight engineer, and a flight attendant).
Serious injuries included 21 passengers and 2 crewmembers.
(10 Fatalities)
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![]() Additionally, the
FAA directed air carrier operators to ensure that their flight crews
are indoctrinated in the principles of flight deck resource management,
with particular emphasis on the merits of participative management for
Captains and assertiveness training for other cockpit crewmembers. |
Last revised: September 06, 2013
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