DCA85AA015

NTSB accident investigation · Boeing 747 SP-09 · San Francisco, CA · February 19, 1985

Accident · Serious injuriesFinal report
Date
February 19, 1985, 10:16 local (18:16 UTC)
Place
San Francisco, CA
Injuries
2 serious, 271 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N4522VBoeing 747 SP-09
Weather
Instrument (IMC) · Day
Status
Completed
Report
Board-adopted at Board Meeting
NTSB office
Major Investigations Division
FAA report
19850219077569A
Case key
15830

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - in flightCruise - normal
Weather condition - unfavorable windFactor
Weather condition - windshearFactor
Weather condition - turbulence,clear airFactor
Powerplant controls - improper use of
Flight/navigation instrument(s) - inattentivePilot in commandCause
Diverted attentionPilot in commandCause
Overconfidence in aircraft's abilityPilot in commandFactor
Airspeed - not maintainedPilot in commandCause
Flight controls - improper use ofPilot in commandCause
Aircraft handling - not maintainedPilot in commandCause
Altitude deviation,uncontrolledCruise
Airframe/component/system failure/malfunctionDescent - uncontrolled
Design stress limits of aircraft - exceededPilot in commandCause
Level off - performed

Analysis

While abv a cloud layer (top at FL 370) nr the jet stream, autoplt was engaged & was in the performance mngmnt sys (pms)mode. The pms provided pitch guidance to hold FL 410, roll guidance to ailerons & spoilers for roll ctl & autothrottle to maint .85 mach (254 KIAS). Acft encountered clr air turbc & airspeed bgn to vary btn .84 & .88 mach. Pms bgn moving throttles fore & aft to hold .85 mach. Drg autothrottle adjustments, #4 eng thrust decreased & 'hung' at aprx 1.0 epr & airspeed bgn decreasing. Flt engineer atmtd to manually rcvr the #4 eng thrust, but did not close the bleed air vlv bfr adjusting the #4 throttle. The #4 eng remained at aprx 1.0 epr. As the acft slowed, autoplt trimmed to hold alt & hdg til the plt disengaged it. At that time, acft rolled/yawed rgt & entered an unctld dscnt into the clouds. As it broke out of the clouds at 11,000', crew rcvrd & lvld at 9500'. Drg dscnt/rcvry, acft was dmgd by accelleration forces & hi speed. There was evidence the plt was preoccupied with eng prblm, didn't monitor instruments & over-relied on autoplt.

Aircraft

Registration
N4522V
Reported as
Boeing 747 SP-09
Category
Airplane
Serial number
4522V
Airframe hours
10,193
Engine
P&W JT9D-7A, 46,150 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 129
Operator
China Airlines, doing business as Sung Shan Airport
Registered owner
Wilmington Trust Company
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · February 2, 1985 · 206 hours before
Departed
Taipei, OF
Destination
KLAX · Los Angeles, CA
Flight plan
IFR

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
55
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
15,494 total · 3,748 in this make and model · 254 in the last 90 days · 82 in the last 30 days

Weather

Conditions
Instrument (IMC) · Day
Lowest ceiling
11,000 ft unknown
Altimeter
29.00 inHg

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.