# NTSB DCA85AA015: Boeing 747 SP-09, N4522V, San Francisco, CA, February 19, 1985

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Final report
- Date: February 19, 1985, 10:16 local (18:16 UTC)
- Place: San Francisco, CA
- Location: 37.7750° N, 122.4194° W: Placed by OpenAirDocs: center of San Francisco, CA, within about 6 miles (OpenAirDocs)
- Nearby events: https://openairdocs.org/map.md?lat=37.7750&lon=-122.4194&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: Serious injuries
- Injuries: 2 serious, 271 uninjured
- Status: Completed
- Report: Board-adopted at Board Meeting
- NTSB office: Major Investigations Division
- NTSB case key (mKey): 15830
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DCA85AA015
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15830/pdf
- Board report AAR8603 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR8603.pdf
- Page: https://openairdocs.org/ntsb/DCA85AA015

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of control - in flight, cruise - normal
  - weather condition - unfavorable wind (contributing factor)
  - weather condition - windshear (contributing factor)
  - weather condition - turbulence,clear air (contributing factor)
  - powerplant controls - improper use of
  - flight/navigation instrument(s) - inattentive, pilot in command (cause)
  - diverted attention, pilot in command (cause)
  - overconfidence in aircraft's ability, pilot in command (contributing factor)
  - airspeed - not maintained, pilot in command (cause)
  - flight controls - improper use of, pilot in command (cause)
  - aircraft handling - not maintained, pilot in command (cause)
- Altitude deviation,uncontrolled, cruise
- Airframe/component/system failure/malfunction, descent - uncontrolled
  - design stress limits of aircraft - exceeded, pilot in command (cause)
  - 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](https://openairdocs.org/deregistered/N4522V-2018-03-14), registration cancelled 2018-03-14, S/N 22805, built 1982 (OpenAirDocs)
- Reported make and model: BOEING 747 SP-09
- Registry model: [Boeing 747SP-09](https://openairdocs.org/model/boeing-747sp-09) (registry code 1384903) (OpenAirDocs)
- Registry engine: [Pratt & Whitney JT9D-3A](https://openairdocs.org/engine/pratt-whitney-jt9d-3a) (registry code 52050, turbo-fan) (OpenAirDocs)
- Category: Airplane
- Serial number: 4522V
- Airframe hours: 10193
- Engines: P&W JT9D-7A 46150 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 55; 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 (OpenAirDocs).

- [Accident 19850219077569A](https://openairdocs.org/incident/19850219077569A), Feb 19, 1985: Boeing 747SP09, San Francisco, CA, Substantial damage. The pilot temporarily lost control of the aircraft due to inattention. Flight engineer failed to isolate problem.

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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