DCA95MA020

NTSB accident investigation · Douglas DC-8-63 · Kansas City, MO · February 17, 1995

Accident · FatalClass 1 · MajorFinal report
Date
February 16, 1995, 20:27 local (Feb 17, 1995, 02:27 UTC)
Place
Kansas City, MO
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Takeoff
Aircraft
N782ALDouglas DC-8-63
Weather
Visual (VMC) · Night/dark
Status
Completed · report February 14, 1996
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
19950216001889A
Case key
10996

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

On this page

Probable cause

(1) The loss of directional control by the pilot in command during the takeoff roll, and his decision to continue the takeoff and initiate a rotation below the computed rotation airspeed, resulting in a premature liftoff, further loss of control and collision with the terrain. (2) the flightcrew's lack of understanding of the three-engine takeoff procedures, and their decision to modify those procedures. (3) the failure of the company to ensure that the flightcrew had adequate experience, training, and rest to conduct the nonroutine flight. Contributing to the accident was the inadequacy of federal aviation administration oversight of air transport international and federal aviation administration flight and duty time regulations that permitted a substantially reduced flightcrew rest period when conducting a nonrevenue ferry flight under 14 code of federal regulations part 91. (NTSB report AAR-95/06)

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 - on ground/waterTakeoff - roll/run
Procedures/directives - not understoodFlightcrewCause
Inadequate trainingCompany/operator managementCause
Fatigue(lack of sleep)Flightcrew
Fatigue(flight and ground schedule)Flightcrew
Fatigue(circadian rhythm)Flightcrew
Inadequate substantiation processFaa(organization)Factor
Procedures/directives - not complied withFlightcrewCause
Directional control - not attainedPilot in commandCause
Loss of control - in flightTakeoff - initial climb
Airspeed(vr) - belowPilot in commandCause
Aborted takeoff - not performedPilot in commandCause
Lift-off - prematurePilot in commandCause
In flight collision with terrain/waterTakeoff - initial climb

Analysis

The airplane crashed immediately after liftoff during a three-engine takeoff. Flightcrew had shortened rest break; rest periods not required for ferry flights. Flightcrew fatigued from lack of rest, sleep, and disruption of circadian rhythms. Flightcrew did not have adequate, realistic training in three-engine takeoff techniques or procedures. Flightcrew did not adequately understand three-engine takeoff procedures, including significance of vmcg. Flight engineer improperly determined vmcg speed, resulting in value 9 knots too low. During first takeoff attempt, captain applied power to asymmetrical engine too soon, was unable to maintain directional control, and rejected the takeoff. Captain agreed to modify procedure by allowing flight engineer to advance throttle, a deviation of prescribed procedure. FAA oversight of operator was inadequate because the poi and geographic inspectors were unable to effectively monitor domestic crew training and international operations. Existing FAR part 121 flight time limits & rest requirements that pertained to the flights that the flightcrew flew prior to the ferry flights did not apply to the ferry flights flown under FAR part 91. Current one-engine inoperative takeoff procedures do not provide adequate rudder availability for correcting directional deviations during the takeoff roll compatible with the achievement of maximum asymmetric thrust at an appropriate speed greater than ground minimum control speed.

Factual narrative

On February 16, 1995, at 2027 cst, a Douglas DC-8-63 freighter, operated by Air Transport International LLC, and registered as N782AL, crashed while attempting a three-engined takeoff from runway 01L at Kansas City International Airport, Kansas City, Missouri. Weather at the time was clear, and the airplane was operating under FAR Part 91 on an IFR flight plan. The airplane was destroyed by impact forces and postcrash fire, and both pilots and the flight engineer suffered fatal injuries. The purpose of the flight was to ferry the airplane to Westover AFB, Massachusetts, for repair of the number one engine.

Aircraft

Registration
N782AL
Reported as
Douglas DC-8-63
Category
Airplane
Serial number
45929
Airframe hours
77,096
Engine
P&W JT3D-7, 19,000 lbs thrust, turbo jet
Damage
Destroyed
Fire
On-Ground
Flight
Ferry · Part 91
Operator
Air Transport International Limited Liability Co
Registered owner
Airolease Finiancial Group Trustee
Airworthiness certificate
Standard, Transport
Last inspection
100 hour · February 11, 1995 · 12 hours before
Departed
MCI
Destination
CEF · Westover Afb, MA
Flight plan
IFR
Airport
MKC · Kansas City International, runway 1L, 10,801 × 150 ft, asphalt

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 · 3

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
48
Injuries
Fatal
Certificates
Flight engineer, Airline transport, Private, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
9,711 total · 4,483 in this make and model · 201 in the last 90 days · 60 in the last 30 days · 3 in the last 24 hours
Role
Co-pilot
Age
38
Injuries
Fatal
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
October 7, 1994
Seat
Right
Flight hours
4,261 total · 171 in this make and model · 142 in the last 90 days · 39 in the last 30 days
Role
Flight engineer
Age
48
Injuries
Fatal
Certificate
Flight instructor
Medical
Class 2, With waivers/limitations
Seat
Rear
Flight hours
4,460 total · 248 in this make and model · 135 in the last 90 days · 57 in the last 30 days

Weather

Conditions
Visual (VMC) · Night/dark
Wind
210° at 4 knots
Visibility
20 statute miles
Lowest ceiling
None
Temperature
30 °F
Observed at
KCI, 1 nm away

FAA reports on this event · 1

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