# NTSB DCA95MA020: Douglas DC-8-63, N782AL, Kansas City, MO, February 17, 1995 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 1 · Major · Final report - Date: February 16, 1995, 20:27 local (Feb 17, 1995, 02:27 UTC) - Place: Kansas City, MO - Location: 39.1257° N, 94.6111° W: Placed by OpenAirDocs from NTSB’s distance and direction from KANSAS CITY DOWNTOWN/WHEELER FLD (MKC), within about a mile (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=39.1257&lon=-94.6111&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report February 14, 1996 - Report: Board-adopted at Board Meeting - Investigation class: Class 1 - NTSB office: Major Investigations Division - Safety recommendations: Yes - NTSB case key (mKey): 10996 - NTSB case page: https://www.ntsb.gov/investigations/Pages/DCA95MA020.aspx - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/10996/pdf - Board report AAR9506 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR9506.pdf - Page: https://openairdocs.org/ntsb/DCA95MA020 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - on ground/water, takeoff - roll/run - procedures/directives - not understood, flightcrew (cause) - inadequate training, company/operator management (cause) - fatigue(lack of sleep), flightcrew - fatigue(flight and ground schedule), flightcrew - fatigue(circadian rhythm), flightcrew - inadequate substantiation process, faa(organization) (contributing factor) - procedures/directives - not complied with, flightcrew (cause) - directional control - not attained, pilot in command (cause) - Loss of control - in flight, takeoff - initial climb - airspeed(vr) - below, pilot in command (cause) - aborted takeoff - not performed, pilot in command (cause) - lift-off - premature, pilot in command (cause) - In flight collision with terrain/water, takeoff - 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](https://openairdocs.org/deregistered/N782AL-1997-03-20), registration cancelled 1997-03-20, S/N 45929 (OpenAirDocs) - Reported make and model: Douglas DC-8-63 - Registry model: [Mcdonnell Douglas DC-8-63](https://openairdocs.org/model/mcdonnell-douglas-dc-8-63) (registry code 302198B) (OpenAirDocs) - Category: Airplane - Serial number: 45929 - Airframe hours: 77096 - Engines: P&W JT3D-7 19000 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 48; injuries: fatal; 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 - Co-pilot; age 38; injuries: fatal; 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 - Flight engineer; age 48; injuries: fatal; 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 (OpenAirDocs). - [Accident 19950216001889A](https://openairdocs.org/incident/19950216001889A), Feb 16, 1995: Doug DC863, Kansas City, MO, Destroyed, 3 fatal. Attempted three engine takeoff. Lost control. Aborted. Lacked speed for vmcg. Pilot fatigue. Training a factor. 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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.