DCA97MA059

NTSB accident investigation · Douglas DC-8-61 · Miami, FL · August 7, 1997

Accident · FatalClass 1 · MajorFinal report
Date
August 7, 1997, 12:36 local (16:36 UTC)
Place
Miami, FL
Injuries
5 fatal; on the ground: 1 fatal
Damage
Destroyed
Phase of flight
Takeoff
Aircraft
N27UADouglas DC-8-61
Weather
Visual (VMC) · Day
Status
Completed · report June 16, 1998
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
19970807021309A
Case key
11028

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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Probable cause

The airplane being misloaded to produce a more aft center of gravity and a correspondingly incorrect stabilizer trim setting that precipitated an extreme pitch-up at rotation, was (1) the failure of Fine Air to exercise operational control over the cargo loading process; and (2) the failure of Aeromar to load the airplane as specified by Fine Air. Contributing to the accident was the failure of the Federal Aviation Administration (FAA) to adequately monitor Fine Air's operational control responsibilities for cargo loading and the failure of the FAA to ensure that known cargo-related deficiencies were corrected at Fine Air.

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 flightTakeoff
Aircraft weight and balance - inadequateCause
Improper use of procedureOther personCause
Inadequate surveillance of operationCompany/operator mgmtCause
Inadequate surveillance of operationFaa(organization)Cause
Trim setting - improperCause
Aircraft control - not possiblePilot in commandCause
Airspeed - not maintainedCause
Stall
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground
Object - vehicle

Analysis

: On August 7, 1997, at 1236 eastern daylight time, a Douglas DC-8-61, N27UA, operated by Fine Airlines Inc. (Fine Air) as flight 101, crashed after takeoff from runway 27R at Miami International Airport, Miami, Florida. The three flightcrew members and one security guard on board were killed, and a motorist was killed on the ground. The airplane was destroyed by impact and a postcrash fire. The cargo flight, with a scheduled destination of Santo Domingo, Dominican Republic, was conducted on an instrument flight rules flight plan and operated under Title 14 Code of Federal Regulations Part 121 as a Supplemental air carrier. Prior to takeoff, the airplane was misloaded to produce a more aft center of gravity and a correspondingly incorrect stabilizer trim setting. This precipitated an extreme pitch-up at rotation. Because of the incorrect stabilizer trim setting the pilots could not gain adequate control of the airplane before it struck the ground :

Factual narrative

On August 7, 1997, a Douglas DC-8-61 freighter, Fine Air cargo flight 14, crashed after departure from runway 27R at Miami IAP, Miami, FL. The flight was operated under 14 CFR Part 121 as a supplemental air carrier. The three crewmembers and one security guard onboard were killed. One individual in an automobile on the ground was also killed. The airplane was destroyed by impact and postcrash fire. Visual meteorological conditions prevailed at the time. See NTSB/AAR-98/02 for details.

Aircraft

Registration
N27UA
Reported as
Douglas DC-8-61
Category
Airplane
Serial number
45942
Airframe hours
39,891
Engine
P&W JT3D-3B, 18,000 lbs thrust, turbo fan
Damage
Destroyed
Fire
On-Ground
Flight
Part 121
Operator
Fine Airlines, Inc., doing business as Fine Air
Registered owner
Fine Airlines, Inc.
Airworthiness certificate
Standard, Transport
Departed
MIA · Miami, FL
Destination
SDQ · Santo Domingo
Flight plan
Unknown
Airport
MIA · Miami International Airpo, runway 27R, 10,502 × 200 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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
42
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
April 27, 1997
Seat
Left
Toxicology
Performed
Flight hours
12,154 total · 216 in the last 90 days · 100 in the last 30 days · 25 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Visibility
10 statute miles
Lowest ceiling
None
Temperature
93 °F, dew point 79 °F
Altimeter
30.00 inHg
Observed at
MIA

Docket · 74

The files NTSB released with the investigation on November 7, 1997, on NTSB’s docket system: statements, records, photos and specialists’ reports. 46.7 MB in all.

Operations/Human Performance 2 - Group Chairman's Factual ReportItem 1 · .PDF · 4.1 MBOperations/Human Performance 2 - Attachments to Factual Report of Group ChairmanItem 2 · .PDF · 5.4 MBOperations/Human Performance 2 - Addendum 1 - Factual Report of Group ChairmanItem 3 · .PDF · 1.0 MBOperations/Human Performance 2 - Addendum 2 - Factual Report of Group ChairmanItem 4 · .PDF · 45 KBStructures 7 - Factual Report of Group Chairman (Part 1)Item 5 · .PDF · 801 KBStructures 7 - Photo 1. Exemplar Locking Pawl Assemblies as ReceivedItem 6 · .PDF · 37 KBStructures 7 - Photo 2. Locking Pawl Assembly Secured in Test FixturingItem 7 · .PDF · 33 KBStructures 7 - Photo 3. Locking Pawl Assembly during Fully Locked Posiiton Load TestItem 8 · .PDF · 38 KBStructures 7 - Photo 4. Breakage of the Lock base after Fully Locked Position Load TestItem 9 · .PDF · 32 KBStructures 7 - Photo 5. Locking Pawl Assembly and Loading Block for the Partially Locked Position Load TestItem 10 · .PDF · 30 KBStructures 7 - Photo 6. Locking Pawl Assembly after the Partially Locked Position Load TestItem 11 · .PDF · 29 KBStructures 7 - Photo 7. Deformation of the backside of the Forward Locking Pawl after the Partially Locked Position Load TestItem 12 · .PDF · 37 KBStructures 7 - Photo 8. Locking Pawl Assembly during Inverted Compression Load TestItem 13 · .PDF · 37 KBStructures 7 - Factual Report of Group Chairman (Part 2)Item 14 · .PDF · 1.7 MBStructures 7 - Appendix A - Metro Dade Police Department DiagramItem 15 · .PDF · 183 KBStructures 7 - Photo 1. View of N27UA crash debris line. (A) Runway 09L and 27R (B) Right stabilizer initial contact with ground (C) Aft fuselage collided with ground (D) Left outboard stabilizer tip embedded in middle bItem 16 · .PDF · 59 KBStructures 7 - Photo 2. View of N27UA crash debris line. (A) Separated right wing (B) Dairy Road (C) No. 1 einge (D) No. 2 engine (E) No. 3 engine (F) No. 4 engine (G) Left wing and center wing sectionItem 17 · .PDF · 67 KBStructures 7 - Photo 3. View of N27UA crash debris line looking to the west. (A) Right stabilizer contact with ground. (B) Aft fuselage collision with ground (C) stabilizer tip embedded in middle marker buildingItem 18 · .PDF · 47 KBStructures 7 - Photo 4. View of N27UA crash debris line looking to the west.Item 19 · .PDF · 34 KBStructures 7 - Photo 5. View of left stabilizer with a section of the right stabilizer embedded in left elevator.Item 20 · .PDF · 50 KBStructures 7 - Photo 6. View of aft fuselage close out bulkhead/cargo liner separated from the aft pressure bulkhead.Item 21 · .PDF · 56 KBStructures 7 - Photo 7. View of the vertical stabilizer and aft pressure bulkhead.Item 22 · .PDF · 48 KBStructures 7 - Photo 8. View of the tail cone.Item 23 · .PDF · 41 KBStructures 7 - Photo 9. Right view of the center wing section looking at the trailing edge of the wing. Note right wing has separated.Item 24 · .PDF · 73 KBStructures 7 - Photo 10. View of right wing.Item 25 · .PDF · 67 KBStructures 7 - Photo 11. View of center wing section and left wing.Item 26 · .PDF · 64 KBStructures 7 - Photo 12. View of center wing section separated from the forward fuselage at the leading edge of the left and right wing.Item 27 · .PDF · 53 KBStructures 7 - Photo 13. View of the forward fuselage lookingh rearward with the 9g cargo restraint separated from the fuselage and cockpit area.Item 28 · .PDF · 61 KBStructures 7 - Photo 14. View of cockpit area with pilot's control pedestal located on top of inverted automobile.Item 29 · .PDF · 71 KBStructures 7 - Photo 15. View of flight engineer's control panel looking forward towards the front of the airplane.Item 30 · .PDF · 62 KBStructures 7 - Photo 16. View of the cargo flooring separated aft of the pallet 18 position with the fixed pallet stop.Item 31 · .PDF · 70 KBStructures 7 - Photo 17. View of the aft cargo flooring looking forward from the 17/18 pallet lock position to the 11/12 posiiton. Note the 17/18-1 pallet lock is in the locked position.Item 32 · .PDF · 66 KBStructures 7 - Photo 18. View of the 17/18-1 pallet lock in the locked position. Note that pallet locks 2 through 5 are in the down position.Item 33 · .PDF · 49 KBStructures 7 - Photo 19. View of the cargo flooring looking aft from the 11/12 pallet lock posiiton towards the 17/18 pallet lock position.Item 34 · .PDF · 63 KBStructures 7 - Photo 20. View of the 7/8-5 pallet lock in the unlocked position.Item 35 · .PDF · 44 KBStructures 7 - Photo 21. View of the lateral locks prior to the recovery of the No. 3 lateral lock. Note that the No. 1 lock is in the locked position. All other lateral locks were found in the down position.Item 36 · .PDF · 41 KBStructures 7 - Photo 22. View of pallet locks found in the vicinity of pallet stations 6 and 7. Four additional locks were located in the same area.Item 37 · .PDF · 83 KBStructures 7 - Photo 23. View of the aircraft wreckage after recovery.Item 38 · .PDF · 36 KBStructures 7 - Appendix C - PEMCO Engineering Pallet Locking Assembly ReportItem 39 · .PDF · 310 KBStructures 7 - Errata/Addendum to Factual Report of Group ChairmanItem 40 · .PDF · 43 KBPowerplants 8 - Factual Report of Group ChairmanItem 41 · .PDF · 570 KBPowerplants 8. Photo 1. Aerial View of Aircraft WreckageItem 42 · .PDF · 62 KBPowerplants 8. Photo 2. Number 1 Engine Front ViewItem 43 · .PDF · 44 KBPowerplants 8. Photo 3. Number 1 Engine Side ViewItem 44 · .PDF · 59 KBPowerplants 8. Photo 4. Number 1 Engine Rear ViewItem 45 · .PDF · 60 KBPowerplants 8. Photo 5. Number 2 Engine Front ViewItem 46 · .PDF · 49 KBPowerplants 8. Photo 6. Number 2 Engine Side ViewItem 47 · .PDF · 60 KBPowerplants 8. Photo 7. Number 2 Engine Rear ViewItem 48 · .PDF · 49 KBPowerplants 8. Photo 8. Number 3 Engine Side ViewItem 49 · .PDF · 50 KBPowerplants 8. Photo 9. Number 3 Engine Rear ViewItem 50 · .PDF · 36 KBPowerplants 8. Photo 10. Number 3 Engine Rear ViewItem 51 · .PDF · 44 KBPowerplants 8. Photo 11. Number 4 Engine Front ViewItem 52 · .PDF · 43 KBPowerplants 8. Photo 12. Number 4 Engine Side ViewItem 53 · .PDF · 34 KBPowerplants 8. Photo 13. Number 4 Engine Rear ViewItem 54 · .PDF · 31 KBMaintenance Records 11 - Factual Report of Group ChairmanItem 55 · .PDF · 2.3 MBCockpit Voice Recorder 12 - Factual Report of Group ChairmanItem 56 · .PDF · 1.0 MBCockpit Voice Recorder 12 - Specialist's Sound Spectrum StudyItem 57 · .PDF · 593 KBAircraft Performance 13 - Factual Report of Group ChairmanItem 58 · .PDF · 2.2 MBAircraft Performance 13 - Addendum 1Item 59 · .PDF · 1.4 MBAircraft Performance 13 - Addendum 2Item 60 · .PDF · 117 KB
All 74 files on NTSB’s docket

FAA reports on this event · 1

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

Other investigations on N27UA · 1

Matched to the same aircraft by N-number and date.