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A I R C K A F T I N C I D E N T REPORT. E A S T E R N AIR L I N E S . INCORPORATED. BOEING 7 2 7 - 2 2 5 . N 8 8 4 3 E T O L E D O , OHIO. A P R I L 10, 1 9 7 3

N a t i o n a l T r a n s p o r t a t i o n S a f e t y Bo* rd W a s h i n g t o n , D. C .

'27 S e p t e m b e r 1 9 7 3

E.R.A.U. UBRARV DISTRIBUTED BY:

National Technical Information Senice U. S. DEPARTMENT OF COMMERCE 5285 Port Royal Road, Springfield Va. 22151

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AIRCRAFT INCIDENT REPORT EASTERN AIR LINES, INC. BOEING 727- 225, N8843E

Washington, D.C. 20591

Ill I.pro.,"'rd b"

NATIONAL TECHNICAL INFORMATION SERVICE

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I. Tl t le and Subtitle Aircraft Incident Reuort - I 5.Rcaart Data

TECHNICAL REPORT SI'ANOARD TITLE PAGE 2.Govsrnment Accesslon No.

NTSB-AAR-73-17

Eastern Air Lines. Inc. Boeing 727-215. N8843E. Toledo, Ohio April 10, 1973

-~ -I-.- - - - - ,September 27, 1973 6.Performlng Orgsnlzatlon

8.PerforminJ Organization- I. Author(s) Code

Report No.

).aiming Organizatlon Name and Address National 'Transportation Safety Bosrd Bureau of Aviation Safety Washington, D. C. 20591

1O.Work U n i t No. 1172

Il.Contract or Grant No.

I3.Type of Report and Perlod Covered

Aircraft Incident Report - ,Z.Sponrorlng Agency Name and Address

April 10, 1973

NATIONAL TRANSPORTATION SAFETY BOARD Washington, D. C. 20591 '14.Sponsoring Agency Code

5.Supplementary hotes This report contains Aviation Safety Recomnendation A-73-75.

l6.Abstract

approach t o Toledo Express Airport, Toledo, Ohio. The incident occurred et 1318 eastern standard tiam, Ap?.il 10, 1973. The leading edge and the t ra i l ing edge

or the crew. flap8 of the right w€ng were damaged. There were no injuries t o the passengers

An Eastern Air Lines Boeing 727-225 struck some trees during an instruuent

a nornal approach and landing without further incident. Polloving the tree str ike, the f l igh t executed a miaaed approach and made

The National Transportation Safety Board determines that the probable calme of th i s incident was the fai lure of the flightdrev to adhere t o established pro- cedures, which resulted i n a descent below the autho,lred minimum descent al t i- tude and an impact with.the trees.

?.Key Words Instrument approach,snowshower, t rees , descent: This document is available to below minimum descent al t i tude, trisscd approach, leading edge and t rai l ing edge w i n g flaps.

the public through t h e h t i o o

Servlce. Springfield, Vir- a l Technical l n f o m t i o n

9.Serurity Classifi- .tion 2O.Security Classification 21.No. of Pages 22.Frice -

(of t h i s report) (of this page) UNCLASSIFIED UNCLASSIFIED 10 /

pPS8 Fozm 1765.2 (11/70) ~q,7.;

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TABLE OF CONTENTS

Synopsis . . . ,. . . . . . . . . . . . . . . . . . . . . . . Investigation . . . . . . . . . . . . . . . . . . . . . . . . AnalytIis . . . . . . . . . . . . . . . . . . . . . . . . . . Rob?b'.; Sauae . . . . . . . . . . . . . . . . . . . . . . . Reconunendations . . . . . . . . . . . . . . . . . . . . . . . Appendices

Appendix A - Crew Information . . . . . . . . . . . . . Appendix B - Aircraft Informarion . . . . . . . . . . .

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tion relevant to the probable cause and safety message t o +his report contains the essential items of informa-

be derived from this accident/incident. However, for thosc hav'ing a need for more detailed informat,ion, the original factual report or ::&e ;;::-!e-t!incident is on file in the Washington office of the. National Transportation Safct)

mercially at an average cost of 1 5 c per page for printed Board. Upon request, the repo'rt will be teproduccd com-

matter and 820 per page for photographs, plus postage. (Ninimum ckarge is $4.00 3

Washington, D. C. business firm which holds the currcnt Copies L E material ordered will be, mailed from the

contract for commercial reproduction of the Board's public files. Billing is sent direct to the requester by that firm and includes a $2.00 user service charge by the Safety Board for special service. This charge is in addition to the cost of reproduction. No payments should be made to the National Transporta'ion Safety Board.

Requests for reproduction should'be forwarded to the:

National Transportation Safety Board Administrative Operations Division Accident Inquiries E Records Section Washington, D. C. 20591

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F i l e No. 4-0012 j

NATIONAL TRANSPOK'rATION SAFER BOARD Washington, D. C. 20591

AIRCRAFT INCIDEI? REPORT

Adopted: September ' 2 7 , 1973 - EASTERN A I R LINES, INt. BOEING 727-225, N8843E

TOLEDO, OHIO APRIL ' 10, 1973

SYNOPSIS

ing an instrument approach t o Runway 25.011 the Toledo Express Ai rpor t ,

Apr i l 10, 1973. Damage t o the a ! v r a f t was l im i t ed Lo the 1ead.ing edge Toledo, Ohio. The inc ident occurred a t 1318 ea s t e rn standard time,

and t r a i l i n g edge f l a p s of the r i g h t wing, There wers no i n j u r i e s t o the 30 passengers or t o ' the 7 crewmenhers aboard the a i r c r a f t .

An Eastern Air Lines Boeing 727-225 s t ruck some trees while execut-

The incident occurred a s the a i r c r a f t passed through a snowshower which was s i t ua t ed near the approach path t o the a i r p o r t . The instrument approach was abandoned, and a second approach and landing were accomplished without fu r the r inc ident .

cause of t h i s inc ident was the f a i l u r e of the f l ightcrew t o adhere t o

minimum descent a l t i t u d e and an impact wi th . the trees. es tab l i shed procedures, which resu l ted in a descent below the authorized

The National Transportat ion Safety Roard determines t h a t t h e probable

Safety Board made a reconmendation t o the Federal Aviation Admi.nistra- t i o n emphasizing the importance of adherence t p c r i t i c a l opera t iona l procedures such as a l t i t u d e awareness.

As a r e s u l t of t h i s inc ident and accidents of a s imi l a r na ture , the

INVESTIGATLOll

F l igh t 322 on Apri l 10, 1973, was a sr.hedu1.d passenger f l i g h t from Eastern Air L i n e s , Inc. , Boeing 727-225, N8843E, operat ing a s

Pensncola, Florida, to De t ro i t , Michigan, w i th scheduled en rou t e s tops

Ohio. While executing a l oca l i ze r back course instrumcnt approach t o a t At lan ta , Georgia; Char lo t te , North Carolina; and Columbus and Toledo,

Runwaj 25 on the Toledo &press Ai rpor t , Tnld-, Ohio, 1 . k a i r c r a f t s t ruck some Crees. The inc ident occurred at 1318 eas t e rn standard time.

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According t o the f l igh tcrew, the f l i g h t was rou t ine u n t i l i t passed the f i n a l approach f i x @AF) inbound a t Toledo. A t t h a t time the cap- tai ,n was a t the con t ro l s , and he was abvised by t h e tower. ". . . SIIOW

b i l i t y t o the e a s t is -- ah -- about a mile nnd a ha l f ." Shor t ly there- storm is Jus t moving ac ra s s the approach end of Runway twenty- five, visi-

a f t e r , the f l i g h t ' e n t e r e d the snowshower. r i ng the descent from t h e FAF t o che minimum descent a l t i t u d e (MDA) ,J'the f i r s t o f f i c e r d e the required announcements a t the 1,000-Ldt height above touchdown (HAT) and the 600-foot HAT, but he did not announce the 500-foot HAT or MDA, a,s required by company procedures. During f l igh tc rew i n t e r - views,, the cap t a in , t h e f i r s t o f f i c e r , and o f f i c e r s t a r ed t h a t they were not aware of the requi1,ement to u n t i l they were

"informed about i t after t h i s inc ident . , ,

while the a i r c r a f t was approachiry: t h e 400-foot HAT s h o r t l y before e- mergiag from t h e snowshower. He was looking f o r t h e rumiay when he heard the cap ta in apply power, and he s t a t e d f u r t h e r that ' I . . . w e w-re still descending and s t i l l increas ing Fower. I s t a r t e d f ee l i ng uneasy about

those trees.'" The cap ta in r e p l i e i t o the e f f e c t , "I do now." The cap-' the cap t a in not applyins power any f a s t e r and I sa id , 'Captain do you see

the prescr ibed a l t i t u d e . . t a in s t a t e d t h a t . h e could not expla in the reasnn f o r t h e descent below

The f i r s t o f f i d e r s t a t e d that he had made gr'ound c o n t a c t ' v i s u a l l y

The f l i g h t d a t a recorder d i sc losed na decrease i n the r a t e of des- cent a t MDA; ' i n f a c t , i t recorded an fncrease i n t h e rate of descent a f t e r the A i r c r a f t passed through MDA.

A tower c o n t r o l l e r , who say the a i r c r a f t emerge from the snowshwer a t t r ee top l e v e l i n a s l i g h t l y nosedown a t t i t u d e , advise", "Three twenty two-ah-go-around!" According t o t he f l igh tcrew, they had a l ready i n i - t i a t e d the go-around when they received this t ransmission from the t w e r .

After t h e a i r c r a f t strucK the trees, the f l i g h t ccntinued the missed

Runway 25 were accomplished. The remainder of t h e f l i g h t ' s schedule was approach without fu r the r incident . A second approach and landing on

then cancel led.

The t r e e s s t ruck by F l igh t 322 were located approximately 6,900 f e e t from the approach end of Runway 25 and approximately 110 f e e t t o the r i g h t of t h e extended runway cen te r l i ne . The ground e l eva t ion a t

- 1/ Minimum Descent A l t i t ude - the lowest a l t i t u d e , oxpressed i n f e e t above mean sea l eve l , t o which descent is anthorized on f i n a l ap- pro:.-:,. Descent below HDA is not authorfhed unless the -4 rc rn f t is in a pos i t i on from whtch a normal approach to the runway of in-

runway or approach 1i ; lhts or other marking i d e n t i f i a b l e with the tended landing can be Fade, and the approach threshold of t h a t

approach end of tha: runway a r e c l e a r l y v i s i b l e to the p i l o t .

the tree s t r i k e was 653 f e e t mean sea l e v e l ( m . s . l . ) , app rox imte ly 25 f e e t below the rumay ' threshold e leva t ion of 678 f e e i m.s.1. The Wee6 were broken approximatel>- 40 f e e t above the ground, or e.ome 15 f e e t above the rutway threshold e leva t ion .

a t the Holland In t e r sec t ion ( the in ' t e rsec t ion of t h e 2490 l o c a l i z e r course and the 347O r a d i a l of tke Va te rv i l l e VOR). The published mini- mum a l t i t u d e mer the FAF is 2 ,200 , f ee t m.s.1. (1,522 f e e t HAT). The d i s t ance from t h e FAF t o the runway threshold, which is a l s o t h e missed

w i t h a g l i d e s lope. The published s t r a i g h t- i n minimums for category "C" approach po in t , is 4.7 nau t i ca l miles. This approach is not equipped

a i r c r a f t are.MDA 1,WC feet m.s.1. '(3ti2 f e e t HAT), v i s ib i l i r : rhree- four ths of a mile.

The instrument appro;lch t o Runway 25 2/ c o n s i s t s of a FAF located

According t o company records, the fli$.tcrc; had success fu l ly ac- conplisked a l l required t ra in ing . However, the 500-foot a l t i t u d e and HDA c a l l o u t s , required by c o q a n y procedures, were not accomplished during tho approach. The f l i g h t c r m e m b e r s s t a t e d t h a t they were not aware of the requirement fo r an NDA c a l l o u t .

e a s t e r n standard time were reported as : The Toledo Express Ai rpor t sur face weather observat ions a t 1307

cast, v i s i b i l i t y 2 1/2 Gdles, l i g h t snow showers. wind "Part ly obscured, l , IOO'sca t te red , estimated 2,500 over-

from 290 degrees a t 13 knots , gus t s t o 20 knots, alt!.meter s e t t i n g 29.60 inches , snow obscuring 2/10 of t h e sky."

w i t h h igh- in tens i ty runway l i g h t s . The runway l i g h t s were operat ing. No approach l i g h t s were i n s t a l l e d for this runway. The runway erLd i d e n t i f i e r l i g h t s fo-: t h i s runway; which are owned by the United S t a t e s A i r Force, were not operat ing.

Runway 2S;whic.h i s 8,700' f e e t long and 150 f e e t wide, is equipped

a b l e a t the a i r p o r t stand by; nor did he advise ground personnel of t h e The cap ta in d i d not request that, ground energency equipment ava i l -

t r e e ? t r i k e .

Tower personnel became aware of the t r e e s t r i k e a f t e r they had received i n q u i r i e s Erom a l o c a l newspaper t h a t had been advised of t h e i nc iden t by a passelger .

barometric a l t i m e t e r s receiving a l t i t u d e i npu t s from the Air Data Computer

7 1 The approach p l a t e i n use ai: the time of t h i s i nc iden t was dated

The a i r c r a f t was equipped wi th f i v e a l t imeters : two servopneumt ic

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Ju ly 6 , 1972.

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and a ' r a d i o a l t imeter i n s t a l l e d on the cap ta in ' s instrument panel; a l s o , a conventional barometric a l t ime te r . and a r a d i o a l t ime te r i n s t a l l e d in the f i r s t o f f i c e r ' s panel,

The station ag,ent ,provided the altimeter Pe t t ing t h a t would make

o f f i c e r ' s barometric a l t ime te r read zero on landing. The c a p t a i n ' s No. the cap ta in ' s No. 1 servopneumtic barometric altimeter and the f i r s t

2 servopneumtic barometric a l t ime te r wa8 aet t o the s t a t i o n sea l e v e l pressure,, t o make i t the' same as m.s.1. e leva t ion on landing. The cap-

meters he had.been uonitoring. t a i n could not ' recall which me of his servopneumatic barometric a l t i-

meter at Toledo Express Airport , disclosed no malfunctions pe r t i nen t t o t h i s inc ident . Althouxn there rrre .i&e S m a l l a l t ime te r e r r o r e and a small e r r o r i n the a l t ime t ry information provided by tke s t a t i o n , t h e cumulative e r r o r s were minor.' With the co r r ec t baromewic pressure set i n t o the altimeters, che ,capta in ' s altimeter read 50 f e e t lower than the Cield e leva t ion , and the f i r s l ' o f f i c e r ' s altimeter read 20 f e e t lower.

Fwwtiona l t e s t i n g of , a l l ' a l t ime te r s , including the s t a t i o n &:ti-

ANALYSIS

Of p r i m r y concern in the ana lys i s of t h i s i n r f d m t is the reason

wi th the airpr:: crx%auaent. Since mechanical f a i l u r e s of t h e a i r c r a f t f o r the descent below t h e uubllsh+.l d.: 'YoLrrra v i s u a l contac t was made

include: misse t t ing o r misreading of the a l t ime te r s , malfunction of the :r +<iacional emergencies were not in evidence, o the r reasons constdered

a l t ime te r s , f a i l u r e of t h e crew to m n i t o r a l t i t u d e during the approach, and an in t en t iona l deacbnt below the NBP. i n an attempt t o e s t a b l i s h and maintain v i s u a l re fe renca t o , t h e ground. Each of these p o s s i b i l i t i e s w a s considered in l i g h t of the information developed during t h e invest$- gat ion. Missettlng or misreading of the a l t i m e t e r s , a s wcll a s malfunction of the altimeters, were r e j ec t ed f o r the following reasons:

1. Misset t ing or misreading of the a l t imeters .

set properly and were cross-checked during the in-range por t ion of t h e , ap- According t o statements N d e by the f l igh tcrew, a l l a l t i m e t e r s were

proach. This procedure is in accordance with company prac t ice . The crew a l s o s t a t ed t 5 a t no changes t o these s e t t i n g s were made by them u n t i l just before deplaning. A t t ha t time, t h e f i r s t o f f i c e r attempted a cross-ch-ck of t h e a1:imetcr system and found no discrepancles . Misreading8 of a l t i - meters normally occur when changes of a l t i t u d e of more than 1,000 f e e t are mde . I n nearly a11 C ; I S F S ' . t F - - ' ..'- f e e t or 10,000 f e e t . In t h i s case , the f i r s t o t f i c e r made a c a l l o u t a t

. ..-Lvc rending e r r o r s of exac t ly 1,000

600 f e e t , and sho r t l y t he rea f t e r s ighted the ground and the trees. As- suming that the capta in checked h i s a l t ime te r when the a l t i t u d e cal louts ,

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were made, i t would have been necessary f o r both p i l o t s . t o have misread t h e i r altimters i d e n t i c a l l y f o r an ,e r ror t o have gone unnoticed. '

The last a l t i nwte r reading which the cap t a in could r r c a l l was 400 , I

f .ee t , which Is c lose ly associated with t i t ' - MOA of 1.040 m.s.l., (362 f e e t a b w e touchdown). &lowever, he could not r e c a l l from which of h i s two a l t ime te r s he had obta,ined t h i s reading.

which was Ret f o r s t a t i o p sea level pressure , the a i x r a f t would have been 278 f e e t below the a i r p o r t elevstion of 678 f e e t m.s.1. Therefore, the cap ta in could not have read the 400 feet on the No. 2 , a l t f m e t e r be- cause the a i r c r a f t would have impacted the gtourtd at nest' a No. 2 a l t i - &ter reading of 678 fec'e. Furtheruore, a t the time the No. 1 a l t i m e t e r , which is set t o read zero a l t i t u d e st touchdown, was reading 400 f e e t ,

two readings a r e d i s s imi l a r in appearance are not compatible v i th the No. 2 a l t imeter should ,have been ,reading 1,078 f e e t m. s .1 . Theoe

misreading of a l t i t u d e . It i s concluded, therefore , that the capta in d i d read the c o r r e c t altimeter' (No. 1); however, he d id not t ake appropr ia te ac t i on t o l eve l the a i r c r a f t a s prescr ibed in t h e approach procedures.

2 . ~ a l f u n o t i o n s of the' a l t ime te r s .

i f the cap ta in had obtained t h i s reading from the No. 2 a l t i m e t e r ,

ramp a t Toledo Express Ai rpor t , and a l l were found t o be well w i t h i n the

was 50 f e e t . Therefore, an altimeter malfunction was not considered to allowable tolerances. The maximum d i f f e r e n t i a l between 3ny two a l t i m e t e r s

be in the causa l area.

The three barometric a l t i m e t e r s were tes ted i n the a i r c r a f t on the

that the descent below MDA was caused by the f a i l u r e of the f l igh tprew

l a y have been i n t e n t upon making v i s u a l contac t with the h i r p o r t environ- t o monitor the a l t i m e t e r s ,deqilatrly during the approach. Both p i l o t s

ment a s soon as poss ib le in order t o avoid the neces s i t y f o r a missed ap-

with good crew d i s c i p l i n e during an approach fo r a landing under i n s t r u - proach. This in no way rel ieved them of the, r e s p o n s i b i l i t i e s c o n s i s t e n t

mene f l i g h t condi t icns .

.With the e l imina t ion of these p o s s i b i l i t i e s , the Board mus't consider

The f a c t s i n t h i s inc ident a r e well def ined. There was LO altimeter e r r o r o r m a l f u n c t i o n of enough magnitude t o have caused t h e p i l o t to descend 349 f e e t below t h e MDA. In f a c t , i f the MDA had been observed

been descended would have been 412 f e e t HAT, o r 50 f e e t above MDA. on the altimeters, the mlnimum a l t i t u d e t o which tLe a i r c r . l f t would have

The Board rrmst conclude, from t h i s and o ther recent acc iden t s and inc iden t s of s imi l a r na tu re , t ha t izadequate a t t e n t i o n t o c r i t i c a l opera- t i o n a l procedures is a dominant causa t ive f ac to r . It i s imperat ive chat

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the ind iv idua l p i l o t recognize the onset of i n a t t e n t i o n i n himself and in o the r s of h i s crew. It may be combatted by the adherencc t o pro- fe s s iona l btandards.' These stdndards mst be msiritained by a l e r t n e s s , by cockpit d i s c i p l i n e , bv s t r ict , adherence t o established procedures, and by prompt, pos i t i ve cor rec t ion of any devia t ion therefrom.

PRCdABLE CAUSE

The na t iona l Transportat ion Safety Board determines t h a t the prob- ab le cause of t h i s incident was the f a i l u r e of the flightcx-ew t o adhere t o es tab l i shed procedures, which r e su l t ed in a descent below the author- iced minimum descent a l t i t u d e and an impact ,with the trees.

RECOMMENDATION

The National Transportat ion Safe ty Board recommends tha t :

The Federal Aviation Administration t ransmit a copy of t h i s r epo r t

management of each operator Rake a copy of t h e r epo r t ava i l ab l e t o t h e i r t o a l l Pa r t 121 and 135 opera tors , wi th an acconpanying reques t t h a t the

f l ightcrews a d use every means t o rpaintain an e f f e c t i v e progrm of com- pany c . o m n i c a t i o n s , emphasizing the importance of adherence t o c r i t i c a l opera t iona l procedures such a s a l t i t u d e c a l l o u t s . (Aviation Safety Recommendation A-73-75).

BY THE NATIONAL TRANSPORTATION SAFETY BOARD:

/ S I JOHN H. REED Chairmn

I s / LOUIS M. THIAYER ?[ember

/s/ ISAHEL A . l<IRtiESS Elember

I s / - IdILl.1AI.I R . HALEY Elember

September 27 , ,1973

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CRW INFORMATION

Captain Thorns A. Woodward, aged '46, held A i r i i n e Transport P i l o t C e r t i f i c a t e No. 1150759. He held type r a t i n g s f o r t h e Convafr 240/340/440 (and the Roetng 727. His f i r s t - c l a s s medical c e r t i f i c a t e , dated Jal1ualy 30, 1973, l i q t ed no 1ir.d.tatiens. He had accumulated a t o t a l of 6,212 f l i g h t hours , of which 1,400 were i n the Boeing 727.

, F i r s t Of f i ce r James R. Sandusky, aged 41; held A i r l i ne Transport P i l o t C e r t i f i c a t e No. 1390701 with c o m r c i a l p r iv i l eges iu a i r c r a f t , single- and multiengine land. His f i r s t - c l a s s medical c e r t i f i c a t e ,

'05 5,244 f l i g h t hours, of which 1,015 were i n the Eoeing 727. dated Elarch 19, 1973, l i s t e d no l imi t a t i ons . He had accumulated a t o t a l

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Crrt i f ica:e No. 1537034 with single- and m i t i e n g i n e land, he l icopter . and f l iF,ut i n s t r u c t o r pr ivi lep,es . He a l s o held r a t i n g s a s a Flight' E n g i n e c x , both t u rbo je t and turboprop. PIS f i r s t - c l a s s medical c e r t i - f i c a t l , dated August 15, 1972, l i s t e d no r e s t r i c t i o n s . Re had accumu- la ted a t o t a l of 1,884 f l i g h t hours a s a f l i g h t engineer. of which 1,659 were i n the Boeing '?7.

Second Off icer William P. Ceese, aged 30, held Comnercial P i l o t

compliance wit ! .the appl icab le Federal Aviation Regula t ims . The th ree f l i g h t crmtlen~be,rs were c e r t i f i c d t e d and qua l i f ied i n

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