Aircraft Accident Analysis: Final Reports / Edition 1

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Fascinating and factual accounts of the world’s most recent and compelling crashes

Industry insiders James Walters and Robert Sumwalt, trained aviation accident investigators and commercial airline pilots, offer expert analyses of notable and recent aircraft accidents in this eye-opening, lesson-filled case file. Culled from final reports issued by military and foreign government investigations, as well as additional research and resources, Aircraft Accident Analysis: Final Reports tells the final and full tales of doomed flights that stopped the world cold in their wake.

Technical accuracy and details, presented in layman’s language, help to clarify:

  • Major accidents from commercial, military, and general aviation flights
  • Pilot backgrounds and flight histories
  • Chronology of events leading to each accident
  • Description of aviation investigation process
  • Insight into NTSB, military, and foreign government findings
  • Resulting recommendations, requirements, and policy changes

Readable, authoritative, and complete, Aircraft Accident Analysis: Final Reports is at once an important reference tool and a riveting, what-went-wrong look at air safety for everyone who flies.

Featured final and preview reports include:

  • U.S. Air Force, U.S Commerce Secretary Ron Brown, Dubrovnik, Croatia
  • Jessica Dubroff, Cheyenne, Wyoming
  • Valujet Airlines 592, Everglades, Florida
  • American Airlines 955, Cali, Columbia
  • John Denver, Pacific Grove, California
  • Atlantic Southeast Airlines, Carrollton, Georgia
  • US Air 427, Pittsburgh, Pennsylvania
  • TWA 800, Long Island, New York
  • Delta Air Lines, LaGuardia Airport, New York
  • John F. Kennedy, Jr., Martha’s Vineyard, Massachusetts
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Editorial Reviews

Covering commercial, general, and military aviation in the United States, this work surveys 18 specific aircraft accidents, summarizing the investigation and findings of the various investigative bodies charged with discovering what went wrong. The majority of the chapters discuss major carrier accidents and provide information on flight background, investigations and findings, National Transportation Safety Board recommendations, and subsequent industry action. Annotation c. Book News, Inc., Portland, OR (
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Product Details

  • ISBN-13: 9780071351492
  • Publisher: McGraw-Hill Professional Publishing
  • Publication date: 1/26/2000
  • Edition number: 1
  • Pages: 400
  • Sales rank: 820,212
  • Product dimensions: 6.20 (w) x 8.90 (h) x 0.90 (d)

Meet the Author

James Walters is a Captain with a major U.S. airline and is Chairman of the Accident Investigation Board for the Airline Pilots Association, International. He is completing studies toward a master's degree in aeronautical science/safety from Embry Riddle Aeronautical University and is a graduate of the Transportation Safety Institute. He frequently participates in National Transportation Safety Board accident investigations and disaster preparedness training exercises conducted by airports worldwide.

Robert Sumwalt is a Captain for a major international airline. Having received training as an aircraft accident investigator from the NTSB, he participates in air carrier accident investigations and also in aviation safety research. A consultant to the NASA Aviation Safety Reporting System, he is the author of numerous aviation articles, training texts, and manuals on aircraft operations, human factors, aircraft accident investigation, and airline policies and procedures.

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Table of Contents

Abbreviations xvii
Preface xxiii
Introduction xxvii
Part 1 Major air carrier accidents
1. The longest investigation in U.S. history: USAir flight 427 1
Flight history and background 2
The investigation and findings 5
The roll event 9
Left rudder deflection 11
Boeing 737 rudder system 11
NTSB testing of the PCU and servo valve 14
Rudder reversals during secondary slide jam 17
Other significant roll/yaw events 18
Crossover airspeed 20
Human performance 21
Conclusions 24
Rudder jam/reversal scenario 25
Pilot input scenario 26
Unfinished business: United 585 and Eastwind 517 27
Lack of FDR information 28
Probable cause 28
Recommendations 29
Industry actions 30
Epilogue 31
References and additional reading 32
2. Pressure falling rapidly: American 1572's brush with disaster 33
Flight history and background 34
The investigation 41
Adequacy of weather information 41
Altimeter settings 42
Descent below MDA 42
Terminal Instrument Approach Procedures (TERPS) 43
Airport issues 44
Flight after the tree strike 45
Evacuation issues 46
Conclusions and probable cause 46
Recommendations 46
Industry action 47
Actions taken by American Airlines 48
Epilogue 50
References and additional reading 50
3. El Deluvio claims American 965 51
Flight history and background 51
The rescue 59
The investigation and findings 60
Research away from the crash site 61
The decision to accept Runway 19 61
Situational awareness 62
Awareness of terrain 62
Automation 64
Crew Resource Management (CRM) 65
Speedbrakes 65
Conclusions and probable causes 66
Contributing factors 66
Other submissions to the report 67
Recommendations 68
Industry action 70
Actions taken by American Airlines 72
Epilogue 72
References and additional reading 73
4. A tale of two tragedies: Bergenair 301 and Aeroperu 603 75
Birgenair, flight history and background 76
The investigation and findings 79
Conclusions and probable cause 85
Recommendations 86
Industry action 86
Aeroperu, flight history and background 87
The investigation and findings 93
Conclusions and probable cause 95
Recommendations 95
Industry action 96
Epilogue 97
References and additional reading 97
5. Carnage in the Everglades: The flight of Valujet 592 99
Flight history and background 100
The investigation 103
Forward cargo bin reconstructed 105
Flammable cargo 106
Outdated oxygen generators 108
Contracting for vital services 109
Time pressure on the shop floor 109
Documentation for removing/replacing oxygen generators 110
Removal of oxygen generators: The maintenance process 112
Packaging and shipping of oxygen generators 113
Oxygen generator fire tests 114
Conclusions 115
Fire initiation and propagation 116
Flight profile after eruption 117
Cargo compartment fire/smoke detection and extinguishing 119
The way ValuJet conducted business 120
FAA oversight 121
The probable causes 123
Recommendations 123
Industry action 126
Epilogue 128
References and additional reading 129
6. A pilot's nightmare: The inflight fire of FedEx 1406 131
Flight history and background 131
Emergency response 139
The investigation and findings 140
Origin of fire 140
Ignition source of fire 142
Flightcrew action 145
Dissemination of hazardous materials information 145
Conclusions and probable cause 146
Recommendations 147
Industry action 148
Epilogue 149
References and additional reading 150
7. Contact approach: A close call for Delta 554 151
Flight history and background 152
The investigation and findings 156
Weather 157
Airport issues 158
The aircraft 159
Flight data recorder information 160
Captain's use of monovision contact lenses 162
Visual cues and illusions 164
Conclusions 164
Delta 554's final approach 165
The probable cause 167
Recommendations 168
Industry action 169
Epilogue 170
References and additional reading 170
8. A final evaluation flight for Airborne Express 171
Flight history and background 171
The investigation and findings 176
Flightcrew factors 176
ABX FEF procedures 180
FAA oversight 180
Conclusions and probable cause 181
Recommendations 181
Industry action 182
Epilogue 184
References and additional reading 184
9. Waiting for rescue: an agonizing night for KAL 801 187
Flight history and background 187
The rescue 197
The investigation and findings 198
The weather 198
Flightcrew actions 199
Flightcrew training 202
Air traffic control 203
KCAB oversight of KAL 204
FAA oversight of KAL 205
Emergency response 206
Other issues 207
Conclusions and probable cause 207
Recommendations 207
Epilogue 209
References and additional reading 210
Part 2 Regional airline accidents
10. Along for the ride: The final descent of ASA 529 211
Flight history and background 211
The rescue 215
The investigation and findings 216
The 14RF-9 propeller design 218
The propeller installed on N256AS 220
History of the 14RF-9 propeller 220
Service history of the accident propeller 222
Weather 222
Communications 222
Conclusions and probable cause 223
Party submissions 224
Recommendations 224
Industry action 226
Epilogue 228
References and additional reading 228
11. Quandary at Quincy: The runway collision of United Express 5925 and Beechcraft King Air N1127D 229
Flight history and background 230
Rescue attempt 233
The investigation and findings 234
King Air's mission and occupants 235
King Air's takeoff distance and accelerate stop time and distance 238
Visibility and conspicuity tests 238
Conclusions 240
Performance of the United Express flightcrew 240
Performance of the King Air pilot and pilot/passenger 246
Performance of the Cherokee pilot 247
Survivability issues 248
The probable cause 249
Recommendations 250
Industry action 251
Epilogue 251
References and additional reading 252
12. Dangerous misconceptions: The legacy of Comair 3272 253
Flight history and background 254
The investigation and findings 258
Wake turbulence 259
Icing 259
EMB-120 development and certification 260
Weather 262
NTSB performance studies 263
History of related icing incidents 265
Pilot actions 266
FAA oversight 268
Conclusion and probable causes 270
Industry action prior to publication of the final report 270
Recommendations 272
Further industry action 273
Epilogue 275
References and additional reading 275
Part 3 Military accidents
13. A missed approach: The fatal flight of Commerce Secretary Ron Brown 277
Flight history and background 278
Accident response 285
The investigation and findings 286
The aircraft 287
The pilots 288
Weather 289
Navigational aids and facilities 289
Design of the NDB Runway 12 approach 290
Air Force supervisory responsibilities 291
Operational pressure 294
Other issues 294
Conclusions and probable causes 294
Epilogue 296
References and additional reading 296
14. A lack of teamwork: HAVOC 58 impacts Sleeping Indian Mountain 299
Flight history and background 299
Emergency response 306
The investigation and findings 309
The aircraft 309
The Jackson Hole Airport 310
The squadron 313
The probable cause 316
Epilogue 317
References and additional reading 317
15. Have Blue: An airshow to remember 319
The aircraft 319
Flight history and background 320
The investigation and findings 327
On scene 328
Aircraft structure 329
Conclusions 333
The probable cause 333
Air Force action 334
Epilogue 334
References and additional reading 335
Part 4 General aviation accidents
16. Shattered dreams: A record-setting flight gone awry 337
Flight history and background 338
The investigation and findings 341
Aircraft weight and balance 341
Weather 341
Human factors issues 342
Conclusions 345
Reduced engine performance 346
Operational factors 347
The probable cause 349
Recommendations 348
Industry action 349
Epilogue 350
References and additional reading 350
17. Falling star: John Denver's final flight 351
Flight history and background 352
The investigation and findings 355
The aircraft 356
Pilot information 360
Fuel consumption tests 361
Other tests and research 362
Conclusions 362
Enhancing safety 365
The probable causes 366
Recommendations 366
Industry action 367
Epilogue 367
References and additional reading 368
18. The investigation continues 369
TWA 800 370
Swissair 111 370
American 1420 371
Glider accident, N807BB 371
John F. Kennedy, Jr. 372
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