1978: DC8 Portland. Dr. Frank Caron, 2008, v0.4, 1 Accidents and serious incidents
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1 1978: DC8 Portland General context 189 people on board Commercial flight JFK-Denver-Portland Descent and approach at Portland International Day light and good weather 1 Accidents and serious incidents
2 Operational context Landing gear is set down at 8000 feet No light indicating main gear fully down and locked Crew felt strange events: Unusual rapid landing gear extension Thump, knocks and jolts Aircraft yawing to the right Maintain 5000 feet for procedures 2 Accidents and serious incidents
3 Situation management During first 23 mn: Crew conversations Accomplished all of the emergency and precautionary actions available to them to assure themselves that all landing gear was locked in the full down position. FE checked the visual indicators on top of both wings 3 Accidents and serious incidents
4 Situation management (con'd) Contacts (6 mn, +29 mn) United Systems Line maintenance Control Center (Dispatch and maintenance) Captain explained: the landing gear problem, what the flight crew had done to assure that the landing gear was fully extended. reported about 7,000 lbs of fuel on board stated his intention to hold for another 15 or 20 minutes. was going to have the flight attendants prepare the passengers for emergency evacuation. 4 Accidents and serious incidents
5 Situation management (con'd) Conversations (7 mn, +36 mn) With CA1 concerning: passenger preparation crash landing procedures evacuation procedures FO raises 2 questions about fuel quantity Feed pumps lights start blinking (i.e. about 5000 lbs of fuel) Further conversation about landing gear status Captain request a current card on weight for another 15 mn FE responded: "Not enough. Fifteen minutes is gonna really run us low on fuel here." 5 Accidents and serious incidents
6 Situation management (con'd) Contact United OPS in Portland (2 mn, +38 mn) FO question about fuel FE responded: "4,000 lbs remained, 1,000 lbs in each tank" Captain sent the FE to the cabin to "...kinda see how things are going..." (4 mn, +42 mn) 2 conversations (4 mn, +46 mn) About giving CAs ample time to prepare for the emergency, About cockpit procedures (evacuation after landing, possible antiskid protection after landing, procedures used during approach and landing) FE returned and reported that the cabin would be ready in "another two or three minutes." 6 Accidents and serious incidents
7 Situation management (con'd) Conversation (3 mn, +49 mn) Captain-FE about pax and their attitudes to the emergency At this time Captain thinks he needs 3 to 5 minutes before starting approach Fuel status given to ATC: 3000 lbs Conversations (3 mn, +51 mn) Checking the landing gear warning horn as further evidence that the landing gear was fully down and locked Whether automatic spoilers and antiskid would operate normally with the landing gear circuit breakers pulled 7 Accidents and serious incidents
8 Situation management (end) FO says to Cpt engine #4 is stopping (+55 mn) Cpt: "Why? FO replied: "Fuel!" Cpt requested FE to reset that circuit breaker momentarily CVR revealed conflicting and confusing conversation between flight crewmembers as to the aircraft fuel status First request for an approach clearance (+56 mn, 19 nm from RWY) Cpt turned toward airport (+58 mn) Engines #1 & #2 stop (+61 mn) Mayday call (+62 mn) 8 Accidents and serious incidents
9 9 Accidents and serious incidents
10 Consequences Crashed into a wooded section of a populated area of suburban Portland 6 nm east southeast of the airport No fire (but no fuel) Aircraft destroyed Of 181 pax: 10 killed, 23 injured Of 8 crew members: 2 killed, 2 injured 10 Accidents and serious incidents
11 1978: DC8 Portland (end) Causes (NTSB conclusion) Captain failed to properly : Monitor the aircraft's fuel Respond with decisive and timely decisions Respond to the crewmember's advisories regarding fuel status To relate time and distance from the airport This resulted in fuel exhaustion to all engines Captain attention was directed completely towards: The diagnosis of the gear problem Preparation of the passengers for an emergency landing Contributing to the accident Failure of the other two flight crewmembers to: Fully comprehend the criticality of the fuel state Successfully communicate their concerns to the captain. 11 Accidents and serious incidents
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