KLM Prestwick Constellation Accident 1948

ICAO
CIRCULAR 18 - A N / I ~
CIRCULAR
JUNE 1951
AIRCRAFT ACCIDENT DIGEST

NO. I
Prepared in the Air Navigation Bureau

and published by authority of the Secretary G e n e r a l
INTERNATIONAL
CIVIL AVIATION
ORGANIZATION
MONTREAL CANADA
T h i s Publication is i s s u e d i n English, F r e n c h and Spanish.
Published in Montreal, Canada, by t h e

International Civil Aviation Organization.
Correspondence concerning publications
should be a d d r e s s e d to the S e c r e t a r y G e n e r a l
of ICAO, International Aviation Building,
1080 University S t r e e t , Montreal, Canada.
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In Canadian c u r r e n c y ($), to In Sterling o r 1 r i s h ' c u r r e n c y (s/d), to
S e c r e t a r y General, ICAO, The United Kingdom Stationery Office,

International Aviation Building, P.0. Box 569,
1080 University Street, London, S. E. 1,
Montreal, Canada. England.
(Cable a d d r e s s : ICAO MONTREAL); (Cable a d d r e s s : HEMSTONERY LONDON);
In F r e n c h c u r r e n c y ( f r ) , to In Egyptian c u r r e n c y ( m / m s ) , t o
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6obis, avenue dfICna, Wadie Saad Building,
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ICAO Representative, ICAO Representative,

South A m e r i c a n Office, F a r E a s t and P a c i f i c Office,
Apartado 680, 17 Robe S t r e e t ,
Lima, Perb. St. Kilda,
(Cable a d d r e s s : ICAOREP LIMA); Melbourne, A u s t r a l i a .
(Cable a d d r e s s : ICAOREP MELBOURNE).
ICAO Circular 18-8N/15 3
Foreword ......................................................... 7
m o t Error ..................................................... 11
P a r t I.- Sunrmarles of Aircraft Accident Reports ....................... 13
ICAO Ref.
-
BURMA
~~/119 Ullion of Burma Ahways, Dove a i r c r a f t XY-DRY crashed
22 November 1950 ...........................e..............

on take-off a t Plingaladon Airport, Burma, on
13
-
CANADA
AR/121
Gander Lake, Newfoundland, on 18 August 1950 ..............
Norseman V I a i r c r a f t CF-GFG crashed on take-off a t
15
Norseman V a i r c r a f t CF-OBH crashed near Ontario,
~./122
on 30 August 1950 .........................................
Timagami,
16
AR/123 M62A-3
Fairchild a i r c r a f t
P o d Huron, Michigan, U.S.A. on 1April 1950 ..............
CF-FXC, crashed north of
18
m/W Fleet 80 a i r c r a f t CF-ENT, crashed on landing at

St. John Airpod, Millidgeville, New B ~ w i c k yon
20 October 1950 .............a.m..................-........ 19
landing a t Sydney, N. S., on 13 December 1950 .............. 20

AR/125 Swissair, Douglas DG-4 a i r c r a f t HB-ILE, crashed on
AR/126
.
Canadian Pacific ALr Lines, Do~uglasDC-3 a i r c r a f t CF-CUF,
crashed a t Okanagan Mountain, B. C. on 22 December 1950 ... 22
ICAO Circular 18-8N/15
ICAO Ref,
mh27 D e b i l l a n d DH82C a i r c r a f t CF-COM, crashed near

Glenore&, Ontario, on 3 A p r i l 1951 ...................... 25
United UH-12 Helicopter CF-GKG, crashed near

Oshawa, Ontarf o, on 8 March 1951 ......................... 26
SAS, Douglas DC-6 a i r c r a f t SE-BDE, crashed on
landing a t Goose, Labrador, on 23 February 1951 o o . o . o o . o . 27
Lusconb $A a i r c r a f t CF-EJC, crashed on the south-

e a s t arm of Trout Lake, Ontario$ on 3 February 1951 , , , . .. 29
DeHavil-d DHC-2 a i r c r a f t CF-FHG, crashed a t
Lake Tessier, P o Q o , on 29 January 1951 ................... 30
Noo~duynNorseman V I a f r c r a f t CF-CPS, crashed at
Kirhness Lake, O n t a ~ i oon 23 December 1950 ............... 31
French registered a i r c r a f t F-BAYM, collided with

Danish Airlfnes DG-4 a i r c r a f t OP-DFI, whilst taxying
out f o r .takeoff from Copenhagen Airport, Kastrup,
on 26 July 1950 ~ O . O O O ~ O , e ~ ~ O O ~ o o O O o O o O ~ ~ ~ 33
O ~ o ~ ~ e o ~ ~ ~ ~
KLM, Constellation a i r c r a f t PH-TDF, crashed when

landing, near Santa CPUZ airf'ield, Bombay, on
12 July 194.9 ..OO~O.OOOOO..O..O.....O......O.............. 35
M M , 6 o n s b l l a t i o n aircraft PH-TEN, crashed near
Prestwfck, Scotlandon20October 194.8 .OO..O.O........... 42
,
Svensk Flygtjanst Ltdo F b e f l y S3-w~crashed during
a forced landing, near Kbge, Denmark, on 13 Jmuqv 1950 0
46
ICBO Circular 18-AN/l5
ICAI) Ref* UNION OF SOUTH aFRICA

w94 M l e s Gemini a i r c r a f t VP-RBK, crashed on take-off
from h d Airfield, Transvaal, on 1 April 1950 ...........
Piper Cub a i r c r a f t ZS-BAH, crashed near Letaba,
T~msvaal,on 12 September 1950 ..........................
.....................................
Bonanza a i r c r a f t ZS-BXM, crashed a t Pornfret, S.W.A.,
on 28 September 1950
BEAG Vik5ng & r e r a f t G-A1VL explosion about 30 miles

soath of Hastings, Sussex, on 13 April 1950 ..............
F a i r f l i g h t Lkd., Tudor V a i r c r a f t G-AKBY,
a t Llandow Airport, on 12 March 1950 .....................
crashed
Psoctor 3 a i r c r a f t G A J C U , crashed a t Brock Tho-'n

West Riding, Yorks,, on June 1950 .....................
Farm,
American Airlines, DC-6 a i r c r a f t N-90728, crashed a t

Eo~feField, Dallas, Texas on 29 November 1949 ............
Air Transperk Associates, Inc., 6-46F aircr&
IT-5095 crashed following take-off, north of Boeing
Field, Seattle, Washington, on 19 July 1949 ..............
Mercer Enterprises, Cessna T-50 a i r c r a f t N-61503
crashad a t Las Angeles, California on 1 October 1949 .....
Eastern A i r Lines, BC-4 a i r c r a f t N-88727, and a P-38
collided when landing a t Washington National Airport,
Washington, D.C., on 1 November 1949 .....................
,
Trwsocean Airlines Inc. DC-4 a i r c r a f t N-79998
ditched off Lurga Point I r i s h Coast, on 15 August 1949 .o.
Consolidated V t r l t e e BT-15 a i r c r a f t NC-63418

crashed off Pasadena, California, 28 April 1950 ..........
N ~ ~ h w e Airlines,
st Martin 202 a i r c r a f t N-93050,
erashed 4 miles west of Minneapolis, Bfinn,, on
7' & W C ~ 1950 ........................o.*..................
6 ICAO Circular 1 8 - ~ ~ / 1 5
ICAO Ref. UNITED STATES (Contd, )
AR/lO7 Private a i r c r a f t Cessna @.I and Piper PA-11,

collision near Miami, Florida, on 22 January 1950 ......... 68
AR/=O -
Northwest Airlines Inc., G54A DC a i r c r a f t
N-95425 crashed into Lake Michigan on 23 June 1950 ........ 69
AR/113
.................
Regina Cargo Aixlines Inc, G&F a i r c r a f t N-9aH
crashed a t Teterboro, N.J. on 27 May 1950 73,
m/m New Tribes Mission Douglas DC-3 a i r c r a f t No16030
9 June 1950 ............................................
crashed at Fonseca, Colombia, South America, on
72
AR/U~ Northwest Ahlines Inc., Martin 202 a i r c r a f t

Montana, on 4 September 1950 ..............................
N-93051 crashed during take-off from Billings,
73
AR/l.l8
................
Moritz Flying Service, collision between two Aeroncas
a t Sharon Springs, Kansas, on 30 April 1950 78
AR/l20
a t Almelund, Minnesota, on 13
October 1950 ................
Northwest Airlines Inc., Martin 202 a i r c r a f t NC-93037
79
Am33 PAA, Boeing 377 Stratocretiser aircraft N-1036V,

England, on 3 January 1951 ................................
l a n d b g gear retraction a t Heathrow Airport, London,
83 .
Part 11.- L i s t of Laws and Regulations ...........................~...~. $7
Part 111.- MiscelPaneous PubLications and Reports ................... .

, 99
SomeB r i t i s h Views on Flight Safety Measures .................... 103
Miscellaneous Extracts r e Accident Prevention ................... 113
- ICAO Circular ~ 8 - = ~ ~--
-- ----- /15 . -.-- 4
The Accident Investigation Division of the Air Navigation Commisai~nof

ICM at its firs%session i n 1946 recommended t h a t S t a t e s forward aopies of
r e p o r b of a i r c r a f t meident investigations and inquiries and aeronautical
pubfications and docwment~r e l a t i n g Px, researoh and development work i n the
f i e l d of a i r w a f t accidenli investigation to ICAO i n order t h a t the S e c r e t a r i a t
might appraise t h e infomation gained and disseminate the know1edge Con-
trac6ing States,
The f f r s t s v was issued i n October 1946 ( L i s t No, 1, Doc 217'7,

81~~056)
e n t i t l e d *Consalldated List of publications rand documents relaking b
Aircraf.t; Acefdent Inves%iga%PonReports and Procedures, Practices, Research
and Development work i n the f i e l d of Aircraf% Accident Investiga%ion re~eeived
by the I@MSeeretsuriaP, fanom Contxaeting Statesw, This was followed by *%her
swanwieas at regular in%emad.s, the Iaat r e p o r t being issued on 3 l July 1950
( ~eft No, 12- Doc 7026, AI6/5%3), These summary reports were f d ta Bs of
con~bderab1atechnical i n t e r e s t and extremely ussfila tx, States, and i n v i w i
of t h e Eaxge number of requests f o r copfee, i t was decidedz ear17 i n 1951, t o
~ e v i a ethe method of publication m d i n gutme to produce the material i n the
fcrr~31of an information I d l e t i n e n t i t l e d 'Aircraft Accident Mgestm,
! h i s is, therefore, %he firlst i s s u e under the new title, though PIhs
fsm and content a r e s W m %CJ that of previous reports, It is hoped thaL
Sta%ss will cooperate to the %ulPest extent t h e i r nationdl laws permit i n the
s u ~ s s i o nof material f o r ine~uesioni n fgtme' issues sf this Digest, 1% i a
reesgxdsed t h a t investigations take a diversity of farms under the varfetiy
of constlt.utiants3, and J u ~ i d l c i dsyrstems
. that e x i s t throughout the memhrsslbip
of ICAO, accident investigation prexien%irmg one of the h o t t i e a t p r o U a 8 o f
a$tmds~°Biziationni n inkrnettionerl! c i v i l aviation f o r t h i s very reason, A t %he
s a w time f % i a a most f r u i t ~ f dsource of material f o r t h e attainment of the
ob$ectivea of the Chicago Canveotfon,
8 ICAO Circular 18-AN/15 *
'%he usefulness of such a publication 88 t h i s is d i r e c t l y proportional

the t$3omghngss with oaHfch aeeidents are investigated, the frankness m d
h p a r k i d i t y of the findings, aaj readiness with which they are dlfscbssed
and mfhoriaed to be poxbEish@d, 1% is only i n t h i s way t h a t t h i s most Per-
t i l e f i e l d f o r international cooperation can be effectively exploited, The
measlare of i n t e r e s t which t h i s publication has aroused, and the salutory
e f f e c t s which the v i t a l intelligence it i m p d ~ shas had i n informing everyone
concerned before they have all indiviikzdly experienced the disastrous possi-
b i l i t i e s inherent i n the vee~ionssituations explored within its ewers, amply
dmonstzakes the p o s s f b ~ i t i e sof ultimate achievement when accident is
investigated with the greatest thorougbe$s and the findings disclosed wi%h
complete frankness.
'She ICAO Manrad of Aircraft Investigation is a valuable guide to se-

curing the information pequfred for aaeident prevention meamares and, whe%he~
availab1e f a c i l i t i e e a d resources g e d t of the f u l l e s t i n v e a t i g a t i ~ nor
not, ff it is followed to the gpeatest practicable extent, unfforrmity of
findings and usefulness sf the Digest w i l l be enhanced, Briefly, the i n t e l -
ligence required in order t o be ueeFul m a t include:
1 ) Aircraft me;
2) State of Registry;
3 ) Date and Place of Accident;

4) sf
R~~SUIBQ the Accident;
5 ) RermPt of the Technicerl Investigation;

6 ) Coneluaions ernd Reconmnenb%ions (lf any),
Any r e s t r i c t i o n upon rep~qducltPicsni n the Digest seriously igtpairs 0%

course the u s e f u h e s s of any report, as it is only by eonparison betmen %he
c i r m e t m o e s t h a t oochae%omed%he accident and the circumstances of sfier
operations that potentially tnsmaous cf scupapltanoee can be foreseen and avo%ded.
s!m!B
ACCIDENT TREND BY TPPE
Camnents
Landing 18 29.5% 16 12 31.6% ll *'%

' Decrease i n number but s l i g h t increase i n percentage.
(Normal o r emergency) S t i l l most prevalent type of accident r f t h p i l o t error
the main cause.
Structural Failure 4 6.6% 1 2.6% - - 4 6 An appreciable decrease presumably due t o better design
and maintenance.
Fire - Explosion 4 6.6% - 1 * 2.6% - -4 % * This case due t o sabotage by infernal machine.
Flying into t e r r a i n 11 18 % 10 # 5 13.26 5 - 4.89 Decrease of 50% i n t h i s major type of accident, where
the consequences are so often f a t a l .
Loss of control 5 8.2% 1 3 8 % 2 - .2k Included in t h i s category are accidents caused by

s t a l l i n g due t o p i l o t error, loas of control due to
icing, buffeting, gusts, etc.
mPBt 61 - 38 38 - 30 - The number of reportable accidents (ccmercial) has

dropped considerably during the l a s t year.
Accidents due to P i l o t Accidents due to Pilot
Error = 62.3% Error = 79% See page f o r discussion on these figures.
i
# P a r t i a l blam. i n two cases t o other personnel.
Note.- The t o t a l number of accidents auoted above has no siznification. nor should the above fieurea be used for s t a t i s t i c a l m s e s as they do not ~ r o v i d e4
gomlete ~ i c t u r edue to lack of information frm a number of Statep.
THIS PAGE INTENTIONALLY LEFT BLANK
-
.
-
--
ICAO Circular 18-~/15
-- --- la
B a T ERROR
Although the percentage of accidents due to pU.ot e r r o r shows an appre-

ciable increase over the previous year, t h i s is mainly due t o the reducfian of
aceidents fram other causes and the d i f f i d t y of evaluating s t a t i s t i e a l l y only
a limited number of reported aceidenthss. The figures convey, however, the a-
palatable bp1ication that, although coasiderab1e progress has been made in
increasing the r e l i a b i l i t y of the airplane, very l i t t l e has been accomplirsh8d
i n reducing the element of human error i n a i r o r a f t accidents.
Jt has been c l a h e d that the possibility of accidents i n flying i s inev-

i t a b l e by reason of the inherent conditions of flying which necessitate, be-
sides reliance on the technical. faator, considerable refiance upon the e t U B
judgment, nermry, and physical and pasgrehologieal conditions of the htman being,
These l a t k e r qualifications ean vary between different human beings and from
day t o dag i n the same huwm being, so that, d i k e the technical faetor,
which can be predicted f a i r l y ~ s u r a t e h y ,the probability and frequency of
accidents occurring due b the hmm factor, are extremely d i f f i c u l t t o predict
and therefore t o prevent,
Since human e r r o r i n r s f r e r d t operation is l e s s l i k e l y to be reduced

by innproving the human being tBm by a b p l i f y i n g the task t h a t is given t o
him, efforta t o reduce a.ccidenta by sore careful selection of personnel land
t h e i r training do not appear to have kept pace with the increasing demand upon
humm capabilities and though these e f f o r t s should be ceaseless they do lglof
necessarily represent the most profitable avenue t o e x p l ~ r e , A large propor-
t i o n of the accidents i n recent years could have been prevented Qr b e t t e r
f l y i n g qualities, a aore r e l i a b l e engines betbr weather forecasting, b e t t e r
lighted runways or some other improvement i n whatever it was t h a t made f l i g h t
~ 0 M i t i o r i 8so d i f f i d t t h a t the pilot, made a mistake, If a task is &ranel$
easy, errors i n i t s performance w i l l be eomespondingBy rare, Aa a task in-
creams i n difficulty, emore grow more frequent, It would seem, thereforep
%hat m r a ruay be reduced im number m d gravity by reduainag the d i f f i c u l t y
encountered by the human i n the p e r f o m c e ~f any taskn
12 -
ICAO Circular 1 8 - ~ ~ / 1 5 *
-
If accidents i n t h i s category are t o be reduced k t i a suggested t h a t

designers, operators, operating personnel and those responsible f o r preparing
air regulations, i n addition to aiming at leth hods f o r the prevention of rds-
takes and emergencies, must always have the following i n mind:
WGanwe, by the sigiplification of controls, equipment, procedures

and Pules, reduce the burden imposed on grmxnd and a i r personnel so
that any i n i t i a l mistake o r eraergency w i l l not be t o o great a lo& f o r
the human link, thereby precipitating further mistakes and an
ICBO Cfr c u l a r 1 8 - ~ / 1 5 13
PART I.- Summaries of Aircraft Accident Reports
-
ICAO REF : AR/119
Union of Burma Airways Dove Aircraft XY-ABR crashed on

take-off a t Minaaladon Aimort on 22 November, 1950
The a i r c r a f t commenced a normal take-off and when airborne, "wheels up"

was selected. Since sticking of the undercarriage s e l e c t o r knob was experienced
t h e radio operator was requested t o operate t h e undercarriage s a f e t y switch,
The undercarriage r e t r a c t e d normally and t h e a i r c r a f t immediately sank and struck
the runway. The p i l o t shut off power and t h e a i r c r a f t s l i d at high speed f o r a
considerable distance down the runway. The a i r c r a f t caught f i r e but all passen-
g e r s and crew were evacuated s a f e l y before the a i r c r a f t was almost completely
destroyed.
The pilot-in-command s t a t e d i n h i s evidence t h a t he had no idea of the

airspeed a t the time he r e t r a c t e d the undercarriage but he was s a t i s f f e d t h a t he
had t h e s a f e t y speed. Although T i l o t s Notest give 20 degrees of f l a p f o r take-
off no f l a p was used i n t h i s case a s the p i l o t f e l t t h a t , i n t h e event of engine
f a i l u r e a f t e r take-off, 20 degrees f l a p would make it more d i f f i c u l t t o handle
t h e a i r c r a f t on one engine, It was brought out i n the evidence t h a t i n handling
t h e undercarriage lever, which i s a t times awkward t o operate i n Dove tiircraft,
t h e a t t e n t i o n of t h e p i l o t can be distracted from a c t u a l f l i g h t .
The Board found a s follows:
1. The a i r c r a f t was airworthy a t t h e commencement of the f l i g h t ,
2. The a i r c r a f t was not overloaded and t h e load w a s c o r r e c t l y

d i s t r i b u t e d about t h e centre of gravity of t h e a i r c r a f t , despite the
fncorrect documentation.
14 ICAO Circular 18-~/15
3 a The aircraft; w a s pulled off a f t e r too short a take-off run at

a low &speed,
4 The undercarriage was retracted too early and before safety

speed w a s reached, whilst s t i l l a t a very low a l t i t u d e *
5, The a i r c r a f t sank back on t o the runway before the safety speed

was reached, T h i s m y be due t o either a thermal disturbance or t o the
f a c t t h a t the pi.lotss attention was distracted by d i f f i c u l t y i n retracting
the undercarriage*
6, The a i r c r a f t caught f i r e t o the rear of t h e starboard engine

nacelle while s t i l l sliding down the P,S,P, runway, due posszbly t o the
fracture of petrol pipes and e l e c t r i c a l circuits,
7. The p i l o t f a i l e d t o operate the f i r e extinguishers i n t h e engine

nacelles which might have prevented the outbreak of f i r e , ( m e i n e r t i a
switch of t h e s t a t i t e f i r e extinguishers i n the engine bays were not oper-
atbg due t o the r e l a t i v e l y slow acceleration) *
80 The airport f i r e tender delivered its f u l l complment of 2,500

gallons of foam, but was l a t e i n a r r i v a l as a r e s u l t of taking the un;ssrv-
iceable t a x i track, and t h e equipment on it was not applied t o the best
advantage due t o the inexperience of the crew, The fire burnt i t s e l f out
and the a i r c r a f t ww almost t o t a l l y destroyed,
9Q No l ~ s s
of l i f e OP injury occurred,
@- The d i f f i c u l t y experienced by the pilot i n undercarriage

retraction w a s not considered t o be a technical defect but merely t h a t the
p i l o t attempted t o r e t r a c t before the safety switch operated by the wheels
dropping t o t h e i r fU1 travel a f t e r the a i r c r a f t was airborne, had had time t o
mctjion, )
CANADA
___I
Norseman Aircraft CP-GPG crashed on take-off a t Gander Lake,

Newfoundland. on 18 Auaust 1950
Circumstances
A float-equipped Norseman VI f i r c r a f t taxied out t o take-off position on

Gander Lake, Newfoundland, with a p i l o t and one passenger on boardo Severed.
people watched the take-off and, according t o one witness, the a i r c r a f t never
did g e t on the s t e p but was pulled off the water i n a noae high a t t i t u d e and
semi-stalled oonditiono A t a height of roughly 10 t o 15 f e e t above the surface,
the l e f t wing went down and the a i r c r a f t began t o s i d e s l i p , continuing t o lose
heQ@t u n t i l the wing t i p struck the water causing the a i r c r a f t t o cartwheel
and p a r t i a l l y submerge
Xnvestinati on and Evidence
The p i l o t and paasenger died a s a r e s u l t of drowningo
b s p e c t i o n of the a i r c r a f t , and evidence of witnesses, f a i l e d t o disclose

any indication of malfunctioning of the a i r c r a f t , engine o r controls p r i o r t o
the crash,
Weather was s u i t a b l e f o r the f l i g h t , Although *,he a i r c r a f t d i d not take

off d i r e c t l y i n t o wind according t o the Gander Airways Weather report, the wind
v e l o c i t y was only 7 MoPoHo
The p i l o t held a valid Senior Commercial P i l o t Licence and had logged well
over 3,080 hoursD f l y i n g time,
16 ICAO Circular 18-AN/15
Conclusions
The immediate cause of the accident would appear t o be t h a t the l e f t wing

t i p of the a i r c r a f t came i n t o contact with the water following which the a i r -
c r a f t crashed and p a r t i a l l y submerged.
The major contributing f a c t o r e would appear t o be:
1 ) poor judgment on the p a r t of the p i l o t i n attempting a turn a t

approximately 1 5 f e e t above the water; and
2) poor technique on the p a r t of the p i l o t i n permitting the a i r -

craft to stallo
ICAO REF: w 1 2 2
Norseman Aircraft CP-OBH. crashed near Timanami,

pntario. on 30 A w s t 1950
C ircumstance s
The a i r c r a f t took off from Trout Lake, (North Bay), with p i l o t , engineer,
four passengers, and roughly 1,200 pounds of equipment f o r Timagemi, Ontario.
A fisherman on I n g a l l Lake s t a t e d t h a t he saw an a i r c r a f t f l y over a t roughly
1,200 f e e t and heard the engine cut out f o r a period of approximately ten
seconds then pick up againo It was t h i s man's opinion t h a t , although the engine
caught again, i t did not appear t o have the same power and sounded a s though
it was missing, B short time l a t e r , two men, located a t separate points on
the shore of Wilson Lake, heard an a i r c r a f t approaching and s t a t e d t h a t the
engine was sputtering and missing and t h a t the a i r c r a f t was losing height, One
of these witnesses s t a t e d t h a t j u s t before the a i r c r a f t went out of s i g h t it
banked steeply t o the r i g h t and then went i n t o a spino A fourth man i n h i s
cabin a t Milne Lake, heard an engine r o a r very loudly and then fade out three
times* The sound seemed t o be q u i t e close and he stepped out the door j u s t i n
time t o see the a i r c r a f t h i t the ground t h i r t y feet' awayo F i r e broke out
immediately and i n a matter of secondsthe a i r c r a f t was a mass of flameo
ICAO Circular 1 8 - ~ / 1 5 17
Investination and Evidence
The p i l o t , a i r engineer, and three passengers were f a t a l l y injuredo The

a i r c r a f t was written off,
The condition of the propeller indicated t h a t very l i t t l e power was being

developed a t the time of impact, The carburettor had been damaged by f i r e , and
the f u e l f i l t e r s could not be foundo There was s t i l l f u e l i n the tanks even
a f t e r the f i r e o The a i r c r a f t landed i n a small clearing surrounded by t r e e s
and cottages, and d id not move more than three f e e t from the point of i n i t i a l
contacto Weather was not conaidered t o have been a contributing factor.
The a i r c r a f t was overloaded by an estimated 173 pounds a t the time of the

accidento
The p i l o t transmitted the d i s t r e s s signal "MAYDAYn but no d e t a i l s of the

emergency were given
Between the' point where the engine was f i r s t reported t o have been
malfunctioning and the location of the accident, the a i r c r a f t passed over two
lakes which could have provided adequate space f o r a successful forced landing.
Gonclusions
The immediate cause of the aecident would appear t o be t h a t the engine

f a i l e d t o supply s u f f i c i e n t power t o maintain heighto
The major contributing f a c t o r would appear t o be poor judgrnent on the p a r t

of the p i l o t i n continuing the f l i g h t beyond two l a k e s where a forced landing
could have been made, a f t e r it became evident t h a t the engine was not operating
i n a normal mannero
18 ICAO Circular 1 8 - ~ / 1 5
ICAO E F : AR/122
Fairchild A i r c r a f t M62A-3, CF-FXC. crashed North of Port Huron,

Michigan, U.S.A. on 1 April 195Q
Circumstances
A t 2117 EST on 31 March, a i r c r a f t CF-FXC with p i l o t the sole occupant,

and w i t h s u f f i c i e n t f i e 1 f o r f o u r hoursD f l i g h t , took o f f from Buffalo, NoYe f o r
Detroit, Michigan. A VFR f l i g h t plan f i l e d by the p i l o t a t Buffalo gave E.T.A.
Detroit City Airport a t 0002 EST on 1 April 1950. After leaving Buffalo the
a i r c r a f t i s not known t o have been seen again i n the a i r .
Between 0045 and Q1QO EST on 1 April, an a i r c r a f t was heard running

smoothly by l o c a l residents a t Port Huron, Michigan. Moderate r a i n was f a l l i n g
a t the time blown by a wind of considerable velocity.
A t approximately 07OQ hours EST a resident of a beach cottage north of

Port Huron saw the t a i l section of the a i r c r a f t sticking out of the water about
1,000 f e e t from the shore, Subsequently the body of the p i l o t was found i n
shallow water o f f the adjacent beach, Death was due t o drowning.
Investigation and Evidence
The accident occurred o f f P o r t Huron, about 55 miles NEJE of the intended

destination, dpproximately seven gallons of f u e l remained i n the a i r c r a f t ' s
tanks. The landing l i g h t was turned on and the t h r o t t l e closed. The mixture
control was s e t t o nrichn. The radio was turned on and tuned t o approximately
290 KC/S. The a i r c r a f t was c e r t i f i e d f o r night flyings The p i l o t held a licence
v a l i d f o r day f l y i n g only.
Examination of the a i r c r a f t f a i l e d t o reveal any evidence of mechanical

f a i l u r e of the a i r c r a f t o r any of i t s components.
ICAO C ir c u l a r 18-AN/15 19
Conelusionp
While it was not possible t o determine the cause of the accident, i t i s

considered l i k e l y t h a t the p i l o t became l o s t and realized t h a t he was in danger
of running out of fuel and a s a r e s u l t attempted t o carry out a precautionary
landing which resulted i n hi8 death by drowningo
ICAO REF:
F l e e t 8b Aircraft CF-ENT, crashed on Landing a t S a i n t John Airwrt,

M i l l i d ~ e v i l l e ,NoB. on 20 October
At 1659 hours AST on 20 October, a l p c r a f t CF-EM' took o f f from MibPinocket,

Maine, UoSoA. f o r Mfllfdgevi%Pe, NBBo, with p i l o t and one passenger on board.
On 20 O c t ~ b %gfiOg
r nightp a s defined i n the Air Regulations, began i n
the MiLPedgevflle area a t 1 7 / ! hours ASTO In the p i l o t g s f l i g h t plan, one hour
and f i f t e e n minutes was shown f o r the time en route, thus giving 1812 hours AST
a s the estirrmated time of a r r i v a l a t M i l l i d g e ~ i l l e ~This time i s t h i r t y minutes
a f t e ~the beginning of night, a s defined i n the Air Re@ationsn The accident
occurred a t approxfm;ately 18% hours AST, forty-eight minutes a f t e r the
beginning of nighto The Saint John a i r p o r t a t MillidgeviPle i s not licensed
f o r night flying and the a i r c r a 4 t i t s e l f carried no l i g h t i n g equipment whatsoever.
During the f i n a l approach t o land, the starboard wing of the a i r c r a f t

collided with a one and one-half inch s t e e l water pipe which extended fourteen
f e e t above %he ground on the a i r p o r t and which had formerly been used by the
Royal Canadian Air Force as a l i g h t standardo This l i g h t standard is located
approximately two hundred and f i f t y - e i g h t f e e t t o the r i g h t of the nearest point
of runway 23-Q6, The a i r c r a f t swerved t o the r i g h t and remained airborne f o r
approximately two hundred and f i f t y f e e t , when it crashed and burst i n t o flameso
20 ICAO Circular 1 8 - ~ ~ 1 1 5
Investiaation and Evidence
The t e r r a i n where the l i g h t standard was located i s e i g h t and one-half

f e e t above the runway level. The top of the l i g h t standard thus protruded
twenty-two and one-half f e e t i n t o the a i r o
After s t r i k i n g the lamp standard, swerving t o the r i g h t , and continuing

f o r approximately two hundred and f i f t y f e e t i n the a i r , the a i r c r a f t struck
the ground i n a nose down a t t i t u d e with power on and burst i n t o flames. Thus
resulted i n the death of the p i l o t and serious t h i r d degree burns t o the
passenger.
A t the time of the accident, there was a t l e a s t two hours1 f u e l remaining

i n the tanks.
After s t r i k i n g an unlighted lamp standard, the a i r c r a f t struck the ground

i n a nose down a t t i t u d e and burst i n t o flames during an attempted night landing
a t an unlighted a i r p o r t . This s i t u a t i o n was caused by the p i l o t departing from
Millinocket with i n s u f f i c i e n t daylight remaining t o complete the f l i g h t t o
S a i n t John before night, a s defined i n the Air Regulations.
JCAO REF: &125
Swissair. Dowlas DC-A Aircraft. HB-ILE. crashed on Landinq

a t Sydney. N o s o on 1 3 December 1950
Circumstanceg
A t l4lO hours on 12 December, Swissair a i r c r a f t HB-ILE took o f f with

eleven crew and twenty passengers f o r New Pork, UoSeAo v i a Geneva, Switzerland;
Shannon, Ireland;*Gander, Canada.
The a i r c r a f t l e f t Shannon f o r Gander a t 2128 hours GMT on 12 December 1950

with Stephenville, Newfoundland, nominated a s the a l t e r n a t e airport. Due t o the
weather a t Gander, diversion t o Stephenville was considered and rejected i n
favour of proceeding t o Sydney and using Moncton a s the a l t e r n a t e airport. The
estimated time of a r r i v a l over Sydney was O95Q hours GMT. During the period
between 0924 hours GMT and the time of the accident, the f l i g h t was advised of
the weather conditions, including fog, a t Sydney and cleared by Honcton ATC t o
Sydney and t o descend and remain a t 4,QOQ f e e t o After establishing contact
with the Sydney Tower, normel routine clearanceswem obtained by the f l i g h t up
t o and including clearance t o lando Between 0954 and 0958 hours GMT the f l i g h t
advised8 "we can see a l l lights", a f t e r which, a t 0958 hours GMT the f l i g h t
advised: "on f i n a l m ; t o which the Tower replied: "clear t o landuo The Captain
had decided, fn view of the v i s i b i l i t y over the town of Sydney, and on the
downwind leg, t h a t he could carry out a landing by v i s u a l meanso
I n v e s t i ~ a t i o nand Fimdinas
During the l a s t stages of the f i n a l approach t o land, the F i r s t Officer

noticed t h a t the a i r c r a f t was too low i n r e l a t i o n t o the approach l i g h t s and
applied backward pressure t o the Control Colu?m9 a t the same time advising the
Captain t h a t they were too lowo Simultaneously, the Captain noticed the approach
l i g h t s and took corrective action and the F i r s t Officer released the C o n t r ~ l
Columno The a i r c r a f t then struck an approach l i g h t pole between numbers 1 and 2
engines, cutting o f f the top of the pole with one of the propellerso The a i r -
c r a f t continued ahead, s t r i k i n g two more approach l i g h t poles and breaking
them o f f o F u l l power s e t t i n g s were applied t o a l l engines a f t e r s t r i k i n g the
first poleo D i f f i c u l t y was experienced i n maintaining d i r e c t i o n a l control of
the a i r c r a f t due t o complete o r p a r t i a l f a i l u r e of Noo 1 engine and malfunetion-
ing of Noo 2 engineo Subsequent examination of numbers 1 and 2 propellers
indicated t h a t serious damage resulted t o both from impact with the approach
l i g h t poleso The ppopeller blades were found t o be a t d i f f e r e n t pitch angles,
( ~ n eblade of each propeller was i n the featherred position), causing low
t h r u s t from numbers 1 and 2 engines when f u l l power was appliedo This, i n turn,
caused the a i r c r a f t t o swing t o the l e f t , E f f o r t s t o r i g h t the a i r c r a f t were
unsueeessful and i t continued t o the l e f t , l o s t height, and struck the ground
i n a left-wing-how a t t i t u d e o
After the l e f t wing touched the ground, the a i r c r a f t continued along the
ground out of control, shearing off the l e f t wing j u s t inboard of the l e f t miin
gear attachment f i t t i n g s , and f i n a l l y came t o r e s t approximately 400 f e e t from
%he point of initial contact u i t h the gr-d, facing lqOO approximately from the
direction of approach, The fuselage, r i g h t wing, and r i g h t main landing gear
remained i n t a c t and engines numbers 3 and 4 were s t i l l operating a t f u l l power
22 ICAO Cfreular 18-AN/15
a f t e r the a i r c r a f t came t o r e s t , Engines 3 and 4 were shut down by the F i r s t

Officer and a l l passengers were successfillly evacuated through the main dooro
After the a i r c r a f t came t o r e s t , small f i r e s s t a r t e d i n the centre section

on the l e f t s i d e o These were put out by the crew, using a i r c r a f t f i r e
extinguishers. Between 25 and 32 minutes l a t e r , f i r e again broke out i n the
centre section but the crew was unable to control i t a s all extinguishers had
already been dischargedo Fire spread rapidly, destroying the major portion of
the fuselage and completely consuming the crew compartraent, cockpit and nose
section of the a i r c r a f t ,
Conclusions
,
The Captain, a f t e r using up h i s Regular ( ~ a n d e r ) and Alternate
,
( ~ t e p h e n v i l l e ) Airports, exercised h i s prerogative and decided t o land a t
Sydney,
The cause of the accident was the impact of the a i r c r a f t with the ground
while out of control due t o f a i l u r e on the p a r t of the Captain t o maintain
s u f f i c i e n t height t o c l e a r the approach l i g h t poles, three of which were struck
by the a i r c r a f t o After s t r i k i n g the approach l i g h t poles, the Captain and
F i r s t Officer were unable to maintain control of the a i r c r a f t due to the mal-
functioning of numbers l and 2 engines and s t r u c t u r a l damage t o the l e f t wing
and f l a p ,
ICAO REF: W 1 2 6
CANADA
Fanadian P a c i f i c Air Lines. Dowlas D E 3 Aircraft, CF-CUF,

crashed a t Okananan Mountain. B o C o . on 22 December 1950
Circamstances
A t I248 hours PST on 22 December, a i r c r a f t CF CUF took off with three

crew and f i f t e e n passengers from Vancouver Airport, B o C o , f o r Penticton, BoCo
ICU Circular 18-AN115 23
The f l i g h t , designated Trip 4, was flight-planned t o cruise from Vancouver

t o Benticton a t P1,000 f e e t and l a t e r revised t o 15,000. feet. Routine progress
reports w e r e received from the a i r c r a f t by radio, the l a s t of whieh was a t
1337 hours PST and a t whieh time A i r Traffic Control cleared the a i r c r a f t t o
Penticton Airport. The a i r c r a f t was due a t Penticton a t 1345 hours PSTd
Qu the a i r c r a f t being f i v e minutes overdue, Canadian P a c i f i c Air Lines

declared an emergency and the A i r T r a f f i c Con%rol Centre, Vancouver, alertad
the RGAF Rescue Co-ordination Centre a t 3,450 hours PST. A t 2040 hours PST,
Canadian Pacf f i c A i r Lines requested the RCAF t o commence the search.
The searching a i r c r a f t located the wrecked a i r c r a f t on the northeast side

of Okanagm Mountain a t an elevation of about 4,500 f e e t during the night of
22/23 December 31950, by means of signal f i r e s s e t by survivors of the accident.
The accident occurred a t approximately 1353 hours PST. 'he a i r c r a f t

struck t r e e s while i n cloud and t r a v e l l i n g on a heading of 173OT, (150%)~ a t
an airspeed of a t l e a s t 120 m.p,h. The a i r c r a f t was southbound on the north
Peg of the Penticton Radio Range and descending on i t s approach t o the Radio
Range Station.
The area of Okanagan Mountain where the a i r c r a f t crashed i s apprexlmately

4,500 f e e t above sea l e v e l , t o protect a i r c r a f t against t h i s hazard, a fan
marker i s i n s t a l l e d a s a navigation aid. The mfnimum a l t i t u d e a u t h o r i ~ e da t
t h i s fen marker i s 6,580 f e e t o G n a t care has t o be taken t o ensure t h a t an
a i r c r a f t has actualby passed the fan marker before the let-down t o the radio
range i a commencedo The let-down t o the range then i s rapid, i a e a 7108-8W f e e t
per minute
The port t a i l plane and elevator were almost immediately sheared o f f by

the t r e e s while the port wing struck a large t r e e shearing the wing o f f outboard
of the centre section a t t a c h angles a f t e r the a i r c r a f t had travelled about
208 feet. This s t a r t e d the a i r c r a f t i n t o a violent r o t a t i o n t o the l e f t ,
grinding the nose gectfon and engines off i n t o the ground, A t the same time,
the a i r c r a f t continued t o s l i d e along the ground, coming t o r e s t on a heading
sf 353O~, (330%) a t approximately 400 f e e t from the f i r s t contact with the
treeso Both the co-pilot and pilot-in-command sustaf ned f a t a l i n j u r i e s *
Examination of torsional bends on the airscrew blades, together with marks

made by the airscrews on the ground, indicated t h a t both engines were developing
power a t the time of impact,
A l l radio equipment and two altimeters were salvaged f o r d e t a i l e d

examination
Later examination of a l l radio equipment indicated no unserviceability

other than s l i g h t damage believed t o have occurred i n the accident.
For an undetermined reason, a f t e r being cleared by A i r T r a f f i c Control

t o Penticton, the a i r c r a f t did not follow usual practice and give i t s position
when by the Penticton Radio Rangeo
The altimeters were both found t o be inoperative and, while one was
damaged more than the other, both had the rocking s h a f t pivot sheared o f f a t
the point of contact with the jewelo It i s considered t h a t the damage t o the
altimeters was caused by the impact of the a i r c r a f t a t the time of the accidento
Barometric s e t t i n g s on the a l t i m e t e r s were found t o be 29*92" Hg, The
discrepancy between the altimeter s e t t i n g a t Penticton and t h a t a c t u a l l y s e t on
the altimeters a t the worst i s 2/10oH Hgo = 20 f e e t error. Altimeter temperature
correction f o r - l l ° C a t 6,500 f e e t indicated would give a t r u e a l t i t u d e of
6,200 f e e t , i o e o the a i r c r a f t would ?x.300 f e e t lower than indicated.
The engine control pedestal and control cables were too badly damaged
f o r t h e i r s e t t i n g s p r i o r t o the accident t o be determinedo The engines showed
no evidence of malfunctioning p r i o r t o the accident, Engine log books and
aircrew log books were a l l up t o date and i n order,
There was ample f u e l f o r the a i r c r a f t t o complete the f l i g h t a s the port

f r o n t main f u e l tank was approximately three-quarters f u l l and the r e a r port
f u e l tank was approximately one-quarter f u l l ( t o t a l of 168 gallons approximately).
me f l a p s and undercarriage were both i n the r e t r a c t e d positiono
The Journey and Aircraft Log Book was up t o date and i n order. The p i l o t -
in-command held a valid Public Transport P f l o t 9 s Licence (No. 346), and a valid
instrument r a t i n g and he had a t o t a l flying time of 8655 hours and 29 minutes,
of which 64 hours and 58 minutes were obtained i n the month of December 1950.
ICAO Cfr c u l a r 18-AN/15 25
During 1950, he had been employed mainly on the Vancouver-Calgary route where
he had acquired 308 hours and 39 minutes a s F i r s t Officer and 560 hours and
58 minutes a s pilot-in-commando
The co-pilot held a valid Public Transport Licence, (No. 318), and had a
t o t a l f l y i n g time of 5594 hours and 9 minutesp of which 63 hours and 4 minutes
had been obtained i n December 1950. During 1950, he had acquired 838 hours and
22 minutes a s F i r s t Officero
Conclusions
The a i r c r a f t struck Okanagan Mountain a s a r e s u l t of being below the

minimum a l t i t u d e permissible when passing through the Greata fan marker during
an instrument approach procedure on the Penticton Radio Range.
ICAO REF: AR/127
De Haarilland DH82C Aircraft CF-COM. crashed near

Glenorchu. Ontario. on 3 A ~ r i 1953,
l
Circumstances
Aircraft CF-COM took o f f with p i l o t and one passenger from Atfkokan,

Ontario, f o r Fort Frances, Ontario, While en route and i n the v i c i n i t y of
Glenorchy, Ontario, engine trouble developed causing the p i l o t t o t r y t o execute
a forced landing. The p i l o t turned off both the gasoline and i g n i t i o n and,
during the process of losing a l t i t u d e by means of gliding turns, the a i r c r a f t
s t a l l e d and struck the ground i n a nose-down a t t i t u d e - The passenger was k i l l e d
and the p i l o t received serious i n j u r i e s o
26 ICAO Circular 1&~?4/15
Inve s t i n a t i o n and Evidence
The p i l o t was properly licensed and had accumulated a t o t a l of approximetely

39 hours' flying time. The weather was favourable and had no bearing on the
accident.
Nothing was found a s a r e s u l t of examination of the wreckage t o indicate

any s t r u c t u r a l f a i l u r e or malfunctioning of the flying controls of the a i r c r a f t .
The a i r c r a f t engine was dismantled and the left-hand magneto was found t o
be defectiveo The spark plug of No* 2 cylinder, operated by the right-hand
magneto, was found t o be unserviceableD This gave r i s e t o the l o s s of power
and excessive rough-running of the engine which resulted i n the f i r i n g of
unburnt f u e l mixture i n the exhaust manifold,
Conclusions
Due t o engine trouble, the p i l o t attempted an emergency forced landing

during the course of which the a i r c r a f t was allowed t o s t a l l . There was
i n s u f f i c i e n t height f o r a recovery t o be made from the ensuing dive and the
a i r c r a f t struck the ground i n a nose-down a t t i t u d e , k i l l i n g the passenger and
seriously injuring the p i l o t .
ICAO FEF: AR/128
United UH-12 H e l i c o ~ t e r . CF-GKG. crashed near

Oshawa, Ontario, on 8 March 1951
United UH-12 Helicopter, CF-CKG, took off with p i l o t and one passenger
from Oshawa Airport, Oshawa, Ontario, and while proceeding a t a low a l t i t u d e ,
struck two s t e e l telephone wires which were strung between poles hidden from
the p i l o t ' s vision by t r e e s * The wires f i r s t contacted the cyclic control
column and then,be%ng broken, became entangled with the main and t a i l r o t o r
blades rendering the controls of the a i r c r a f t inoperative. The a i r c r a f t swung
t o the r i g h t and, facing the opposite direction, crashed upside down i n a d i t c h
seriously injuring both the p i l o t and passengero
The p i l o t had accumulated a t o t a l of approximately 2060 hours of f l y i n g

time of which 335 hours was f l y i n g time on r o t a r y wing a i r c r a f t o
There was no evidence of malfunctioning of e i t h e r the a i r c r a f t o r engine

and the weather a t the time of the accident was sunny and clear.
Conclusions
The a i r c r a f t became out of control through c o l l i s i o n with telephone wires

and struck the ground seriously injuring both the p i l o t and passenger.
ICAO REF: AR/129
CANADA
Scandinavian Airlines System, Dowlas DC-6 Aircraft. SE-BDE,

crashed on landing a t Goose, Labrador, on 23 February 1951
Circumstance s
A i r c r a f t SE-BDE took o f f with six crew and e i g h t passengers from Idlewild,

New Pork, f o r Gander, Newfoundland, Canada, en route overseas.
28 ICAO Circular 1 8 - ~ ~ 1 1 5
On a r r i v a l a t Gander the a i r c r a f t was diverted t o Goose a s Gander was

below limits. The weather a t Goose a t the time was well above a l t e r n a t e limits
and forecast t o remain t h a t wayo
When the a i r c r a f t arrived a t Goose the weather had dropped t o below

a l t e r n a t e limits but was s t i l l above the GCA minima, Permission f o r a GCA
approach t o be made was requested by the Captain and granted. The f i r s t two
approaches were unsuccessful and the GCA Controller suggested t h a t the a i r c r a f t
proceed t o another a l t e r n a t e o I n view of the diminishing f u e l supply t h i s was
not possible.
On the t h i r d attempt when the GCA minima were reached ( c e i l i n g 400 f e e t

and v i s i b i l i t y 1 mile), the a i r c r a f t was instructed t o p u l l up and ga around
again. This i n s t r u c t i o n was not heard by the crew on the a i r c r a f t and the
a i r c r a f t continued t o l e t down t o 400 f e e t indicated without change of courseo
The Captain sighted the l i g h t s of runway 27 t o the r i g h t of the a i r c r a f t , f l a p s
were lowered, and t u r n s t o the r i g h t and then l e f t were made t o bring the
a i r c r a f t i n t o l i n e with the runway.
The wind was M.N.W. a t 8 mph. and the a i r c r a f t f i r s t struck the runway
while d r i f t i n g t o port. Corrections with the rudder and steering gear were
made without success; the a i r c r a f t bounced and the p o r t wheel struck the snow
on the south side of the runway. The nose-wheel was torn o f f and the a i r c r a f t
f i n a l l y came t o r e s t t o the l e f t of the runway a t 2309 hours GMT on the main
wheels and the nose, The passengers were uninjured a s were the crew except
f o r one member who received minor scratches and c u t s o
I n v e s t i ~ a t i o nand Evidence
The a l t i m e t e r s of the a i r c r a f t were s e t t o 1013.5 m i l l i b a r s which i s the

equivalent of the altimeter s e t t i n g given by the tower and the M A Controller
a t 29.93 i n s o Hgo
Communication had been established betwen the a i r c r a f t and GCA on the

i n t e r n a t i o n a l emergency frequency (12105 MC/S), but due t o an unreliable receiver
i n the GCIL hut, the tower monitored transmissions and relayed them t o GCA, when
necessary.
ICAO Cf rcular 1 8 - ~ ~ / 1 5 29
Through the unserviceability of the l i g h t s on runway 35, runway 27, which

was slippery on account of l i g h t snow, had t o be used with a crosswind of
nearly 70°0 The windspeed was 8 mpho
The a i r c r a f t suffered substantial damage
Conclusions
The immediate cause of the accident would appear t o be the f a i l u r e on the

p a r t of the Captain t o compensate f o r wind conditions p r i o r t o touch down
together with the ineffectiveness of the steering gear a f t e r touch down due t o
slippery runway conditions.
ICAO FEF: AR/130
Luscombe 86 Aircraft, CF-EJC. crashed on the S oEe a m

of Trout Lake, Ontario, on 3 Februam 1951,
Circumstances
A i r c r a f t CF-EJC took off with p i l o t alone from Trout Lake, Ontario, f o r

Parry Sound, Ontarioo J u s t before take-off, a passenger on the in-bound f l i g h t
t o Trout Lake a s s i s t e d i n freeing the s k i s from the aticky snow by pushing on
the port wing s t r u t , A s the a i r c r a f t moved o f f he was knocked unconscious by
a blow i n the back from the t a i l p l a n e o When he regained consciousness, the
passenger who was the l a s t known person to see the a i r c r a f t i n f l i g h t , s t a t e d
t h a t he saw it a t tree-top height i n a steep nose-down a t t i t u d e a f t e r which it
struck the i c e on the lake. The p i l o t died a s a r e s u l t of multiple i n j u r i e s
received i n the crash.
30 ICAO Circular 18-AN/15 -
The a i r c r a f t had ample f u e l i n the tanks f o r the f l i g h t , Examination of
the wreckage indicated t h a t the engine was developing considerable power a t the
moment of impact. There was no evidence t h a t would indicate malfunctioning of
e i t h e r the a i r c r a f t o r engine p r i o r t o the accident- The p i l o t held a v a l i d
licence and had accumulated approximately 250 hours' f l y i n g time, of which
40 hours had been obtained within the last six months*
The a i r c r a f t struck the i c e i n a nose-down a t t i t u d e f o r reasons t h a t have

not been determined.
ICAO REF: w 1 3 1
DeHavilland DHC-2 Aircraft. CF-FHG. crashed

a t Lake Tessier. P4.. on 29 January 1951
Circumst a m e a
On 29 January 1951 a i r c r a f t CF-FHG took off with p i l o t , helper and two

passengers from Caupichigau f o r Oskelaneo.
A s the a i r c r a f t was not due back a t i t s base u n t i l 31 January 1951, no

concern was f e l t f o r the a i r c r a f t u n t i l t h i s date, After preliminary i n q u i r i e s
on 31 January 1951, established t h a t the a i r c r a f t was missing, a search was
commenced by the RCAFo Search and Rescue organization which l a s t e d f o r four
day8 when the wreckage of the a i r c r a f t was found on Lake Tessier.
ICAO Circular 18-AN/15 31
The p i l o t held a valid Commercial Licence and had accumulated a t o t a l of

approximately 1400 hours of f l y i n g timeo
Examination of the wreckage indicated t h a t the a i r c r a f t struck the i c e

while i n a steep right-hand s p i r a l diveo The impact was such t h a t the engine
had broken through 3 f e e t of blue i c e o
The weather i n the area was bad with large patches of ground fog covering
areas of 4 t o 5 miles and which extended up t o 3,000 t o 4,000 f e e t i n height.
V i s i b i l i t y was 3/4 of a mile a t the most and the temperature was about -50°F.
The l a s t radio contact with the a i r c r a f t was a t 1515 hours EST a t which
time the p i l o t reported t h a t he was about h a l f way between h i s point of departure
and Oskelaneoo
Only the bodies of Gilbert Comtsis and Charlie Neepush were recovered.
The bodies of Eleear Gomtsis and Mrso John C o Meepush a r e s t i l l misaingo
For undetermined reasons, the a i r c r a f t struck the i c e on Lake Tessier

while i n a steep s p i r a l diveo
ICAO REF: w 1 3 2
CANADA
Noordwn Norseman V I Aircraft. CF-CPS. crashed

a t Kirkness Lake, Ontario on 23 December 1950
Circumstances
A i r c r a f t CF-CPS took o f f with p i l o t , one passenger and f r e i g h t from Red Lake,

Ontario f o r Pekangfkum, Ontarioo
In the v i c i n i t y of Kirkness Lake, Ontario, the p i l o t flew i n t o a region

of bad weather including heavy snow, with reduced v i s i b i l i t y , violent turbulence
and very strong northerly windso
The a i r c r a f t was not seen due t o the weather conditions but could be heard
c i r c l i n g the lake where i t crashed between 1100 and 1130 hours CST.
The a i r c r a f t was completely destroyed on impact with the ice. Amongst

other parts, the a i r c r a f t engine and airscrew went through the i c e t o the
bottom of the lake through the force of the impact.
The a i r c r a f t and engine were airworthy f o r the f l i g h t and had only

recently undergone complete overhaul f o r the renewal of the C e r t i f i c a t e of
Airworthiness.
The p i l o t held a valid commercial licence and had accumulated approximately

4800 hoursa solo f l y i n g time some of which was night f l y i n g o Although the p i l o t
did not hold an instrument rating, he was considered t o have a good knowledge
of instrument flying,
There was ample f u e l on board the a i r c r a f t f o r the f l i g h t ,
Through continuing VFR f l i g h t i n t o mifavourable weather the a i r c r a f t

struck the i c e a t Kbkness Lake, Ontario, i n a nose-down a t t i t u d e . This resulted
i n the dedtruction of the a i r c r a f t and the death of both the p i l o t and the
passenger
ICAO Gfr c u l a r 18-AN/15 33
fCPO REF o A R b 1
DENMARK
B French registered aircraft, F-BAY& type SO 30P,

s w h f i s t t a x v i n ~out f o r take-off
from Copenhapen Bimmrt, Kastmx), 26 July, 19500
A i r c r a f t F-BBYM, operated by C%e Aigle-Bxur on a charter f l i g h t , Le

Bourget - - - -
Lyons Amsterdam -. Stockholm Copenhagen Baris, with freight,
landed a t Copenhagen a t 2112~on 26 July 1950 and parked i n f r o n t of hangar B
f o r removal of f r e i g h t o After completion of unloading and loading the p i l o t
a t 2231s asked the ATC f o r taxying instructions f o r take-off, Clearance was
given and the a i r c r a f t was directed towards the taxi-fine along the aprono
According t o the p i l o t he headed f o r some red flashing l i g h t s (actually ob-
s t r u e t i o n l i g h t s marking t h e VHF tower) mistaking these l i g h t s for the begin-
ning of R w a y 2% Although the taxi-line curves south i n order t o c l e a r
parked a i r c r a f t , the p i l o t continued in h i s o r i g i n a l directiono The a i r c r a f t
collided with Danish BfrPfges D L 4 OY-DFI parked a t point 8 with position
l i g h t s on and f l o o d l i t by prcpgector Moo 2 f'rom the Administration Building.
The position l i g h t s of OY-DFI were mistaken by the p f l o t of the French air-
c r a f t f o r various obstruction l i g h t s beyond the a i r c r a f t , The port wing t i p -
of F-BUM struck the port outer wing of BY-DFI causing considerable damage t o
both a i r c r a f t o
The p f l o t i s M h e r reported t o have s t a t e d t h a t he attempted t o dfa-

continue the f l i g h t a t Stockholm, a s he had never operated i n t o Copenhagen
.
before but t h a t he was pressed t o continue the f l i g h t (by whom was no% estab-
lishedg
The accident was due t o the p i l o t o s f a i l u r e t o follow the correct taxi-

l i n e and t o pay s u f f i c i e n t a t t e n t i o n t o the position l f g h t s of OY-DFI s o t h a t
he taxied F-MY61 too @Pose t o OY-DFIo
34 ICAO Circular 18-~/15
These errors must presumably be attributed t o the p i l o t ' s ignorance of

the l o c a l conditions of Copenhagen Airport (the p i l o t had never previously
operated into Copenhagen Airport, nor had he endeavoured t o obtain infomation
before taxying out) coupled with the f a c t that the crew had been on almost
24 hours1 continuous duty, including about 9 hours' flying, which must have
contributed t o fatigue,
ICAO Circular 18-AP?/15 35
ICAO REFS
z
lamum
(See Government of India Report i n L i s t bla, 12 hlc 7026, AIG/s~)
(This amnary is given i n considerable d e t a i l by reason of its technical

importance. )
On 12 July 194g9 a% 0039 hours M, a Netherlands Lockhe& Cons-&ella-

t i o n transpewrlt, erfrcrraftp registered PH-TDF, of KLM took off from Palam h r o -
dsasre (Delhi) f o r Bo~nbqy, om a specid. f l i g h t fPau Batavia to Amsterdm via
Indfa, The airercrft carrigd a crew of 11 agad 34 passengers.
A t 0322 homa GMT %he a i r c r a f t arrived, by means of the MF beecon, over

Smta C w Aerdromae a t an edltitu.de of 7,000 feet, It was then brought down
through the clouds by means of the XF beacton t~ a height of 500-600 feet
above the ~ u r r * a e ,
Thrs erJscsafl was then advised t h a t it was approaching %he aerodrome

from thb n o ~ ~ s t e r direction
l y whence the ground could be seen, The
hmding gear and f l a p s were lowered. Flying at a low a l t i h d e i n an e a s t e r l y
o r north-e~b~terly direction, P$e eircraf% began a turn i n order tho land on
runway 23, A% appro3siiPlately 0350 h m a GNT, however, it crashed i n t o a
674 foot mist-sWd& H11 located three Dnilea eat-north-esrst of %he aero-
drome, The arircr&%wss totally deslsoyw3 and a l l occupants ware killed,
me Board investigating the accident eonaidered i t s e l f fortunate i n

havlng at l % e di8porsQa. the iaPomtiean availab1e i n the axeellent report
p k e p d by the Indian authorities in their inquiry i n t o the aeeident,
36 ICAO Circular 18-ANj'15
Consideration of the circumstances has led t o the following comments:
a) EPTE: of Santa Crus aerodrom there i s a l i n e of hills, the

highest point of which is 674 f e e t high and l i e s 3-1/2 miles approx-
iPsately EM6 of the aerodrome, This was mentioned i n the documents
carried on board the aircraft, but not i n accurate detail, as there
were inconsistencies in the various docnments, These reference docu-
mts consisted of an aerodrome chart on which, near runway 05-23,
an arrowp pointed i n the 05 direction with the inscription n H i l l s
690 f e e t 2,5 miles*, Although t h i s indication was not i n i t s e l f cor-
rect, the Board was of the opinion that the charts gave a clear warning
of the danger of collision when f l y b g over the t e r r a i n ENE of
Santa C m aerodrome,
Before departure from Palam aerodrome near Delhi, the p i l o t was
shown by the o f f i c i a l on duty a chart which gave complete and accurate
d e t a i l s of the t e r r a i n a t Santa C,m, Furthermore, an a e r i a l photo-
graph displayed i n the a i r t r a f f i c control s t a t i o n gave an accurate
picture of the group of h i l l s o It has not been ascertained, however,
whether the p i l o t had looked a t t h i s photograph, I n any event his
attention was not specially drawn t o it,
On the basis of these various c ~ n s i d e r a t i o n athe
~ Board a- to
the conclusion t h a t it was unlikely that the p i l o t was not aware of the
existence of the h i l l s ,
b) The weather forecast received by the p i l o t at Delhi was more

favourable than the aca;lal weather prevailing on the a r r i v a l of the
a i r c r a f t a t Bombay, at l e a s t insofar as the height of cloud base was
concerned, It i s confirmed t h a t the a i r c r a f t received weather reports
fMan Bnznbay a t 0L26 and 0230 hours, It was also ascertained, from the
portions of the l o g book which were found, that a weather repert was
received fmappromh control a t Santa C m at 0316 hours, actcording
to which the v i s i b i l i t y was down t o XK).600 yards on account of heavy
rain, A t 0322, approach control reported that v i s i b i l i t y was 500-700
yards and improving;, a& that t h e cloud base was at 600 feet, There
is l i t t l e doubt t h a t the pilot, on errrival over the aerodrome, had
acaurate knowledge of the prevailing weather conditions,
c) gLM had l a i d down no I m i n b a f o r operations a t Santa Cruz

aerodrome sinoe the l a t t e r does not l i e on t h e route usually flown
by its a i r c r a f t ,
It is castaxnary f o r the p i l o t , i n the case of a 8cbgdh;lled
landing a t an asrodrow f o r which hie: wrapany has prescribed no weather
mimima, t o adopt the weather plin.tmn Paid down by afrUmes vhoae air-
c r a f t frequently land on the aerodromec
It a p p e a ~ s%hat weather minima f o r Santa Cruz aerodrome were

l a i d doam hy % b e e airlines: Air India International, British Owrsetss
$.Lrase$s Corporation and Transeontinantal and Weatern Airlines, The
WAC and TWA mirdma m a -re 01-Pesa identical, i.e, v i s i b i l i t y 2 n U e s
and eland base 1,000 fee%e Air India, prescribe8 a v i s i b i l i t y of 2,500
yards and a 600 f e e t cloud base, but requires t h a t the 674 foot h i l l
be free of cloud f o r landings on runway 23,
'Phis difference i s readily explained by the f a c t tha% the Air

bdhreian%ma appRgs to pilots who f l y regularly fnto Santa C r w t wherem
.%he TWA and BOAC minima appw to p i l o t s who, adnittedly, have not aneh
&wive expriencse of Santa C m as the Air India pilots,
It was therefore recammandad to pflota who had never flown i n t o
Swta C n m %O observe tihe TWA or BOLLC minima,
X t wae not definitely a s a e ~ t a i n e df m the investigation whether

$he p i l o t of a i r a r a f t PB-TI@had obtained inforo~ationon t h i s -%+are
!be Comdssfola whiah condhreted the local investigation o~nsideredit
likely $hat the p i l o t vas unacquainted w i t h the minima, The Board
considered, however, that an experienced p i l o t wcvuld have ascertained
tllem,
It 5s confirmedo however, t h a t even the lowest mf- laid d~wn

were not colaplied with and t h a t the landing procednre (the break-tbmgh)
was teed onP, under conditions which were less favourable t&an the
&P In&a rui- and very mch I s a s favourable than the BOAG and TWA
Bltnha,
d) !!/tF c~nananieatiowon 6440 kc/@ were When flying
cmw $be beacon a t 7,000 fee%at 0322 hours, the a5rcraftreceivedi
h s t m e % i o n s on the caberse tx, be flown during the break-though t o
3,000 feet, and l a t e r * a t 0332 hoursb %o 1,500 f e e t ,
These ina%mctions were complied with by the a i r c r a f t e
There is no indieation, however, of there having been any dfs-
a s a i o n be&we@eathe tower and the p i l o t as t o whether it was advisable
'%aland mder %he prevailing aonditions,
fin vfetr of the nature of the %esnlla i n the neighbornhood o f Santai C n q ,

the weather conditions on arrival over the aerodrome and the aWe-mentioned
a ~ Board is of the opinion t h a t the p i l o t muat have decide4
weather ~ ~ L a L r a%he
t o delay the landing u n t i l v i s i b i l i t y and ceiling had improved d f i c i s n t u ,
,38 ICAO Cf rcular 1 8 - ~ / 1 5
otherwise t o divert t o another aerodrome, He did not request pmmission of

the l o c a l air t r a f f i c control t o do this, On the contrary, he simply took
the normal holding a l t i t u d e of 3,000 feet, which the Board considered t o be
an e r r o r of judgment on his part,
The Board notes, in t h i s connection, that no advice was given by t r a f f i c

control which could have deterred the p i l o t f r m t h i s intention to land imrPe-
diately. When giving its instructions, air t r a f f i c control apparently did not
take into consideration the f a c t t h a t the crew, unlike the crews of other
scheduled aircraft, did not how the l o c a l conditions from experience, and
that, f o r t h i s reason, it was desirable ts a s s i s t the crew with more than the
normal taiaunt of advice.
Although the Board considered the deoieion t o carry out the landing
unwise, i n view of the foregoing, t h a t decision was not neceseblrily the cause
of the accident, since the p i l o t s t i l l had the p o s s i b i l i t y of breaking off
t h e landing proceduret cl-biag to a safe altitude and clearing all the
t e r r a i n EBE of the aerodrome The Board considers the following f a d s to be
of importance i n considering what happened during the latter stage of the
landing procedureo,
I) After having received from the tower the regular instruction

t o descend t o 500 feet, the a i r c r a f t made b i s u a l contact with the
ground a t 0345 home a t a height which, according t o witnessesbstfmates
wss between 500 and 600 feet, which haight corresponded to the aloud base
reported by the tower* It was observed that the undercarriage w a ~down,
The aireraft turned to the r i g h t mound the aerodrome and then headed
over the aerodrome i n an e a s t e r l y direction, Its height a t t h a t time
(again according t o witnessee estimates) w a s approxhately 300 f e e t ,
The a i r c r a f t r d n e d i n sight f o r about three minutes and then dis-
appeared i n the clouds t o t&e e a s t of the aerodrome. The three minutes
muat have been sufficient 60 give the p i l o t a clear picture of the
weather conditions above and i n the neighburhood of the aerodrome, and
to permit him t o estimate the possibilitiee of making a landing,
m i n g the t h e the cnfpcrerft was i n sight, the rain, which
shorj3.y before had reduced the v i s i b i l i t y a t the aerodrome, waa t o the
e a s t of the aerodrome. Consequently, the h i l l s were no longer v i s i b l e
f'rm the aerodrome, and the p i l o t could therefore certainly not have
seen them.
2) The a i r c r a f t collided with the highest point of the hill a t

an e l w a t i o n of appro%imately 600 feet, From the tracks made, it ap-
pears t h a t the a i r c r a f t was turning t o the l e f t a t the time, It was
ICAO Circular 18-~~/15 39
ascertained from the wreokage that, a t the time of the crash, the
anderemiage was still down and t h a t the f l a p s were half down, i,e,
approximately i n the take-off position, It was not possible to aacer-
tain anything definitely from the apparent eetting of the engine con-
-
t r o l s , It appeara like-
normal gradual not rapid - however, that the controls were s e t f o r
climb, According t o one of the experts
who uaa heard a t the investigation i n India, it could be deduced from
the position of the a i r o r a f t and from the probable position i n which
the engines were found, that the r a t e of c l h b =st have bean q p r o x -
iasatsly 200 f e e t per minute* From the difference between the height of
%he point where the crash occurred and the a l t i t u d e at.whieh the air-
c r a f t flew over the asrodrm it follmm t h a t the a i r c r a f t mat have
been d5mbing gradaally when it flew over the aerodrcmwr.
A much greater rate of elironb would have been obtained ff the power
had been increased and the undercarriage mtrwted,
3) The radio cnrramnioations which took place during %helatter

portion of the flight dare born only from the ATC log, as the p a r t of
the aircraft l o g recovered runs up to 0316 only, It i s certain that
the original entrfea i n the log were i n p a r t eraeed and new warding
intsortuced, This is not surprising. It is common knowledge t h a t ~ / k
cammications are carried oat rapidly and i n a very abridged f ~ m ,
making it extrantely d i f f i c u l t for the operator t o record iately
what is being s a i d or heard, Under these circuatstsnces, it is not un-
asnal t o f i n d &asions i n the record since the data are transcribed
fkan memory a f t e r the conversation has talcen place, The data i n the
l o g must therefore be considered as a b r i e f l y written synopsis made by
a person whose veracity -ere is no reason t o doubt,
To t h i s m w f be added the f a c t t h a t Beewan, the radio operator
concermgd, and Pigott, h i s W e d i a t e superior on duty a t the tW9
atabd, tander oath, at the pre1imhu-y investigation i n India, %at the
l o g provides an exact transcript of the conversation t h a t takes place.
On the other hand, the Board does not attach such importance t o t h i s
her t o consider the entries to be an exact reproduction of the messages
exchanged, I n this connection, it is aignificant t h a t the witness
h t i a , second p i l o t of an Air-India aircraft, who overheard the radio-
telephony i n s b c t i o n s except during a short interruption, stated %hat
he had not understood several of the nessages.
It is possible t o ascertain the followfng only from the log:

after,%& a i r c r a f t had reported, a t 0347$ t h a t its undercarriage vas
extended, the tower gave i m t r u c t i o n s t o land on runvay 23 and warned
that the wind was S W 15 h o t s , Thereafter, the l o g contained the part
in which the above-mentioned alterations had been made: .
Bdesc, t o 500 it, Caution hills EZIE 674 f t , 0 347* ycru

z a q land on 05 QAN SIJ kn 0 349 over the a i r f i e l d ,
R C J i a b 800 f t o base l e g
0 35@ no contact on 6440 when it was observed that he
wars ppoeeeding t o base leg of 23,"
As already stated, it i s doubtful whether t h i s l a a t report was

a&bml.ly received, In asnnee$ion with the instruction to descend t o
500 feet, it ~shotrldbe noted t h a t this instruction cannot have been
given a t the apppopria=be Iseation, since the a i r e r a f t w a a already a t
thia height a t 0 3 u 0
The clearerace to %and on m w a

gr 05 had to be given, since the
a f r c r a f t was making a r i g h t turn round %he f i e l d , It is uncertain
whether t h i s clearance was received by the pilot;, It can, howt~ver,
acmoely have been taken into considepation by the p i l o t since a l a n d -
ing with a t a i l vPnd of 1 5 h o t s i s eonaidered by experts t o be azt of
-
the question, A s the a f r m a f t did not appear to land on m w a g r 050
-
the instruetion was apparentlr gfvem to olfiPb t o 800 f e e t i n view of
the apparent hmaPB whiuh the h i l l a presented which altitudeo i n view
sf the pl"oXiBtity of the U s , e&ot be eonafdered maffiaient,
4) Santa Crua ag~sdr~aae has +bee runwqe. Rupway 09/27 was

unavailable owhg to constmetion work whiah hae been duly notified, A
moss-wind of 15 knots was blowing mroae runway l.4/32, Becording t o
the d a w t t r r e r 0 speofffsations,
~ a Con&eIfation e m make (r safe land-
ing with a crosc~-wind of 20 mph (1'7 knots), The t h i r d runway, 05/"13,
is the one referred to i n the above-mentioned log entry,
I n considering the sequence of events dming the l a a t par%of the

manoeuvre, the Board again psfn&ed out; %ha&%he p i l o t e o d t t e d en e m r of
judgrsent i n not emeludfng, though v i m d ~ e f e ~ e mt oe the g~cnand~ that it
was imperative f o r h h fbO a3m a~ rapidly w possible t o a a d e altftade,
.
i f he was ts avoid the hilly h m a i n ,
Before m k b g h ic~ mound the wreapae, tlhe p iPot should have

requested elearagee to do so,' He apperrenely did not request t h i s clearance,
but flew i n the d2rtecttion of the r a i n and sf the hills, cliaibing gradually,
thereby losing visual eontaet with the ground EM w e l l as the possibility of
Baaging a visual landing on m w a y 23, since there wwe no f a e i l i t i e s f o r
rmagiBg an instrument landing on t h a t runway, The moat likely explanation
t h a t the Board oould give f o r t h i s behavioa~is t h a t the p i l o t , although he
heeded the warning from control to e l b b to 800 f e e t D was not suffieisnfly
aware of %he presence of the dangerow h i l l s duping the shorttPlne available
t o Bia b come t o a decision,
!be Board observed, sonover, that no advice based on the prevailing
conditions olas given by air t r a f f i c control, The inatmaation to l a d on
runwqy 23 a dangerousr one i n view of the f a c t t h a t the low c l o d made
the approcash t o the runway inaecessibla, In particular, .it should be re-
asllled that the p f l o t aslnnot have been eonsidered b be acl%qampnintedwith tha
l o ~ conditian~,
a
Air t r a f f i c control appears l a t e r to hare realiaed the dangero given

the warning concerning the hill% and given the Inetmction to climb to
800 fee%, Even if these instructions were s&ually rrceived, vhiah i e open
t o doubt, it musf b aoaafdered that the warn* raas extremely tardy asrd that
the instruction to tho p i l o t tie c l b b t o 800 feet clearly m a t ham beeas too
late, S i n c e 800 f e e t is not a usual he5ght to w e i n air t r a f f i c control
instmctionr and i n .olaw of the faef t h a t it-provided very litt56 d e a r ~ o e
of neighbonring h i l l s , the instruction may have led the p i l b t to believe
t h a t he s h a d not c l h b any M@er on account of the possi'ble presence of
other a i r c r a f t ,
!he DireetOr feneral of the IJeparbent of Adation mther stated, a t

the aitting, t h a t decisions concerning initiation, coatlnaation or te-a-
tion of flights r e s t e n t i r s l y with the eampany or its authorbed agents, i n
wfnose cstpaeity the captain frequently acts, This is what i s houn,a8
@operationalcontrolw. I n this c o m e t i o n , the Boerd Blade the following
cormoen%e:
I n the f i r s t place, the Board could not escape the ispression
that, even i n t e r n a t i ~ a a l l yt~h i s tiem had at5J.l not m y l~gnerally
tmesptS,d saeaning, #orewer, compliance with f a u l t y iastrhetions from
the, ti<rwernay definitely be constmed as an error on the ptuct of t h e
pXlot, It raa$ also happen, however, that the cirnunrataaces are such
that no blame whatsoever attaches t o the pilot, Another entirely
different queatien arises, Inowever, and that i s wfietber the pilot,
aasn though ha haa committad no arror, c m be held otherwise reapon-
sible2 i n ~ o f a rarB d l a ~ i p l I 1 i~s~ concerned,
4 f o r having acted on inac-
amate advice from the tower, The Board was not competent, however,
tQ e v e anblwera t o these questions.
In view of the foregoing, the B o d was of the opiaion that two me-
ccrsaive errors of judgment were colosoittcrd by the pilot, These we= as,
f0 1 1 0 :
~
L2 ICAO Circular 18-Mh.5
1) he i n i t i a t e d a landing procedure at an aerodrome with which

he was not acquainted, i n weather conditions which were lower than t h e
minima prescribed f o r landings on t h a t aerodrone;
2) on a r r i v a l over the aerodrome, he flew a t too low an a l t i t u d e

over a t e r r a i n which he xnust have known t o include a h i l l which consti-
tuted a hazard f o r h i s a i r c r a f t , which h i l l he was not able t o see, on
account of t h e poor v i s i b i l i t y and low cloud,
The Board f'urther considered t h a t the following f a c t o r s eontribrzted

towards the accident t o a considerable extent:
a) air t r a f f i o control did not advise the p i l o t t o delay h i s

landing u n t i l the weather conditions had improved, o r otherwiee t o
d i v e r t to another aerodrome;
b) a i r t r a f f i c control designated a runway f o r the landing
uhich necessitated the a i r c r a f t venturing low over'dangerous t e r r a i n a s
indicated i n 2) above.
ICAO REF3 AFt/l04

NETHERLANDS
KL&l Constellation PH-TEN crashed near Prestwiek, Scotland,

on 20 Octwber 19L18, Report issued bs Betherlands
andl released 3 J O , 1950,
(Secretariat note,- A report on the accident w a s a l s o issued by the United
Kingdom, See List No, 10, ~ ~ / 5Doe
6 6951, A I ~ / 5 l l ~ )
On 20 October 1948 a t 2111 hours GMT the Dutch public transport air-
c r a f t registered as PH TEN type Lockheed Constellation, owned by Royal h f c h
Airlines Ltd, took off from Schiphol Airport f o r a f l i g h t t o New Pork during
wfniah an intermediate landing was Ca be made at Prestwick Airport, On board
t h e r e wrre a crew of 10 persons and 30 passengers,
1 0 Circular 18-AN115 43
8%an a l t i t u d e of 9,000 f e e t the a i r c r a f t established radio e m f -

cation with the air t r a f f i c control of Prestuicrk Airport a t 2255 horns, a f t e r
which it was directed t o the approach to runway 32 with the assistance of
the GCA*
The p i l o t however deei&d to perform a landing with visual approach on

runway 26. After having overshot runway 32, the a i r e r a f t , while flmg a t l e w
altitude, turned t o port at the in%eraection of t h e two runways,
A few minutes later at 2332 GMT, the a i r w a f t whilst a t ap a l t i t u d e of

440 feet, collided with the high tension cables of the national @id System
runni8g fkom K%bmnock t o South Scotrand at about 3-112 miles e a s t of the
centre of bestwick Airport, as a consequence of which the airmdt eaught
f i r s , It i s probable t h a t the airerafat then flew a complete l e f t h;a
short time a f t e r the collision, in dense fig, it crashed into the ground,
A l l p r s o n s on b a r d were killed and the aircraf't was contpletely

destroyed,
Probable Cauae
The Board was able t o avai1i;tsel.f of the detailed md e l e m report

drawn up by the Court of Inquiry s e t up f o r t h a t purpose by the British
Mlnistry of C i v i l Aviation,
The t e r r a i n e a s t of the airport and within 3 miles slepea u p m d to a

height of nearly 500 f e e t , mere were on board maps giving detcsils of t h i s
t e r r a i n and advising great caution when landing on runww 26, The piPat wartl
very familiar with the airport and m o m d 9 n g terrain, A t 2236 and 2306
the p i l o t was notified by RT i n code t h a t vis%biPfty was deteriorating with
low olmd 300 f e e t (90 m t r e s ) 4/%0, A t 2308 W T a weather r e p ~ r wa8 t
broadcast t o the aircraft, There was eonfliet of opinion as t o the contents
o f this message o r rnesaaps as the ground semices gave a v e r y m ~ h . l a w e r
v i s i b i l i t y figure than the 3,400 yards (3#600metres) agreed by the Board
as the a c W figure broadeast,
A weather report mads a t 2320 hours GMT, twelve minutes before the
accident, shoved t h a t the weather had deteriorated below the mininaua es4a.b-
lished by gLH f o r a night landing with v i s u a l approach, U n f o ~ % ~ ~ ~t h
~ itse l y
report did not reach the p i l o t o as f t was broadeast a t 2336 W e
ICAO Circular 1 8 - ~ ~ / 1 5
I n accordance with the p i l o t Q sintention to land on m w r r y 26 the air-

craftg after havfng overshot runway 32 at a low altitude, turned to port
above the i n t e ~ s e c t i o nof the two ranways carry clut a visual. approach on
runway 26, Leas than three raimtes l a t e r the a i r c r a f t collided with high
tension cables, From the weekage it appeared t h a t the a f r c r a f t was headed
i n a direction of about N 4@ E and had apparently already s t a ~ t e dits tupn
ta the l e f t , It.was themfore eoneluded that the p f l o t s t a r t e d hfs turn
i n t o base l e g sf runway 26 too far e a s t and, consequently, too l a t e ,
The Board took f o r wanted t h a t the pilot, a t the moment t h a t he should

have emumeneed his turn into base l e g of runway 26, had l o s t v i s u a l contact
with runway 26 and was, therefore, tanable to use t h i s as a cheek, The p i l o t ,
i n these eireumatanees, should have abandoned his intention of landing on
runway 26 and carpied out a e b e p climb t o m i d the high jpound, The Board,
however, considered t h a t the p i l o t did not abandon the landing and therefore
decided that the p i l o t mst have delayed Ma turn i n t o base l e g f o r some
reasons anknown but whieh might be explained by assuming t h a t the p i l o t ,
having l o s t sight of the l i g h t s of runway 26, waited a short while hoping to
regain h i s reference, F'urther, the tail-wind ( i n the direction of the air-
craftas f i r s t turn) msy have been greater than estfmated by the pflot, !l%e
Board, how eve^, was of the opinion that t h i s @auldonly partly explain t h e
delayed action, Another Iikelihood wakp engine f a i l a r e which might have
dfverted the a t b n % i o n of the p f l o t from his proaedure and with flaps and
landfig par down presenbd ~onsfderabled i f i d t y f o r a a b e p climb,
Evidence showed theat No, 2 propel$or was s e t at 6 O (featheping 810)

w h f l s t the other propellms were s e t at 24O, In addltfon the distribtltor
value of the f i r e extinguisher wets s e t fer No, 2 engine, There waa howevep
no further evidence t o suppo~tthfs theory as the remains of No, 2 engine
were - P and were not averflable f o r further examination,
1, That when the p i l o t s t a ~ t e dMa landing manomme f o r

runway 26 of Prestwfek Airport t h e weather eonditione, were already below
the lMta f o r this manoeuvre but that from the weather forecasts received
t h i s could not be, known t o him and t h a t t h i s could not be personally judged
at the time,
ICAO Circular 18-AN/~S 45
2,. That, although the landing on runway 26 under the weather

conditions, aa far as these were known t o the pilohrequired the greatest
-
caution, the p i l o t could not be blamed f o r having commenced t h a t landing
procedure,
3. That, flying too long on the downwind-leg of runway 26

caused the accident.
4e That, i f no unknown circumstances contributed t o the exten-

sion of the f l i g h t on the downwind-leg of runway 27, the extension was due t o
t h e del-d action of the p i l o t a f t e r he l o s t visual approach,
5. That it was not impossible t h a t a stronger wind than the

p i l o t accounted f o r contributed t o the extension of the f l i g h t on the
downwind-leg of m m q 26,
6. That the possibility of other circumatancea as mentioned

under 4 could not be ruled out, but t h a t no data was available which could
give cause f o r the supposition t h a t they contributed t o the extension of the
f l i g h t at a low a l t i t u d e on the downwind-leg of runway 26,
46 ICAO Circular 18-AN/I~- - --
IGAO REF: AR/101
SWEDEN
Svensk Flygtjanst. Ltd,. Firefly SE-BRF crashed a t Hellested,

16 miles south of ~ d on~ Januam
e 13a 1950.
Circumstanee s
The f l i g h t ~ r i g i n a t e don 13 January a t the military a i r f i e l d of Valkenburg

i n Holland, The purpose of the f l i g h t was t o deliver the a i r c r a f t t o Svensk
Flygtjanst i n Stockholm.
On approaching h i s destination the p i l o t encountered bad weather with

only half an hourts fuel remaining, and observing a cloudless area of about
5 square km approximately 16 km t o the southwest of Kastrup, decided t o make a
forced landing i n a field, The landing i t s e l f passed off smoothly, but in the
final landing run9the ground being very soft, the a i r c r a f t was bogged and
turned over on i t s back,
The investigation revealed t h a t the weather reports for the route i n

question, a s received i n Holland, were not i n f u l l agreement with those issued
by the MET office a t Kastrupo It m e t be considered t h a t the pilot, i f he had
knowledge of the weather forecasts in the form i n which they had been issued
by the MET Office, Copenhagen, would have postponed take-off*
-
Probable Cause of the Accident
The accident was due t o the f a c t that the a i r c r a f t during the forced
landing on a s o f t f i e l d bogged and thereby turned over on its backo
The forced landing was made because on a r r i v a l a t the terminal weather

condition8 were found t o have deteriorated so t h a t a landing could not be made
there, The a i r c r a f t did not carry any instrwnent landing equipment. The acci-
dent might have been avoided i f the pilot, on encountering bad weather condi-
tions a t Vordingborg, had turned back and attempted a fanding a t Holland or
F e h which appeared t o have been feasible a t t h a t timeB
ICAO Circular 18-~U?/r15 47
ICBO REF: AR/q,4
UNION OF' SOUTH AFRICA
caning airborne, it -
The a i r c r a f t took off a t 1240 hours with three passengers and an overload
of 167 lbs, On t a b - o f f the f l i g h t ran 435 paces along the runway before be-
then airbarne for a f'wther 455 paces which brought it
almost t o t h e aerodrome boundary by which time it was about 50 f e e t above the
ground, After crossing the boundary the a i r c r a f t w a s seen t o sink wfth its nose
w e l l up i n t h e a i r , it managed t o clear aone t r e e s but then the starboard wing
dropped and struck the ground. The a i r c r a f t was completely wreckedo The con-
-
ditions prevailing at the time were pressure, 8343 mbso and temperature 75.50Fl
This gave an equivalent density a l t i t u d e of 7,500 f t , and a corresponding de-
meass of 24 per cent i n the engine power available, compared wfth t h e sea l e v e l
power. T h i s coupled with t h e overload resulted fn the a i r c r a f t being unable t o
gain height and i n ultimately stalling.
The probable cause of t h i s accident was stated t o be t h a t :

a) the a i r c r a f t w overloaded 167 l b s ;
b) the p i l o t caused the a i r c r a f t t o become airborne and t o climb

with insufficient safe margin of airspeed above the s t a l l i n g speed of the
a i r m a f t for the pressure and temperature conditions p e v a i l i n g a t the
time*
These factors combined with a clfmbing turn t o the r i g h t t o avoid obstruc-
tions, caused the airspeed t o f a l l t o s t a l l i n g speed which culminated i n
the a i r m a f t mashing,
48 ICA0 Circular lB-AN/15
Contributory causes were possibly the comparative inexperience of the

p i l o t on the type of a i r c r a f t and the take-off along the p a r t i c d m runway of
the a i r f i e l d , the peculiarities of which are generally appreciated. Lack of
airmanship was displayed by the p i l o t in t h a t he did not take advantage of the
briefing f a c i l i t i e s available and that, he failed t o use the f u l l length of the
runway available for his take-off,
-UNION OF SOUTH AFRICA
A-aft Pi= Cub 25-BAH, emaped ,$n crog-&g&&g,~ash&

after fasing: i n t o t e l e ~ h o n ewires a t Letaba, TVL, on 12 S e ~ t q p b e r19%,
On 12 September 1950 a licensed p i l o t flying Piper Cub ZS-BAH was engaged

i n a e r i a l dusting an orange plantations Ha had been flying on and off f o r a
number of hours abwe a l i n e of telephone wires and a t approximately 10 f e e t
above the trees.
About 1608 hours the p i l o t started t o d w t another area of younger t r e e s ,

containing a telephone l i n e on r i s i n g ground, Due t o the f a c t t h a t the t r e e s
were shorter i n t h i s particular area, the difference between the original height
of the a i r c r a f t and the new t r e e s had increased, which necessitated the p i l o t
flying lower, during which the a i r c r a f t wheels struck the telephone wires and
the a i r c r a f t crashed i n t o the trees,
The accident was not investigated i n s i t u , The weather was good. The
pilot' B t o t a l flying experience was 900 hours of which 110 were on Piper Cub
a i r c r a f t , He had only 9 hours crop dusting low a l t i t u d e flying experience,
Probable C a m
The probable cause was error of judgment on the part of the p i l o t when
low flying, Fatigue due t o concentration on low flying for a number of hours
previously during the day was probably contributing, The dust collects i n the
cockpit, and workirng i n t h i s atmosphere for a number of horns might possibly
have affected his vision and judgment,
ICAO REF: AR/l&$
UNION OF SOUTH AFRICA
-A c BOe h e d on t&-off from

unlicensed a i r f i e l d a t Pornfret, S,W,A., on 28 Se~tenbar1950,
0x1 28 September 1950 a t about 1500 hours a licensed p i l o t and 3 passengers

attempted t o take off from an Prnfieensed a i r f i e l d i n Bonanza ZS-BXM, The p i l o t
stated that a f t e r running along the ground for some distance (310 degree f l a p )
the a i r c r a f t l e f t the ground and then sank backo On touching down it swung
violently t o the l e f t , i n t o thorn trees and f i n a l l y Pnto a hole i n the ground
when the nose gear assembly collapsede
The accident was not investigated i n s i t u , The weather was good, The
p i l o t gB t o t a l flying experience was 940 hours, of which 280 were on Bonanza
aircraft, The f l i g h t was f o r hire and rewardo
50 ICAO Circular 18-~~/15
The ground surface i s soft a3ad sandy and i s 3,600 ft. A,M,S,L, At
1500 hours it would be very hot. The aircraft was heavily loaded, The prob-
able cause was error of judgment on the part of the pilot in attempting t o
take off under these conditions, He probably attempted to become airborne
too q~icklyb
ICAO Circular 18-Ati/l5 51
IUO REF: w103

UNITED KINGDOM
B U G Viking B nVfnUantn G-AlBL sustained an e m l s s i o n a p ~ r o x f n a t e l v

20 miles south of Hastings, Sussex on l3 A D P U 1950, MoCoAePoNoo 86-
When about halfway across the channel during a scheduled f l i g h t from

Northolt t o Paris an explosion o c c u r ~ e din the r e a r of the &crafto
Thbnk- t h a t it had been struck 'by Ifghnfazg and being t o l d of extensive
s t r u c t u r a l damage and serious i n j u r i e s t o the Stewardess, the Captain
returned t o Northolto The Captain found t h a t the rudder controls and the
rudder and elevator trim controls f a i l e d e n t i r e l y t o respond and that there
was greatly reduced elevation movement. The ailerons a l s o appeared l e s s
positive than usualo Although the first Eanii-Sng attempt f a i l e d due t o the
.unusual load necessary t o move the contra1 e o l m , -the second attempt was
SUCC~SS~UP~
The Si~wardgssrecollected t h a t j u s t before the explosion, whilst

L&tb5ng on t h e s e a t in the pantry, she was eonsciws of a f a i n t kt a-
familfar smell described a s b e h g an odotu: which she associated ~ 5 t haaido
Investfgatlon on t h e following day made it e l e a r t h a t there had been an
explosion of an Lfnfernal machine %nt h e lavatory r e s u l t i n g fi a ragged
hole 5 f t by 5 f t % ins, being torn 2x1 the r e a r p o r t s i d e of the fuselage
opposite the lavatory, On tihe starboard sfde next t o %he t o i l e t empart-
m n t , a similar Bole of even greater dimensions, 5 ft 2 heat %he top
and 8 f t 2 in. a t t h e b t t a m , had been blasted, A considerable amount of
damage was done i n t e r n a l l y and t o the rear controls,
Nothing was found %hat could be d e f b L b l y said t o be p a r t of an

explosive object, i t s detonator o r t m b g mechanismo The easplosipfe used
had not been detenn%md up t o the % h e sf -the report,
Conclusions
The damage t o the a i r c r a f t was the result of an explosion of an

infernal machine i n the t o i l e t compartment, The probable location of t h i s
destructive agent was i n the used paper towel receptacle.
ICAO REF: Wl05
UNITED KINGDQM
Fairflight LMra Tudor V G-AKBY crashed a t Llandow on 2.2 March 1950.

M n i s t r s of C i v i l Aviation R e ~ o r t88.
Circumstances
On 10 March 1950 the Tudor V a i r c r a f t GAKBY, owned and operated

F a i r f l i g h t Limited, l e f t Llandow a i r f i e l d f o r Dublin on a charter f l i g h t
with f i v e erew and seventy-eight passengers, On 12 March, t h e a i r c r a f t
with the same crew and passengers took off from Dublin with the intention
of returning t o Llandowo While making an approach t o land on runway 28
a t Llandow the a i r c r a f t entered a steep climb with engines f u l l on,
apparently stalled, f e l l away t o starboard and crashed, A 1 1 the crew and
seventy-five of the passengers were killedo
The main problem of the inquiry was t o determine how the a i r c r a f t ,

apparently making a normal approach i n what were described as ideal condi-
tions f o r landing a t Llrandow, suddenly got into such an a t t i t u d e beyond'the
correction of an experleneed pilot. Evidence showed that during the
approach there was a s l i g h t tendency t o undershoot and that when 800 yards
from the runw4y and a t a hefght of 150 f e e t there was an additional use of
power followed by the sudden application of f u l l t h r o t t l e , concurrent w i t h
which the a i r c r a f t rose steeply t o 300 f e e t presenting its fuselage a t an
angle of about 35 degrees t o the vertical. Engine noise then ceased abruptly
and the a i r c r a f t f e l l t o the ground,
The findings of the report are divided i n t o four parts, Par*-l;sI

and II being devoted t o particulars of the a i r c r a f t ' s history, the crew
and the organizationm Part III i s solely concerned with the position of the
centre of gravity a t the material t h e , sharing t h a t it was located a t
l e a s t 9 inches a f t of t h a t permitted and t h a t the p i l o t was misinformed of
a most c r i t i c a l dbension, the "mean passenger armtt.
Consideration of seven theories complete the report* Of these theories

only two were not dismissed hy the Court. One was suggested by the Managing
Director of F a i r f l i g h t Ltd. who attributed the accident t o the displacement
of the p i l o t ' s s e a t upon the sudden use of power, tmt t h i s theory was
regarded as "inherently improbableno The remaining theory was that the a f t
displacement of the centre of gravity beyond the compulsory limits resulted
in there being insufficient angular movement of the elevators l e f t t o
neutralise the climbing tendency which occurred, and t h a t i n any case an
acute degree of i n s t a b i l i t y would e x i s t near the s t a l l , The Court f i n a l l y
accepted t h i s theory and concluded that the most proba'ble cause of the
accident must be found i n the loading conditions of the a i r c r a f t which
g a k a centre of gravity position too f a r a f t and outside the l i m i t permitted
in the relevant Certificate of Airworthiness. The report terminated with
criticisms of the passenger and luggage loading arrangementso
IGAO REF: Wl09
North East Flying Services Proctor 3e-E.AJCU at Brock Thorn Farm,West

Ri&gr Yorkshire on 21c June 19504 Ministry of C i v i l Aviation
Report No. C. 562,
Circumstances
The a i r c r a f t had been chartered t o f l y three people t o Blackpool from

West Hartlepool. About an hour a f t e r take-off the g i l o t l o s t h i s bearings,
landed in a f i e l d and enquired from the l o c a l inhabitants a s t o his
approximate position. He said his radjio was not functioning. A t the time
of the landing the v i s i b i l i t y was poor and there was low cloud. About an
hour l a t e r , after the weather had improved, the p i l o t commenced t o take off
54 ICBO Circular 18-AN115
and a f t e r the a i r c r a f t had crossed the f i e l d from the NW t o SE corner it

struck a 5-foot w a l l adjoining the southern boundary. It crashed i n the
adjoining f i e l d and caught f i r e . 811 the occupants were killed. The
f i e l d was 475 yards long but the width, for the major part, w a s l e s s than
half t h i s distance. The surface consisted of meadow grass 12 t o 18 inches
high, From the northwest end there w a s a s l i g h t up-hill gradient which
changed t o a down-hill one towards the south from approximately the centre
of the field.
The report concluded w i t h the opinion t h a t the accident was due t o an

e r r o r of airmanship by the p i l o t i n attempting t o take off under the condi-
tions which prevailed.
ICAO REF: ~ ~ / 9 6
UMITJID STATES
American Airlines. Inc, BC-6 N-90928 mashed a t Love Field,

D a l l a s , Texas on 29 1Jovembr 19A9. CAB Accident
Investination Remrt No, f-0120.
Released: 30 hsuat 1950,
The a i r c r a f t was on a f l i g h t from New Yopk t o Mexico City via Uashington,

D.C. and Dallas, and was gc- 46 passengers,
A t 2L$7 on 28 H o v a b r the f l i g h t l e f t New Pork arriving at Wahingbn

after an uneventful journey, A t Waashfngbn a f l i g h t plan was f i l e d and ap-
prwed s p e c i m n g Inatmugent Flight Rules =toDrillas, Wichita F a l l s as the
alternate and a e a s i n g altitude 02 18,000 ft,
A t 0206 the f l i g h t waes granted pem&ssion t o change its f l i g h t plan t o

VFRo A t 0254. a position repox% was relceived over Nashville a%16,080 $PI, and
a desoent to 6,000 f t , was s t a ~ t e d , Aa the flight approached INashKLle, No, 1
engine started backfiring at intervals of about 20 seeonds, Deepite various
corrective Blsaernres including the application of d c o h o l and carkxsetor heat
and the richening of f u e l mixture, the bdcf'iring continued, A t apppoxhate3-y
0300 and 25 sonthwert of Ia8hviUe9 No, f engine was feathered and a%
0429 when the f l i g h t was i n the vicinity of APtheha, Ark,, the crew advised
its company t h a t a change s f a t r e r a f t w u neeeeaary a t DaL1as, When n e a r h g
Dallas the captain and the f l i g h t engineer co&erred regarding the re- of
Noo 1 engine to service and decided against it, No attempt 'Mas made tQ trane-
f e r f'hele, resulting i n lL+OO pounds Bore weight on the l e f t sfde of the air-
c r a f t on a r r i v a l at Dallas,
A t 0536 the a i r c r a f t waa 15 miles n o ~ t h e a s ts f D a l l a s and was given

permission to enter the t r & f i c pattern at Love Field with a righthand turn
and i n s h c h d to land on runway 36, The a P t h t e P s e t t i n g and the weather,
which included unlimited ceiling, v i s i b f l i t y of" 15 rniPes9 wind at 5 WH, were
given to the f l i g h t , In the f i n a l approach, at an a l t i t u d e estimated by the
captain at 1200 ft, and the first o f f i c e r a t 800 ft, above aerodrome level,
and at a dietwee of about 1-1/2 miles fram the approach end of the runway,
\ha I p i n i %%pis ~ . . i 8%,am\~L Shmtly ~~BFBTS~SP

'pihiY k q ! w tb ~LZBSB W.FB
T?SS'\j ehnh.ei, %Q b x m b f'i.nd plxceb the ahcrtaft l ~ tot \ the mnvprg 8nh
to correct t h i s an S t a r n was made, during which the a i r c r a f t skidded t o t h e
l e f t , the airspeed dropped abruptly and the a i r c r a f t s e t t l e d rapidly, The
captain i n an a t t q t t o maintain control increased power t o engines 10s. 2,
3 and 4, The a i r c r a f t cleared t h e 30 f t , obatruction poles 800 f t , south of
the approach end of the runway by approxbately 75-100 ft. and continued
across the a i r p o r t i n a tail-low a t t i t u d e , on a heading of about @ to the
l e f t of runway 36. The airspeed continued t o f a l l and i t s a t t i t u d e became
increasingly nose-high until the a i r c r a f t s t a l l e d j u s t before s t r i k i n g a
hangar and other buildings on the airport, Fire followed a t once,
The Board i n i t s report on the investigation s a i d t h a t on f i n a l approach

and when the a i r c r a f t was approximately a t the proper a l t i t u d e to start f l a r i n g
out, the f l i g h t engineer saw a warning l i g h t f l i c k e r and the fuel-flow meter
of No, 4 engine reading %era, He immediately notified the p i l o t s t h a t No. 4
engine was cutting out, and the captain t o l d h i a to put t h e boofitter pwnp t o
it, The f l i g h t engineer did so, Fzill t h r o t t l e was then quickly applied t o
engines Nos, 2, 3 and 4, The captain s t a t e d t h a t No, 4 engine came i n with
a m t e r r i f i c * surge of power (overspeeding), the l e f t wing dropped, and t h e
a i r c r a f t s t a r t e d t o turn l e f t ,
He then retarded throttles Nos, 3 and 4 i n ern attempt to r a i s e the l e f t

wing u i t h No, 2 engine, When the wing was p a r t i a l l y up he opened t h r o t t l e s
Nos, 3 and 4 and c a l l e d f o r gear and f l a p s up, The Board s a i d the first
o f f i c e r ~ a i s e dt h e gear but did not r a i s e t h e flapso He then observed t h a t
No, 4 tachometer indicated only 1,200 repem,, noted t h a t t h e Fuel pressure to
t h a t engine was zero, and 5rrnbdiatefy feathered No, 4 propeller.
I n an analysis of the investigation, the Board said: "The decision t o

land with No, 1 engine inoperative placed c e r t a i n added responsibilitiesr upon
the crew* F i r s t p it i s vitally necessary t o plan an engine-out (three en-
gines) approach with extrame care and thought concerning altitude, air s p e d ,
r a t e of descent, and distance from apgroaeh end of the runway, all of which
should be determined at a greater distance f l . 0 ~the a i r p o r t than f o r a nof-
m a , ,!+-engine landing, I n addition, it i s inportant t h a t the a i r c r a f t be i n
close alignment with the r u n w a y w e l l before beginning descent i n t o f i n a l
approach, making any f'urther M n g unnecessary,
"The turn into f i n a l approach was made about 2 miles frcm the end of
t h e runway, Since t h e a i r o r a f t was not l i n e d up with t h e runway a f l a t IS1
turn wsa attempted t o correct t h i s error, During t h i s ' S f h ,the a i r c r a f t
skidded, r e s u l t i n g i n a l o s s of air speed which was augmented bg the f u l l y
extended flaps, It i s v i t a l l y h p o r t a n t t o use proper f l a p settings t o corn

p l e t e an engine-out approach,"
I n a smmnsry of what it said "seema to be the most plausible reconstruc-

t i o n of events immediately preceding the accident," the Board continued: gThe
turn i n t o final approarch was misjudged, requiring f i r s t an extension of t h e
right-hand turn, and then a left-hand turn, to align with the runway, Such
turns were made while the aircraft, according t o ground witnesses, appeared
to be keqt qaib l e v e l laterally. To change direction f r o a a r i g h t turn t o a
l e f t tarn, with the a i r a r a f t being kept apprQximately l e v e l would necessitate
a large amount of l e f t rudder control to start the l e f t turn, together with
considerable r i g h t aileron control, Such control caused the aircraft t o skid
to the l e f t and then t o the right. The relatively small amount of f i e 1 i n
E30. 4 main tank, due t o 3aproper fie1 nanagement, would lawe aentriftxgally to
the r i g h t during the r i g h t skid, or away Pmrm and uncovering the o u t l e t of the
task a i e h is at t h e inboard, o r l e f t , side of the tank, No. 4 engine did
not respond becaazee it had no Are1 at the moment. When it did respond, almost
immediately, it surged (overaped) and the resulting strong unbalance of tbru8t
-
caused the a j r e r a f t to yaw to the l e f t and the l e f t wing t o drop the dropping
tendency being aggravated bJr the approximate 1,400 pounds of f h e l d i f f e r e n t i a l
i n the l e f t tanks,
*The a i r c r a f t was then i n a position f r a a which recovery was impossible,

The alm~stimmediate feathering of l o , 4 engine by the f i r s t officer, because
be beliwed it inoperative, had no bearing on the accident*.
ICAO REF: AR/97

UNITED STATES.
Air Trmaport Associates, Inu, C-16F N-5075 crashed a f t e r take-off

from Boeina Field. Seattle, WasNnPton on 19 July 1949.
CAB Accident I n v e s t i ~ a t i o nReport F i l e No, 1-0056,
Released: 30 Aumst 1950.
A t 2043 the f l i g h t , scheduled t o fly Seattle, Idashington, t o Chicago,

Ill., taxied from the loading ramp t o the south end of runway 31 where there
was a delay of 13 minutes f o r the before take-off check, The aircraft t o t a l

weight was within the allowable l i m i t and was properly loaded, 91 and 100
octane f u e l were carried, the run up being carried out on 91 octane fuel,
A t 2058 the f l i g h t received clearance frm the tower and began take-off
using 91 octane f u e l because of f a i l u r e of the l e f t centre f u e l pressure boost
pump, One of the engines was heard t o splutter and backfire and an unusual
amount of torching o r exhaust flame was seen coming from both the engines,
A t a p p r m h a t e l y 3,500 f e e t down the runway, the a i r c r a f t became airborne but
the l e f t engine did not seem t o be developing f u l l power, and the p i l o t there-
f o r e retarded the t h r o t t l e s and the a i r c r a f t s e t t l e d baek on the runway, A t
the time of the accident the green threshold l i g h t s had been moved i n f o r
repair purposes so t h a t the runway was reduced by 1,700 f e e t t o 5,800 f e e t i l a
length, The p i l o t considered t h i s insuffioient apace to accomplish a safs
stop, advanced the t h r o t t l e s t o the l i m i t ~f 52 inches, both engines responded
but the l e f t continued to misfire, and the a i r c r a f t became airborne a t an air
speed of 105 d l e s per hour, The f l f g h t passed the end of the runway at a
height of about 50 f t . above the ground i n a nose-high attitude. However
there waa insufficient altitude to fly over the power l i n e s and poles thus
the a i r c r a f t strnck a 56 f t , pole (2 f e e t f'rcm i t 8 top), 1,500 ft, beyond the
end of the runway, A second and t h i r d pole we- struck, 1,480 f t , and 200 f't.
a f t e r each other, A s a rearrlt the a i r c r a f t rapidly l o s t a l t i t u d e and crashed
i n t o a three-storey house com2ng t o pest i n a single-storey brick dwelling,
The investigation found the probable causes of t h i s accident were p i l o t

indecision and the use of 91 octane f u e l f o r take-off, A contributing c a s e
was t h a t the runway threshold l i g h t s a t the far end of the mnway had been
moved in, making t h e runway appear shorter than the actual usable length.
The investigation further found t h a t none of the three p i l o t s on board had
received training or a f l i g h t cheek on t h i s type of a i r c r a f t ; take-off power
settings used were f a r above those allowable f o r 91 octane fiel; engine was
obsolete and no instmotions other than axmy technical orders were published
f o r maintenance of the engine and these were d i f f i c u l t t o obtain.
ICAO Circular 18-AN115 59
ICAO REF: AR/98

UNITED STATES
Mercer E n t e r ~ r i s e s . Cessna T-50 I?-61503 a t Los An~eles

on 1Oebber 39L9, CAB Accident Investigation
Report P i l e No. 2-0700, Releaseqt
6 September 1950.
'Phe a i r c r a f t w a s on P t s return f l i g h t from Palo Alto t o Bwrbank, Calif.

carrying 5 pasaengers, The p i l o t estimated the constunption on the first half
of the t r i p as 30 gallons an how, or t o t d of 60 gallons. T h i s w a s half the
120 gallons of f u e l carried. Another 35 gallons was put i n before the return
flight.
The aircred't l e f t Palo Alto a t approxfmately 1835 having f i l e d a f l i g h t

plan with San Francisco radio fop PFR Burbank a t 7,000 f t , The f l i g h t plan
also indicated 2 hums f l i g h t time w i t h sufficf ent h e 1 f o r 3 hours,
The f l i g h t proceeded without incident u n t i l about 61 miles fram Bnrbank

when the p i l o t w a s concerned as t o whether he would have sufficient f'uel;
however, as his f u e l g a g e s indicated 35 gallons (1 hour % f l i g h t ) and Burbank
was 30 minutes' f l i g h t time away he decided t o eontime. A t 2056 the p i l o t
requested the shortest route to Burbank and asked i f there were any lighted
f i e l d s between Newhall (16 miles north of Burbank) and Burbank. The oontrol
tower replied t h a t there ~ g p sno lighted f i e l d s and the shortest route was
12h0, After paasing Newhalf the Plight began descent from 7,500 ft. Apprax-
iraately 9 minuter, l a t e r the afxeraft emerged &om a lryrer of c l a d s 3,000 ft,
over domtown Lo8 Angeles, The p i l o t made a tarn t o go back t o Burbank
approxbatel;l. 8-1/2 miles to the northwest, During the turn, however, both
engines ceased t o operate thpaugh lack of Fuel and the p i l o t attempted an
emergency landing on Beverly Boulevard, A t 50 f t , the a i r c r a f t h i t 3 power
l i n e s and crashed out of control t o the s t r e e t ,
Probable Cause
The investigation found that the probable cause of t h i s accident was

the exhanetion of h e 1 prior to a r r i v a l at the intended destination, due t o
improper f l i g h t planning and operatian,
The investigation also found t h a t the t o t a l weight of the aircraft was

approxinatcaly 272 pounds more than its certificated weight when it departed
Palo Alto. The f l i g h t overflew the destination and the engines f a i l e d due to
f u e l exhaustion; the p i l o t did not determine the actual h e 1 consumption of
the engines ( e a t h a t e d aa 34.4 gallons per hour); no attempt was made t o
u t i q i z e the available radio f a c i l i t i e s f o r the purpose of orientation,
ICAO REF: ~ ~ / 9 9
UKtTED STATES
Eastern Air Lines, Inc. DG-L and a P-38 collided near

Washindan National Aimort on 1November 19Q.
CAB Accident Investfpation R e ~ o r tNo, 1-0138.
Released: 26 Se~tember1950,
The Eastern A i r Liners DC-4 Flight 537 was being landed a t Washington
Airport a f t e r a f l i g h t *om Boston and the P-38 waa being t e a t flown i n the
v i u i n i t y of the Washington Airport.
Clearance for landing was given to Eastern when on its donnrind l e g

west of the f i e l d , Ikistern made a contimaus turn f i a m i t s downwind l e g west
of the f i e l d to a f i n a l approach to runway 3, During t h i s turn, the P-38 was
-
south .of the end of runway 3 on a high straight-in approaah f o r landing on
the same runway on which Eastern had been cleared to land Runway 3.
Following the DC-4's clemanoe t o land, instructions were given t o the

P-38 t o enter the l e f t t r a f f i a pattern and t o c a l l the tower when west of
the field, These instructions, although repeated by the tower, were neither
acknowledged nor complied with, Instead, the P-38 8tarted a straight-in
approach on an approxinsQte heading of 20 degrees, The P-38 was f f i n requested
to make a 360-degree turn to the l e f t and to land number two following the
Eastern DC-4 turning on f i n a l approaah be$- him,
d8 the Eastern DC-4 rdlled out of i t s l e f t turn onto final approach,

approxigstely 3/4 mile frc#a the end of runway 3, and as the P-38 continued
t o descend above and behind the DC*C, the tower transmitted to the Pb38 either,
"Rxm l e f t , turn left,ff' or "Clear t o the l e f t , clear t o the l e f t e n Since the
P-38 still did not c q l y , and a oollieion now appeared irmninent, the hwer
sKftched t o the DC-4 frequency and instructed the Eastern crew to turn l e f t
because a P-38 was on the approash behind them, The Eastern f l i g h t responded
immediately by applying powero levelling off, and turning l e f t . But, before
more than 5 degrees of turn waa made, the two a i r c r a f t collided at a point
i n l i n e with and 1/2 lglile *om the appxaaeh end of runway 3 a t an a l t i t u d e of
300 feet. A l l of the 51 passengers and the crew of four i n the DC-4 were
k i l l e d and the p i l o t of the P-38 was aireriausly ingured,
The report s t a t e s t h a t the testimony of the control tower personnel

and t h a t of the p i l o t of the P-38 were i n conflict.
Prior t o taking off the p i l o t of the P-38 had notified the control tower
through a second party of his intention t o mke the t e s t f l i g h t and t h a t he
would communicate with the tower control over VHF radio channel "BW on 126.18
megacycles, He s t a t e d he had aeked the second party to also notify the tower
control to signal by l i g h t i f radio contact was not established, The tower
control did not receive t h i s l a a t message and the second party denied hearing
the p i l o t make t h i s second request. During the ground operation and clear-
ance f o r take-off no d i f f i c u l t y w a s experienced i n communications by the
tower control or by the p i l o t i n the P-38, His testimony included the state-
ments t h a t t h i n g manoeuvres shortly d t e r We-off e r r a t i c operation of the,
r i g h t engine occurred and he decided to land as soon as possible, He trans-
mitted a message to the tower s t a t i n g t h a t he had engine trouble and re-
quested landing instruotions, but received no immediate ansfrer, neither did
h e observe any l i g h t signal from the towar* He i s reported t o have s a i d
t h a t shortly afterwards the t o w e r control queried h i s c a l l and gave hlm ine-
tructions as "Bolivian P-38 c;Leared t o land mznber two on runway 3" but he was
not informed t h a t the a i r c r a f t ahead of him was an Eastern DC-4, According t o
the tower control the c6ntFBl;ter instructed the P-38 n t o enter a l e f t t r a f f i c
pattern for runwey 3 and to report when west of the tower on downwind l e e .
When the instruction w a s not coknowledged by the P-38 it was repeated, The
p i l o t of the P-38 s t a t e d t h a t whilst on h i s base l e g he observed a C-60 or
C-45 complete i t s landing and turn off the runway, He also stated that a f t e r
completing a l e f t tura frem the base l e g t~ an approach coarse for landing
on runway 3 he transmitted a message t o the eontrob @BolivianP-38 on approar?hw
and received an answer fiom the control tswer *Bolivian P-38 cleared to l a d
on runway 3w, He also heard the tower control say "Clear t o the l e f t , e l e m
t o the l e f t w but he did not know f o r whom it was intended bechnxse no call s.@
was used, Almost immediately afterwards he f e l t the shock of the collision
with the DC-4. The r e p a ~ rsltates
t t h a t the P-38 was never given a clearance to
land number one, The report implies t h a t %he p i l o t of the P-38 reporting what
he considered t o be the number one a i r c r a f t , a C-46 or C-60, land, may have
been c o m s e d by a 33-24 t h a t did make a simdated instrument approach t o
runway 36, Airport obeerV8re arid the tower records did not report a C-46 o r
C-60 landing during t h i e per%&
It is conceived t h a t a good p a r t of the control tower instructions t o

the P-38 aray not have been received as transmission and reception on any one
particular radio frequency cannot be effected simltaneonsfy hence the p i l o t
of the P-38 would not have received intended messages from the control tower
i f he had been c a l l i n g a t the same time t h a t the control was attempting to
give him instruotions+
I n a footnote it i s r e o d e d t h a t %here were no recordings of any of the

conversations wf%h the P-38 because they m e made from the "An position
( ~ o c a Control
l Position) whi& had no recording apparatus, The P-38 was on a
frequency of 326,18 megaayeha, while Ess-rn was en a freqneney of ll9,l
megacycles, conaqusntlp., neither plane cmld hear the transraissisns between
the tower and the other planeb Howeverp simultaneous trcmsmissiona could hsve
been made on both fiequenclea if the operator had erimply held two frequency
toggle switches "onP iolPdtead of one,
m e captain of the DC-4 was advised by the tower %hat the F-38 waa in
the t r a f f i c and l a t e r warned t o 1ookauDi f o r it, Eviden$ly tigbe was too short
t o take mccesrsf'ul evasive asction when as he was headed i n f o r the landing
and the final warning was g%wnt o turn let%, wlth the P-38 on the approach
behind, and with r e a r v i s i b i l i t y i n t4e IIC-4 restricted, The forward v i s i -
b i l i t y in the P-38 was also l-ted unless the aeroplane w a s manoekred to
see ahead*
The Boardl while imparting pgor judgment t o the tower personnel i n

adhering t o the single course of guiding and corrective action wfiioh was
selected, even though aorrPraUy they had the r i g h t t o q e c t such action t o
be effective, did not, oonsidering all the cfrcumtances and particularly
the p i l o t of the P-38's unpredictable actions, assert t h a t a different o r

'additional course of action by the tower i n the time available t o it t o
reaeonably select such action, w u l d have averted the accident,
It is stated i n the findinga that the t o w r did not a a t with the reqai-
82% alertness and promptness i n commnnicating to Eastern the position of the
P-38 i n the c r i t i c a l t r a f f i c situation which confronted it, b u t t h i s cannot
be said t o have contributed to the cause of the accident,
Probable Cause
The Board deteraines that the probable cause of t h i s accident was the
execution of a straight-in f i n a l approach by the P-38 p i l o t without obtaining
proper clearance t o lahd and without exercising necessary vigilance,
zcA0 RFF: AB/iQQ

UNITED STATES
TransoaeanAirlines, Inc, X-1 N-79998 near Luraa Point

on the I r i s h Coaat on 15 Busrust 191*90 CAB Accident
Jnvestiaation Rewort No, 1-0086,
Released t 15 September 1950,
The aeroplane depqted Rome, Italy, on a non-scheduled f l i g h t to

Shannon, Ireland a t 1608 GST, U. August 1949, There were 49 passengers and
a crew of nine on board. The report describes the lack of coordination of
the work undertaken i n the pre-flight planning by the various f l i g h t crew
members, who did not have any agreement o r acrcurate knowledge as to the route,
fuel on board, f u e l requirexnenta, or duration of f l i g h t , The captain f a i l e d
t o examine any of the documents before take-off, The crew diecovered t h a t
there were only 2200 gallona of h e 1 on board which on the basis of a con-
sumption r a t e of 200 gallons per how, a standard estimate of the companyt
provided f o r Il hours range and was not sufficient f o r the required fuel
reserve of two hours' n o d cruise a f t e r f l i g h t t o Shannon, The original

f l i g h t plan prepared by the navigator w u based on 12 hoursa f u e l over an
indirect route via a i m and Paris with Orly airport as the alternate aaro-
drone, This was disoarded f o r one v i a the direct route from Marseille w i t h
Dublin as the alternate aerodrome, but the change was not transmitted t o the
Rome AX, The lack of precision i n naegation i s debcribed at length i n the
report. Relatitrely c l e a r weather with l i g h t t o moderate winds existed over
the route between Rome and $hannon, 'Phe f l i g h t forecast given t o the crew at
Rome covered the irrdireot route to Shannon ria Paris and did non'contain spe-
c i f i c wind information f o r the d i r e a t rcvute.
The navigator drawing tbe courses of the Shannon radio range when an
wAn signal of t h i s radio aid was being received'in the aircraft, erroneously
Labeled the southeast a6eLop of the range Qw instead of the proper desig-
nation *P. Be believed, bebase of the signal, t h a t the f l i g h t had not
passed Shannon,
A c e l e s t i a l Pix o6t;tl.2jied by the navigator a t about 0030 GST, when

plotted, placed the aeroplane at a position 175 miles northeast of Shannon,
Cauraes on different beruping;a were then flm u n t i l the weat l e g of the
Shannon radio range was intetoepted. A t this time only about 1-1/2 hours Rtel
remained, The aeroplane had been airborne a t o t a l of 9 hours six minutese
At 0106 GST the f l i g h t dsr.f;eathe Air-Sea-Rescue f a c i l i t i e s at Shannon giving
the aeroplaneus position as 100 anilea wes% of Shannon f l y i n g inbawd on a track
of 80' with ground w peed e s t b a t e d a t I40 h o t s , The f l i g h t continued toward
S h h o n u n t i l 0240 6ST when h e 1 was exhaeretad a%which time the aeroplane
was ditched'in the sea st a poeition about seven miles northwest of L u r e
Point on the west I r i s h Weihlt,
It i s significant that no use waa made by the f l i g h t of 500 kc/s. the

International Distress Frequency.
The a i r c r a f t remlned afloat f o r about 15 minutes, during which time

the crew and passengers remved and manned a l l but one of the l i f e rafts.
Aircraft clrcling over the l i f e ~ a f t swere able t o d i r e c t the British trawler
'Stalbere t o the scene, All rusaue operhtions were completed shortly a f t e r
daylight of 15 Auguat 1949, Seven passengers and one crew member d$ed as a
~ e 8 d . tof exposure o r drowning$ 0 t h W ~BTe~ ~ ~ ~ ~ e s ~F ~fB dC lU .B 1
~ ~~
The report i n summqr staters t h a t there can be l i t t l e doubt t h a t the

f l i g h t m t with diesstax beewee of inadequate Plight planning and h a p b a r d
performance of f l i g h t d t l t i e ~ r During the planning stage of the flight the
*
crew did not confer with one another and they had no agreement nor accurate
kirowledge of route, f u e l hours on board, f u e l requirements, nor duration of
f l l g h t , The weather information obtained was not applicable t o the route
which was aetuaZly flown, and no attempt waer made en route to secure t h i s
information. Accurate hourly positions of the a i r c r a f t were not determined
and plotted. Radio f a c i l i t i e s , i n particular the Shannon radio range, were
not used t o t h e i r best advantage, And, finally, c e l e s t i a l navigation was not
used as a mean8 of ratine position determination though the stars were vis-
i b l e at a l l times,
It is apparent from the various errors and omissions of the crew, t h a t

the captain did not empervise e i t h e r the f l i g h t planning o r the f l i g h t duties
a e - h i s responsibilities required, As a result, the aircraft; waa flown beyond
i t s destination and f u e l was exhasted before the return t o Shannon could be
conpleted,
Probable Cause
The Board determines that the probable c a s e of t h i s accident was the

f a i l u r e of the captain t o eprerciae the proper supervision over his crew during
f l i g h t planning and while en route,
UNITED STATES
P r i v a b l s owned ConsoUdated Vultee BT-15 NC-63L18

crashed i n residential area of Pasadena. Calif.
on 28 bril 1950, Civil Aeronautics Board
Accident Investiaation R e ~ o r tNo. 4 ~ 1 9 9 3 ~
Releaseda 3 December 1950.
A t approximately U05 the aircraft took off with two occupants from
East Los h g e l e s A i ~ p o r ten route f o r Oroville, A f l i g h t plan wae f i l e d indi-
cating t h a t the p i l o t would proceed i n acco~dancewith VFRo A t U37 the
66 ICAO Circular 1 8 - ~ ~ / 1 5
a i r c r a f t was observed spinning just below a 2,500 f t , overcast, The a i r c r a f t

colapleted two turns of a spin, but a t about 4OO f t , from the ground recovered
t o enter a steep climb, however, the a i r c r a f t again s t a l l e d and control wae
l o s t f o r a second ti- and the a i r c r a f t crashed into a house on a h i l l a t an
elevation of about 1,100 f t , Both oemparrts were killed, The weather a t the
t h e of the accident wa9 variable c e i l i n g 2,500 f t , and v i s i b i l i t y of 5 miles,
kith the mountain i n the direction of the intended f l i g h t oovered by
cloud, It was not established whether the p i l o t obtained a weather report
before taking off,
The a i r c r a f t was f i t t e d w i t h f l i g h t instruments which included a direc-

tional gyro and a r t f l i c i a l horizon, The p i l o t had .approximately 300 flying
hours but there w m no indleation t h a t he had ever flown solely by instru-
ments, o r that he had received tmy instrument training whatsoever,
Probable Cause
-
The probable cause of t h i s accident was loss of control of the a i r c r a f t
by the p i l o t while flying into an overeast,
ICAO REF: A
Rh
O6
XJBITED STATES
Borthwest Airlines, Ina, Flight 309 Martin 202 M-93050 crasheq

a p ~ r o x h a t e l sL M l e s west of Minneawolis. Minn,
on 7 March 1950, Civil Aero&utice Bow4
Accfdent Investigation Re~ortgo, 1-003%
Released: U Dee~mber1950,
On 7 March 1950, Che a i r c r a f t with 13 occupants began its f l i g h t

-
Washington8 Winnipeg, Scheduled stops were Detroi-t, Mich., hdi~son, Wis
Rocherstar, fainn, and HinneapoUs, Miw. A t Detroit the f l i g h t wa8 held up
.
'an hour and a half f o r the replacement of a ring s e a l i n the h y d r a z l i c syatc3111,
ICBO Circular 18-~/15 67
A t 2023 the a i r c r a f t reached Rochester bwt &e to l i g h t freezing rain

did not attempt cr landing. A t 2035 a report was received from over Stanton,
a radio beacon 30 miles south of Minneapolis airport, and a t 2041 the control
tower was contacted f o r landing clearancee
The f l i g h t waa informed of existing weather conditions, precipitation

ceiling at 900 feet, v i s i b i l i t y 1/2 t o 3/4 mile, wind ~prth27 mph with @eta
up t o 40 mph* As the a i r c r a f t reported over the outer marker 4.7 miles eouth
of the approach end of the runway the v i s i b i l i t y tras 1/2 mile and the f l i g h t
was given clearance t o land, The a i r c r a f t was not seen from the tower but
was heard passing over the control t ~ w e ra t which time the following message
received- nI have got to get ina. Clewmce was again given, whereupon
the f l i g h t advised that it would climb t o 2,400 f e e t on the northwest c m s e
of the Minneapolis radio range, After a pause a second message waa received
"We a r e going in, we a r e going inw, After flying over the f i e l d the air-
-
craf't was observed flying s t r a i g h t and l e v e l 3.8 miles north-west of the aero-
drome. A wing was seen t o f a l l away and then the whole a i r c r a f t dived alrmost
v e r t i c a l l y from about 300 f e e t i n t o a house, A l l occupants of the a i r o r a f t
and two i n the house were W e d ,
The main wreckage was situated 4-3/8 miles north-east of the afrpmt
w h i l s t the l e f t wing outboard from s t a t i o n 252 wgs located 3,8 miles north-
e a s t of the airport, The wing showed that, a f t e r being cut or t ~ r nthrough
the forward section, it had rotated upward and rearward and, as a r e s u l t of
t h i s twisting action, separated from the r&nde~ of the wing, A taper&
a h e l nagpole loca6ed 4,180 f e e t south of the approach end of the rummy d
650 f e e t west of the centre l i n e of t h a t runway and extending to a height of
70 f e e t above ground was dmaaged and bent i n an azimukh of 1 7 degrees,
A large ornamental American eagle which had been m a t e d on the tQlp

20 f e e t south of the poless base while the red neon marking l i g h t s
W ~ E Ifound
were found 40 f e e t t o the nor*, It w a s apparent %hat the a i r c r a f t had
struck the pole during the attempted approach,
It waa established that when the a i r c r a f t atruck the pole it was I28
f e e t below Lhe ILS glide path, 650 f e e t west of the centre l i n e of the runwag
and flying a course 17 degrees t o the r i g h t of the mnway heading,
A s f a r as could be determined, there wm no defect i n the operation of

the ILS ecpipmnt, o r in any of the other landing f a c i l i t i e s on or near tbe
w o r t a t the time of the accident, Purthennore, no defects are known .kr
have existed i n any of the a i r c r a f t flight; instruments o r related equipsen%,
68 ICA0 Circular 18-AN115
It was established that the p i l o t was particularly expert i n landing

the Martin 202 and i n the execution of ILS approaches, (He had Igade over 200
ILS approaches t o the Twin Cities Airport,) If was therefore assumed t h a t
the p i l o t attempted t o complete h i s landing visually and did not use the ILS,
otherwise he would have been warned of h i s position by the ILS indicatorso
It was concluded t h a t falling snow r e s t r i c t e d v i s i b i l i t y thereby obstructing
the neon obstruction lighting on the pols, It was probable t h a t the p r o p e l l e
b l a s t of an a i r c r a f t which took off j u s t previously raised both the height and
density of the snow condition,
Probable Cause
The probable c a s e of t h i s accident was the attempt t o complete a land-

ing approach by visual means during which time visual reference to the gromd
was l o s t *
ICAO REF: &ba

UNITED STAfi'B
Private Aircraft Gessna 1/,0 N-292% and P i ~ e rPA011 M-45A%

collided near Mami, Fla, on 22 January 1950, Civil
Aeronautics Board Accident Investivation Report
F i l e No, 3-0006, Released: 18 Dcfobgr 1950,
Circumstances
The Cessna, camying two persone, l e f t Jacksonville, Fla. on 22 January

on i t s way t o Miami. An intermediate stop was Bade a t Helbnume for reflzelling.
A t approxhmteely 1540 h m s the Cessna reached 9uMy South Airport and was
informed t h a t a right-hand traf'fic pattern existed when the surface wind was
i n an easterly direction,
A t approximately 1530 the Piper took off i n an e a s t e r l y direction with

the p i l o t and one student p i l o t on board, f o r the purpose of a final check
r i d e before the latter took his f l i g h t examination,
ICA0 Circular 1 8 - ~ ~ / 1 5 69
Between 1540 and 1 x 5 both a i r c r a f t followed the correct traffict pattern

but on converging eourses, The Piper was observed making a r i g h t tarn p r i o r
to the f i n a l approach l e g while $he Cessna wars Ilaa%ing a s t r a i g h t in approach
f r m a westerly direction, The collision o c m d at an approximate height of
200 ft, One occupant of the Piper survived,
Probable Cause
The probable cause of t h i s accident was, primarily, the f a i l u r e of the

Cessna p i l o t t o observe and avoid another airwaft while making a landing
approach; andb a l e s s e r degree9 the f a i l u r e or the inetructor p i l o t i n a
8
Piper t o remain vigilan% a t a l l times f o r other aircraf% i n the air even thahgh
he had the r i g h t of way,
UNITED STATES
Rorthwest Airlinesa Ine, C-54A-DCe 1-95425 crashed into

Lake MicM~anon 23 J m e 1950, CAB Accident
-
Inveskiaation Report No, 1-0081,
-.Released: 18 January 1958.
AP, appro-tev 193 hours the a i r c r a f t l e f t New Pork en route f o r

S e a t t l e via Khneapalfa and Spokane, On board were 58 pwsengers, a crew of
three, weight being l e s s than the mmimm permissible take-off weight and
properly di~trilbrrted,
%he Slight plan specified a crmieing d t i b d e of 6,000 f t , t o & i i a n ~ @ E ~

although a r q n e s t had been made f o r one of 4,060 f t , owing to forecast of
thundarstmm, howevep, &'PC refused t h i s because of other t r a f f i c at t h i s
level, A t a 9 when over Cleveland the &reraft agPn requested a cruising
altiP;ude of 4,000 f%, whioh was t h i s time a g p r m d ,
70 ICAO Circular 1 8 - ~ / l 5
A t 2229 the f l i g h t was requested by ARTQ t o descend t o 3,500 f t , because

of the difficulty of an eastbund f l i g h t t o a n t a i n i t s assigned alti*ude due
to severe turbulence, A t 2551, a report was received to the e f f e c t %hat the
f l i g h t was over Battle Creek a t 3,500 f t b and d d be over Milwaukee a t 2337,
A t 2313 the f l i g h t when near Benton Harbour made a reqrzest f o r permission t o
descend t o 2500 f t , This was refused by gRTC because of other t r a f f i c i n the
v i c i n i t y and acknowledgment of the l a t t e r message was glade by the afrcraft a t
2315 which was the last commarslication received,
A t 2337 the Milwaukee Radio advised New Pork tiad Chicago t h a t the f l i g h t
was PO ndmtes over&za. A t approximately 2345 d l the CAB radio stations
t r i e d to contact the f l i g h t on rall frequencies* A t 2358 dl 4.r-sea rescue
f a c i l i t i e s i n the area were alerted, After an extensive searah, an 00slick,
a i r c r a f t debris and the aircraft log book were found approximately 18 m i l e s
north north--west of Benton H a ~ b o u r ,
A t the approxiglate time of the accident a l i n e squall with widespread

thunderstorm a c t i v i t y extended from southern Wisconsin eastward i n t o lower
Michigan with i t s southern edge located west of Benton Harbour, Later evidence
indicated t h a t the squall l i n e was q u i t e severe,
Impact damage found i n fraepents of the &craft t h a t were recovered

showed that the aeroplane stmak the water with considerable force,
l o definite conefusions were drawn &om the evidence available, A

p o s s i b i l i t y that the accident resulted from mechanical f a i l u r e was remote,
The evidence howaver indicates t h a t t h e accldent probably resulted from e i t h e r
a a s t r u c k a l f a i l u r e caused by turbulence or because control of the aeroplane
was l o s t ,
- - --
ICAD Circular 18-~/15 -we-
n
ICAO UP: AFiFi2
Reai&o Airl&Qn&- C 4 6 L Nm9&06H, crashed about a

- -
hdlf mile froa Teterboro. New J e r s e j Aimort on 27 May, 1950,
C& Acofdent Investigation Report Noa 1*OQ78e
Released: 1 0 April. 9951,
The flight3e81"rying two crew and a niscellaneous cargo, orfginated a t

Teterboro; New Jersey. A t 1727 the a i r c r a f t was cleared to m w e y 19, Take-
off was estimated as longer than umal and several witnesses saw puffs of
black smoke coming from the port engine immediately a f t e r take-off, A t an
a l t i t u d e e s t h a t e d as 200-300 f e e t the l e f t engine s t a r t e d t o misfbe, Thia
condition became worse and the l e f t propeller was feathered, A t 400-500 f e e t
a left %urn wba s t a r t e d as if t o return t o the airport during which the air-
speed f e l l t o 85-90 mph and the afroraff s e t t l e d i n a s t a l l e d condition rstriking
the ground later* and longitudinally lfvel. The a i r o r a f t vaa compIete1~
weeked and the captain lcilled,
Impection of the engines disclosed that the port engine ignition showed
rrbnamalities3 six spark plugs were defective, f i v e plugs exceeded the apaci-
f i e d 1Mts when t e s t e d f o r gas leakage, Tlbelaatsode gaps of the 32 plagil
tested varied from 0,014 inches t o 0,023 inches ( w d 0,012 fnches). The
breaker p i n t s of both magnetos were b e d and oily, Both of these magnetos
Toare improperly timed, 'Phe sterrboard engine also had a mmber of ignition
abnormalities bat to a lesser degree than the p a r t engine, !K%e company which
had % b e &era.f% employed two nmahanicos who a l s o assisted i n loading thta
af~craft, Records showed that the a i r c r a f t had flown 92 haups 55 minutes since
the b s f , 80-how inspection and was therefore overdue f o r its next; 80-hour
inspection, No cargo plstnifsst was prepared and subsequent investigation
showed t h a t the a i r c r a f f ww 5,000 Ibs, overloaded,
The r s p o ~ pofnts
t out the e w e l e s s manner i n which the company conducted
its operations and s t a t e s that both t h e company and the p i l o t , as commander
af the aircraft, are t o be severely eenaured f o r permitting the f l i g h t t o
,depart, i n its overloaded condition$ without a f l i g h t manifest and with the
8 0 - h m inspection overdue,
72 I C A a Circular 18-AN/15
The Board d e t e a n e d t h a t the probable cause of the accicient was over-

loading of the a t r e r a f t due t o faulty loading and dispatch procedures, coupled
with engine malfunctioning due t o inadequate maintenance,
UNITED STATES
New Tribes Mission Douglas DC3, M-16030 crashed and b e d on

the S e r r d a de V d l e d u ~ a rRange. Colombia. South America
on 9 June 1950e CAB Accident Investipation Report F i l e
No, k-16730 Releaeed: 9 Awil 1951.
The a i r c r a f t was on a f l i g h t from Mi&, Florida, t o Maracaibo, Venezuela

via Kingston, Jamaica, c-ng a crew of three, twelve passengers and cargo,
The f l i g h t departed Kingston on an i n e t m e n t Plight plan of faur hoursp to
cruise at 9,000 fee$ d i r e c t t o l4arercaibo wi%hBarranquilla, Colombia, as an
alternate,
The f l i g h t progressed s a t i s f a c t o r i l y and radio contacts were made a t

1558, 1658 and 17'52 h m s , A t 1802 Balboa, C a n a l Zone, sent a message t o the
f l i g h t advising it t h a t the Maracaibo radio w a s already closed on FA ( a i r to
ground) and closing shortly on FX ! (point t o point), It was therefore suggeeted
t h a t Balboa be contacted when the f l i g h t landed at Maracafbo i n order to close
t h e f l i g h t plan, A t 1852 the f l i g h t advised Balboa t h a t it was "over the eoagt
l i n e a t 5,000 f e e t and descending WRn, This was the last message received
from the aircraft which never reached hracaibo,
The owners bseeune coneemed when they had no news of t h e i r aircraft and
on June L$ a conwmmfcations search was instituted when it was revealed t h a t
the f l i g h t plan had never been closed and the a i r c r a f t was unreported since
its last message quoted above,
The report continues ,that on June 18, aince it was apparent t h a t the
a i r c r a f t was missing, search procedure was initiated, The search was unsuc-
cessful and was called off on 28 June, The Hew Tribes Mission, however,
-
aantinuad %he air searoh aging a Stinson 1LIr~raf'% and cpn July 6 spotted t h e
wscked & c r a f t near t h e b p of a ntaun%afnat m elevatian of 4,400 f e e t s
qproxlmatrsly 42 Paflea w ~ s *of t h e d f r e c t B n g s t o n ~ l 4 a r a c a i beoarss.
A.recae&rtfetion of the probable eoupae followed by the trirerdt ahawed

%hat, bad the aimraft f a U o w d s d i r e c t o m s e From Kingaton t o HawPacaibo, it
would have in-terssseted the CoZosahim s a a s t l i n e near the village of' Tu~rtlraaas~
mpprox%n&elg 95 miles northwest of #aracafbo, f m whieh p a i t i o n on %o its
destination no point of the tamaln exaeeda 1,000 feet slevatlsn, B-m,
3% appams l i k e l y that t h e f l i g h t fntsrssated the coas% l i n e near the v i l l a g e
of Rio Hacha i w t e a d , whia3l-i is approximateljr 30 Biilea west o f Tumracas, To
have contimud t h e south@rlyheading frmn t h i s p s i t i o n would have brought
the airmaf%t o the point where the wreekd~gewae found, The l a a f aeresa(39
the &waft ind5acrted t h a t they did n a t know they were off soarse and descent
was therefore begun. It established t h a t darknees had f a l l a n at the time
the d r a a f t i s ewtimeted to have erashed,
The Board found t h a t there was not s u f f i c i e n t evidence upan which t o

W e s d ~ t e m h a t i s nof &he probable crmse,
--
UBITED STATES
-__0
Nor.t%lwmt Airlines I n . c M . M t i n 202, H-93051e erashed on talrsr-off

--
fra~ B i l l i p s Aim=, Montana, on 4 Sewtember 1950.
CAB Acohdsnt. Ipvea%$.tf on R e ~ o r t130, 1-@2&
Relsged t 2LFebPrxa1~19Ske
-v-
me &c?r&t had campletad the fir& half of the f l i g h t fm MPmmp~IlrS,

Minn, ta Seattle, Wash, and was taking off frw Billings* Mont, f o r %he r e s t
a f tha jmmney to battle, The a i r e r a f k was loaded properlp and waZl within
its U ~ v a b l el i m i t , Them were $6 paseengera and a crew of 3,
The p i l o t parked the a i r c r d t to the southwest end of -way 4 and

campleted h i s pre-take-off check, Having been cleared f o r take-off by the
tower, t h e p i l o t advanced Pthe t h r o t t l e s , but before the a i r c r a f t had r o l l e d
far, blue smoke was noticed between the rudder pedals on the l e f t side of the
cockpit, When about one-third of the way down the runway (length of runway
i s 6,000 f e e t ) and a t a speed of appro-tely 80 mph, a laxge puff of blue
smoke, accompanied by a sharp meld. of burn$ng, f i l l e d the cockpit. Throttles
were retarded and brakes applied immdiately with only s l i g h t deceleration
resulting, The runway has a downhill gradient of 1,sa t the approach end
which increases t o 3,U%,at t h e north-east end so t h a t the a i r c r a f t waa in-
creasing speed even though take-off had been discontimed. The p i l o t then
applied f u l l reverse thrust and instructed the oo-pilot to e t e e r t h e a i r c r a f t
by t h e nose wheel. control, However, the nose wheel steering control, as were
the brakes, was totally ineffective, A t this time t h e hydraulic pressure i n
the main and emergency s y s t e m was notea at sere. The a i r o r a f t l e f t the paved
area and r a n over t h e hard, dry ground, The application of reverse thpUgt
slowed t h e aircraft t o 15 rnph bat, affGr that, the reverse thruert appeared
t o be ineffective. The a i r c r a f t struck a cement d v e r f and a l i g h t standard
cansing t h e r i g h t main landing gear t o f a i l and perplit the r i g h t wing t o
touch gronnd swinging the a i r c r a f t t o a atop, The pcaareengers and crew escaped
through the fopward cargo door and emergency e x i t s , The main cabin door and
r q could not be lowered since the t a i l seetion where the ramp is located
was r e s t i n g on the ground,
No evidence of braking action was found i n t h e examination of the t i r e

tread marks, e i t h e r on the m w a y o r d i r t eurface, nor was evfdence of fire
found i n the a i r c r a f t , However, consideeable hy&axllic f l u i d was found i n
the nose wheel compartntent and t h i s was traced to a separation of the tubing
f ~ o mthe reducer f i t t i n g i n t h e hydraulic l i n e fs& the emergency a c c d a b r
t o t h e emergenay pressure gauge i n the eoakpit.
I n t h e Martin 202 %he emergency accuanzlator is charged from t h e same

l i n e which supplies the main accurrmlator, The two accumulators a r e separated
by a cheak valve which prevents t h e f l u i d fPom returning frsm t h e emergency
system, The f i t t i n g which f a i l e d i n t h i s case was located i n t h e l i n e between
t h e emergency aeczuatrlator and t h e emrgenoy power brake valve, When the fail-
u r e occurred f l u i d from the main a c d a t o r flowed tbKnzgh t h e check valve
i n t o the emergency ac&ator and from there o a t of t h e open l i n e where the
f i t t i n g w a s located, As a r e s u l t , aU pressure was l o s t from both meuom-
lators, and neither the brakes nor the b y d r d S o nose-vbeel s t e e r i n g mech-
anism conld be actuated,
ESOrthwestgsMaintenance &mal includes detailed instructions f o r t h e

i n s t a l l a t i o n of the type f i t t i n g involved, t h e trade name of which is " E m t a w .
ICAO Circular 18-AN/l5 75
Briefly, these instructions provide for tightening of the parts so as to

collapse a metal eleeve around the end of the tube or l i n e to be joined,
When the work is proper* done the sleepre actually cuts into the tubing and,
in effeot, becomes a p a r t of it, Incrtruetions then require t h a t the f i t t i n g
be dfsarasabled so as t o dete-ne whether o r not tb aleeve has cut i n t o
the tubing, Examination of the f a i l e d f i t t i n g i n t h i s case showed t h a t the
sleeve had not o u t into the tubing, Ae a r e s u l t o the necessary holding powex,
of the f i t t i n g was never obtained when it waa i n ; s f U e d +
I n Ootober of 194gp lorthwest Airlines experienced a s h i l a r failare.

Xn this ease an w E m m ~ f*i t t i n g , located a t the same position as the one
which Failed a t BiUings, separated while the a i r c r a f t was i n f l i g h t from
Minneapolis t o Chicago, The r e s u l t waa the same, A l l hy&razlic preseare waa
l o s t f k e m both the aaih -1 the bIQ8Fgency a c ~ t o r s . Thie incident, which
occurred U o r %t one year b fore the Billing8 baccldent, demnetrated, fhat one
single f a i l u r e c d d r e d t i n the loscr of b t h the main and amrgeney brake
sfl-**
Following the Chicago incident, the Administrator, blgion I, notified

%he Glenn L, M a r t i n Coi~grrnyof' t h i s oondttion i n the mdel 202 hydraulic
s ~ ~ p jTo h correat
~ the defect the d s c t a w e r r on 2J Febraa~y1950, isstred
Semicle Bulletin No, 105, This h l l e t f n described the i n s t a l l a t i o n of a
h ~ ~ i d aPnsew
i a i n &he 1%ne between %helgaln and the emergency a c d a t o r e ,
!!!he h s e was, i n effect, a sprinplcaded valve designed to prevent a sub-
stan'kial flow of f l a d from the m a i n accuolulat~rt o the emergency a c d a h r ,
Service F U l e t f n 105 was considered t o be satisfactory by the Civil

Aerourautics Administration; ~ O W Northweat ~ F ~ Airlines did not believe that
the fuse gave complete protection since it required a substantial flow of
:quid %o a e h a t e the h a s and c o n s e p n t l J r did not protect against small
leakage in the system, According to tests of the fuse made bg E J O r t h ~ s tAir-
flners, a quarter ~f a gallon per m f m t e could pass through it without causing
it- t;(p closep The c o m p w , i n t m , suggested t h a t a manual ahtat-off valve
lw i n s t a l l e d t o separate the two systems,
*' Section 4b.337 .

of the Civil Air Regulations provides i *. (2) The
brake system s h a l l be so designed and constructed t h a t i n the event of
a eing1e f a l u r e fn any connection or transmitting element i n the brake
p1ptea (excluding the operating pedal o r handle), o r the l o s s of any
single source of hydraulic or other brake operating wdrglp # v p m r $,ti
shall be possible t o bring the airplane to r e s % nndar conditions apeoi-
f i o d i n 4b,122,,
76 ICAO Circular 18-m/15
The modification incorporating the shutroff valve was t o be the subject

of Martin's Service Bulletin 107, T h i s W e t i n was never issued f o r the
reagon t h a t the substantiating t e s t data required by the M n i s t r a t o r was
not furnished by the manufacturer and the Administrator did not issue an
airworthiness directive requiring northwest t o i n s t a l l the fuse described i n
Service Bulletin 105,
Tests were made by the Glenn L. Martin Company t o determine the effec-
tiveness of reverse thrust i n stopping the a i r c r a f t @ The t e s t s showed t h a t
on a level runway and with calm wind conditionra, the a i r c r a f t could be brought
t o a complete stop from a r o l l i n g speed of 80 miles per hour in 1,750 f e e t if
the t h r o t t l e s were placed i n the f i r s t d ~ t e n tof the reverse t h r u s t t h r o t t l e
quadrant, This would be using approximately 750 brake horsepower per engine*
Tests conducted by the Martin Company Further showed that a t high speeds
reverse t h r u s t was as effective as wheel b r a h e i n reducing the speed of an
aircraft, but t h a t a t low speeds wheel brakea -re ameb more effective,
Tests were also conducted by Northvest Airlines a t the time the reverse
thrust feature was added t o the 202%, It was found t h a t the airplanes could
be brought t o a f u l l stop without brakes by use of reverse thrust, These
t e s t s were conducted on a l e v e l r u n w a y at the ~ e a p o l i and
r $t,Paul airports,
It is apparent from the f a c t s described above *ha% this accident occurred

as a r e s u l t of an improperly i n s t a l l e d "Ennetott f i t t i n g , Because the f i t t i n g
was not properly installed, it separated; and the separation permitted all
pressure i n the main and the emergency hydraulic systems t o escape, Without
hydraulic pressure, the &craft could not be stopped by brakes, nor could
it be steered, The only means of control that remined was reverse thrmst.
Reverse thrust served as a secondary safety device, though the a i r c r a f t

was not completely stopped u n t i l it struck the cement culvert and the l i g h t
standard, By t h i s means the crew was able t o decelerate the a i r c r a f t from
80 to approximately 15 miles per hour, and they a l g h t have stopped it com-
pletely i f it had not been f o r the downhill gradient of the runway, A more
positive determination i n t h i s respect is not possible, since the ava5lable
t e s t information, referred t o above, does not take i n t o account such varia-
bles as runway gradient and a i r c r a f t wight.
ICAO Circular lg-AN/lfi -
77
Underlying the irmnsdiate cause of t h i s accident, the separation of the

hydraulic f i t t i n g , is the f a c t t h a t t h i s accident should not have occurred
If the r e q u i r a e n t of Section 4b,337 of the C i v i l Air Regulations had been
satisfied, Akl previously ratated, this regulation provides i n e f f e c t t h a t a
brake system be designed so t h a t the a i r c r a f t can be stopped even though
there i s a single failure, such as occarred i n t h i s case, Compliance with
% U s regulation was required before the Martin 202 vapr certificated, After
%he similar f a i l u r e on the f l i g h t t o Chicago, which was almost a year before
%his accident, the government, the manufacturer, and the operator were fklly
aware t h a t the design of the Martin 202 hydraulic system did not s a t i s f y the
regulation inasmuch as the separation of the f i t t i n g t h a t occurred on that
f l i g h t resulted i n a loss of pressure i n both t h e main and emergency hydraulic
systems the same aa it did a t the time of t h i s accident, Accordingly, it i s
cona3,uded t h a t the f a i l u r e of the mamfac-er t o comply with Section 413,337,
%he f a i l u r e of the government t o require eoprpliance a t the time of c e r t i f i -
cation, and the lack of positive corrective action pequired by the government,
trll were contributing factors,
One month a f t e r t h i s accident o c m e d , the Administrator of Civil

b r o n a u t i c s required by an airworthiness directive t h a t the hydraulic fuses
be i n s t a l l e d as described i n the Glenn L, Martin Service Bulletin 105,
The Board found that8
1) The c a r r i e r and the crew were properly certificated,

2) The a i r c r a f t was not properly certificated i n t h a t Section
4b0337 of the C i v i l Air Regulations was not eampfied with,
3) An nEmmton reducer f i t t i n g i n the hydraulic l i n e between the

emergency a c d a t o r and the emergency accumulator gauge was not prop-
e r l y b s t a l l e d , and, as a result, it separated, This separation reseahted
i n the l o s s of preasure i n both the main and emePgency hydraulic sys-a,
4 ) Although a similar f a i l u r e occurred one year prior t o the

tfmpe of t h i s accident, no positive corrective aetion was taken by either
the goverment, the marrrsfacturer or the operator,
5 ) Reverse t h r u s t was a substantial safety factor i n this acci-

dent i n t h a t it permitted the deceleration of the afrcrcaft from 80 t o
15 niiles per h ~ t l ~ e
Probable Cause
The probable cause of t h i s accident was the f a i l u r e of an uEnnston

hydraulic f i t t i n g due t o improper installation,
ICAO REF: ~~h.18

UNITED STATES
Moritzr Flying Service, Aeronca Tmes 7AC (M-2427E) and

ISAC (N-l086H), mid-air collision 8 miles NW of
Sharon S ~ r i n n s . Kans., on 30 A p r i l 1950, CAB
Accident Investigation Report No, 3-0251,
Released: 18 January 1951.
-Circumstances
Aircraft N-2427E was being used t o practice "SN turns a t 500 f e e t
within the l o c a l practice area of Sharon Springs Airport, Aircraft N-1086H
was apparently being used f o r pleasure.
Approxbmtely 25 minutes a f t e r take-off both a i r c r a f t were about 8 a i l e s

NW of Sharon Airport (within the local practice area), Aircraft N-1086H per-
formed a s e r i e s of steep dives and climbs a t low altitude, thereafter contin-
uing eastwards s t r a i g h t and level, During the same period a i r c r a f t M-2Q7E
executed *Sn turns a t 500 feet, also progressing eastwards. Immediately
before the collision a i r c r a f t M-1086H seemed t o be s l i g h t l y below, ahead and
to the r i g h t of a i r c r a f t N-2427E, Both a i r c r a f t turned l e f t but as EJ-1086H
h e d a t a considerably steeper angle than 8-2427E, both a i r c r a f t collided,
The investigation did not disclose any evidence of mechanical malfunc-

tioning or structural failure, nor did it indicate t h a t either of the a i r c r a f t
was i n an airworthy condition, Testimony was received that both windshields
were clean and clear, A t the time of the accident v i s i b i l i t y and ceiling
were unlimited,
ICAO Circular 1 8 - ~ ~ / 1 5 '79
--- - Cause
Probable
The cause of this aacident was the f a i l u r e of the p i l o t i n a i r c r a f t

N-1.086H t o properly c l e a r h i s posftion before s t a r t i n g a steep l e f t turn,
-
UNITED STATES
Northwest Airlines Inc,-tia 202, MC93037, crashed

a t Illmeland, Minnesota, on 13 October 1950,
-
CAB Accident Investiaation Report lo, 1-0119.
-
Released: 23 BDri1 195%.
-
The a i r c r a f t departed froxa Minneapolis St, Paul International Airport
i n c l e a r weather and unlZBljlted v i s i b i l i t y f o r purposes of a P i l o t Six Months
InstPrrPaent Competency Check, The &craft was properly loaded well within
its allowable l i m i t and there were six ocortpants, B e p i l o t Mae presumed to
be flying the a i r c r a f t under t h e hood,
Following take-off two simulated ILS approaches t o the a i r p o r t were

made, a f t e r which t h e control tower was n o t i f i e d by radio ( l a s t known contact)
%ha1this phase of the check f l i g h t was completed, Thereafter, 43 miles NW
sf Minneapolis, the a i r ~ r a f was
t observgd t o execute a s k e p turn w i t h landing
gem down a t an estimc$%ed a l t i t u d e of 4/5,000 feet and then start a s h d l a w
eIlmb, Throughout these manoeuvres the engines sounded n o d ,
A few n m e n t s l a t e r when next observed the a i r c r a f t was i n ei p a r t i a l l y

inverted position, s t a r t i n g a steep dive, After losing 2,500 f e e t , _ m appar-
ently normal recovery was made t o a level f l i g h t a t t i t u d e , and the a i r c r a f t
proceeded BE, Shortly afbz-wmds %he aircraft; was seen to lnake two o r three
pitching o s c i l l a t i o n s about i t s l a t e r a l a s , During each o s c i l l a t i o n appw,xX
imately 400 f e e t was l o s t and a noise, usually associated with a surge of
engine power, was heard,
%o miles south of Almelundp Minnesota, the a i r c r a f t was seen t o make

a shallow r i g h t turn of approximately 2700 and rettlrn to a l e v e l a t t i t u d e
heading NW, Throughout the above-mentioned manoeuvres the a i r c r a f t was
gradually losing a l t i t u d e and, towards the l a t t e r p a r t of the f l i g h t , the
r i g h t propeller was observed t o be turding slowly, Near Almelund, a t an
a l t i t u d e of approximately 500/600 f e e t , a steep r i g h t turn was commenced,
Altitude was l o s t rapidly and, a f t e r turning approximately 90°, the a i r c r a f t n s
r i g h t wing stsuck the ground, The six occupants were k i l l e d and the a i r c r a f t
was demolished,
Investigation
Investigation did not reveal any evidence of s t r u c t u r a l failure of the

a i r c r a f t p r i o r t o impact and there was no indication of f i r e e i t h e r before
or a f t e r the crash occurred, A teardown examination of the r i g h t engine
f a i l e d t o reveal any indication of s t r u c t u r a l f a i l u r e , however, there were
indications t h a t a t some time t h e engine had oversped, A functional t e s t
was made of t h e f u e l feed valve, using a standard flow bench, and when the
normal. pressure of 10 PSI (pounds per square inch) was applied, the valve
f a i l e d t o maintain pressure, indicating that the valve was being held off i t s
seat, On disassembly a small piece of phenolic r e s i n of s u f f i c i e n t s i z e t o
have caused t h e valve t o s t i c k open, i f it had lodged i n the s e a t o r any other
vital. place i n the valve mechanism, was found near the valve s e a t (phenolic
r e s i n had been used to coat t h e valve a t the time of manufa~ture*)~ Failure
of t h i s valve would c a s e an unbalanced pressure condition i n t h e carburetor,
u l t i n a t e l y r e s u l t i n g i n f u e l starvation t o t h e engine thus causing complete
engine f a i l u r e , It was determined t h a t the crankshaft of the r i g h t engine
was r o t a t i n g i n the proper direction a t the t i m e of impact and t h a t l i t t l e ,
if any, power was being developed,
Examination of No, 1 blade of the r i g h t propeller revealed t h a t the

blades of t h i s propeller were 7" t o 10° fn reverse p i t c h a t the time of
impact, I n addition, examination of the propeller dome disclosed t h a t the
stop levers were i n the retracted position and t h a t the piston sleeve had
moved outboard over the l e v e r s t o an extent corresponding t o t h e reverse
blade angle,
* A1950service b u l l e t i n was issued by the engine manufacturer on 17 February

which advised all owners of t h i s model engine t h a t the phenolic
coating on the f u e l feed valve could be discontinued at overhaul, It
further s t a t e d t h a t any peeling of the phenolic coating on the valve due
t o poor bonding or deterioration could affect f u e l valve and f u e l slinger
operation,
81
--- f CAO Cfrcular 18-AN/l5
The cover p l a t e of the r i g h t propelfor governor solenoid valve, found

damaged (depressed inwards 0,072 inches), was examined, Tests revealed t h a t
the damaged cover p l a t e held the aolenoid valve i n a p a r t i a l l y energized
position and t h a t under ac-kal operating conditions the e f f e c t of such a
damaged cover p l a t e on the solenoid v d v e would be t o move the bladee of i t e
propeller i n t o t h e reverae p i t c h range a f t e r t h e engine had been running f o r
a few aoments, Other testas indicated however t h a t t h e cover p l a t e could not
have been damaged p r i o r t o take-off without the crew being aware of an unusual
propeller actiono Examination of the engine and i t s nacelle f a i l e d t o reveal
cury evidence t h a t the engine# nacelle or solenoid valve had been struck by any
object while i n f l i g h t ,
To determine what might have caused the r i g h t propeller t o be i n reverse

pi-beh a% t h e time of impact, a s t u d y was made of all possible conditions which
would permit t h i s t o oacur, It was found t h a t several situations might have
o c m e d such as:
a ) the p i l o t , while being checked, intentionally placed t h e

propeller i n reverse t h r u s t by means of manual manipulation of the con-
t r o l s - This p o s s i b i l i t y was discarded since t h e p i l o t s were highly
s k i l l e d and since such a manoeuvre would not be a p a r t of a p i l o t ' s
competency check because of the danger involved.
b ) the observer s i t t i n g on the jump s e a t with an unfastened or

loosely fastened eafety b e l t , being thrown forward, as a r e s u l t of an^^
violent manoeuvre o r unusual a t t i t u d e sf t h e a i r c r a f t , against t h e
p i l o t D s control pedestal on which m e l o c a b d pertinent propeller con-
%rols, It was determined t h a t the observerPs safety b e l t was b u c u d
at t h e time of impact and the l e f t side a t t a c h f i t t i n g was broken,
PartOctilar emphasis was placed on studies r e l a t i v e t o inadvertent o r

uwern'ted reversing as a r e s u l t of e l e c t r i c a l malfwnctioning i n f l i g h t under
n o d governing conditions, as well as when attempting t o feather OP enn-
fes.thar, It was found t h a t several situations might occur which would cause
the propeller t o reverse a s a r e s u l t of such malfbctioning, however the
p r o p l l a r e l e c t r i c a l system was so extensively damaged at impact t h a t it WEIS
n ~ possible
t t o dehrmlne if any of the envisaged p o s s i b i l i t i e s occurrbd,
Bs-te,- Aa p a r t of the investigation it w a s learned t h a t during a mann-

% s c t a r e r g stest f l i g h t of a W t i n 202 a propeller was inadvertently reversed
i n f l i g h t , Study of t h i s f l i g h t revealed that an aluminum propeller was on
the r i g h t engine and a hollow s t e e l propeller on the l e f i , The aluminan
prcpel3Ler not being equipped with a reversing mechanism, a Jam4per wire was
i n s t a l l e d t o ground i n the junction box, thereby permitting the propeller 4~
bo W e a t h e r e d once it w a s feathered, I n e r r o r a similar i n s t a l l a t i o n was
82 ICAO Circular 18-AN/l5
made t o t h e c i r c u i t of t h e s t e e l propeller which was equipped with reversing

mechanism. A t a l t i t u d e 3,500 f e e t , airspeed 130 mph the p i l o t attempted t o
e e a t h e r t h e l e f t propeller by advancing mixture control and holding t h e
feathering button i n the W e a t h e r e d position u n t i l the propeller reached
approximately 500 RPM. The engine, however, d i d not s t a r t o therefore t h e
p i l o t momentarily held t h e feathering button out, The propeller surged
s l i g h t l y i n RPM and apparently went a few degrees i n reverse t h r u s t , there-
a f t e r windmilling backwards slowly, The p i l o t , not c e r t a i n t h a t the propellor
was r o t a t i n g backwards, immediately pushed t h e feathering button t o feather
position without r e s u l t , As a consequence of t h e windmilling propeller, power
could not be increased and as drag became heavier it was necessary t o dive the
a i r c r a f t t o maintain control, Altitude thus l o s t could not be regained, By
using 1 2 p f l a p s and MET0 (maximum except take-off) the p i l o t managed t o
maintain 1,500 f e e t and 120 mph airspeed, howeveq there was considerable rud-
der buffeting throughout t h i s portion of the f l i g h t , therefore t h e p i l o t ,
considering t h a t control of the a i r c r a f t was marginal, nade an immediate
forced landing,
Another propeller r e v e r s a l occurrence on a similar Martin 202 was

disclosed as a p a r t of the investigation, I n t h i s instance t h e reversal oc-
curred when t h e a i r c r a f t was on the ground and the p i l o t was performing the
pre-flight check p r i o r t o take-off, Analysis revealed t h a t t h e cause had
been an intermittent e l e c t r i c a l short i n the junction box,
Findings
1a The c a r r i e r , crew and a i r c r a f t were properly c e r t i f i c a t e d ,

2, The f u e l feed valve of the r i g h t engine malfunctioned when
tested,
3, The r i g h t propeller was found i n 7O t o 10° of reverse

thrust.
40 A review of the evidence of a similar occurrence indicated

t h a t with a propeller i n the reverse t h r u s t position the a i r c r a f t would a s m e
dangerous f l i g h t characteristics,
50 The f a c t t h a t the a i r c r a f t P s wing f l a p s were r e t r a c t e d may

have contrikuted t o the uncontrollability of t h e a i r c r a f t a t speeds below
140 raphe
ICAO. Circular 1 8 - ~ ~ / 1 5 83
Probable Caue
The probable cause of t h i s accident was the unwanted reversal of the

r i g h t propeller during f l i g h t , as a r e s u l t of which the crew was unable t o
maintain control of the a i r c r a f t ,
ICAO REF:
-..9-
A.Eih.33
UNITED STATES
Pan Americ Uorld Airwavs* Inc,. Boeing 377 S t r a t o c d s e r Aircraft,

peardetracted &win= landing at Heathrow Airport,
London, E n ~ P a n d a n3 Januar~1951. CAB Accident Investiaation
Report No. 1-0002, Released: 10 May 1951.
Aircraft N-1036V arrived i n the London Area on 2 January and was diverted
t o Hurn, due t o the London weather being below the minima. A landing a t Hnrn
uas lllade a t 0923 h m a , and at 1100 Emrs the weather a t London being still
below minima, the decision was t&n;to send the passengers on t o London by
train, and to f e r r y the a i r c r a f t t o Heathrow Airport the n d morning t o cover
t h e re- f l i g h t la the United States,
At 0803 hours on 3 January, the a i r c r a f t with nine crew departed Xurn

f o r London, The take-off weight of about 103,576 pounds was approximately
42,000 l e s s than the maximum permissible and the load was so distributed t h a t
the centre-of-gravity waa within the certified liaits,
A t 0900 hours London weather waa given as "high scattered, v i s i b i l i t y

3,300 yards, wind 300/08, temperakwe 32,2w, The f l i g h t plan carried t h i s
natation wrunwaybraking conditions good a t run-up o r touchdow~, t o f a i r
f a r t h e r down r u n w a y due t o alushw, which referred t o tba conditions at London
where portions of runways were covered with three t o four inches of snow and
slash,
A t 0850 hours a normal landing was commenced on rtanway 28, during the
landing r o l l , howeverp the r i g h t main landing gear retracted permitting the
plane t o s e t t l e down on the No, 3 and No, 4 engine nacelles and the r i g h t
wing, I n this position it skidded t o a stop, p a r t l y off the runway after
turrsing approx5mately %loo t o the right, There was no -violent,deceleration
and only a s l i g h t change of direction down the m w a y , The crew of nine
uninjured,
Investigation
Major damage t o the a i r c r a f t was confined t o the r i g h t wing t i p , aileron

and f l a p and t o the propellers and nacelles of No, 3 and No, 4 engines, The
runway along t h e portion over which the a i r c r a f t traveled was covered with
slush which made it extremely d i f f i c u l t t o e s t a b l i s h the exact point of
touchdown,
Due t o the known condition of the runways it had been previously decided
t o use 300 f l a p on l a d i n g t o prevent, insofar as possible, damage t o t h e
flaps, by snow and i c e being thrown against them during t h e landing r o l l *
A smooth landing was made, i n i t i a l touchdown being approximately 1,400

f e e t p a s t t h e approach end of the runway, The nose wheel became grounded
alraost immediately and No, 2 and No, 3 propellers were reversed, After un-
reversing and noting the s l u s h was getting deeper, it was decided t o r a i s e
the f l a p s , Instead of actuating the f l a p switch, however, the captain mis-
takenly moved the landing gear switch t o the s'ups"osition,* Although it
w a s immediately returned t o t h e "dogan" position t h e landing gear warning
horn sounded and shortly t h e r e a f t e r the r i g h t wing began t o drop,
There is no testimony o r evidence t o indicate t h a t t h e brakes were at

any time e f f e c t i v e l y applied,
* The gear operating switch i s located on the control pedestal approximately

24 inches f o m d of t h e f l a p switch, It i s f u r t h e r protected against
inadvertent movement by a hinged guard which rmst be raised before t h e
switch toggle can be operated,
Exadnation of the r i g h t Bzain landing ,par and all its components was
-8, followed by operational and f'unational t e s t a , No mechanical o r elec-
t r i a d f a i l u r e of t h e gear o r gear control system was found and all t e s t s
inclieated n o d operation,
Each landing gear oleo strut is equipped with two micro-switches which
are actuated when the landing gear wheel i s grounded firmly enough to compress
the s t r u t approximately one-half inch of its travel, These svitches a r e par*
of two e n t i r e l y separate s a f e t y system, t h e purpose of one being t o prevent
the t h r o t t l e s being mved into the reverse t h r u s t position before the a i r c r a f t
i s grounded, and the purpose of the other t o prevent an extended landing gear
from being retracted after it is firaraly grounded even though t h e landing gear
control switch is placed i n the gear @upaposition,
However, it is not necessary t h a t all three landing gear u n i t s be

firsly on the gruund before t h e t h r o t t l e s can be manueJly moved i n t o the
reverse t h r u s t position. This can be acoomplished a s soon as any one of the
landing gear u n i t s is supporting s u f f i c i e n t weight t o actuate t h e approprfab
mlmo-switch. However, if the landing gear control switch i s placed i n the
gear mupa position during landing r o l l , any landing gear unit w i l l unlock
and r e t r a c t i f t h e m is not s u f f i c i e n t weight maintained t o hold t h e micro-
~witBhi n i t s actuated position,
lfhe micro-switch concerned was removed, exatained, and h c t i o n a l t e s t a

were made which found t h a t a l l p a r t s were i n excellent working condition,
Probable C a s e
The probable cause of the accident was t h e captaints action i n &st&-

snly placing the landing gear control switch i n the *upmposition during
Panding r o l l ,
ICBO Circular 18-AN/15 87
List of Laws and Regulations of the Contracting States containing pro-

visions relating t o aAircraft Accident Investigation*.
AUSTRALIA
-
A i r Navigation Regulations, 1947, S,R, No. 112
Bir
Part XVI, ( ~ e g u l a t i o n smade under the
Navigatf on Act 1920-1947. )
BOLIVIA
junio 18
( ~ o l e t f nOficial) (~h. -
Procedimiento para e l informe de accidentes
2 Sec, OP-loo).
l?BrZO Reglas Generales de Operaciones (Provisional) t

Accidentes de Aeronaves (02,4642.52).
May 11 A i r Regulations, Order i n Council P,C, 2129,

as amended to 1950.
Nw, 1
-
A i r Navigation (Investigation of ~ c c i d e n t)s
Regulations, 193'7, Sec, 6 Preliminary
investigation of accidents. (Made under
Sec, 12 of the U,K, Air Navigation Act, 1920,
a s modified and extended t o Ceylon by the
Colonial Air Navigation ( ~ p p l i c a t i o nof ~ c t s )
order, 1939. )
a March 29 Afr Navigatf on Act, Noo 15/1950 Part I, A i r

Bavigationg Sec, 12, Power t o provide f o r
investigation Into accidents,
88 ICAO Circular 18-~~/15
CHINA
91__
Regulations covering accident investigation

of c i v f l a i r c r a f t ,
Law No, 196: Accidents and insurance of

technical personnel of c i v i l aviation.
March Manual of Regulations - P a r t IV, Sec. I,

@,13,0t Accidents,
COSTA RIGA
Oct, 18 Ley de Aviacidn Cdvf 1 -

Parte I, Titulo
Primro, Csp, 2, Sec, $a Accidentes
(Art'%45-47),
Decree of Ministry of I n t e r i o r on accident

inve stfgation (NO, 1608/1947),
Sept, 11 A i r Navigation Regulations a Par, 22 -

Notifications i n case of certain a i r c r a f t
accidents,
Departmental Regulations issued by C i v i l

Av&ation Departanent including n h e s t i g a t i o n
of Aepidentsw,
FRANCE
DQcret r e l a t i f i l a ddolaration des accidents
d laviation, (Bulletin de Renseignements
CINA 7@/3).
I C Circular
~ '18-~/15 89
m July 8 Decree relating t o rules f o r prevention of air

navigation accidents.
(Me
-
Decreto Nth. 563: Ley de Aviacidn Civil,
Capitulo X De &a siniestroe aeruduticos,
U6-U1) 0
u3Q marzo 14
-
Decr6to N&n. 121s Ley de Aero&utica:
Cap, IV, Sea, Cuarfa Accidentes y
Fhergencias (Art, 'Xl-88),
A i r Navigation Regulations of 1932,
19
-
The &dian Aircraft Act, 1934, (corrected up
t o 1949) Sec, 7% Powers of Governor
General i n Council t o make rules f o r
investigation of accidents,
a March 23
-
The Indian Aircraft Rules, 1937 (as corrected
up t o 1949 P a r t X8 Imeatigation of
Accidents ( A r t , 68-77).
zzi2 Amst 6 ~ iNavigation

r Law No, a/1939: Article 5 (h)-
The Air Bavigation (Investigation of ~ c c i d e n t s )

Regulations No, 21,
A i r Navfgation and Transport A c t , No, 40, Part

V I I , Section 60s Investigation of Accidents,
his Act was amended i n 1942 (NO, 10) and
1946 (No, 231,)
90 ICAO Circular 1 8 - ~ ~ / 1 5
IRELAND (Contd, 1
-
ASr Navigation Regulations (Investigation.
of accidents) (Amendment 1933 lo. 288
t o Regulation No, 21 of 1928).
-
-
ITALY
m,5 Jan, 11 Decree Law No, 356:

Chapo V I I .
Rules f o r Air Navigation -
&%i April 21
- -
Navigation Code, Second Part A i r Navigation,
Book I, T i t l e V I I I I m e s t f gation of
Accidents (Art, 826-4333),
x&2 Jan, 11 Aviation Law: Chap, 111, Flying,, Sub,

Chap, 2, Landing of a i r c r a f t (Art. 39),
L%i Dec, 27 C i v % 1 Aviation Law (replacing Book IV

of Law concerning General Lines of
Comunications, Aerial Communications,
19433; Chap, XIV, Accidents, Search
and Re~cue( A r t , 358-3631).
Law eoncernPng General Unes of C o ~ c a t i o n s ,

Book IV -Aeronautical Commnioations,
Chap, IX (Art, s 3 7 3 ) ,
ITETHERLANDS
Sept. 10 Act regulat%ngthe Investigation of Accidents

t o C f W Aircraft (Aeronautical Disasters
Act So 522 as amended on 31 December 1937,
So 527).
h p t , 22 Order f o r the application of paras. 8 and 9
of Art, 1 and of par, 5 of A r t , 32 of the
Aeronautical Disasters Act (s. 579),
a p t , 22 Order f o r the application o f par, 2 of A r t , 6
of the Aeronautical Disasters Act, (3, 5 7 9 ~ ) ~
ICAO Circular 1 & ~ ~ / 1 5 '31
uZ Jan, 14. ~ k r e eof Ministry of Water Works regarding

A r t . VI of the Law of aviation accidents,
Oct. 19 Decree of the Minister of Water Works

regarding landing of c i v i l a i r c r a f t outside
the designated area, and accident s o
NEW zEaLAND
z%!2 July 1
t o 1950. Arts* 35 t o 4.4
accident so
-
A i r Navigation Regulations, 1933, as amended
Investigation of
B& Aug, 26 The Civil Aviation Act, 1948. Article 8

Power t o provide f o r investigation of
-
accidents.
MORWAY
Dec. 7
-
Civil Aeronautics Act, as amended c p t o
March ll, 1949 Chapter 11, Par* 46.
-
Royal Resolution Regulations on 'a.vLation
enacted by the Department of Defence,
15 October 1932 and 11December 1936, i n
accordance with the C i v i l Aeronautf cs Act
of 7 December 1923 and the Royal Resolution
-
of 22 April 1932 as amended up t o 1947*
VIII Aircraft Accidents-
PAKISTAM
&%% Aug. 19 The Indian Aircraft Act, 1934, No. XXII ( a s

adopted by Pakistan and correcter? t o 1947)
Paro 7: Powers of Governor General i n
-
Council t o make rules f o r investigation of
accidentso
xi!z March 23
by Pakistan and amended up t o 1949)
Part X .o Invegtf g a t i ~ nof accidents*
-
The Indian A f r c r a f t Rules? 1937 ( as adopted
ICAO Circular 18-AN/l5
Commonwealth Act No, 168, Chapter IV -

Powers and Dutjies of the Director ( ~ e c , 6 (g) )
Investigat5on of Accidents,
Aircraft Accident Investigations.

-
C i v i l A v i a t i ~ nRegulations Chapter XVI:
April 27 Decree No, 13n537 A i r Navigation Regulations

Chapter V I I I ,
-
April 20 Royal Proclamation NO, 85 regarding

Application of the Decree of 26 May 1922
(NO, 383) on A i r Navigation (amended up t o
9 ,. -
Par, 28 i s relating t o Notifica-
t i o n of e r c ~ a f accidents*
t
Decree of Federal Council regulating the

proedure t o be followed in case of air-
c r a f t accidents,
April 20 -
A i r Navigation Law F i r s t Part, T i t l e I
Chap, IIo Articles 22-26,
-
June 5 R&glleanentdrexdcution de l a l o i sur l a
navigation adrfeme (entrde en vigueur
le 15 jufn 1958)t
XIPI. Accidents d d r o n e f s ( A r t s . 129-137).
June 1 A i r Wavf gation (Accidents ),

LWON aF SOUTH AFRICA
Adation Act No, 16

t i o n of AceSAsnts,
- Article 10: Xnvestlga-
The Air Navigation Regulations, 19% (came fnto

operation on the 1st day of January 19% and
canael the Air Navigation Regulations, 1935
and subsequent amemhents thereto):
(bg, 29,l -
Chap, 2qe Investigation of AccTdents
29,7),*
UNJJ'ED KINGDOM
The A i r Nav3gation (%meskigw.21ianof

Acaidents) Regulations, 1922 (S,R. & 0,
No, 650), Amended by the Air Navigati~n
(Invest ' ation of Accidents ) Regulations
?
of 1925 S,R, & 0, ]No, 1099)j 1930
(S.R, L 0, NoB 840) and 1935 (S,R. & 0. No. 381).
The Aircraft (Wreck and salvage) Order No. 136,

The A i r Navigation Order, 1949# Article 68
Application of accident regulations t o
-
a i r c r a f t belonging t o or employed i n the
service of His Majesty*
* The C i v i l Aviation Act, 1949 (12 & U Geo. 6. Ch. 671, repeals ths " A j x
-
Navigation Act, 1920," Part 11, Section 12 of the 1920 Act is replacad
-
by: Part 11 Section 10 Investigation of Accidents, C i v i l Aviation
Act# 19496
94 ICAO Circular 1 8 - ~ ~ / 1 5
UNnm KINGDOM COLONIES
Section 12 of the A i r Navigation Actp 1920 (as amended by the Air Plavuation
Act, 1935) applies t o the underantfoned Colonies by virtue of "The Colonial
Air Navigation ( ~ p p l i c a t i o nof ~ c t s )Order, 1937' 1*
Aden (Colony and ~ m t e c t o r a t e )
Baharaas
Barbados
BasutgPanii
Bechuanaland Pro%eetxra%e
Bemda
British Gui-
British Honduras
British Solomon Islands Protectorate
C g ~ w
FaUcEand Islands and Dependencfes
Fiji
Gambia (Coloqy and Fkotectorate
Gibraltar
Gold Coast -
Gilbert aad Elllice Islands Colony
e010w
ba{ Ashant5
c ) Northern Territories
d ) T o g o h d under British Mandate.
Hong b wz
Jamaica (including Turks and Caicos Islands and the Cayman ~ s l a n d s )
lZenya (Colony a d P r o t e c h r a t e )
Leeward Islands
wi
g us
Montserrat
St, Christopher a d N a s
Virgin Islands.
Malta
Mauritius
Nigeria
a) Colony
b) Protectorate
c ) Cameroons under British Mandate
* The Civil Aviation Act, 19/69 (12 & U Geo, 6, Ch, 67), the t e x t of which
-
Section 12 of the 1920 A c t is replaced byr Part I1 Section 10
Investigation of Accidents, Civil Aviation Act, 1949.
-
has just been received, repeals the nAir Navigation Actp 1920.w Part 11,
UNITED EIHGDOM COLONIES (Contd. 1

Horth Borneo
Northern Rhodesia
ESyasaland Protectorate
M e stine (excluding ~rans-Jordan)
St, Helena and Ascension
Sarawak
Settlements of P e w and Malacca
Ssy~.helles
Sierra Leone (Coloay and ~ r o t e c t o r a t e )
s*apo=
Somallland Protectorate
Swaziland
Tang- Territory
Tr$nidad and Tobago
Uganda Protectorate
Windward Islands
Dominica
Grenada
St, Lucia
St, Vincent
Zanaibas Protectorate,
BRITISH GKtAlU
A%@ March 15 Air Navigation (Investigation of Accidents)

Regulations (S.ReQ, 1939, No. W ) .
love 15 Air Navigation (investigation of Accidents)

Regulations, No, 17/1937,
GOID COBST
Feb, 17 Aircraft (Accident ) Regulations, No, 5 of 1937.
ZEEWPA
June 22 ) Regulations,
Air Navigation (~ccident
96 ICAO Circular 18-AN/~S
ma March 22 Air Navigation (Investigation of Accidents)

Regulations, (&No ~31/38),
NICE-
XQf2 Oct, 7 Afreraf t (Accfdent ) Regulations, No, 33/36,
2232 Feb, 26 f s ) Regulations

A h Navigation ( ~ c cdent
(GeHo W 2 ) a
The Air Navigation ( ~ c c i d e n t )Regulations
(G,N, 171/48),
SIERRA LEONE
,uz Jw~e 19 Afrcraf t (Accident) Rules (80, 17/1938),
&%i June 30 A i r Navigation (Investigation of Accidents)

bgulations, (GoNo 91/33 )
TRINIDAD .
U P .Oct, 26 A i r Wavigation (Investigation of Aecf dents)
Regulations 1940 (revoking Air Navigation
,
Regulat iom (Aecf dent s ) 1931) as amended
on 16 August 19@, Go No 139/48,
Navhgatf on (Investigation of Accf dents)
(Amendment) Regulations 1948 (G,N, No. 13/48).
a222 apt* 4 Iwestbga-bion of Accidents Regulations

(Gd, 4/37),
ICAO Circular 18-AN/~S 97
Civil Aeronautics Act

safety).
- Title V I I (Air
-
C i v i l Aeronautics Board: Organizational
Regulations P a r t 302 Description of
h;mctionst Course and Method bg which
functions are channeled: Scope a d
contents of documents8
Part 302.l.b) (4);
Part 302.2. Functions of Offices and
Bureawgt
(d) (2) The Accident Investigation
Ilivision
(3) The Accident Analysis
Division.
-
C i v i l Air Regulations Part 62. Notice
and Rapprta of Aircraft Accidents an3
missing -crafto
ICAO Circular 1 8 - ~ ~ / 1 5 99
PART I11
~ s c e l l a n e o u sPublications and Re~orthl
ACCIDENT STATISTICS
S t a t i s t i c a l Analysis of Civil Aircraft Accidents and oasualties 1948.

Departarent of Civil Aviation,
S t a t i s t i c a l Analysis of Civil Aircraft Accidents and casualties 1949.
Departigent of C i v i l Aviation. Sunmtuary of accident and incident reports.
Mamh 1950-August 1950. Beparbent of C i v i l Aviation.
summary of Accident and Incident Reports Dec. 1949-Feb. 1950. Depart-
ment of Civil Aviation,
Anxual Report on Aircraft Acaidemts 1950, Department of Traneport,

Air Service Branch, C i v i l Aviation Division, Ottawa,
S t a t i s t i c s of Aircsaft Accf dents i n Sweden 1950 and 1946-1950.

100 ICAO Cfrcular 18-iW/l.5
Rappor$s st rensef gnments a%a%i stiques a m 1es accidents d agronef s,

u%iffs6s en s e n f e e e m e r e i ~ ,du I e r aatobre 1947 au 31 mars 1949,
Berne 194.9,,
A m m e y sf Accfdenta t c A%r~rehft
~ 0% the lJni%ed Kingdom i n the year
ended 3Ps$ h c a b m 89L,.9, Minis* of Civff AvSation 89, H i s & j e s t y o s
Stationery Off%se, h n d s a 1950,
Resume sf U,S, fir Carrier Aeefdents (Calendar Year 19491, Civil

t f Board, Wahfngton 258 DOC, Pssaed May- 1950,
k s n t ~ ~ 1os
"Mon-Air Carrier Atmident Trend Reporb [bat One Thousand 1950) C i d

Aeronautpica Bomd, Umhia@sn 25, D O C o Issued July 1950,
Ron-Air Carrier kebfden% !hend Repor% (2nd Qne Thousand 1950), Civil
Aeronautics Board, WwMng%on 25, DOC, Issued Septanber 1950,
Accf dents i n U,S, Scheduled kir %mi e r Passenger Operations (Calendar

Pear 1949-P9@), C i g P f l Aeronautics Board, Mashfn@sn 25, DOC, I s m e d July
19500
NOR-Air C m f e r Acaf dent Trend Report (3rd One Thousand 1950)
Aeronmtica Bomd, WaBPIn&on 25* DOCo Issued November 3.950,
. Civil
6mas"atfve Safety Sta%Ssticsf n Qpera.%fctnof UoS, Scheduled f i r l i n e s
(Calendar Year 1938-1949). Revised 22 June B950, C i v i l Aeronau%fcs Board,
Washington 25, DOCo
Acei dents i n UoSo Sehedded Air Cmrf e r Passenger Qperations (1st md

2nd @ar%ers 1950 and 1949). Civil lbe)ronau%icsB ~ m d ,Uwhingbon 25, D o C o
Issued December 1950,
Aceidenti8 i n UoSo Scheduled AIr C m ie r Passenger Operations (1st

Tlhapee Quarters 1950 and 19&9) C i v i l hrsmautfccs Board, Uashingbn 25, DOC,
Issued April 2951,
ICAO Circular 18-AN& 101
UHIOIi OF SOUTH AF'RICA
Bircraft Accident Review 1949. Departnent of Transport, Division of

C i v i l Aviation,
RESEARCH
AUSTRALIA
Air Traffic Simulator by T.C. Newnham and Industrial Research Orgad-

sation. Division of Radiophysics. RPR. 96, October 1949.
NEWZEALAND A
I n s t a l l a t i o n and operation of V-G recorders i n New Zealand Transport

Aircraft and Analysis of twelve months recorded data from the Trans-Tasman
route. Wellington, N.Z. 1950,
UNITED KINGDOM
The investigation of d r c r a f t acrridents involving a i r f r m e failure,

by V.B.B. Owen and F, Grinsted, London 1949,
Experiments i n T a i l Flutter, edited by C. Scruton, London 1949.
UNITED STATES OF AMERICA
Technical Development Report No. 123 Airline P i l o t Questionnaire Study

on Cockpit V i s i b i l i t y Problem, by George L. Pi- and M. Edwards, Aircraft
Division, Civil Aeronautics Administration, Technical Developlaent and Eval-
uation Centre, Indianapolis, Indiana. September 1950.
102 ICAO Circular 1 8 - ~ / 1 5
Technical Development Report No, 134, An Investigation of the Crash-

F i r e problem i n Transport Aircraft Fuel Tanks, by RoL. Field, Melvin F. Miller
and George L. Pigman, Aircraft Division, Civil Aeronautics Administration,
Technical Development and Evaluation Centre, Indianapolis, Indiana, Janaary
1951e
SnmPlary Report of Anti-Skid Braking, Boeing Airplane Co, S e a t t l e
Mvision, Washington.
Survey of Research Projects i n t h e Field of Aviation Safety. I n i t i a l
Report January 1951, The Danial and Florenee Guggenhiem Aviation Safety
Centre at Cornhill University,
ACCIDENT PFUWENTION BUUETINS
UNITED STATES OF MEXICA
-
Accident Prevention Bulletins 1950 Series 18 28, 1951 Series 1 12 -
.
D i s t r i h t e d by the Flight Safety Foundation, 2 East 64th Street, Hew Pork 21,
IeY
Special Aircraft Accident Bulletins 1950 Series 7
1 and 2. Special Airport F i r e Bulletin, 1950 Series 10 -- 13., 1951 Series
Conunittee on Aviation and Airport F i r e Protection, National F i r e Pro-
tection Association, International 60, Batter~nnarshStreet, Boston 10, Mass,
Safety Bulletin No, 185-51, h e 1 Exhaustion i n Flight; by Harold B, C a r r .
Civil Aeronautics B o t ~ d , Bureau of Safety Investigation,
Aviation Safety Release No, 337* P i l o t S t a t i c Systems, C i v i l Bsro-
nautics Administration, Aviation Pnf'ormatfon Office, Washington, D.C.
ICAO C ir c u l a r 1 8 - ~ , / 1 5 103
"SOME BRITISH VIWS ON FLIGHT SAFETY MEASURESM

I
The following paper was presented by Group Captain J, Veal, Director of

Ops-Safety and Training, Ministry of C i v i l Aviation, United Kingdom, a t t h e
Third h u a l Safety Seminar of t h e F l i g h t S a f e t y Foundation a t Denver, C o l o ~ a d o
on 30 October 1950,
I n this discussion I propoae t o limit myself t o - i n d i c a t i n g b r i e f l y the

m n n e r i n which f o l l w u p action on a i r c r a f t accidents and measures f o r accident
prevention i n t h e United Kingdom have been developed and t o mentioning a few of
the i t e m on whfch our a t t e n t i o n i s currently focussed. Before doing so, how-
ever, I would l i k e t o say how glad I am $0 have t h e opportunity of par&%cipa%%ng
in t h i s s e r i e s of discussions arranged by t h e Fligh& S a f e t y Foundation since I
am convinced t h a t an exchange of idea@ and of experiences can make an invaluable
eontributfon t o t h e furtherance of our e f f o r t s t o achieve s a f e r a i r t r a v e l ,
A s you probably know, i n t h e United Kingdom accidents a r e investigated by

a%Accidents Investigation Branch, of which t h e Chief Inspector of Accidents,
A i r 60mmodore Vernon Brownp i s i n charge. H i s r e s p o n s i b i l i t i e s a r e exercised
by v i r t u e of a s t a t u t o r y authorfty s o t h a t he a c t s independently of the Ministry
of C i v i l Aviation of which, administratively, t h e Accidents Investigatfon Branch
is a p a r t , The Chief Inspector, however, makes h i s r e p o r t t o t h e Minister.
Early a f t e r t h e war it became apparent t h a t accident reports, when c i r -

culated, d i d not always achieve immediate correction of the s i t u a t i o n s condncive
t o accidents which were revealed, I t was c l e a r t h a t t h e r e was a need f o r a eo-
ordinaP1Bng s e c t i o n which would undertake a c a r e f u l a n a l y s i s of accident r e p a r t s
or of other matters r e l a t i n g t o accidents which might come t o a t t e n t i o n , and,
i n t h e l i g h t of such en analysis, ensure t h a t proper consequential a c t i o n was
taken, I n t h e l i g h t of experience which has been gained Prom the treatment of
accident matters i n this way I believe t h a t i n the United Kingdom the f u l P e s i
use 3.a now being made of t h e experience which, however r e g r e t t a b l e , i s derived
from a i r c r a f t accidents.
104 ICBO Circular 18-AN/15
I should perhaps make it c l e a r t h a t this f'oUow-up of aecidents by t h e

Administration i s q u i t e separate from t h e action taken by t h e Air Registration
Board, t h e independence of vhfch we f e e l it i s most important t o preserve.
Equelly, however, it i s necessary t o have a very c l o s e co-operation between t h e
people responsible f o r follow-up a c t i o n and the Accident Inspectors.
F O W - U P ACTION
Our treatment of f o l l w - u p a c t i o n breaks down i n t o t h r e e phaseso F i r s t

t h e r e i s t h e c o r r e c t i v e phase. Under t h i s t h e a c t i o n which may a r i s e is:
a) C r i t i cism and correctf on of ground s e r v i c e s arrangement so
b) C r i t i c i s m and request for c o r r e c t i on of o p e r a t o r e s organisation

and techniques.
c) Re-qualification of personnel,
The question of airworthiness, a s such, has so seldom a r i s e n t h a t I have n o t

included this a s an item requiring s p e c i a l consideration, b u t I believe it is
neceseary i n a h o a t every case t o consider t h e standard and adequacy of e q q p -
merat, since s o e a s i l y i s it possible otherwise t o n e g l e c t t h e primary cause of
crew f a i l u r e ,
Closely concerned with c o r r e c t i v e action i s the preventive e f f o r t wbfch

must a r i s e f'rom consideration of any accident, Here t h e main p o i n t s which we
consider are:
a) Regulatory action, whether operational o r airworhhiaess,

b) P u b l i c i t y for accident causes.
e) Ilnprwement of standardso whether it be f l i g h t crews, ground

s e w i c e s personnel, operational or airworthiness matters,
Our t h i r d category of action r e l a t e s t o a c c i d e n t survival. Although i n

t h e first f l u s h of y d i h , we, l i k e s o mamy other people, f e l t t h a t we ought not
t o acoept t h a t accidents w i l l happen, w e were forced i n e v i t a b l y t o accept t h a t
they dl1 and t h a t we a h d d make provision agafnat them, Thus w e have t o con-
s i d e r i n r e l a t i o n t o accidents:
ICAO Circular 1 8 - ~ ~ / 1 5 105
a) Improvement of c r a s h worthiness.
b) Improvement of rescue facf l i t i e s .
I Feel it i s most important there should be most c a r e f u l consideration sf

a l l t h e d e t a i l s of i n d i d d u a l accidents, A c a r e f u l a n a l y t i c a l approach w i l l ,
i n most easesp provide a c l e a r i n d i c a t i o n of the form and extent of t h e corrective
aetfon which i s necessary, It i s equally important, however, t h a t t h i s consfdera-
t i o n should be w e l l balanced and t h a t we should not rush i n t o c o r r e c t i v e actfon
based on only weakly supported premises. I think t h a t f t i s q u i t e easy t o remem-
ber a number of accidents i n t h e p a s t which have r e s u l t e d i n a demand f o r provi-
sion of s p e c i f i c a i r c r a f t equipment where, i n f a c t , the t r u e c o r r e c t i v e a c t i o n
was f a r gore fundamental,
T h i s i n d i v i d u a l treatment of accidents i n t h e United Kingdom is, i n f a a t ,

p a r t l y forced upon u s since t h e s t a t i s t i s a l approach o f f e r s l i t t l e a s s i s t a n c e due
t o the r e l e t f v e l y small l e v e l of common operations and t h e d i v e r s i t y of a i r a ~ a f t
typeso Thfs is p a r t f d a r l y t h e case i n nonoscheduled o r n a t i o n s and I doubt
whether, unl.ess the mattez is put on en i n t e r n a t i o n a l basis, we s h a l l d e r i v e any
~t81v.6whatsoever from the purely s t a t i s t i c a l approach, T h i s does not mean, sf"
eousae, t h a t f n t h e periodiu survey of accidents which we condwt on an a w u a l
bqsia weld0 not attempt t o group causes of accidents and endeavour t o d e r i v e some
$nd?cstfon of general c o r r e c t i v e a c t i o n *an the list,
I n v e s t f g a t i m of accidents is, of course, only one s o w e e of information

on whJlcb P O U D W Ia~c~t i o n i n r e l a t i o n t o accident prevention can be %ased, the
ot,h_sw20wces beZng fnnidenta and defeets, We d e f i n e i n c i d e n t s as occurrencesy
uM&h, bPft fop fortuPtppls c%rcum~tances,would have r e s u l t e d i n an accident and
we s e r i o u s l y considered, a t one stage, t h e p o s s i b i l i t y of making t h e reporting
of imxcidentg mandatory, Closer examination of such a requlrernernt, hswever, made
&t q a t e obvious t h a t it was unenforceable and t h a t t h e derivation of f n f o m t i o n
an fmfdentrs by f n v f t a t i o n t o operators, p i l o t s , e t c , would be equally e f f e c t i v e ,
Such a system now e x i s t s ,
A i r e r a f t and equipment d e f e c t s a r e another matter and do n o t become

d i r e e t l y my concern being reported, a s appropriate, by t h e operators t o manufac-
t u r e r s and t o t h e A i r Navigation Board f o r remedial s e t i o n , A s you a r e n o t
f a m i l i a r with t h e organieation of the administration f o r c i v i l aviation matters
in t h e Unbted Kingdom, 1 should perhaps say t h a t t h e A i r Registration Board i s e
106 ICAO Cfr e u l a r 18-m/15
s t a t u t o r y a u t h o r i t y independent of t h e Ministry of C i v i l Aviation with responsi-

b i l i t y i n regard t o the design, construction and maintenance of c i v i l a i r c r a f t .
The Air R e g i s t r a t i o n Board exercises these r e s p o n s i b i l i t i e s byo
a) Prescribing t h e B r i t i s h C i v i l Airworthiness Requirements i n

respect of t h e design, construction and performance of a i r c r a f t , engines
and a n c i l l a r y equipment.
b) Recommending t o t h e Mini s t r y of C i v i l Aviatf on, based on these

standards, t h e i s s u e and renewal of C e r t i f i c a t e s of Airworthiness,
c) The approval and supervision of inspection systems,
AIR SAFETY BOARD
There is a second independent body which I might mention a t t h i s sltage

which i s concerned with a i r s a f e t y and t h a t i s t h e A i r S a f e t y Board, This i s a
standing advisory body of technical experts appointed by t h e Minister with t h e
function of undertaking t h e continuous review of matters concerning s a f e t y i n
B r i t i s h C i v i l Aviation both a s regards the operation of B r i t i s h a i r c r a f t and the
e f f i c i e n c y of the ground f a c i l i t i e s provided i n t h e United Kingdom f o r c f v f l QUP-
poses. Its advice on a v a r i e t y of problems i n t h e p a s t has influenced consider-
ably the development of a i r s a f e t y policy,
ACCIDENT CAUSES
I think t h a t one of the mst d i f f i c u l t problems with which aeeident

i n v e s t i g a t o r s a r e faced when considering most accidents is t h e extent t o whfch
t h e cause i s a t t r i b u t a b l e t o an e r r o r of? judgment on t h e p a r t of t h e p i l o t , I
know t h a t t h i s matter has caused considerable f l u t t e r i n g i n the dove-cotes i n
many countr&es and, of course, the F l i g h t Safety Foundation has r e c e n t l y been
giving considerable a t t e n t i o n t o it i n i t s b u l l e t i n s , I n the United Kingdom
t h e B r i t i s h A i r Line P i l o t s 9 Association has been by no means s i l e n t ,
During t h e annual survey of n o t i f i a b l e accidents i n 1949 i n t h e United

Kingdom the causes of which were determined, 55 percent had a s t h e i r primary
cause p i l o t e r r o r , and t h e r e i s no doubt t h a t i f w e a r e t o make f l y i n g s a f e r
t h i s m a t be t h e major l i n e of a t t a c k , I know t h a t , i n many cases, t h e r e a r e
other contributory causes a r i s i n g from such things a s design of equipment which
nrakes it possible f o r a p i l o t t o misinterpret some instrumental o r o t h e r indica-
t i o n . Thus t o reduce accidents we have got t o s e e how we can make p i l o t s l e s s
#
ICAO Circular 18-AN115 l.07
p o p e %p eq3-or0 t h e bLne of attack, a s evidenced by $he eontributmy eausee %s

whOob H have refgrrgd, i s s h p l f f ' i e a t i o n of instrument presentation, proper
g~o\rafngsf fnstmfatnfs, stacpdardi%a$iionand prpventfon of fakigwb
On %his pof p$ of preven$$on a# $atPgue, incideptallg, I think there %ss no

doubt t h a t i n the p a s t some a e r o p l a ~ e eb v e been theplselves inherently t o blame
f o r %be f a & that they erashed, I t %a no help t o the p r e s e ~ a t i o nof a p%lo$@s
gfffeieraey t o bg ds)llged wish wgter %boughgmdeqwte window sealing, s.trUek bg
draught@from wsry erpgle, fiaflng h%s brafa begtep i n t o g senseless s t a t e a
o o d e eaeopbony of engin*, ~ertdgnermieapd rad3.0 .%e$errerpaee nofges gnd &$en
c vgbro wagage through Ma hatads, Us f e e t a ~ tdh e s e a t of h i s pants, Happily,
$t seem tbt the nm aerqpJ,a@es with pressmized f l f g h t decks, sound proofing,
%heuse of mrs fs$priereacca-$'pee radPo cbapnels end vlbrationless pouer plants
fn the fae.m aP torrbfxlss w$ll P$prwe the ~ S t w t f o p%ffemendouslyo Altboqh ye
have gfaea a l o t of % h q b f t o t h e p p ~ b l wwe b v e , PDP t h e moment, given up %he
idea whhb wemcsbad of at$mnptfong t o regulate agafnet t&e possible onsef of
fa%$@@ tw6ugh r@str$@%f on o f f l f i n g hours, due t o t h e maw paralaetera wFf a$
eP$ecs$ %bffll;mr(s rbfph ean be aepq9dered relatgveay safeo We are, however,
@s~$%rrau%ng )rP$h research a t the Canrbrfdge Laboratory and it may be t h a t wf t h
@eate$.kswJedge sowth$.ng @or9d e f i n i t e can be dope, I n this eonneetion
geres~% of' Unfterd K%p@pp npti$%cb,$y sseOdepte fna 19169 m e ~ ~ l ~ ir ne dt h e f9ml
s%ages of f l i g h t and )rh%lst f n no ease was there sufiPafsa% evidence t o inelude
fa$%gue a s a soqatrihtory f a c t o r , %his possfbflf%y b s t o be b a ~ n si n mflpd, and
we b v e She paradsx%aal sftuation %kt the p i l o t a s e f f i ~ f e n e yLennds t o d e t e r f ~
Y@%@ ab %hevery % h e tihat f t ipl vf $a1 tbt -be shotikd be sn $he top Bfrse, Pm
exa~p$e,w h e ~le%%hg d m t o lgndlfng a t h3.g deatinatfon a% tha end sf a long
atage flOgR% through poor gnd ~ o ~ r y f nyea%her g oondi$Pons,
Designers have a l a r g e p a r t %o play Pxl %ber&ue%ion of p i l o t emor aeci-

dellats t b w g h s i ~ q > l ; P f $ ~ q t i o fp t h e p % l s t O task
s generally, whether it be %a
%bedss89gp BPC~ r s b e t 9 o n in nwbers of fnastmen%s, awitehsa, knob8 and levere
CPIIll %he $%9gbt decfs er t h e prooedwes which he has t o f o l l w , A g r e e t d e a l of
wP)r&h a p of couree, been dons on the la3fff%gpy side on rs~ndard%aat%ort of esakpft
le~youtand altbovgh a l l tws v ~ r kmay plpt be ppglPcab2.e t o a c5vil airorsfjet $;here
f -e? PO dovbt i n py mfpd, $hpt g eprtisfrn msssure pf s%aqimrdi'l~atOop ou&t t o
r e f l e e t som Oqspvsment i n safety, I n thOa connection we have, of course, go%
tbc) prime smmple wbicb exf a t s today in ~stapdardfl;ed ebntrol mwemeatso It bas
aPso been ppt f ~ ~ ~ 5x1 a rt hde United IQpgdom %bgt we oug;h%t o have complete
~$aadardOaat$onof control loading, %hat i s t o go ftusther than presarfbing
maxfmm loading, but I suspect t h a t t M s f s too melb for wMe& to hopeo
With t h e fntroduetions of" synthetic t r a i n e r s , such a s %he D e b % , %he vista

f a opening up %n yhieh the mosk-up, instead of being &be Pifeltass t h f e g which f6
is now, m y beeow something wMcb could snake a r e a l contrfbut%on t o g praatiea51
108 ICAO Circular 1 8 - ~ ~ / 1 5
solutPon of cockpit layout from t h e p i P o t O spoint of view, I n s o many mock-zrpe

i n the p a s t wbat has appeared t o be a nice layout has been agreed only t o f i n d
i n service t h a t p a r t of the instrument o r control arrangement a f f o r d s a source
of irritgti on o r even perhaps danger,
An annoying, wwpyfng and s o unnecessary type of" accident i s t h a t which

a r i s e s from c o l l i s i o n with t e r r a i n , We had three such accidents which occurred
i p bad weather last year, and although they formed but a -11 proportion of
t h e t o t a l number of' accidents during the year this type of accident has accounted
f o r an unnecessariBy high proporti on of accidents i n t h e past, Since 1946 we
have had seventeen of t h i s nature, nearly a l l of which could have been avoided
by proper use of" the equipment earrfed, This b e l i e s t h e b e l i e f s o often put
forward t h a t i f t h e p i l o t had had such and such an a i d t h e accident would n o t
have happened, The p o s s i b i l f t y of equipment f a i l u r e i n individual cases cannot,
of course, be completely ruled out and regard mst a l s o be had t o the f a e t t h a t
p i l o t s m y be working under eonditiona of p a r t i c u l a r s t r e s s , Notwithstanding
t h i s , however, the h i s t o r y of this type of accident underlines t h e need f o r
s p e c i a l c a r e i n bad weather, p a r t i c u l a r l y i n s e l e c t i n g and maintaining a l t i t u d e s
f o r en-route f l y i n g which give adequate t e r r a i n clearance, allowing f o r possible
e r r o r s i n navigation i n p o s i t i v e l y f i x i n g the a i r c r a f t u s position before l e t t i n g
downo and i n s o arranging a l t i t u d e s during letsdasn t h a t a l l a f a n c e i s made for
n o r m 1 tolerances i n t h e a i d befng used and srrms i n following the f l i g h t path
which i s marked by t h e approach and landing aid,
P r e s s w i g a t i o n i n enabling a i r c r a f t t o f l y above t h e weather i s a g r e a t

s t e p towards r e l i e v i n g t h e e~-ra\~%e stress imposed upon t h e p i l o t by meteor-
o l o g i a s l conditions rand improving t h e comfort of t h e passengers, But with t h e
increases i n opepatipg heights with t h e introduction of j e t a i r c r a f t , pressurisa-
t i o n has c e r t a i n l y brought its own d i f f i c u l t i e s along with it, A g r e a t d e a l of
vork baa been done i n t h e Unfted Kingdom in connection with t h e physiological
aspeots of explosive decompression a r i s i n g from sudden pressure aabin f a i l u r e
and our physialog%sts s t a r t e d off with t h e obviously unacceptable advice, fkom
t h e a i r l i n e s p o i n t of view, t h a t a i v i l transport should not operate above
28,000 f e e t , or, i f they did, %hat %hey should have no windows. The psycholog-
i e a l aspect bore no weight, Why, they adced, should,you have windows i f you
f l y so high t h e r e i s nothing t o see except the clouds; i f passengers want t o
see something, p a i n t t h e clouds on t h e cabin walls! However since it was s o
obvious with t h e a r r i v a l of the jet t h a t aeroplanes would f l y high and have
cabin windows i n s p i t e of t h e i r advice the carriage of oxygen against the pos-
s i b i l i t y of p r e s s u r i s a t i o n f a i l u r e was urged, But when you consider t h e r i s k s
ICAO C i r c u l a r 18-AN/15 109
a t t a c h f i g t o p ~ e s s u y i z a t i o nf a i l u r e a t high a l t i t u d e s , t h i s a f f o r d s l i t t l e
ermelissatiw, and t h e obvious answer i s t h a t transparencies i n the cabin6 and
f l i g h t deck $n high-flying pressurized a i r c r a f t must be designed and conartructed
t o a allfficffsptly high standard a s t o afford no r i s k of f a i l u r e ; i f we a r e going
t o bave s a f e t y i n t h i s regard we have t o have standards sWbr t o those we apply
t p the r a g t of t h e structure. The man vho preaahed t h e provision of parachutes
because s wing might f a l l off would get s h o r t shwt!
Ow d s s i p e r s have gone f o r t h e p r w f sfon of double windows with a high

f a c t o r of safe$y and, a t the same time, a hill i n v e s t i g a t i o n of f a t i g u e of the
perrticvlar designs $8 being undertaken, I t seems, however, t h a t with a smll
s a e r i f f c s of t h e a e s t h e t i c appeal, by the provision of metal l a t t i c e reinforce-
ment outsfde t h e window, very considerable strength could be provided with a
I l a r p saving i n weight, Although t h e comerefa1 s i d e s of t h e a i r l f n e s may no%
l i k e this idea a t the moment, I t h i n k it is n o t beyond t h e bounds of p r o b a b f l f t g
t h a t t h i s type of window may emerge i n cabin transparencies i f operating a l t i -
tudes a r e Further increased. Another l i n e of a t t a c k , although it introduces
ssome d f f f i c u l t design problems, would seem t o be t o arrange t h a t a l l t h e material
of t h e window is i n compression.
SAFETP BELTS AND HBRNESSES
W s e r e s h o r t l y going t o make t h e requirement a s a safeguard a g a i n s t tr8ao-

bulence due t o c l e a r a i r g u s t s o r other r i s k s , or f a i l u r e of the power operated
c o n t r o l s and automatic p i l o t s , due t o which strong negative G might be s e t up,
%bat a t l e a s t one p i l o t s h a l l be strapped i n throughout every public t r a n s p o r t
Plfgh$. On new aeroplanes we now require t h e f i t k i n g of a shoulder harness t o
a p i l o t ' s seat tits an a d d i t i o n a l rpafeguard, but i n order t o prevent undue r e s t r i e -
t i o n , we a r e r e c m n d i n g t h a t t h e harness should be of t h e type i n wNch l e g
satraps can be w m 88 a belt. I n f a c t , I believe t h a t unless meh an arrangement
is made t h e f n t r p d u c t f m pf t b e shoulder harness can lead t o a reduction f n
s a f e t y due t o t h e antipatby of p i l o t s t o w e r - r e s t r f c t f on,
A s I eafd e a ~ l i e r ,a t one time we thought t h a t t h e b i g thing was t o s t o p

accidents and t h a t t h a t l i n e of approach would leave u s no worriea about crash
s ~ i v a l but
, realism won t h e day and we appreciate t h a t accidents a r e inevitable,
110 ICAO Cfreular 18-8~/15
MT, Hansbrry has d e a l t with b i t i s h f i r e precau%Pons and it i s suf'ficient a t

t M s stage t o say t h a t one of t h e objects of our' f i r e precautions i s s through
the provision of crash operated switches, t o prevent a f i r e happening when an
aeroplane crashes. The record of accidents t o B r i t i s h a i r c r a f t which have
occurred since t h e war, durfng which time crash operated f i r e switches have
been mandatory, gives us great kope t h a t something concrete i n the advance of
safety has been achieved, We have i n i t i a t e d a f u r t h e r c a r e f u l survey of acci-
dents t o g e t a f u r t h e r assessment of the value of these precautions,
Elimination of t h e f i r e r i s k ought t o r e s u l t , we f e e l , i n some 50 percent

reduction of crash f a t a l i t i e s , In addition t o f i r e suppression precautions,
therefore, we believe t h a t it is most important t o pay close a t t e n t i o n t o f u e l
tank degign, The poasible dangers introduced by i n t e g r a l tanks have had pro-
tracted examination, At one stage there was strong pressure t o ban them cann
pletely, However, we now take the d e w t h a t providing good design standards
a r e applied i n t e g r a l tanks should be acoe ted where they a r e placed outside the
8
outer engine nacelles and t h a t eare s h a l l be taken i n the arrangement of eom=
p o ~ e n t st o ensure t h a t i n t h e event of an accident they w i l l not pierce t h e
f u e l 'tbl&a. General design requirements are, a t the moment being drafted by
t h e AOr Navigation Board t o e w e r these points,
As i n the United S t a t e s of Arnerf~a,cossiderable research has been done

i n t o thp p o s e i b i l i t y of reducing f a t a l i t f e s by t h e f it t i n g of rearward facing
s e a t s Pn B r i t i s h a i r c r a f t , A s you probablykmow, i n the Royal Air Force R.ans-
p o r t Command, the Hastings ( t h i s i s a Bandley Page kengined transport) has been
f i t t e d with rearward facing s e a t s stres.sed t o 25 G o Fortunately there have been
no accidents t o this a i r c r a f t whPeb would indicate what has been gained from
t h i s innovation, but it i s i n t e r e s t i n g t o h o w t h a t passengers t r a v e l l i n g in
them, although admittedly they have been Service personnel, have been very
happy, I know t h a t t o achieve a similar innovation i n c i v i l a i r c r a f t i s fraught
with commercial d i f f i c y l t i e s , The immediate reaction from the a i r l i n e s i s t h a t
t h e i r machines do not crash and why qhould they do this or t h a t which would have
commercial repercussions and favour t h e i r competitors, I t i s elaimed t h a t the
changeover w i l l be p a r t i a l l y achieved through t h e modem tendency t o i n s t a l l the
compartment type of s e a t but, i f t h i s i s t o be effeetfve, care w i l l have t o be
taken t o achieve adequate strength of s e a t , s a f e t y b e l t s and s e a t a t t a c h e n t s 9
otherwise passengers s i t t i n g opposite those facing the r e a r mfght, i n a serious
craah, a c t a s human projectllea,
ICAO Circular 18-~~/15 11%
Some ameli oration of t h e s i t u a t i o n might be achieved, by the f i t t i n g of

sPPsonger segts end safety b e l t s , (without going t o rearward facing seats) and
stronger s e a t attachments and adequate f l o o r s t ~ e n g % hproviding , the design of
s e a t backs i s given s u f f i c i e n t a t t e n t i o n a s f a r a s padding i s concerned, Seat
designers i n the p a s t have often been content t o leave rasor-like edges QP
strang and awktJarfl$y s b p e d meta), tvbes i n @aces where portions of passengers
would make coptaot with them. Let me say a t once t h a t f am sure t h f s does not
papply t o gay ddtsf gners who may be present today! l 9
I n a real;ly serious accident, of course, it i s I f k e l y t h a t only passengers

who a r e seated t o the r e a r sf the main spap would h v e P even with rearward
faafng seat8 of adequate strength, I% may i n t e r e s t you t o how t h a t i n a reeelgt
accfdent i n $he UnOted Kingdw with oonventfonal seating there i s no doubt tibe
passengers were seriously injured through uontact with t h e back of t h e s e a t i~
fron% of' thew. Whether t h i s happened before or a f t e r t h e i r s e a t s beeame dataehed
from the f l o o r is not of eourse knoym, Singe the e s t i m t e d deceleration a t the
-
b a a of the rnaalage was egtfaslted a t 1 0 2.5 G 2% seems a s though r e a r faefng
s e a t s of adequate strength might i n t h i s case have l e d t o some saving of l i f e ,
and prmsdes strong p r a c t i c a l argument,
The l a r g e r the a i r c r a f t become the more egtastrophie the r e s u l t of craah

firlras and where these bave occurred it is lamentable t h a t rescue s e m i e e s have
had t o atand by helpleas, Althovgh bigger and b e t t e r crash f f r e f i g h t i n g
vsbiclee have been developed capable of f l i n g i n g C02 (3600 lbs, per minute] a t
phenomenal r a t e s a t arash 4%res9we have s t i l l t o have prae"c%cel demonstra%fm
%ha%they a r e capable of dealing wi%h the serious p e t r o l f f r e which some$$mes
R~lppen?when an aeroplane crashes, It is, of course, afiomatic t h a t %o be eff'ec-
%fve the araah tender must be on %he scene a s t h e crash happens. The i n t r d u a -
t f o p of &be use of f"we$s low of vqBatlJfty such a s kerosene my well kelp t o
deBay the spread of f i r e and thus make crash rescue vehicles more effective,
In t h f s connection, one of the d i f f i e u l t f e s En the p a s t 'has been t h a t of mrak5nag
~ a p i dentry i n t o orashed aeroplanes t o rescue s m i v o r s where doors and other
e x i t s have jammed through dis%ortfon of t h e structure, The f i r s t l i n e of attack
is, of Gourge, t o design emergency e x i t s and doors so t h a t they do not jam, but
from the rescue Crew agpect $he provision of some means of breaking i n t o a i r e r a i t
is obviously neces8ary0
Pressure cabins have, of eourse, introduced the* own d f f f i c u l t i e s with

baersased thickxees of eabin walls, I n the Unf$ed Kingdom develapment work is
going on with power driven saws and i t %shoped t h a t these v d l l provide sm effec-
tive answer, To be f u l l y effective, hmever, it i s thought some system of marking
break-in points may have t o be evolved,
Thpre i s no doubt i n our minds t h a t with the r e a l i z a t i o n op t b e p a r t of

everyone t h a t c a r e f u l a t t e n t i o n t o h i s own task i s e s s e n t i a l , together with a
cpntinued pursuit of high standards of proficiency, f l y i n g can be made a l o t
s a f e r tban ;lt i s t @ g ~ . Aviation has been pursuing f o r many pears the apparent
mirage of a safety f u g l and wMlst kerosene may be some way frcm being a c a m
ple$e answer we hgve every rgason t o hope t h a t i t 9 use i n the t p b o j e t a i r -
c r a f t , shortly coraipg i n t o service on British AirTines, w i l l be' an important
factor i n reducing t h e danger of catastrophic post-fire crashes: coupled with
what has been done regarding f i r e precau+$.ons t h e r i s k of such outbreaks should
be greatly reduced. The simplicity which evolved from t h e use of t h e new pro-
pulsion systems, and the decrease-in fatigue through the absence of noise and
vibration w i l l , we hope, r u l e out a further souroe of accidents and open up a
new era of safety Zn t h e a i r .
IGAO c i r c u l a r 18-AN/15 113
MISCELLANEOUS EXTRACTS RE ACCIDENT PREVENTION
1.- A PLACE FOR EVERY TOOL, EVERY TOOL I N I T S PLACE
A wrench, a screwdriver, a pair of p l i e r s inadvertently l e f t inside an

engine cowl, i n a wheel well o r i n the control system rnay be more serious
than a f o r ~ e p sa~sponge o r a knife l e f t inside a patient by a surgeon. One
m y k i l l f i f t y people, the other only one.
2,- PAPER WORK vs COLLISION
An a i r l i n e p i l o t s t a t e 8 t h a t he orders h i s mew to c u t out all paper

-
work on take-off u n t i l he reaches c a s i n g a l t i t u d e and on all let-downs
fro^ a r u i s i n g a l t i t u d e u n t i l he i s safely on t h e runway,
3,- CREW TRAIMIIG

-
- DIEHIFIG
The time t o learn how your safety q u i p e n t i works i s before ya~lneed
it, not while you are bobbing around i n the water, hoping t h a t someone will
f i n d you,
4.- FATAL TIRE EXPLOSION
!hm mechanics were remv1,sg a wheel of t h e s p l i t type with the halves

held together by t i e bofte, One o r more of t h e t i e b o l t s had f a i l e d and
t h e inflation pressure tended to expand the wheel halves so t h a t t h e nut on
t h e axle was actually doing most of the holding of the wheel together,
Consequently t h e nut was hard t o back off, The mechanic8 attsmnpted to get
the nut off bg cutting it with a cold chieel, Qn the l a a t cMp, t h e mat
114 ICAO Cfrcular 18-8N/15
suddenly released and the pressure i n the t i r e propelled the rim and tyre off
with s u f f i c i e n t force t o injure seriously one mechanic and throw the second
mechanic over 60 feet, breaking nost of his bones and blowing h i s head W s t
off.
Moral,- I f a device does not work smoothly, find out nwhy" before
f o r c i e .
5.- EMERGENCY CHECK LISTS vs TELEPHONE NUMBERS
Same p i l o t s have found a new use f o r telephone address books (the kind
where the cover springs up t o the pre-selected l e t t e r when a t a b i s pressed).
On the @overi n place of the index l e t t e r s , they paste the l i s t of emergencies
t h a t c a l l f o r immediate action but require a check list t o be certain that
no step i s overlooked,
6,- OXYGEN BOTTLES
It i a inadvisable t o locate oxygen bottles i n the plane of the propellers.

Pieces of the prop might f l y off and go through the bottle creating an explo-
sion h a r d and possible oxygen deficiency when oxygen might be most needed.
Oxygen bottles located near skin of the belly also can cause hazard.
An instance i s reported of a militmy alpcraft i n a belly landing, the skin
was worn away by sliding d o n g %he concrete, This exposed the oxygen bottle
which also was worn through by friction, The resulting release of owgen on
hot dzxral s t a r t e d a very hot f i r e , Plane was consumed.
7e-ELECTRIC SHORT BY WASTE WATER
A waste water tank s t r a i n e r i n the lounge of an air transport caused

water to overflow which resulted i n a shorted f i r e unit,
RmeQ,- Drain holes were d r i l l e d mound the screen r e t a i n e r band of
the waste water strainer, T h i s allows waste water t o drain i n t o a water
tank i f the screen becomes clogged.
ICAO Circular 18-AN/I.5 115
8.- CONTROL C A B U CAUGHT BY BOLT
After t a k e - ~ f f ship went into abnormal climb and control oolmm could
not be pushed forward, Hose dropped and control colnman became f r e e then
power was reduced, Down elevator control cable had been cmght i n threaded
end of a b o l t in the control system,
T e m o r a r s remedy.- Bolt position changed ao head of bolt faces cable.

Permanent r&,- Present bolt t o be replmed bg a clevis b o l t with
recessed head,
An air transport made an emergency landing due t o heater f i r e warning

(caused by shorting of switch), C* bottles discharged but pressure remained
in system, Investigation revealed check valves down stream of Cq2 bottles
were full of water, corroded and frozen i n closed position,
Note
-0
- -
Water may enter though C02 discharge nozzles moisture laden
a9r flowing by the nozzles could do this, This a i r flow may conre from out-
side or be c a s e d bg. d i f f e r e n t i a l air pressures within the aeroplane,
especially pressurized aeroplanes,
Reme&,- Relocate C02 diecharge l i n e s so water will drain a u t of them

iw%erPd of down into sptera, i,e,, imer'k the l i n e s *
10,- A WRa FROM THE WISE
a) Know where you a r e before ysu let-down,

b) Adhere to designated I n e t m n t Approach Procedures.
c) Mrcrew - keep your s e a t b e l t s fastened,

dl) Don't take off with frosen precipitation on the wings,
e) Take it easy on slippery runwayso

116 ICAO C ircular 18-AN/15
f) Beware the e f f e c t s of altimeter errors, clear air gusts, downdrafts,

and all other factors t h a t affect the a i r c r a f t ' s position i n height,
g) One's nose can be a very sensitive detector of smoke ( f i r e ) , smells
.
(hazardous cargo leaking) and aechanfcal trouble (leaking fuel,
hydraulic f l u ids, ete, )
h) Use windshield f o r purpose designer intended - Observation!

i) The definition of "Pilot Errorn i s debatable, however tlie results of
same are often wFatal@,
j) wAbsolute safetyw i s preferable t o r%Calculated riskn.

k) If a p i l o t is where he thinks he i s we would not have collisions
with mountains.
ll,~PtEXIGLASS TOPIC
The possibility of s t a t i c discharge caused by cleaning plexiglass

b e c w a f i r e hazard is removed if cleaning takes place a f t e r refuelling.
12,- TRANSPORT OF BANGE3iOUS GOODS
The o f f i c i a l inquiry i n t o the forced landing near Tangali, i n Eaat

Bengal, of a DC-3 belonging t o Airways (India), Ltd,, last December, has
resulted i n a verdict of lack of caution on %he p a r t of the company and
agross negligencen of its booking section,
A wooden crate containing chemi@dLsemitted fumes and caased a f i r e i n

the luggage eonparbent while the airwaft was en route from Calcutta t o
Gauhati on 17 December. There was no damage t o the a i r c r a f t nor were any of
the occupants injured i n the landing, kt l a t e r two passengers and two laamnberer
of the crew died from the e f f e c t s of the poison fumes.
- END -

KLM Prestwick Constellation Accident 1948

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ICAO

AIRCRAFT ACCIDENT DIGEST

Prepared in the Air Navigation Bureau

Published in Montreal, Canada, by t h e

O r d e r s for ICAO publications should be s e n t , on payment:

In Canadian c u r r e n c y ($), to In Sterling o r 1 r i s h ' c u r r e n c y (s/d), to

S e c r e t a r y General, ICAO, The United Kingdom Stationery Office,

ICAO Representative, ICAO Representative,

In Peruvian c u r r e n c y ( s o l e s ) , to In Australian c u r r e n c y (s/d), t o

ICAO Representative, ICAO Representative,

22 November 1950 ...........................e..............

m/W Fleet 80 a i r c r a f t CF-ENT, crashed on landing at

landing a t Sydney, N. S., on 13 December 1950 .............. 20

mh27 D e b i l l a n d DH82C a i r c r a f t CF-COM, crashed near

United UH-12 Helicopter CF-GKG, crashed near

Lusconb $A a i r c r a f t CF-EJC, crashed on the south-

French registered a i r c r a f t F-BAYM, collided with

KLM, Constellation a i r c r a f t PH-TDF, crashed when

ICAI) Ref* UNION OF SOUTH aFRICA

BEAG Vik5ng & r e r a f t G-A1VL explosion about 30 miles

Psoctor 3 a i r c r a f t G A J C U , crashed a t Brock Tho-'n

American Airlines, DC-6 a i r c r a f t N-90728, crashed a t

Consolidated V t r l t e e BT-15 a i r c r a f t NC-63418

ICAO Ref. UNITED STATES (Contd, )

AR/lO7 Private a i r c r a f t Cessna @.I and Piper PA-11,

AR/U~ Northwest Ahlines Inc., Martin 202 a i r c r a f t

Am33 PAA, Boeing 377 Stratocretiser aircraft N-1036V,

Part 111.- MiscelPaneous PubLications and Reports ................... .

The Accident Investigation Division of the Air Navigation Commisai~nof

The f f r s t s v was issued i n October 1946 ( L i s t No, 1, Doc 217'7,

'%he usefulness of such a publication 88 t h i s is d i r e c t l y proportional

'She ICAO Manrad of Aircraft Investigation is a valuable guide to se-

3 ) Date and Place of Accident;

5 ) RermPt of the Technicerl Investigation;

Any r e s t r i c t i o n upon rep~qducltPicsni n the Digest seriously igtpairs 0%

Landing 18 29.5% 16 12 31.6% ll *'%

Loss of control 5 8.2% 1 3 8 % 2 - .2k Included in t h i s category are accidents caused by

mPBt 61 - 38 38 - 30 - The number of reportable accidents (ccmercial) has

Although the percentage of accidents due to pU.ot e r r o r shows an appre-

Jt has been c l a h e d that the possibility of accidents i n flying i s inev-

Since human e r r o r i n r s f r e r d t operation is l e s s l i k e l y to be reduced

If accidents i n t h i s category are t o be reduced k t i a suggested t h a t

WGanwe, by the sigiplification of controls, equipment, procedures

PART I.- Summaries of Aircraft Accident Reports

Union of Burma Airways Dove Aircraft XY-ABR crashed on

The a i r c r a f t commenced a normal take-off and when airborne, "wheels up"

The pilot-in-command s t a t e d i n h i s evidence t h a t he had no idea of the

The Board found a s follows:

1. The a i r c r a f t was airworthy a t t h e commencement of the f l i g h t ,

2. The a i r c r a f t was not overloaded and t h e load w a s c o r r e c t l y

3 a The aircraft; w a s pulled off a f t e r too short a take-off run at

4 The undercarriage was retracted too early and before safety

5, The a i r c r a f t sank back on t o the runway before the safety speed

6, The a i r c r a f t caught f i r e t o the rear of t h e starboard engine

7. The p i l o t f a i l e d t o operate the f i r e extinguishers i n t h e engine

80 The airport f i r e tender delivered its f u l l complment of 2,500

@- The d i f f i c u l t y experienced by the pilot i n undercarriage

Norseman Aircraft CP-GPG crashed on take-off a t Gander Lake,

A float-equipped Norseman VI f i r c r a f t taxied out t o take-off position on

Xnvestinati on and Evidence