Aviation Statistics

Preliminary Data Show Downward Trend

In Controlled-flight-into-terrain Accidents
Among Large Western-built Commercial Jets
These data also show that approach-and-landing accidents
remain a significant safety problem.

FSF Editorial Staff

Preliminary data from The Boeing Co., Airclaims and Don or in categories often related to ALAs (aircraft off end of
Bateman, chief engineer, flight safety systems, Honeywell runway on landing, aircraft off side of runway on landing,
International, show that three accidents involving controlled hard landing, landed short, gear collapse/gear failure/gear up
flight into terrain (CFIT) and nine approach-and-landing and windshear). Thirty accidents in these categories (7.8
accidents (ALAs) have occurred from Jan. 1, 2000, to Oct. 15, percent of total accidents in all categories) occurred among
2000, to Western-built large commercial jets, those heavier first-generation airplanes,1 which had 22.5 accidents per
than 60,000 pounds (27,216 kilograms). million departures. Eighty-seven accidents in these categories
(22.6 percent of total accidents in all categories) occurred
Flight Safety Foundation defines a CFIT accident as one that among second-generation airplanes,2 which had 2.2 accidents
occurs when an airworthy aircraft under the control of the flight per million departures. Eighteen accidents in these categories
crew is flown unintentionally into terrain, obstacles or water, (4.7 percent of total accidents in all categories) occurred among
usually with no prior awareness by the crew. This type of early wide-body airplanes,3 which had 4.1 accidents per million
accident can occur during most phases of flight, but CFIT is departures. Ninety-two accidents in these categories (23.9
more common during the approach-and-landing phases, which percent of total accidents in all categories) occurred among
typically comprise about 16 percent of the average flight current-generation airplanes,4 which had 1.8 accidents per
duration of a large commercial jet. million departures.

Boeing’s definition differs slightly, describing a CFIT accident Figure 2 (page 203) shows that 6,655 fatalities occurred
as “an event where a mechanically normally functioning worldwide in large Western-built commercial jet accidents in
airplane is inadvertently flown into the ground, water or 1990 through 1999 (including 6,464 fatalities aboard
obstacle (not on airport property while attempting to land).” airplanes), and 379 of these fatalities occurred aboard airplanes
The Boeing data include worldwide Western-built large in 1999. CFIT accidents resulted in the largest number of
commercial jet airplanes that are heavier than 60,000 pounds fatalities by category — 2,111, with five in 1999 — and 204
maximum gross weight; the data exclude airplanes fatalities, 37 in 1999, occurred in the landing category.
manufactured in the Commonwealth of Independent States.
Figure 3 (page 204) shows hull-loss accidents, fatal accidents
Boeing defines a hull loss as damage to an airplane that is and fatalities on board Western-built large commercial jets
substantial and beyond economic repair. Boeing also classifies during the last four phases of flight (descent, initial approach,
an airplane as a hull loss if the aircraft is missing, if the final approach and landing). Fifty-nine percent of the accidents
wreckage has not been found and the search has been and 56 percent of the fatalities occurred during these phases
terminated, or if the airplane is substantially damaged and is of flight.
inaccessible.
Figure 4 (page 205) shows the distribution of 18 events
Boeing data (Figure 1, page 202) show that in 1990 through involved in 199 landing accidents among Western-built large
1999, 227 accidents occurred worldwide in the CFIT category commercial jets in 1990 through 1999. The five events reported

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000 197

 most often in these accidents were hard landing, aircraft off categorization). No fatalities occurred in five of the accidents;
the side of the runway, aircraft off the end of the runway, wet/ 335 fatalities occurred in the other four accidents.
icy runway and loss of directional control.
Figure 6 (page 206) shows that during an approximate 11-
Table 1 (page 199) shows the hull-loss accidents that involved year period, the number of ALAs among Western-built large
Western-built large commercial jets from Jan. 1, 2000, through commercial jets has ranged from a low of seven in 1998 to
Oct. 15, 2000. Fifteen hull-loss accidents occurred worldwide a high of 18 in 1992, an average of about 12.5 ALAs per
during this period. Seven accidents were survivable accidents year.
with no fatalities.
Figure 7 (page 207) shows that CFIT accident rates and ALA
Table 2 (page 199) shows that seven hull-loss accidents rates for Western-built large commercial jets have followed a
occurred worldwide during the same period to Western-built cyclical pattern and that a downward trend in ALAs currently
commercial jets less than 60,000 pounds. Six accidents resulted exists based on the three-year moving-average lines.♦
in one or more fatalities.
Notes
Table 3 (page 200) shows that 18 hull-loss accidents occurred
1. In its definition of first-generation commercial jets, Boeing
worldwide during the same period to Western-built commercial
Commercial Airplanes Group includes the British
turboprop airplanes with more than 15 seats. Seven of the
Aerospace Comet, Boeing 707/720, McDonnell Douglas
accidents occurred during approach and landing. Five accidents
DC-8, CV-880/-990 and Caravelle.
involved no fatalities; 120 fatalities were reported in the other
13 accidents, an average of nine fatalities per accident. 2. In its definition of second-generation commercial jets,
Boeing Commercial Airplanes Group includes the Boeing
Table 4 (page 200) shows that three hull-loss accidents, which 727, British Aerospace Trident, British Aerospace VC-10,
occurred during this period among Western-built large BAC-111, McDonnell Douglas DC-9, Boeing 737-100/
commercial jets, have been categorized — on a preliminary -200 and Fokker F28.
basis — as involving CFIT during approach. No fatalities
3. In its definition of early wide-body commercial jets,
occurred in nine of the accidents; 274 fatalities occurred in
Boeing Commercial Airplanes Group includes the Boeing
two accidents.
747-100/-200/-300/SP, McDonnell Douglas DC-10,
Lockheed L-1011 and Airbus A300.
Figure 5 (page 206) shows that during an approximate 11-
year period, the number of CFIT accidents among Western- 4. In its definition of current-generation commercial jets,
built large commercial jets has ranged from a low of one in Boeing Commercial Airplanes Group includes the
1999 to a high of seven in 1992 and in 1998, an average of McDonnell Douglas MD-80, Boeing 767, Boeing 757,
about 3.8 CFIT accidents per year. Airbus A310, British Aerospace BAe146, Airbus A300-
600, Boeing 737-300/-400/-500, Fokker F100, Airbus
Table 5 (page 201) shows that nine hull-loss accidents that A320/319/321, Boeing 747-400, McDonnell Douglas
occurred worldwide during this period among Western-built MD-11, Airbus A340, Airbus A330, McDonnell Douglas
large commercial jets were ALAs (based on preliminary MD-90, Boeing 777, Boeing 737-NG and Boeing 717.

198 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000

 Table 1
Hull-loss Accidents
Worldwide Large Commercial Jet Airplanes1
Jan. 1, 2000–Oct. 15, 2000
Phase Total
Date Operator Aircraft Location of Flight Fatal
Jan. 30, 2000 Kenya Airways Airbus A310 Abidjan, Côte d’Ivoire Climb 169
Jan. 31, 2000 Alaska Airlines McDonnell Douglas MD-83 Near Oxnard, California, U.S. Descent 88
Feb. 3, 2000 Trans Arabian Air Transport Boeing 707-320 Mwanza, Tanzania Approach 0
Feb. 11, 2000 Air Afrique Airbus A300B4 Dakar, Senegal Taxi Out 0
Feb. 12, 2000 TransAfrik Boeing 727 Luanda, Angola Approach 0
Feb. 16, 2000 Emery Worldwide McDonnell Douglas DC-8-71F Sacramento, California, U.S. Climb 3
March 5, 2000 Southwest Airlines Boeing 737-300 Burbank, California, U.S. Landing 0
April 19, 2000 Air Philippines Boeing 737-200 Davao, Philippines Approach 131
April 22, 2000 Turkish Airlines RJ Avroliner Siirt, Turkey Landing 0
April 30, 2000 Das Air Cargo McDonnell Douglas DC-10-30F Entebbe, Uganda Landing 0
July 12, 2000 Hapag-Lloyd Airbus A310 Vienna, Austria Descent 0
July 17, 2000 Alliance Air Boeing 737-200 Patna, India Landing 57
July 25, 2000 Air France British Aerospace/ Paris, France Takeoff 113
Aerospatiale Concorde
Aug. 23, 2000 Gulf Air Airbus A320 Manama, Bahrain Approach 143
Oct. 6, 2000 Aeroméxico McDonnell Douglas DC-9 Reynosa, Mexico Landing 4
Total 708
Note:
1. Heavier than 60,000 pounds (27,216 kilograms) maximum gross weight; excluding the Commonwealth of Independent States.

Source: The Boeing Co.

Table 2
Hull-loss Accidents
Worldwide Business Jet Airplanes1
Jan. 1, 2000–Oct. 15, 2000
Phase Total
Date Operator Aircraft Location of Flight Fatal
March 26, 2000 Private CitationJet Buda, Texas, U.S. Approach 1
April 5, 2000 Bankair Learjet 35 Marianna, Florida, U.S. Landing 3
May 2, 2000 Northern Executive Aviation Learjet 35 Lyon, France Landing 2
May 10, 2000 Price Aircraft Sabreliner Kaunakaki, Hawaii, U.S. Approach 6
June 13, 2000 Grand Aire Express Falcon 20 Peterborough, Ontario, Canada Landing 0
June 23, 2000 Universal Jet Aviation Learjet 55 Boca Raton, Florida, U.S. Climb 3
Aug. 14, 2000 The Colonel’s Sabreliner Ironwood, Michigan, U.S. Cruise 2
Total 17
Note:
1. Business, corporate or executive jet operations; less than 60,000 pounds (27,216 kilograms) maximum gross weight; excluding the
Commonwealth of Independent States.

Source: Airclaims

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000 199

 Table 3
Hull-loss Accidents
Worldwide Commercial Turboprop Airplanes1
Jan. 1, 2000–Oct. 15, 2000
Date Operator Aircraft Location Phase Fatal
Jan. 5, 2000 Skypower Express Airways Embraer EMB-110 Abuja, Nigeria Landing 2
Jan. 10, 2000 Crossair Saab 340 Niederhasli, Switzerland Climb 10
Jan. 13, 2000 Avisto Shorts Brothers 360 Marsá al Burayqah, Libya Approach 23
Jan. 15, 2000 Aviones Taxi Aéreo Let L-410 San Jose, Costa Rica Climb 4
Feb. 8, 2000 Sabin Air Embraer EMB-110 Maputo, Mozambique Initial Climb 1
Feb. 10, 2000 Alp’Azur DHC-6 Twin Otter Courchevel, France Takeoff 0
March 17, 2000 Aeroperlas DHC-6 Twin Otter Pico Carreto, Panama Descent 10
March 17, 2000 Skypower Express Airways Embraer EMB-110 Kaduna, Nigeria Landing 0
May 17, 2000 Avirex Beech 1900 Moanda, Gabon Approach 3
May 21, 2000 Executive Airlines Jetstream 31 Wilkes-Barre, Pennsylvania, U.S. Approach 19
May 25, 2000 Streamline Aviation Shorts Brothers 330 Paris, France Taxi 1
June 2, 2000 Paraclub Moorsele ASTA Nomad Leopoldsburg, Belgium Cruise 0
July 1, 2000 Channel Express Fokker F27 Coventry, England Landing 0
July 8, 2000 Aerocaribe Jetstream 31 Villahermosa, Mexico Descent 19
July 19, 2000 Airwave Transport Gulfstream I Linneus, Missouri, U.S. Climb 2
July 27, 2000 Royal Nepal Airlines DHC-6 Twin Otter Dhangarhi, Nepal Descent 25
July 31, 2000 Win-Win Aviation DHC-6 Twin Otter Raleigh, North Carolina, U.S. Approach 1
Sept. 6, 2000 Aeroperlas DHC-6 Twin Otter Río Sidra, Panama Landing 0
Total 120
Note:
1. Greater than 15 seats; excluding the Commonwealth of Independent States.

Source: Airclaims

Table 4
Controlled Flight Into Terrain1 Hull-loss Accidents
Worldwide Large Commercial Jet Airplanes2
Jan. 1, 2000–Oct. 15, 2000
Phase Total
Date Operator Aircraft Location of Flight Fatal
Feb. 3, 2000 Trans Arabian Air Transport Boeing 707-320 Mwanza, Tanzania Approach 0
April 19, 2000 Air Philippines Boeing 737-200 Davao, Philippines Approach 131
Aug. 23, 2000 Gulf Air Airbus A320 Manama, Bahrain Approach 143
Total 274
Notes:
1. Categorization of accidents for 2000 is preliminary.
2. Heavier than 60,000 pounds (27,216 kilograms) maximum gross weight; excluding the Commonwealth of Independent States.

Source: Don Bateman, Honeywell International

200 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000

 Table 5
Approach and Landing1 Hull-loss Accidents
Worldwide Large Commercial Jet Airplanes2
Jan. 1, 2000–Oct. 15, 2000
Phase Total
Date Operator Aircraft Location of Flight Fatal
Feb. 3, 2000 Trans Arabian Air Transport Boeing 707-320 Mwanza, Tanzania Approach 0
Feb. 12, 2000 TransAfrik Boeing 727 Luanda, Angola Approach 0
March 5, 2000 Southwest Airlines Boeing 737-300 Burbank, California, U.S. Landing 0
April 19, 2000 Air Philippines Boeing 737-200 Davao, Philippines Approach 131
April 22, 2000 Turkish Airlines RJ Avroliner Siirt, Turkey Landing 0
April 30, 2000 Das Air Cargo McDonnell Douglas DC-10-30F Entebbe, Uganda Landing 0
July 17, 2000 Alliance Air Boeing 737-200 Patna, India Landing 57
Aug. 23, 2000 Gulf Air Airbus A320 Manama, Bahrain Approach 143
Oct. 6, 2000 Aeroméxico McDonnell Douglas DC-9 Reynosa, Mexico Landing 4
Total 335
Notes:
1. Categorization of accidents for 2000 is preliminary.
2. Heavier than 60,000 pounds (27,216 kilograms) maximum gross weight; excluding the Commonwealth of Independent States.
Source: The Boeing Co.

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000 201

 Accident Categories by Airplane Generation
Selected Accidents1 — Worldwide Large Commercial Jet Operations2
1990–1999

in
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Wi
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Of

Of

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Airplane Generation

First 5 7 3 3 4 8 0 30

Second 17 17 20 15 9 8 1 87

Early Widebody 3 3 3 5 1 2 1 18

Current 11 22 11 32 2 13 1 92

Total 36 49 37 55 16 31 3 227

10-Year Accident Rate by Airplane Generation

First 22.5

Second 2.2

Early Widebody 4.1

Current 1.8

0 5 10 15 20 25
Accidents per Million Departures
Airplane Generation

First British Aerospace Comet, Boeing 707/720, McDonnell Douglas DC-8, CV-880/-990, Caravelle

Second Boeing 727, British Aerospace Trident, British Aerospace VC-10, BAC-111, McDonnell Douglas DC-9,
Boeing 737-100/-200, Fokker F28

Early Widebody Boeing 747-100/-200/-300/SP, McDonnell Douglas DC-10, Lockheed L-1011, Airbus A300

Current McDonnell Douglas MD-80, Boeing 767, Boeing 757, Airbus A310, British Aerospace BAe146, Airbus A300-600, Boeing
737-300/-400/-500, Fokker F100, Airbus A320/319/321, Boeing 747-400, McDonnell Douglas MD-11, Airbus A340,
Airbus A330, McDonnell Douglas MD-90, Boeing 777, Boeing 737-NG, Boeing 717
Note:
1. Boeing source data show 385 accidents in 27 categories for this time period.
2. Heavier than 60,000 pounds (27,216 kilograms) maximum gross weight; excluding the Commonwealth of Independent States.

Source: Boeing Commercial Airplanes Group

Figure 1

202 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000

 Fatalities by Accident Categories
Fatal Accidents1 — Worldwide Large Commercial Jet Fleet2
1990–1999
2,500 Total Fatalities = 6,655 (6,464 on board)
5 1999 Fatalities = 379 (on board)
29
2,111
2,011
2,000

1,500
Fatalities

1,000
223
482
600
506
500
37 80
238 204 140 5
110 100 91 45
6 5 3 3
0
CFIT Loss of In-flight Midair Fuel Landing Takeoff Ice/ Fuel Wind Runway Misc. On RTO Turbulence Unknown
Control Fire Collision Tank Config- Snow Exhaus- Shear Incursion Fatality Ground
in Flight Explosion uration tion
Number
of Fatal 28 29 3 2 2 14 3 3 5 2 4 3 3 1 3 7
Accidents
= 112

CFIT = Controlled flight into terrain

RTO = Refused takeoff

Notes:
1. Accidents involving multiple, non-onboard fatalities are included. Accidents involving single, non-onboard fatalities are excluded.
2. Heavier than 60,000 pounds (27,216 kilograms) maximum gross weight; excluding the Commonwealth of Independent States.
Source: Boeing Commercial Airplanes Group

Figure 2

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000 203

 Accidents and On-board Fatalities by Phase of Flight
Hull Loss and/or Fatal Accidents
Worldwide Large Commercial Jet Fleet1
1990–1999

Percentage of Accidents/Fatalities
49%

Initial Final
Descent Approach Approach Landing

Accidents 5% 5% 8% 41%
Fatalities 16% 16% 18% 6%

24%

Initial Final
Approach Approach
Fix Fix

Exposure2 11% 12% 3% 1%

Distribution of Accidents and Fatalities

100 95 2000
87
80
Hull Loss and/or
Fatal Accidents

1500

60 1,023
1,145 Fatalities
1,006
1000
40 659

19 500
20 11 11 262

0 0
Descent Initial Final Landing
Approach Approach

Hull Loss and/or Fatal Accidents Fatalities

Note:
1. Heavier than 60,000 pounds (27,216 kilograms) maximum gross weight; excluding the Commonwealth of Independent States.
2. Exposure = Percentage of flight time based on flight duration of 1.5 hours.

Source: Boeing Commercial Airplanes Group

Figure 3

204 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000

 Landing Accidents by Event Descriptor
Worldwide Large Commercial Jet Operations1
1990–1999

Hard Landing 57
Off Side 56
Off End 51
Wet/Icy Runway 43
Loss of Directional Control 41
Collision With Ground Obstruction 34
Gear Collapse 26
Landed Long 25
Tires 21
High Descent Rate 20
Engine Nacelle 19
Tail Strike 15
Terrain Impact on Final 15
Landed Short 14
Crosswind 13
Wheel/Braking Difficulty 11
Gear Up 10 Landing Accidents = 199 Total Events2
Touchdown Speed 2 10
0 10 20 30 40 50 60
Number of Accidents

Notes:
1. Heavier than 60,000 pounds (27,216 kilograms) maximum gross weight; excluding the Commonwealth of Independent States.
2. Each event may involve more than one event descriptor; therefore, the sum of the items may be more than the total accidents
of this type.

Source: Boeing Commercial Airplanes Group

Figure 4

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000 205

 Controlled-flight-into-terrain1 Hull-loss Accidents
Worldwide Large Commercial Jet Airplanes2
1990–20003
10
9
8
Number of Accidents

7 7
7
6
5
5
4 4
4
3 3 3 3
3
2
2
1
1
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 20003

Year
Notes:
1. Categorization of accidents for 2000 is preliminary.
2. Heavier than 60,000 pounds (27,216 kilograms) maximum gross weight; excluding the Commonwealth of Independent States.
3. Accidents through Oct. 15, 2000.

Source: Don Bateman, Honeywell International

Figure 5

Approach-and-landing1 Hull-loss Accidents

Worldwide Large Commercial Jet Airplanes2
1990–20003
25

20
18
Number of Accidents

16 16
15
15 14
12 12

10 9 9 9
7

0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 20003
Year
Notes:
1. Categorization of accidents for 2000 is preliminary.
2. Heavier than 60,000 pounds (27,216 kilograms) maximum gross weight; excluding the Commonwealth of Independent States.
3. Accidents through Oct. 15, 2000.

Source: The Boeing Co.

Figure 6

206 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000

 Controlled-flight-into-terrain and Approach-and-landing1
Hull-loss Accidents
Worldwide Large Commercial Jet Airplanes2
1990–20003
1.5
Per Million Departures
Hull-loss Accidents

1.0

0.5

0.0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 20003
Year

Approach and Landing (ALA) Accident Rate Three-year Moving Average (ALA Accident Rate)
Controlled Flight Into Terrain (CFIT) Accident Rate Three-year Moving Average (CFIT Accident Rate)

Notes:
1. Categorization of accidents for 2000 is preliminary.
2. Heavier than 60,000 pounds (27,216 kilograms) maximum gross weight; excluding the Commonwealth of Independent States.
3. Accidents through Oct. 15, 2000.

Source: The Boeing Co.

Figure 7

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000 207

 Publications Received at FSF
Jerry Lederer Aviation Safety Library

FAA Publishes Specifications for

Portable Boarding Devices

The publication includes recommendations for the design of equipment

used to help airline passengers whose mobility is impaired.

Advisory Circulars Report GAO/RCED-00-111. 101 pp. Figures, tables, appendix.

Available through GAO.***
Guide Specification for Devices Used to Board Airline
The U.S. General Accounting Office (GAO) reviewed the
Passengers With Mobility Impairments. U.S. Federal
implementation of the U.S. Federal Aviation Administration
Aviation Administration (FAA) Advisory Circular (AC) 150/
Safer Skies initiative to reduce the fatal aviation accident rate
5220-21B. March 17, 2000. 9 pp. Available through GPO*
by 2007. Safer Skies, developed in 1998 to unify government
and DOT.**
and industry efforts, addresses six major safety problems in
commercial aviation: loss of control, approach-and-landing
This AC contains performance standards, specifications and
accidents, controlled flight into terrain, runway incursions,
recommendations for the design, construction and testing of
weather and uncontained engine failures.
portable devices used to help passengers with mobility
impairments to board airliners. Design criteria in the guide
The GAO report recommended that the Safer Skies program
discuss two classes of devices: those that are self-propelled
develop quantifiable performance measures to evaluate the
and those that are manually transported or towed. The
effectiveness of the accident-reduction efforts and that the
document does not address passenger-loading bridges. The
program study growth and technical changes within the
portion of the AC that pertains to lifts was developed in
industry to anticipate change-related problems. The report
coordination with the Canadian General Standards Board
also said that data from past accidents and incidents alone
CAN/CGSB-189.1-95, Lifting Systems for Aircraft Boarding
may not be an adequate predictor of the future. [Adapted
of Passengers With Mobility Impairments. Equipment
from report.]
specifications meet boarding-device requirements contained
in U.S. Department of Transportation regulations Part 27 and
National Airspace System: Persistent Problems in FAA’s New
U.S. Federal Aviation Regulations Part 382. This AC cancels
Navigation System Highlight Need for Periodic Reevaluation.
AC 150/5220-21A, Guide Specification for Lifts Used to Board
Report to the Chairman, Subcommittee on Transportation,
Airline Passengers With Mobility Impairments, dated July 26,
Committee on Appropriations, U.S. Senate. June 2000. Report
1996. [Adapted from AC.]
GAO/RCED/AIMD-00-130. 38 pp. Figures, tables,
appendixes. Available through GAO.***
Reports Plans are underway for the U.S. Federal Aviation Administration
(FAA) to transition from an aging, ground-based navigation
Aviation Safety: Safer Skies Initiative Has Taken Initial Steps system to the satellite-based Global Positioning System (GPS).
to Reduce Accident Rates by 2007. Report to the FAA officials believe that, even with planned improvements,
Subcommittee on Aviation, Committee on Transportation and GPS will not satisfy all requirements for safe aircraft operations.
Infrastructure, U.S. House of Representatives. June 2000. The report by the U.S. General Accounting Office discusses

208 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000

 concerns about costs of improving the GPS program, scheduling, Priorities, Organization, and Sources of Information
performance goals and technologies. [Adapted from report.] Accessed by Pilots in Various Phases of Flight. Schvaneveldt,
Roger; Beringer, Dennis B.; Lamonica, John; Tucker, Richard;
Refractive Surgery in Aircrew Members Who Fly for Nance, Christopher. U.S. Federal Aviation Administration
Scheduled and Nonscheduled Civilian Airlines. Nakagawara, (FAA) Office of Aviation Medicine. Report DOT/FAA/AM-
Van B.; Wood, Kathryn J.; Montgomery, Ronald W. U.S. 00/26. 31 pp. Figures, tables, appendixes. Available through
Federal Aviation Administration (FAA) Office of Aviation NTIS.****
Medicine. Report DOT/FAA/AM-00/19. May 2000. 8 pp.
Figures, tables. Available through NTIS.**** Keywords
1. Flight Information
Keywords 2. Pathfinder Analysis
1. Aviation 3. Clustering of Flight Information
2. Vision 4. Priorities of Flight Information
3. Refractive Surgery
4. Aeromedical Certification The authors discussed two projects involving a study of
5. Occupational Health information sources used by pilots during flight, with the
objective of specifying what information pilots need, during
The authors reviewed aeromedical certification and medical which phase of flight the information is needed and how
records of U.S. civil aircrew members who had undergone pilots organize the information. In the first project, 27 pilots
refractive surgery. Of 114 airline pilots and flight engineers were asked to rate 29 information elements during seven
who had undergone refractive surgery, 97 had incisional phases of flight. The results revealed the pilots’ shifting
procedures, 15 had laser procedures and two had complex priorities during flight. In the second project, 34 pilots
surgical procedures. Three airmen experienced serious participated in collecting data for 231 pairs of information
complications, including problems with depth perception, a elements. The authors discussed the data’s potential for use
perforated cornea and a condition that resulted in a cataract. in several areas, including instrumentation layout,
Nevertheless, the report said that, although some serious integration of cockpit information systems and development
complications have resulted, the complications have not of curriculum for flight instructors. [Adapted from abstract
affected the ability of most pilots or flight engineers to receive and report.]♦
medical certificates. [Adapted from abstract and report.]

Prevalence of Drugs and Alcohol in Fatal Civil Aviation Sources

Accidents Between 1994 and 1998. Canfield, Dennis V.;
Hordinsky, Jerry; Millett, David P.; Endecott, Boyd; Smith, *Superintendent of Documents
Dudley. U.S. Federal Aviation Administration (FAA) Office U.S. Government Printing Office (GPO)
of Aviation Medicine. Report DOT/FAA/AM-00/21. June Washington, DC 20402 U.S.
2000. 6 pp. Tables. Available through NTIS.**** Internet: www.access.gpo.gov

Keywords **U.S. Department of Transportation (DOT)

1. Forensic Science Subsequent Business Office
2. Toxicology Annmore East Business Center
3. Drugs 3341 Q 75th Ave.
4. Prevalence Landover, MD 20785 U.S.
5. Aviation Internet: www.faa.gov

As required by law, the FAA Civil Aeromedical Institute ***U.S. General Accounting Office (GAO)
(CAMI) monitors the use of alcohol and drugs in aviation. P.O. Box 37050
CAMI collects toxicology data by analyzing specimens from Washington, DC 20013 U.S.
pilots who died in aviation accidents and stores the data in Internet: www.gao.gov
computer databases for future use. This report uses the data to
compare the prevalence of drugs and alcohol in fatal accidents ****National Technical Information Service (NTIS)
in five-year and 10-year periods. Tables show alcohol, drug 5285 Port Royal Road
and medication use by pilot class, drug class and substance Springfield, VA 22161 U.S.
schedule. Internet: www.ntis.org

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000 209

 Updated U.S. Federal Aviation Administration (FAA)
Regulations and Reference Materials
Advisory Circulars
AC No. Date Title
147-2FF Sept. 20, 2000 FAA Certificated Aviation Maintenance Technician Schools Directory. [Cancels AC 147-2EE,
Directory of FAA Certificated Aviation Maintenance Technician Schools, dated March 12, 1999.]
120-71 Aug. 10, 2000 Standard Operating Procedures for Flight Deck Crewmembers.
61-89E Aug. 4, 2000 Pilot Certificates: Aircraft Type Ratings. [Cancels AC 61-89D, Pilot Certificates: Aircraft Type
Ratings, dated Feb. 21,1991.]
25-24 Aug. 2, 2000 Sustained Engine Imbalance.
121-29B July 24, 2000 Carry-on Baggage. [Cancels AC 121-24A, Carry-on Baggage, dated June 25, 1998.]
00-61 July 24, 2000 Event Planning Guide.
21-2J June 27, 2000 Export Airworthiness Approval Procedures. [Cancels AC 21-2H, Export Airworthiness Approval
Procedures, dated Sept. 6, 1995.]
65-30 June 27, 2000 Overview of the Aviation Maintenance Profession.
23-18 June 14, 2000 Installation of Terrain Awareness and Warning System (TAWS) Approved for Part 23 Airplanes.
60-25D June 9, 2000 Reference Materials and Subject Matter Knowledge Codes for Airman Knowledge Testing. (Can-
cels AC 60-25C, Reference Materials and Subject Matter Knowledge Codes for Airman Knowl-
edge Testing, dated Aug. 23, 1999.)
60-26B June 8, 2000 Announcement of Availability: Flight Standards Service Airman Training and Testing
Information. (Cancels AC 60-26A, Announcement of Availability: Flight Standards Service Air-
man Training and Testing Information, dated Feb. 26, 1997, and AC 60-27, Announcement of
Availability: Changes to Practical Test Standards, dated Nov. 18, 1996.)
20-143 June 6, 2000 Installation, Inspection, and Maintenance of Controls for General Aviation Reciprocating
Aircraft Engines.
25-23 May 22, 2000 Airworthiness Criteria for the Installation Approval of a Terrain Awareness and Warning
System (TAWS) for Part 25 Airplanes.
150/5345-26C April 17, 2000 FAA Specification for L-823, Plug and Receptacle, Cable Connectors. (Cancels AC 150/5345-
26B, Specification for L-823 Plug and Receptacle, Cable Connectors, dated Jan. 28, 1981.)
25-22 March 14, 2000 Certification of Transport Airplane Mechanical Systems. (Cancels AC 25-14, High Lift and Drag
Devices, dated May 4, 1988.)
21-29B March 13, 2000 Detecting and Reporting Suspected Unapproved Parts.

International Reference Updates

Airclaims
Supplement No. Date
122 Sept. 18, 2000 Updates Major Loss Record.
121 Sept. 21, 2000 Updates World Aircraft Accident Summary.
120 June 8, 2000 Updates Major Loss Record.
119 June 2000 Updates World Aircraft Accident Summary.

210 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000

 Accident/Incident Briefs

Uncommanded Engine Shutdowns

Prompt Emergency Landing
Two of the DC-8’s engines flamed out as the airplane was being flown
over the Atlantic Ocean after departure from an airport in the Caribbean.

FSF Editorial Staff

The following information provides an awareness of problems descent to FL 350, the no. 4 engine had an uncommanded
through which such occurrences may be prevented in the future. shutdown. The flight crew performed the second engine-failure
Accident/incident briefs are based on preliminary information “phase one” items, declared an emergency and received vectors
from government agencies, aviation organizations, press to fly the airplane to the departure airport. As the airplane
information and other sources. This information may not be descended through FL 220, both engines were restarted. They
entirely accurate. operated normally for the remainder of the flight, and the
landing was normal.

Landing Gear Collapses

During Takeoff Roll
Boeing 747. Substantial damage. No injuries.

The airplane was beginning a takeoff roll on a runway at an

airport in Italy when the right-main landing gear collapsed.
The airplane veered to the right and came to a stop with one
Engines Restarted During engine touching the runway.
Return to Departure Airport
An airline official said that the collapse probably was caused
by torsional failure “at the upper end of one of the landing-
Douglas DC-8. No damage. No injuries.
gear cylinders.” He said that the torsional failure might have
Visual meteorological conditions prevailed and an instrument been a result of corrosion or a stone chip.
flight rules flight plan had been filed for the pre-dawn flight
from an airport in the Caribbean. The airplane was in cruise Pitch Oscillations Prompt Aircraft’s
flight at Flight Level (FL) 390 over the Atlantic Ocean, about Removal From Service
170 nautical miles (315 kilometers) from the departure airport,
with climb thrust set to about 95 percent N1 (low-pressure Boeing 747. No damage. No injuries.
compressor speed) when the flight crew disengaged the ignition
override. About two minutes later, the no. 3 engine had an The airplane was in cruise flight at Flight Level 370 during an
uncommanded shutdown. early-morning flight from the United States to England when
the flight crew observed that vertical-speed indications on each
The captain said that he executed the “phase one” items and pilot’s primary flight display were fluctuating about plus or
re-engaged the ignition override to “all engines.” During minus 200 feet per minute. (Actual altitude deviation during

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000 211

 the fluctuations was less than 100 feet.) Because the pilots of correction signal from the autopilot. The reduced rate at which
other aircraft in the area had reported clear air turbulence, the the aircraft returned to the correct pitch attitude would have
flight crew initially regarded the altitude fluctuations as initiated a series of responses that resulted in pitch oscillations,
weather-related. the report said.

Later, the captain observed that “the motion at the rear of the The report said that analysis of the FDR data was the only
flight deck felt different [than] normal,” the report said. The means of identifying the defect before it was experienced by a
crew disengaged the autopilot and engaged a different flight crew. The manufacturer of the PCUs had addressed the
autopilot, but the vertical speed fluctuations continued, now bearing corrosion by changing to stainless steel bearings with
at about plus or minus 300 feet per minute. The pitch better drainage, and issued a product improvement document
oscillations persisted at irregular intervals during the crew’s to inform aircraft operators of the change. The report said,
use of a third autopilot and during a period of hand-flying. however, that because PCUs are dismantled infrequently,
operators have few opportunities to assess their condition. The
“The [captain] reported that, during manual handling, the aircraft manufacturer issued a service letter Aug. 31, 2000,
control column felt very stiff to move in the required direction recommending that operators install the stainless steel bearings
and, after the exertion of considerable pressure, would become at their next opportunity.
free and the aircraft would respond immediately, then requiring
opposite control input,” the report said.

Because the captain was concerned about the possible

effects of the pitch-control problem during the landing flare,
he declared “pan, pan” (urgency) status with air traffic
control and was given a priority approach. As a precaution,
passengers were told to adopt the “brace” position for
landing.

The first officer assisted with flight control pitch inputs during
the landing, and the touchdown was described as “smooth and
accurate.” Shortly after the airplane was taxied clear of the
runway, a flight attendant reported smoke and a burning odor Bird Strike Damages
in the cabin. An external inspection revealed no abnormal
indications, but as the airplane continued to taxi, smoke was
Wing Leading Edge
reported coming from the no. 4 engine. Subsequent inspection
revealed that the burning odor in the cabin was tire smoke that De Havilland DHC-6-300. Substantial damage. No injuries.
resulted from the full autobrake landing and that smoke from
the no. 4 engine came from the oil breather and was not an The airplane was being flown on the downwind portion of the
unusual event. landing approach to an airport in the United States. Night visual
meteorological conditions prevailed.
Information from the flight data recorders (FDRs) confirmed
that the aircraft had experienced periods of pitch oscillations, The airplane was about 1,800 feet above sea level when the
but an examination of the aircraft’s pitch control and trim flight crew observed several birds, then felt an impact. After
system revealed no defects. The problem did not recur during landing, they observed damage to the left wing leading edge
a test flight, but a lack of synchronization of elevator positions and found small portions of a bird on the leading edge.
was observed and was repaired.
Examination of the wing revealed that the leading edge was
The airplane was returned to service and was operated with dented, the upper wing surface was wrinkled and two nose
no apparent problems for five days. Then, an analysis of ribs had been broken.
recorded data confirmed that pitch oscillations similar to those
of the incident flight were continuing during autopilot Crew Fails in Efforts to
operations. The airplane was withdrawn from service for Extend Landing Gear
further inspection, which determined that ball bearings in one
inboard-elevator power-control unit (PCU) were corroded. The Lockheed L382-G. Substantial damage. No injuries.
corrosion was attributed to condensation that penetrated the
PCU dust seals and washed lubricant from the top bearing When the flight crew moved the landing gear switch to the
onto the lower bearing, leading to corrosion of both bearings. down position in preparation for landing at an airport in
The report said that the corrosion probably resulted in reduced Australia, the left-main landing-gear position indicator
movement of the entire pitch-control mechanism for each indicated that the landing-gear position was unsafe. The crew

212 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000

 recycled the landing-gear switch, but the left-main landing- Leaking Hydraulic Fluid Found
gear position indicator continued to indicate that the landing- After Airplane Rolls off Runway
gear position was unsafe. The flight crew conducted checks
that confirmed that the left-main landing gear had failed to Learjet 60. Substantial damage. No injuries.
extend.
Night visual meteorological conditions prevailed for the second
The crew used emergency gear-extension procedures and segment of a flight that followed maintenance on the airplane.
attempted to lower the landing gear hydraulically by overriding Two miles from the destination airport in the United States,
the landing-gear-selector valve, but those attempts were the crew told air traffic control that the airplane had a hydraulic
unsuccessful. problem.

“The crew then attempted to extend the landing gear manually, They landed the airplane at the destination airport. After
but the emergency engaging handle could not be moved,” the touchdown, the airplane rolled off the departure end of the
report said. “The manual-selection system appeared jammed, runway and struck a localizer antenna array.
and consequently, the selection could not be made. They then
attempted to lower the landing gear by disconnecting the Examination of the airplane revealed that the actuator-extend
universal joints on the vertical-torque shafts of the left-main hose-line connector for the left-main landing gear and the right-
landing gear. However, the castellated nuts on the rear-wheel main landing gear were not torqued to specifications and that
vertical-torque shaft universal joint could not be unwound the left-main landing-gear actuator-extend hose-line connector
without the use of spanners, and after about 30 [minutes], only was leaking hydraulic fluid.
two of the four bolts had been undone.”

By that time, the airplane’s fuel supply was low, and the captain
Controller’s Action Stops Crew
decided that there was insufficient time to remove the From Landing at Wrong Airport
remaining bolts before a landing would be required. The crew
then retracted the nose landing gear and the right-main landing Cessna Citation 550. No damage. No injuries.
gear and landed the airplane.
The flight crew was flying a very-high-frequency
omnidirectional radio (VOR) approach to an airport in Northern
Ireland in early afternoon and had received clearance to land
Corporate on Runway 7. An air traffic controller observed that the air
Business traffic monitor showed that the airplane was south of the typical
approach track at a lower altitude than typical.

“The controller asked if the crew had the approach lights in

sight,” the report said. “[T]he crew responded that they had
the runway in sight but no approach lights. The controller then
advised the crew that there was a similar airfield three [nautical]
miles [5.6 meters] to the west … and to advise her when they
could see the approach lights.”

Loss of Power Prompts Fatal Forced The crew said that they could see no lights but that they were on
Landing on Basketball Court short final approach. The controller then instructed the crew to go
around and to climb to 3,000 feet. After the climb, the crew told
Piper PA-32-260. Airplane destroyed. Five fatalities. the controller that they could see approach lights on their left, and
they received clearance for a visual approach to Runway 7.
Visual meteorological conditions prevailed for the mid-
morning departure from an airport in Ecuador. Witnesses said On several previous occasions, pilots had mistaken the other,
that, during the initial climb, they heard engine power fluctuate private airport (with Runway 8/26 and Runway 3/21) for the
and saw the airplane gliding with its propeller stopped as the larger airport.
pilot maneuvered to avoid buildings in a downtown business
district. “Because of this, the ATIS [automatic terminal information
system] … was advising pilots of the existence of [the private
The airplane struck a telephone post before impacting an airport] and that Runway 7 … would have its approach lights
outdoor basketball court. A postaccident fire destroyed the illuminated,” the report said. “On this occasion, close
airplane. The accident killed the pilot and all four monitoring and effective action by the controller stopped the
passengers. crew … from landing at [the wrong airport].”

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000 213

 An investigation revealed that the engine was producing
power at the time of the impact and that there were no pre-
existing defects that could have affected the airplane’s
operation. The airplane flight manual said that a stall during
a steep turn causes both the airplane’s nose and a wing to
drop. The maneuver described by witnesses was consistent
with a stall during a steep left turn. Turbulence and wind
gusts to 27 knots were reported at the time of the accident,
when the temperature was 33 degrees Celsius (91 degrees
Fahrenheit); the accident report said that those conditions
would have reduced the airplane’s performance and made
Parked Aircraft Struck By Airplane stall recovery more difficult.
Being Prepared for Instructional Flight
Airplane Veers off Runway After
Piper PA-34-200T. Minor damage. No injuries. Landing; Brake Failure Blamed
A student pilot applied the parking brakes before starting the Champion 7GCAA. Substantial damage. No injuries.
engines for a night training flight from an airport in England.
An instructor occupied the other front seat; another student The airplane was flown on a morning flight in visual
pilot sat in back. meteorological conditions to an airport in the United States.
The pilot said that the landing at the destination airport was
When the engines were started, both the student pilot and the normal until he applied the brakes during the rollout, and the
instructor applied the foot brakes, and the instructor looked left brake did not engage.
out the window to ensure that the airplane did not move. Then
the instructor transferred his attention inside the cockpit as The airplane veered off the runway to the right. The pilot took
the student pilot conducted more pretaxi checks. When the his foot off the right brake pedal in an attempt to keep the
instructor realized that the airplane was yawing to the left, he airplane traveling straight ahead, then applied the right brake
closed both throttles. again to steer around a hill in the airplane’s path. The pilot
said that he had not observed a ditch on the left side of the
The instructor and the students observed that the airplane airplane and that, when the airplane’s left wheel entered the
had collided with a parked Piper PA-28, with the left ditch, the left wing was bent.
propeller damaging the PA-28 rudder and tail cone and the
right propeller damaging the PA-28 right aileron. The left Faulty Brake Valve Blamed for
engine on the PA-34-200T had stopped, and the pilots shut Airplane’s Departure From Runway
down the right engine. The instructor said that the parking
brake apparently had not been applied fully. Because of Beech 58. Minor damage. No injuries.
darkness, he had no sensation and no visual cues that the
airplane was moving until he observed the abrupt yawing The airplane was being taxied to the departure end of the
movement. runway in preparation for takeoff. As the pilot applied the
brakes to aid in a turn to align the airplane with the runway
Airplane Strikes Terrain centerline, the airplane rolled toward the edge of the tarmac
During Photo Flight and onto the grass.

Cessna 172R. Airplane destroyed. Four fatalities. The pilot said that, when he applied the right brake, no braking
occurred, and that he shut down both engines in an attempt to
Visual meteorological conditions prevailed for the afternoon stop the airplane’s movement. The left propeller was still
flight from an airport in Australia. Photographs taken from turning as the left-main wheel left the tarmac and sank into
the airplane during the flight indicated that the pilot had the ground, and the left propeller struck the edge of the tarmac.
conducted a number of steep turns, and witnesses in several
locations saw the airplane turning. Tests by maintenance personnel revealed that, although the
brakes worked properly when the left pedal and right pedal
Radar information showed that the airplane was flown in a were pressed simultaneously, there was no braking action on
series of left turns between 550 feet and 950 feet above the right-main landing wheel when only the right-brake pedal
ground level. Witnesses said that, during the final turn, the was applied. They said that the braking characteristics indicated
airplane’s angle of bank steepened before the airplane that the right-brake shuttle valve was defective, although no
pitched nose-down. The airplane was destroyed when it wear or damage was found. The right-brake shuttle valve was
struck the ground. replaced, and full braking was restored.

214 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000

 procedure was to transfer fuel from the auxiliary tank to the
main tank when there was less than 100 liters (26 gallons) of
fuel in the main tank, but the pilot said that the transfer
sometimes was delayed until the “fuel” warning light
illuminated, indicating that 50 liters (13 gallons) of fuel
remained in the main tank. (Main tank fuel capacity is 455
liters [120 gallons].)

About 25 minutes after departure, the helicopter’s engine failed

because of fuel starvation. The pilot prepared to land the helicopter
in a field and conducted an autorotation. When he applied
Helicopter Strikes Terrain additional collective control to avoid a stone wall, the main-rotor
During Ferry Flight speed decreased. The helicopter landed hard and bounced, and
two main-rotor blades struck the three vertical stabilizer surfaces.
Bell 47J-2A. Helicopter destroyed. Two fatalities.
The pilot said that he had not transferred fuel from the auxiliary
Visual meteorological conditions prevailed for the mid- tank, which was full at the time of the accident.
morning flight from an airport in Australia. The flight was
one of a series of ferry flights to be conducted over three days. Ground Worker Electrocuted During
The pilots planned at least four refueling stops, and the External-load Operation
helicopter carried seven 20-liter (5.3-gallon) containers of fuel.
Bell UH-1B. No damage. One fatality.
When the helicopter did not arrive at the destination, a search
was begun. The burned wreckage was found in flat, open land The helicopter was being flown in visual meteorological
about 150 nautical miles (278 kilometers) from the previous conditions to perform external-load operations in the United States.
refueling stop.
The pilots hovered the helicopter near high-voltage wires with
The postimpact fire, fed by fuel from the fuel containers, a 110-foot (34-meter) cable attached to the helicopter and to a
destroyed the cockpit and the forward section of the tail boom. load of steel beams on the ground.
The engine also had received significant impact damage and
external fire damage, but the internal components were capable The company’s chief pilot occupied the right seat to provide
of normal operation. guidance to the pilot flying, who was flying the helicopter
from the left seat for the first time. Two members of a ground
Examination of the wreckage revealed no pre-existing defects crew secured the lifting cable to the load of beams. Before the
that might have contributed to the accident. The accident report helicopter began to lift the load, a “slight amount of slack”
said that main-rotor speed probably was too low for a controlled was in the lifting cable, which touched an electrical wire about
descent, that one fuel tank contained a “minute quantity” of 50 feet (15 meters) above the ground. One of the ground
fuel and that the other fuel tank was empty. The rest of the crewmembers, who was holding the helicopter long-line cable
fuel system was damaged extensively by fire. Investigators and waiting to attach it to the load straps, was electrocuted.
could not determine whether there had been a fuel leak during
the flight or how much fuel had been in the tanks after the The left-seat pilot — who had 15,000 flight hours in helicopters
previous refueling. — said that he had begun work at the construction site two days
before the accident flight, flying a McDonnell-Douglas 500. The
Fuel Starvation Prompts Landing; day before the accident, he was the second pilot (right-seat pilot)
Auxiliary Tank Full of the accident helicopter for about one hour during external-
load operations. On the day of the accident, he flew the accident
Aerospatiale SA-341G. Minor damage. No injuries. helicopter from the left seat for about one hour and conducted
about nine lifts before the accident. He said that he had not known
The helicopter was flown from a private landing site in England that the electrical wires at the construction site were energized.
with about 80 liters (21 gallons) of fuel in the main tank. The The chief pilot said that he had known that the wires were
90-liter (24-gallon) auxiliary tank was full. The standard energized.♦

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000 215

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