File 1 4 0 2 3

AIRCRAFT ACCIDENT REPORT

4 Adopted,: December 31, 1968

UNITED AIR LINES, INC.

BOEING 727 QC, N7425U

CHICAGO OHARE INTERNATIONAL

AIRPORT, ILLINOIS
MARCH 21, 1968

NATIONAL TRANSPORTATION SAFETY BOARD

DEPARTMENT OF TRANSPORTATION
WASHINGTON D.C. 20591

~~~ ~ ~~~
-
For sale by Clearinghouse for Federal Selentlfle and Teehnieal Information, 0,s.Department of
Commerce. Springtield, Va. 22151. Annual subscription price $12.00 Domestic; $15.00 Foreign:
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.?
 UNITED AIR LINES. I N C
BOEING 727 QC. N7425U
.
CIDCAGO O'HARE INTERNATIONAL
AIRPORT. ILLINOIS
MARCH 21. 1968

TABLE OF CONTENTS

Synopsis .......................... 1
ProbableCause . . . . . . . . . . . . . . . . . . . . .
. . . . ..... .. .. .. .. ..... .. .. .. .. ..... . . . 23
. 1
1.1
1.2
. Investigation
History of t h e F l i g h t
. . . . . . . . . . . . . . . . . . 39
I n j u r i e s t o Persons
1.3
1.4 . . . ..... .. .. .. .. ....... .. .. .. .. ....... . . . 109
Dsmage t o Aircraft
Other I)smage
1.5 Crew Information. . ....... .. .. .. .. ....... .. .. .. ...... . . 10
A i r c r a f t Information
1.6 10
1.7 Meteorological Information
. . . . .
. .
. .
. .. .
. .. .
. .
. .
. .
. .
. .. .
. .
. .
. 11
1.8 Aids t o Navigation 12
1.9 Comnications . . . . . . . . . ... .. .. .. ....... .. .. .. . . 12
Aerodrome and Ground F a c i l i t i e s
1.10 12
1.11 .
F l i g h t Recorders
Wreckage
. . . . . .
........................ . . . . . . . . . . . . . 13
14
1.12
1.13 Fire . . . . . . ........................ .. .. .. .. .. .. .. .. 18
1.14 Survival Aspects 19
1.15 Tests and Research ...................
1.16
2 . Other Information . . . ....................... .. .. .. .. . 19
Analysis and Conclusions
21

2.1 Analysis ........................ 21

21
2.2 Conclusions . . . ....... .. .. .. ....... .. .. .. .. ....... . . . 36
(a) Findings
(b) Probable Cause . . . . . . . .. .. .. .. .. .. .. .. .. 3836
3 . Recornendations and Corrective Action
Appendices
39
 . File No. 1-0023
NATIONAL TRANSFORTATION SAFETY BOARD
DEP- OF TRANSPORTATION
AIRCRAFT ACCIDENT REPORT

Adopted: December 31, 1968

UNITED AIR LINES, INC.

BOEING 72'7 QC N7425U
CHICXGO O'HARE INTERNATIONAL
AIRPORT, ILLINOIS
MARCH 21, 1968

sYNoPsIs

A United Air Lines, kc., being 727 QC, w425U, operating as

Cargo Flight 9963, crashed on~~-takeoff from O'Hare International

Airport, Chicago, Illinois, on March 21, 1968, at approximately

0353 c.s.t. The aircraft .~~~

was
.
destroyed by impact and ground fire.

The three crewmembers, who were the only occupants of the aircraft,

evacuated through the cockpit windows. The captain sustained

injuries requiring hospitalization, while the first and second

officers received only minor injuries.

Shortly after conmencement of the takeoff roll on Runway 9R,

the intermittent takeoff warning horn sounded, indicating an

improper setting for takeoff of any one or a combination of the

following items: flaps, speed brakes, stabilizer trim, or auxiliary

I power unit exhaust door. As the takeoff progressed, the crew

'i attempted unsuccessfilly to locate the condition which initiated

the warning horn. The horn finally ceased just prior to reaching

rotate speed.

Almost immediately after the captain rotated the aircraft,

the stick shaker came on, indicating the aircraft was approaching
 - 2 -

a stall. The captain lowered t h e nose s l i g h t l y and added t h r u s t ,

but t h e a i r c r a f t f a i l e d t o climb or a c c e l e r a t e . The captain there-

f o r e elected t o discontinue t h e takeoff and allowed t h e a i r c r a f t

t o s e t t l e back t o t h e macadam shoulder off t h e r i g h t s i d e of t h e

runway. The a i r c r a f t then proceeded across t h e ground a t an

angle of approximately 4" with t h e runway u n t i l it came t o r e s t

a t a point 1,100 f e e t beyond t h e e a s t end of Runway 9R and

300 f e e t t o t h e r i g h t of i t s c e n t e r l i n e . During t h e l a t t e r part

of t h e r o l l o u t , t h e a i r c r a f t struck a drainage ditch, causing

damage which r e s u l t e d i n t h e f u e l fed ground f i r e which consumed

much of t h e a i r c r a f t .

Evidence i n t h e wreckage established that t h e f l a p s were 2 _

s e t a t t h e 2' position. This s e t t i n g i s outside t h e takeoff

range of 5' t o 25' and t h u s c o n s t i t u t e s a condition which would

a c t i v a t e t h e warning horn.

The Safety Board determines that t h e probable cause of t h i s

accident was t h e f a i l u r e of t h e crew t o abort t h e takeoff a f t e r

being warned of an unsafe takeoff condition.

 ~~~~~ ~ ~

- 3 -
1. INVESTIGATION
1.1 History of t h e F l i g h t

United A i r Lines, Inc., (UAL) Boeing 727 QC, L/ N@25U, Cargo

Flight 9963, crashed on takeoff, Ikrch 21, 1968. F l i g h t 9963 was

a r e g u l a r l y scheduled cargo f l i g h t o r i g i n a t i n g a t Newark Airport,

New Jersey, and destined f o r San Francisco, California, w i t h an

en route stop a t O'IEare I n t e r n a t i o n a l Airport i n Chicago, I l l i n o i s .

A crew change was effected a t O'Hare, and t h e crew involved i n t h e

accident took charge of t h e a i r c r a f t .

The f l i g h t planning was c a r r i e d out i n a r o u t i n e manner.

Because t h e planned gross weight of t h e a i r c r a f t was near t h e

maximum allowable f o r takeoff, and i n view of t h e nearing- freezing

temperatures, t h e first o f f i c e r computed t h e maximum allowable

takeoff weights f o r several runways, including 9L and 9R, f o r f l a p

s e t t i n g s of 5' and l5', with and without engine a n t i - i c e . Although

these computations indicated that t h e a i r c r a f t weight was within

limits f o r a 15' f l a p takeoff, t h e captain elected t o make a 5'

f l a p takeoff since t h e weight was only s l i g h t l y under t h e 5" f l a p

gross weight and, i n h i s view, t h e a i r c r a f t performed b e t t e r a t

such weights with t h e lower f l a p s e t t i n g .

F l i g h t 9963 departed from t h e blocks a t t h e UAL cargo a r e a

a t approximately 0339 c. s.t., z/ and was cleared t o t a x i t o

Runway 9R. The first o f f i c e r s t a t e d that, a s they began t o t a x i out,

-1/ Quick change, cargo/passenger

-2/ A l l times herein a r e c e n t r a l standard based on t h e 24-hour clock.
 - 4 -
he lowered t h e f l a p s t o 5". He f u r t h e r s t a t e d t h a t , s h o r t l y there-

a f t e r , he checked the controls by pushing t h e yoke full forward and

r o t a t i n g t h e wheel t o t h e extreme r i g h t . He was a b l e t o d e t e c t out-

board a i l e r o n movement because t h e a i r c r a f t was s t i l l i n t h e well-

l i g h t e d cargo a r e a . He then r o t a t e d t h e c o n t r o l wheel t o t h e full

l e f t position, and t h e captain looked out h i s l e f t window and signaled

t h a t he a l s o observed a i l e r o n movement. -
31
While performing t h e pre-takeoff checklist during t h e t a x i - o u t ,

t h e crew noted that t h e No. 1 engine a n t i - i c e l i g h t did not i l l u m i n a t e

w i t h t h e a n t i - i c e s e l e c t o r switch i n t h e wing position, i n d i c a t i n g

t h a t t h e No. 1 engine a n t i - i c e valve was stuck open. When attempts

t o close t h e valve were i n i t i a l l y unsuccessful, t h e captain decided

t o r e t u r n t o t h e ramp and procured a t a x i clearance for t h a t purpose.

A s t h e a i r c r a f t was being turned around, t h e a n t i - i c e valve returned

t o i t s normal or closed position. The crew then t e s t e d t h e valve,

which operated normally, and obtained clearance t o resume t h e i r t a x i

toward t h e runway.

The pre-takeoff checklist was resumed where t h e crew had l e f t

o f f , s t a r t i n g with t h e item " altimeters," and t h e remainder of t h e

t a x i t o t h e runway was routine. The captain asked f o r t h e final

items a s t h e a i r c r a f t t a x i e d onto t h e runway following r e c e i p t of

takeoff clearance a t 0351. The takeoff was commenced i n a r o l l i n g

manner, r a t h e r than from a full stop, with t h e c a p t a i n making t h e

The a i l e r o n movement observed by t h e p i l o t s a t t h i s point i s

only possible with t h e f l a p s a t 5" o r more. The outboard a i l e r o n s
~

a r e locked when t h e f l a p s a r e i n t h e 2 O position, but a r e f r e e

w i t h t h e f l a p s positioned at 5".
 - 5 -
takeoff and t h e f i r s t o f f i c e r holding forward pressure on t h e yoke.

The prescribed UAL procedure f o r a r o l l i n g takeoff i s t o advance t h e

41 and, when t h e a i r c r a f t i s
t h r o t t l e s t o approximately 1.4 EPR-

aligned on t h e runway and r o l l i n g , t o advance t h e t h r o t t l e s t o take-

off Em, which i n t h i s instance was a value of 1.98.

According t o t h e crew, t h e takeoff roll was progressing normally

u n t i l t h e i n t e r m i t t e n t takeoff warning horn was a c t i v a t e d . This horn

sounds when any of t h e following conditions e x i s t a s t h e No. 3

t h r o t t l e i s advanced t o 65 percent, or g r e a t e r , of takeoff t h r u s t

while t h e a i r c r a f t i s on t h e ground:

(1) Speed brake l e v e r i s not i n t h e 0' detent.

(2) Flap c o n t r o l l e v e r i s s e t o u t s i d e t h e takeoff f l a p

range of 5" t o 25'.

(3) S t a b i l i z e r t r i m s e t t i n g i s outside of t h e green band

limits (1 t o 9-112 u n i t s noseup).

(4) APU 2' exhaust door i s not closed.

The warning horn cannot be silenced except by c o r r e c t i n g t h e

condition causing i t s a c t i v a t i o n , o r , a s designed, when t h e nosegear

oleo s t r u t becomes extended.

The crew r e l a t e d t h a t t h e y immediately began t o check t h e

items t h a t would cause t h e horn t o be a c t i v a t e d . The captain

s t a t e d that he looked a t t h e speed brake handle, which i s on t h e

l e f t s i d e of t h e center pedestal. He s a i d he "grabbed t h e handle

and tugged on it t o be sure it was i n t h e detent and it was." He

-b/ Engine pressure r a t i o

-5/ Auxiliary power u n i t
 n I

, ~1

- 6 -
a l s o s t a t e d t h a t he "looked down a t t h e trim i n d i c e s on my s i d e and

saw it was i n t h e green band." He then asked t h e f i r s t o f f i c e r t o

check t h e f l a p s and received an answer that they were "0.k." He

a l s o remembered looking and seeing t h e green leading edge f l a p l i g h t

illuminated. He further s t a t e d that "the f l a p s i n d i c a t o r , t h a t

i s , t h e d i a l s , a r e r a t h e r d i f f i c u l t t o read a t night, and t h e y ' r e

j i g g l i n g around q u i t e a b i t . " I n addition, he noted that t h e l o c a t i o n

of t h e f l a p handle, as well as' t h e l i g h t i n g , makes it d i f f i c u l t t o

see.

The f i r s t o f f i c e r gave t h e following account of h i s a c t i o n s

immediately subsequent t o t h e a c t i v a t i o n of t h e warning horn:

"I c a l l e d ' f l a p s ' and f e l t t h e handle was i n a detent which i n t h e

dark was well back from t h e zero p o s i t i o n and I f e l t c e r t a i n t h a t it

was t h e 5' detent. I observed t h a t t h e needles of both f l a p i n d i c a t o r s

were a t t h e 3 o'clock o r 5' p o s i t i o n though I d i d not read t h e number

5' on t h e i n d i c a t o r , and t h e green leading edge device l i g h t was on.
I then c a l l e d 'speed brake' and rammed my f l a t palm against t h e

handle and could f e e l it f u l l forward and i n t h e d e t e n t . ...I

c a l l e d trim and used my hand f l a s h l i g h t t o d e f i n i t e l y v e r i f y that it

was i n t h e aft portion of t h e green band and was c e r t a i n t h e index

was stationary."

-6/ With
when
t h e f l a p l e v e r i n t h e 2' position, t h i s l i g h t will illuminate
two leading edge slats on each wing a r e extended. When t h e
flap l e v e r i s i n o r beyond t h e 5" position, t h e light will illuminate
when a l l leading edge f l a p s and s l a t s a r e r e t r a c t e d .
 - 7 -
The second o f f i c e r s t a t e d that h i s f i r s t r e a c t i o n t o t h e horn

was t o look a t t h e APU door l i g h t which was out. He a l s o r e c a l l e d

that t h e f l a p gauges "looked normal.''

The crew f u r t h e r r e l a t e d t h a t t h e warning horn ceased a t or

s h o r t l y p r i o r t o reaching V The captain, b e l i e v i n g that t h e

R'
condition which had caused t h e horn t o sound was no longer a problem,

rotated the a i r c r a f t . He s t a t e d that t h e a i r c r a f t r o t a t e d very

e a s i l y and with "abnormally light pressure." Iwaediately t h e r e a f t e r ,

t h e s t i c k shaker was a c t i v a t e d , i n d i c a t i n g that t h e a i r c r a f t was i n

a f l i g h t condition approaching a s t a l l . The captain reacted by

pushing t h e nose over and shoving t h e t h r o t t l e s forward. He s t a t e d

t h a t "at t h i s point I was faced with t h e decision of t r y i n g t o keep

t h e a i r p l a n e i n t h e air and c l e a r t h e freeway, which was not t o o far

o f f , o r put it back on t h e ground. Since it was not climbing o r

a c c e l e r a t i n g and t h e s t i c k shaker was s t i l l going, I e l e c t e d t o do

the latter." Accordingly, he closed t h e t h r o t t l e s as t h e a i r c r a f t

s e t t l e d back t o t h e macadam shoulder off t h e r i g h t s i d e of t h e

runway.

The captain r e c a l l e d that he used t h e wheel brakes and reverse

t h r u s t during t h e r o l l o u t , b u t could not remember i f he used speed

brakes. The crew r e l a t e d that, a f t e r proceeding over t h e ground i n

VR ( r o t a t e speed) and V ( c r i t i c a l engine f a i l u r e speed) were

both calculated t o be 1&knots f o r a 5" f l a p takeoff.
 -8-
a f a i r l y smooth manner, t h e a i r c r a f t struck a d i t c h and decelerated

rapidly. A s t h e a i r c r a f t skidded t o an abrupt stop, t h e crew was

tossed around v i o l e n t l y i n s i d e t h e cockpit.

The crew r e c a l l e d that t h e engine instruments were normal

i n s o f a r as they were observed during t h e takeoff. I n addition,

t h e f i r s t o f f i c e r s t a t e d t h a t , when t h e s t i c k shaker became a c t i v a t e d ,

he "glanced again a t t h e airspeed i n d i c a t o r and saw t h e needle pass

through t h e V2 bug by a t l e a s t 5" of t h e d i a l . " The V2 bug had

been s e t f o r 161 knots. The f i r s t o f f i c e r was a l s o of t h e view that,

during t h e period following r o t a t i o n , 15' a i r c r a f t noseup a t t i t u d e was

never exceeded.

The accident was viewed by a number of ground witnesses, most

of whom were located i n t h e v i c i n i t y of t h e cargo area, which i s

approximately 1,000 f e e t north of t h e e a s t end of Runway 9R. Three

witnesses described t h e takeoff r o l l , r o t a t i o n , and l i f t - o f f a s

being smooth and normal. The eight witnesses who saw t h e a i r c r a f t

i n f l i g h t estimated that i t s maximum a l t i t u d e above t h e runway was

from 10 t o 50 f e e t , and t h a t t h e a i r c r a f t was i n a normal noseup

a t t i t u d e , although it seemed t o maintain an a l t i t u d e r a t h e r than

climb out. Some of t h e witnesses noted t h a t t h e a i r c r a f t touched

down i n a noseup, l e f t wing low a t t i t u d e , and s e v e r a l of t h e s e

described hearing a power reduction during touchdown. Three witnesses

heard t h e engines go i n t o reverse a f t e r touchdown, while o t h e r s

1 described t h e f i r e and separation of t h e t a i l section.

-8/ Takeoff s a f e t y speed.

i
 - 9-
With respect t o t h e landing l i g h t s during t h e takeoff regime,

one witness "saw a light shining down ahead of t h e wheels," another

(an a i r c a r r i e r p i l o t ) noted that t h e " l e f t wing landing light appeared

t o be approximately one-half o r more r e t r a c t e d , " while a t h i r d s t a t e d

t h a t "the l i & t s appeared t o be shining a t a s l i g h t angle downward

on s t r a i g h t ahead." A fourth witness f e l t that t h e l i g h t s "were

on before r o t a t i o n but were out j u s t a f t e r rotation." -91

The a i r c r a f t came t o r e s t approxilmtely 1,100 f e e t beyond t h e

east end of Fiunway 9R and 300 f e e t south of t h e runway c e n t e r l i n e . -

101

The accident occurred a t nighttime at approximately 0353.

1.2 I n j u r i e s t o Persons

The t h r e e crewmembers, who were t h e only occupants of t h e

a i r c r a f t , were taken t o a l o c a l h o s p i t a l f o r f i r s t - a i d treatment.

The first and second o f f i c e r s were t r e a t e d f o r minor c u t s and

bruises and released. The captain was h o s p i t a l i z e d and t r e a t e d

f o r a back injury.

1.3 Damage t o A i r c r a f t
The a i r c r a f t was destroyed by impact with t h e drainage d i t c h

and by t h e ensuing ground f i r e .

9/ The outboard landing l i g h t s a r e mounted on t h e outboard kreuger

f l a p s . Thus, with a 5" o r higher f l a p s e t t i n g t h e s e l i g h t s a r e
directed forward, whereas with a 2' f l a p s e t t i n g they a r e d i r e c t e d
downward.
The geographic coordinates f o r O'Hare F i e l d a r e 41' 59' N and
87" 54' W, and t h e f i e l d elevation i s 667 f e e t m.s.1.
 - 10 -
i: 1.4 Other -ge
'!

There were scrape marks on t h e runway and impressions on t h e

adjacent macadam shoulder, as w e l l as deep ruts i n t h e muddy ground

t o t h e south of Runway 9R. One runway light was damaged when over-

run by t h e r i g h t main landing gear t i r e .

1.5 Crew Information

An examination of company and Federal Aviation Administration

(FAA) records of t h e f l i g h t personnel aboard F l i g h t 9963 revealed

that all crewmembers were properly q u a l i f i e d and c e r t i f i c a t e d f o r

t h e flight involved. Detailed information i n t h i s regard i s s e t

f o r t h i n Appendix A.

1.6 A i r c r a f t Information

An examination of p e r t i n e n t a i r c r a r t records i n d i c a t e d that t h e

a i r c r a f t met airworthiness requirements and a check o f maintenance

l o g sheets f o r t h e period subsequent t o January 1, 1968, indicated

that a l l discrepancies l i s t e d thereon had received appropriate

attention. Records a l s o disclosed that maintenance checks, s e r v i c e

checks, terminating p r e - f l i g h t checks, and en route s e r v i c e checks

were performed as required and t h e r e l a t e d forms executed i n t h e

proper manner. &d S t a t i s t i c a l data concerning t h e a i r c r a f t , in-

cluding t h e powerplants, a r e s e t f o r t h i n Appendix B.

The weight manifest form prepared for F l i g h t 9963 l i s t e d a

takeoff gross weight of 166,051 pounds and a c e n t e r of g r a v i t y of
9 In searching t h e records, p a r t i c u l a r a t t e n t i o n was focused
on items p e r t a i n i n g t o f l i g h t c o n t r o l systems and r e l a t e d
i n d i c a t i n g systems.
 - 11 -
16.0 percent MAC. -
12/ Due t o a change i n cargo weight, t h e center

of g r a v i t y was a l t e r e d t o 14.1 percent MAC. The change i n MAC was

3. given t o t h e crew v i a company radio p r i o r t o departure; however,

- t h e weight change i t s e l f was not transmitted t o t h e crew. Investi-

gation a l s o revealed t h a t t h e cargo weight was overstated b y . 9 0

pounds. However, n e i t h e r of t h e weight discrepancies had any e f f e c t

1 on t h e c e n t e r of gravity. The corrected takeoff gross weight,

which was 165,695 pounds, and t h e center of g r a v i t y both were within

limits.

The a i r c r a f t was serviced with 4,331 gallons of a v i a t i o n kerosene

at O'Hare, bringing t h e t o t a l f u e l load t o 43,800 pounds.

The captain of F l i g h t 9963 on t h e Newark-Chicago segment s t a t e d

the that t h e a i r c r a f t flew normally i n a l l r e s p e c t s except f o r takeoff.

?e The f i r s t o f f i c e r was f l y i n g t h e aircraft and noticed that it had

ed a tendency t o overrotate. It required a considerable amount of

forward pressure on t h e yoke t o hold a 10' noseup a t t i t u d e . After

,ice retrimming t h e a i r c r a f t f o r t h i s apparent tail- heavy condition, no

:ks f u r t h e r problem was encountered. This item was not entered i n t h e

3 a i r c r a f t f l i g h t log.
- A check of other p i l o t personnel who had flown t h i s a i r c r a f t

during t h e s e v e r a l days p r i o r t o t h e accident revealed t h a t t h e

airplane had performed normally.

of 1.7 Meteorological fnformation

-
1 The surface weather observation a t O'Hare for 0350 was as follows:

-
121 Mean aerodynamic chord.
 n 7

.~ ~- a
~~ ~

---F

- 12 -
measured c e i l i n g 1,000 f e e t broken, 1,700 f e e t overcast, v i s i b i l i t y

7 miles, very l i g h t snow, temperature 34' F., dew point 30" F.,
wind 020" 12 knots, a l t i m e t e r s e t t i n g 30.05 inches.

The amended a v i a t i o n terminal f o r e c a s t issued at 0240, v a l i d f o r

t h e period 0240 t o 1100, c a l l e d f o r c e i l i n g 500 f e e t broken, 1,800

f e e t overcast, v i s i b i l i t y 5 miles, l i g h t snow, wind 010' 1 2 knots,

b r i e f l y c e i l i n g 800 f e e t overcast, v i s i b i l i t y 1-1/2 miles, l i g h t snow.

Copies of t h e terminal f o r e c a s t s were among t h e weather documents

which were attached t o t h e company f l i g h t plan,log, and dispatch

r e l e a s e , which were signed by t h e captain. A self- help weather

b r i e f i n g display was a v a i l a b l e t o t h e crew i n t h e UAL Dispatch Office.

The general consensus among ground witnesses concerning weather

was t h a t a very l i g h t snow was f a l l i n g , v i s i b i l i t y was good, and a

s l i g h t wind was blowing from t h e e a s t .

1.8 Aids t o Navigation

Not involved.

1.9 C o m i c a t i o n s
There were no reported problems with c o m i c a t i o n s .

1.10 Aerodrome and Ground F a c i l i t i e s

Runway 9R i s 10,000 f e e t long and 150 f e e t wide, with a cement

surface. There i s a macadam shoulder approximately 10 f e e t wide on each

s i d e of t h e runway, and a macadam b l a s t pad a t each end of t h e runway.

High i n t e n s i t y runway l i g h t i n g i s a v a i l a b l e f o r t h i s runway. There was

no appreciable accumulation of moisture on t h e runway.

 c _ _ .~

- 13 -

1.11 F l i g h t Recorders

( a ) F l i g h t Data Recorder

The a i r c r a f t was equipped with a F a i r c h i l d f l i g h t data recorder,

model 5424, SIN 7837, which was recovered from t h e wreckage. The

f l i g h t recorder was damaged by impact and f i r e , but t h e recording

medium was i n t a c t and readable. However, t h e r e were malfunctions

i n t h e airspeed and a l t i t u d e parameters. Consequently, t h e only

information obtainable was t h a t derived from t h e v e r t i c a l , a c c e l e r a t i o n

and magnetic heading parameters.

The magnetic heading t r a c e on t h e f l i g h t recorder data graph

remained within 4" of 090" ( t h e runway heading) from commencement

of t h e takeoff roll u n t i l breakup occurred. The vertical. a c c e l e r a t i o n

t r a c e appeared normal until t h e approximate point i n time when t h e

a i r c r a f t was rotated, following which t h e r e were a s e r i e s of r a p i d

and s u b s t a n t i a l excursions o f t h i s t r a c e , which reached extreme values

of 2.0 p o s i t i v e g ' s and .5 negative g ' s .

( b ) Cockpit Voice Recorder

The aircraft was equipped with a United Control Corporation

model V-557 cockpit voice recorder, S/N 1014, which was recovered

from t h e wreckage i n s a t i s f a c t o r y condition. The cockpit area

ch
microphone recorded t h e voices of t h e crew from engine s t a r t u p

u n t i l t h e crash. Voice i d e n t i f i c a t i o n information set f o r t h i n t h e

.S
t r a n s c r i p t prepared from t h e recording was provided primarily by

t h e first o f f i c e r on F l i g h t 9963.
i'
1
I

!
i
 - 14 -
The recording contains t h e sound of t h e i n t e r m i t t e n t warning

horn f o r a period of 31 seconds during t h e takeoff roll. The horn

ceased 2 seconds p r i o r t o t h e f'irst o f f i c e r c a l l i n g out " r o t a t e , "

and 4 seconds a f t e r that utterance, t h e s t i c k shaker i s heard.

A c o r r e l a t i o n of t h e f l i g h t d a t a recorder and t h e cockpit

voice recorder, based on a common time reference, i n d i c a t e s t h a t

t h e transmission from F l i g h t 9963 acknowledging takeoff clearance

commenced 39 seconds p r i o r t o t h e start of takeoff roll.

Attached hereto as Appendix C i s t h a t portion of t h e cockpit

voice recorder t r a n s c r i p t commencing with t h e issuance of takeoff

clearance and terminating with t h e end of t h e recording.

1.12 Wreckage

During an examination of Runway 9R, an impression was found

i n t h e f l e x i b l e (macadam) pavement of t h e r i g h t runway shoulder.

The start of t h i s impression was approximately 2,230 f e e t short of t h e

e a s t o r far end of t h e runway. The impression was approximately

100 f e e t long and was angled approximately 4' t o t h e r i g h t of t h e

runway c e n t e r l i n e . The measured width of t h e impression was approx-

imately 5-7/8 inches, which c l o s e l y corresponds t o t h e measured

width (5-3/4 inches) of a worndown a r e a found on t h e drag l i n k

lower t i p of t h e t a i l s k i d assembly. The lower s k i d was fractured

on t h e l e f t side, approximately 5 inches from t h e skid end, and

t h e drag l i n k lower t i p had sustained a heavy, continuous scraping.

 - 15 -
A second mark was found along s i d e of t h e above described

impression. This mark, b e s t described as a scrape, s t a r t e d on t h e

cement portion of t h e runway a t a point j u s t short of t h e 5-7/8-inch

impression and continued off onto t h e f l e x i b l e pavement. The No. 2

(center) engine t h r u s t r e v e r s e r f a i r i n g , which i s located at t h e

6 o'clock position, was found scraped through. Material which was

similar t o t h e runway cement and t h e f l e x i b l e pavement was found

embedded within t h e scraped portion of t h e fairing.

The first contact of t h e r i g h t gear was made i n t h e d i r t

adjacent t o t h e runway, approximately 15 f e e t from t h e f l e x i b l e

pavement edge and approximately 2,050 f e e t short of t h e far end

of t h e runway. The l e f t main gear r o l l e d off t h e runway approximately

1,940 f e e t short of t h e far end.

The l e f t and r i g h t main gear wheel t r a c k s were continuous

until joined by t h e nosegear t r a c k a t a point approximately

9 0 f e e t short of t h e end of t h e runway. From t h i s point on, t h e

three gear t r a c k s were continuous u n t i l t h e a i r c r a f t crossed a

drainage ditch, which was e s s e n t i a l l y perpendicular t o t h e path of

the a i r c r a f t .

The impact with t h e ditch, which i s approximately 6 f e e t deep,

sheared t h e landing gears and damaged t h e l e f t wing and underside

of t h e fuselage. After contacting t h e ditch, t h e a i r c r a f t skidded,

shedding portions of t h e lower fuselage s t r u c t u r e and b e l l y cargo,

the v e n t r a l stair, and portions of t h e r i g h t wing. Just before t h e

s t a b i l i z e r assembly separated from t h e i r respective a t t a c h i n g

structures.

The a i r c r a f t came t o r e s t approximately 640 f e e t beyond t h e

ditch, on a magnetic heading of approximately 095". The f i n a l

wreckage s i t e was approximately 1,100 f e e t e a s t of t h e far end of

Runway 9R and approximately 300 f e e t south of t h e runway c e n t e r l i n e .

Attached hereto i s a c h a r t depicting t h e impression i n t h e f l e x i b l e

pavement, t h e t i r e t r a c k s , and t h e d i s t r i b u t i o n of t h e wreckage.

During t h e examination of t h e wreckage, p a r t i c u l a r emphasis

was centered on those components ( f l a p s , APU exhaust door, speed

brakes, s t a b i l i z e r trim) whose s e t t i n g o r p o s i t i o n might have a c t i v a t e d

t h e takeoff warning horn. The evidence uncovered may be summarized

as follows:

1. The A R J exhaust door was recovered i n i t s frame and found

closed and latched.

2. The speed brake panels and a c t u a t o r s were found i n t h e

stowed and locked position. The speed brake handle was

found out of t h e stowed position.

3. According t o t h e most r e l i a b l e evidence, t h e h o r i z o n t a l

s t a b i l i z e r trim s e t t i n g was 8.5 u n i t s a i r c r a f t noseup,

which would have been t h e approximate c o r r e c t trim s e t t i n g

f o r a takeoff with a center of g r a v i t y o f 14 percent MAC.

 7

~- ~
--- -

- 17 -
4. The flaps were s e t a t t h e 2' position, as indicated by

t h e following evidence:

a. The f l a p c o n t r o l handle was fixed i n t h e 2' position

by t h e s o l i d i f i e d p l a s t i c from t h e cockpit overhead

panels, which had melted during t h e ground f i r e .

b. The f l a p c o n t r o l handle t r a c k guide was f i t t e d t o

t h e handle and t h e mechanism aligned with t h e 2'

detent.

C. Leading edge slat Nos. 2, 3, 6, and 7 were extended

and locked, while Nos. 1, 4, 5, and 8 were r e t r a c t e d
and locked. This combination occurs only a t a

s e l e c t i o n of 2" f l a p s .

d. The main quadrant i n t h e t r a i l i n g edge f l a p followup

system was i n a p o s i t i o n corresponding t o l e s s t h a n

5" f l a p s .
e. The measured p o s i t i o n of t h e t r a i l i n g edge f l a p jack-

screws placed t h e f l a p s a t 2'.

f. The a i l e r o n lockout mechanism that i s programed by

t h e a c t u a l f l a p p o s i t i o n was recovered i n t h e 2'

f l a p position.

A l l four f l a p p o s i t i o n t r a n s m i t t e r s operated properly when

functionally t e s t e d . However, t h e p u l l i n g and breaking of cables

t o t h e t r a n s m i t t e r s bent and t o r e away mounting s t r u c t u r e t o t h e

extent that no r e l i a b l e p o s i t i o n information existed.

!

I..
~
 -18- .
The f l a p p o s i t i o n switch, AFU door switch, speed brake switch,

and s t a b i l i z e r p o s i t i o n switch f o r t h e takeoff warning system were

removed and examined. A11 switches were t e s t e d and functioned

properly, with t h e exception of t h e Am door switch, which was too

damaged t o be t e s t e d .

There was no evidence t o i n d i c a t e t h a t t h e f l i g h t control,

hydraulic, a u t o p i l o t , e l e c t r i c a l , pneumatic, communication, navigat ion,

f i r e protection, o r air conditioning systems were malfunctioning

p r i o r t o t h e accident; nor was t h e r e any evidence suggestive of any

abnormalities o r discrepancies within t h e powerplants, t h e i r compo-

nent and accessories, or' t h e f u e l system, other than those a t t r i b u t e d

t o damage caused by ground impact. The No. 2 engine t h r u s t r e v e r s e r

was i n t h e c r u i s e ( f l i g h t stowed) position, while t h e Nos. 1 and 3

engine t h r u s t r e v e r s e r s were i n t h e " i n t r a n s i t " position.

An examination of Runway 9R was conducted i n order t o a s c e r t a i n

if any parts might have become disengaged from t h e a i r c r a f t during

i t s takeoff roll. The r e s u l t s of t h i s search were negative.

-
1.13 F i r e
The majority of t h e a i r c r a f t was destroyed by a fuel- fed ground

f i r e r e s u l t i n g from t h e impact with t h e drainage d i t c h which severely

damaged t h e wing s t r u c t u r e , causing f u e l s p i l l a g e from t h e wing tanks.

The f i r e was fought by t h e Chicago F i r e Department which maintains

i a s t a t i o n a t O'Hare Field.
 ___- ~. .~ ~

- 19 -
1.14 Survival Aspects

The captain evacuated from t h e a i r c r a f t through t h e l e f t cockpit

window. He s t a t e d that he Jumped, r a t h e r t h a n use t h e rope, because

the f i r e was illuminating t h e ground well enough t o enable him t o

see where he would land. The first o f f i c e r was t h e second crew-

member out, jumping through t h e r i g h t cockpit window. He was followed

;ion, out t h i s window by t h e second o f f i c e r . The t h r e e crewmembers then

met near t h e nose and together proceeded away from t h e a i r c r a f t ,

r which was r a p i d l y becoming engulfed i n flames.

Shoulder harnesses, although a v a i l a b l e , were not worn by t h e

t ed crewmembers.

er 1.15 Tests and Research

On March 29, 1968, t e s t s were conducted a t Denver, Colorado,
u t i l i z i n g a UAL E 7 2 7 f l i g h t simulator and t h r e e UAL E727 q u a l i f i e d

,in flightcrews. The t h r e e crews were n o t i f i e d t o r e p o r t f o r simulator

t r a i n i n g without knowledge of t h e program or of t h e f a c t s regarding

Flight 9963, although they were aware of t h e accident. Each crew

was b r i e f e d s e m a t e l y and was unable t o converse with t h e o t h e r crews

md who were about t o t a k e t h e t e s t s o r who had completed t h e t e s t s .

rely The crews were t o l d t h a t no names would be taken and t h a t t h e

snks . t e s t s were being conducted t o gather data i n connection with t h e

S investigation of t h e accident involving F l i g h t 9963. They were

briefed that they would make f i v e takeoffs and that, within i t s

c a p a b i l i t i e s , t h e simulator would be p r o g r m e d with t h e following

information:
'!,

- 20 -
Airport elevation 667 f e e t
Runway heading 090"

Wind 020' 11 knots

Gross weight 166,595 pounds

Center of g r a v i t y 14 percent MAC

Temperature 34" F
Each crew was asked t o u t i l i z e t h e normal operating procedures

f o r each f l i g h t t e s t conducted. Al takeoffs were i n i t i a t e d by f i r s t

l

s t a b i l i z i n g t h e engines a t takeoff EPR and then r e l e a s i n g t h e wheel

brakes simultaneously.

The f i r s t two t e s t s were 5" f l a p takeoffs, t h e f i r s t f o r warmup

purposes, while t h e second was used t o c o l l e c t data. The t h i r d t e s t

was a l s o a 5" f l a p takeoff, but t h e i n t e r m i t t e n t warning horn was

a c t i v a t e d by an e l e c t r i c a l switch 10 seconds a f t e r brake release.

The horn could not be silenced by t h e crew. Crew Nos. 2 and 3

aborted t h e i r takeoffs 3.5 and 7 seconds r e s p e c t i v e l y after commencement

of t h e horn. The captain of crew No. 1 asked if he should continue

t h e takeoff t o s a t i s f y t h e t e s t . He was t o l d "no" and he aborted t h e

takeoff 17 seconds a f t e r t h e horn was activated.

The fourth t e s t was a 2" f l a p takeoff u t i l i z i n g 5" f l a p VR and

V2 speeds. The captain of crew No. 1 knew t h e f l a p s were set at 2O,

but t h e captains of crew Nos. 2 and 3 d i d not and assumed t h e y were

conducting a 5" f l a p takeoff. The warning horn was s i l e n c e d f o r t h i s

L2l
I test. Al crews experienced a c t i v a t i o n of t h e s t i c k shaker at VLoF,
l
x/ L i f t - o f f speed.
 __. ~~ .. ~

- 21 -
and t h e i r immediate r e a c t i o n was t o apply forward yoke which i n t u r n

deactivated t h e s t i c k shaker and climbout was continued. Crew No. 3,

on experiencing t h e s t i c k shaker, a l s o applied forward yoke t o

deactivate it. Following t h i s , climbout a t t i t u d e of 8" t o 9" noseup

a t t i t u d e was established, and almost immediately t h e s t i c k shaker was

activated again. They reapplied forward yoke, again deactivating

t h e s t i c k shaker, and then continued t h e climbout without f u r t h e r

3

s t a l l warning.
rst
The f i f t h and f i n a l t e s t was a l s o a 2' f l a p takeoff u t i l i z i n g 5'
1
f l a p VR and V2 speeds. The captain of crew No. 1 was t o l d it would

be a 5" f l a p takeoff, while t h e o t h e r two crews knew t h e f l a p s were,

[UP
i n f a c t , s e t at 2'. The warning horn again was silenced. A l l crews
!St

experienced t h e same s t a l l warning a s occurred i n t h e f o u r t h t e s t .

Crew No. 3 experienced t h e i d e n t i c a l stall warning twice as described

i n t h e previous t e s t .

1.16 Other Information

ncement

ue (a) Prior Incidents

A spot check of FAA A i r Carrier En Route Inspection Reports
L the
revealed two similar occurrences of t h e i n t e r m i t t e n t takeoff warning

horn being a c t i v a t e d during takeoff of a E727 a i r c r a f t . Both of

md
these incidents occurred at Denver, Colorado.
P,
On November 2, 1966, t h e crew of F r o n t i e r A i r Lines F l i g h t 771
ere
aborted t h e i r takeoff because of a c t i v a t i o n of t h e warning horn. The
this
2d horn sounded because t h e wing f l a p s were s e t a t 2'.
MF'
 t, ...,
!

!I
I1 - 22 -
!I/
1; On A p r i l 29, 1967, United Air Lines F l i g h t 227 a l s o experienced
hearing a warning horn, aborted t h e i r takeoff, and found t h e f l a p s

were s e t a t 2'.

(b) Performance Igta

According t o t h e b e i n g 727 Operations Ma

n ua
l, s t i c k shaker speeds

-
f o r a gross weight of 165,000 pounds a r e 169 KIAS 14/ f o r 20 of f l a p s

and 143 KIAS f o r 5" of f l a p s . S t a l l speeds f o r a gross weight of

165,000 pounds a r e 152 KIAS f o r 2' of f l a p s and 128 KIAS f o r 5' of

rlaps. 22l

141 Knots indicated airspeed.

The f i g u r e s l i s t e d above a r e t h e upper limits of t h e s t i c k
shaker and s t a l l speed ranges. I n other words, t h e s t i c k shaker
w i l l a c t i v a t e and t h e a i r c r a f t will s t a l l a t o r below t h e above-
l i s t e d speeds.
 - 23 - <

2. ANALYSIS AND CONCLUSIONS

2.1 Analysis

The i n v e s t i g a t i o n disclosed that t h e only causal f a c t o r s involved

i n t h e accident were d i r e c t l y r e l a t e d t o t h e chain of events i n i t i a t e d

by t h e f l a p s being i n t h e 2' i n s t e a d of t h e 5" p o s i t i o n . The evidence

uncovered i n t h e wreckage conclusively e s t a b l i s h e d that t h e f l a p s

were i n t h e 2' position. Furthermore, t h e events which occurred

during t h e f l i g h t a r e consistent with such a s e t t i n g . This s e t t i n g

i s outside t h e f l a p takeoff range of 5' t o 25' and t h e r e f o r e accounts

for t h e a c t i v a t i o n of t h e takeoff warning horn during t h e takeoff r o l l .

~

The 2' f l a p s e t t i n g a l s o explains why t h e s t i c k shaker came on iuunedi-

I
a t e l y a f t e r t h e nose was r o t a t e d and why t h e a i r c r a f t was r e l a t i v e l y

unresponsive t o c o n t r o l and power inputs during t h e b r i e f time it

was airborne. Finally, t h e ground witness' statements that t h e

landing l i g h t s were r e t r a c t e d o r shining downward a l s o support t h e

conclusion that t h e f l a p s were a t t h e 2' p o s i t i o n during t a k e o f f . With I

a '5 o r higher f l a p s e t t i n g , t h e outboard landing l i g h t s a r e d i r e c t e d

forward, whereas with a 2' f l a p s e t t i n g , those l i g h t s a r e d i r e c t e d down-

ward I

Apart from t h e evidence regarding t h e f l a p s , t h e r e was no other

indication of any condition or malfunction which could have accounted

for t h e a c t i v a t i o n of t h e takeoff warning horn and t h e s t i c k shaker

or the sluggish flight c h a r a c t e r i s t i c s of t h e a i r c r a f t . The evidence

i n the wreckage indicated that t h e o t h e r components connectea t o t h e

 I - 24 -
ill
'1 takeoff warning system ( s t a b i l i z e r trim, speed brakes, and APLT exhaust
I'

door) were properly s e t f o r takeoff and therefore would not have caused

~ t h e horn t o sound. Moreover, t h e r e was no evidence of a malfunction o r

discrepancy i n t h e powerplants o r f l i g h t c o n t r o l system which might have

explained t h e i n a b i l i t y of t h e a i r c r a f t t o climb o r a c c e l e r a t e . I n this

instance, except for an adverse r e f l e c t i o n on UAL f l i g h t preparation

procedures, t h e s e v e r a l discrepancies i n t h e computed gross weight were

not s i g n i f i c a n t , and t h e weight and balance of t h e a i r c r a f t were within

limits. Finally, an a n a l y s i s of t h e e x i s t i n g weather conditions discounted

airframe i c i n g as a causal f a c t o r .

In attempting t o determine t h e l a t e s t point i n time at which t h e

f l a p s were s t i l l i n t h e 5" position, a careful examination was made of
t h e taxi- out portion of t h e f l i g h t . The f i r s t o f f i c e r s t a t e d that he

placed t h e f l a p s i n t h e 5" p o s i t i o n as t h e a i r c r a f t l e f t t h e blocks and,

while t h e a i r c r a f t was s t i l l i n t h e well- lighted cargo area, that a check

of t h e f l i g h t controls was made. He further s t a t e d that t h e p i l o t s detected

outboard a i l e r o n movement on both wings t h a t could have occurred only w i t h

a f l a p p o s i t i o n of 5" o r more. The cockpit voice recorder i n d i c a t e s that,

s h o r t l y t h e r e a f t e r , t h e f l a p s e t t i n g was checked at 5" as t h e f i r s t and

second o f f i c e r s proceeded with t h e pre- takeoff c h e c k l i s t . -

16/A t t h i s

stage of t h e taxi- out, therefore, it appears that t h e f l a p s were i n t h e

proper p o s i t i o n f o r takeoff.

i It i s d i f f i c u l t t o a s c e r t a i n e x a c t l y when o r how t h e f l a p s came t o

be i n t h e 2" position. There a r e , however, two possible explanations

The portion of t h e cockpit voice recorder r e f e r r e d t o above i s not

included i n t h e t r a n s c r i p t i o n which i s excerpted i n Appendix C.
 - 25 -
i n t h i s regard. The first involves t h e events immediately following

the detection of a malfunction of t h e No. 1 engine a n t i - i c e valve

during t h e pre-takeoff c h e c k l i s t . A s t h e flight proceeded t o t u r n

around and t a x i back toward t h e cargo ramp, it i s possible t h a t t h e

first o f f i c e r , through force of h a b i t , s t a r t e d t o perform t h e t a x i - i n

checklist. T h i s checklist i s not performed by t h e challenge-response

method, but r a t h e r i s accomplished s e p a r a t e l y by t h e first o f f i c e r .

This would account for t h e absence of any o r a l mention o f ' t h e check-

I t ed l i s t on t h e cockpit voice recorder.

The f i r s t item on t h i s c h e c k l i s t i s "Flaps-up,'' which would

' position.
c a l l f o r moving t h e f l a p handle t o t h e 0 However, when

' p o s i t i o n during f l i g h t , a pause i s made

moving t h e f l a p s t o t h e 0

a t the 2' p o s i t i o n t o provide f o r operation of t h e leading edge devices.

f Accordingly, it i s possible that t h e first o f f i c e r i n s t i n c t i v e l y

ck paused at t h e 2' detent when r a i s i n g t h e f l a p s , even though such a

;ected pause was not required since t h e a i r c r a f t was on t h e ground.

qith Continuing with t h i s l i n e of reasoning, before t h e first o f f i c e r

hat , could continue t h e r e t r a c t i o n of t h e f l a p s from 2' t o Oo, he may

d have become absorbed i n t h e attempts t o c o r r e c t t h e a n t i - i c e valve

malfunction. Indeed, t h e cockpit voice recorder r e v e a l s t h a t t h e

he first o f f i c e r a c t i v e l y p a r t i c i p a t e d i n t h e crew's e f f o r t t o a l l e v i a t e

that problem. When t h e a n t i - i c e l i g h t went o f f , and t h a t system

to tested normally, t h e crew resumed t a x i i n g toward t h e runway and t h e

-
.ot
pre-takeoff checklist was a l s o resumed. However, t h e crew s t a r t e d
 - 26 -
where t h e y had lef't off with t h e item " altimeters," and i n t h e

process of completing t h e c h e c k l i s t d i d not check t h e preceding

-
items, one of which was t h e f l a p s . 17/Accordingly, the 2" f l a p

p o s i t i o n would have remained undetected. Although a c o n t r o l check

was conducted j u s t p r i o r t o takeoff, no mention was made of outboard

a i l e r o n movement which would have indicated a 5" flap position. In

any event, it i s doubtful t h a t such movement could have been detected

because t h e a i r c r a f t was positioned i n an unlit area a t that time.

It should be emphasized t h a t t h e aforedescribed chain of events

i s only a p o s s i b l e explanation based on a s e r i e s of assumptions which

i n t u r n r e s t on circumstantial, r a t h e r than d i r e c t , evidence. The

first o f f i c e r , when questioned s p e c i f i c a l l y on t h i s matter, s t a t e d

that he "most d e f i n i t e l y d i d not r e p o s i t i o n t h e f l a p s or touch t h e

f l a p handle or any o t h e r item normally associated with t h e ' t a x i - i n . ' "

On t h e other hand, t h e e n t i r e theory as postulated above, r e s t s on

t h e proposition that he repositioned t h e flaps i n s t i n c t i v e l y , without

being consciously aware t h a t he was doing so. Accordingly, it would

be expected t h a t he would not r e c a l l such an a c t i o n .

The second possible explanation regarding t h e improper f l a p

position is that, when t h e f l a p s were positioned t o t h e 5" s e t t i n g

by t h e first o f f i c e r as t h e a i r c r a f ' t l e f t t h e blocks, t h e f l a p

-
l7/ UAL policy with respect t o t h e takeoff c h e c k l i s t i s that "If
following t h e completion of t h e Challenge-Respond, a delay of
s u f f i c i e n t duration i s incurred t o cause repositioning of any
c o n t r o l s , t h e Challenge-Respond must again b e completed i n i t s
e n t i r e t y . " Thus, if t h e first o f f i c e r i n f a c t moved t h e f l a p s
from t h e 5' position, it was incumbent on him t o resume the pre-
taXeoff c h e c k l i s t s t a r t i n g with t h e first item.
 - 27 -
handle was placed j u s t short of t h e 5" detent r a t h e r than i n t h e
detent i t s e l f . A t some l a t e r time during t h e taxi- out, the handle

crept forward u n t i l reaching t h e 2' detent. I n order t o t e s t t h e

v a l i d i t y of t h i s theory, a number of experiments were conducted

during t h e i n v e s t i g a t i o n by placing t h e f l a p handle on a E727

on t h e l i p of t h e 5' detent and then t a x i i n g t h e a i r c r a f t at normal

taxi speeds. These t e s t s demonstrated that t h e f l a p handle will s l i p

toward and i n t o t h e 2' detent, and not toward t h e c l o s e r 5" d e t e n t .

Again, however, t h i s theory i s not based on d i r e c t evidence, b u t

rather i s offered only as a possible explanation of what happened.

On balance, t h e Board concludes that t h e a v a i l a b l e evidence

does not allow a determination, w i t h any reasonable degree of

certainty, as t o when and how t h e f l a p s came t o be i n t h e 2' p o s i t i o n .

~

It
The only conclusion that can be reached i s that t h e f l a p s were i n f a c t
i
i n t h e 2' p o s i t i o n a t t h e time t h e warning horn became a c t i v a t e d I
during t h e takeoff r o l l . i

A c o r r e l a t i o n of t h e f l i g h t and cockpit voice recorders, based

on a common time reference, shows that t h e transmission from F l i g h t

9963 acknowledging takeoff clearance comenced 39 seconds p r i o r t o

the start of takeoff r o l l . I n addition, the cockpit m i c e recorder

t r a n s c r i p t i n d i c a t e s that a period of 44 seconds elapsed between t h e

beginning of that transmission and t h e a c t i v a t i o n of t h e takeoff

warning horn. (See Appendix C. ) Accordingly, t h e horn began

sounding approximately 5 seconds after t h e commencement of t h e takeoff

e-
roll.
j(
/i - 28 -
;ji
'?
,I,
The approximate 5 second delay between t h e commencement of t h e I

takeoff r o l l and t h e a c t i v a t i o n of t h e warning horn i s explained by

t h e handling of t h e t h r o t t l e s prescribed by t h e UAL takeoff procedure.

For a r o l l i n g takeoff, t h e t h r o t t l e s a r e advanced t o t h e 1.4 EPR

p o s i t i o n as alignment i s completed. When t h e a i r c r a f t i s aligned on

t h e runway and r o l l i n g , t h e t h r o t t l e s a r e advanced t o takeoff E m .

The 65 percent takeoff t h r u s t position, a t which t h e warning horn

i s a c t i v a t e d , i s beyond t h e t h r o t t l e p o s i t i o n corresponding t o a

power s e t t i n g of 1.4 Em. Consequently, t h e horn would not have been

a c t i v a t e d u n t i l t h e t h r o t t l e s were advanced through t h e 65 percent
p o s i t i o n t o takeoff t h r u s t following t h e b r i e f pause a t t h e 1.4 EPR
position.

A s noted previously, evidence i n t h e wreckage e s t a b l i s h e d not

only t h a t t h e f l a p s were i n t h e 2' position, but a l s o that t h i s

s e t t i n g would have been a c c u r a t e l y r e f l e c t e d i n t h e cockpit both

by t h e f l a p p o s i t i o n i n d i c a t o r and by t h e p o s i t i o n of t h e f l a p handle

itself. Accordingly, it i s d i f f i c u l t t o understand why the crew

was unable t o detect t h e improper f l a p s e t t i n g which caused t h e horn

t o sound continuously f o r 31 seconds. The statements of t h e crew-

members, however, shed some l i g h t on t h i s matter. The first o f f i c e r

"felt that t h e ( f l a p ) handle was i n a detent which i n t h e dark was

well back from t h e zero p o s i t i o n and I f e l t c e r t a i n was i n t h e 5'

detent." His determination was t h e r e f o r e based on " feel" r a t h e r

than v i s u a l observation, apparently because of lack of l i g h t i n g .

i
 - 29 -
The captain a l s o s t a t e d t h a t t h e f l a p handle, by reason of i t s

position a s well as t h e l i g h t i n g , i s d i f f i c u l t t o see a t night. It

should a l s o be noted t h a t t h e distance between t h e 2' and 5" d e t e n t s

i s only about 1 inch.

With respect t o t h e f l a p i n d i c a t o r s , t h e first o f f i c e r s t a t e d

t h a t , although he observed t h e needle t o be i n about t h e 3 o'clock

or 5' position, he did not read t h e number 5' on t h e d i a l . In

addition, the captain noted that t h e f l a p i n d i c a t o r s a r e ,"rather

d i f f i c u l t t o read a t night, and t h e y ' r e j i g g l i n g around q u i t e a b i t . "

Both t h e captain and t h e first o f f i c e r a l s o appear t o have r e l i e d

t o a c e r t a i n extent on t h e f a c t that t h e green leading edge f l a p

l i g h t was illuminated. Such r e l i a n c e was not j u s t i f i e d , however,

-
because a green f l a p l i g h t i n d i c a t e s not that t h e f l a p s a r e within

the takeoff range, but only that t h e leading edge devices agree w i t h

the position of t h e f l a p c o n t r o l l e v e r . Thus, t h i s l i g h t w i l l be

illuminated when t h e f l a p s a r e i n t h e 2' o r any o t h e r p o s i t i o n , as

lle
long as they a r e i n f a c t i n t h e p o s i t i o n c a l l e d f o r by t h e l e v e r .

Regardless of t h e reasons why t h e crew d i d not d e t e c t t h e

rn
improper f l a p s e t t i n g , it i s obvious t h a t t h e takeoff roll i s not

a period during which a crew should be troubleshooting a n unsafe

:er
takeoff condition. During t h i s period, t h e a i r c r a f t i s r a p i d l y
3

accelerating, leaving a n ever- decreasing amount of time w i t h i n which

t o discover the problem. Furthermore, any attempts t o scan t h e

cockpit i n order t o l o c a t e t h e warned-of condition, p a r t i c u l a r l y a t

'I:

ti - 30-.
#Ii night i n a darkened environment, only serve t o d i v e r t t h e crew
,I

from t h e i r other c r i t i c a l d u t i e s .

The only s a f e procedure, d i c t a t e d by sound judgment, would

be t o abort t h e takeoff and correct t h e problem before attempting

another takeoff. Indeed, any o t h e r a c t i o n has t h e e f f e c t of defeating

t h e purpose of t h e warning system, which i s i n s t a l l e d on t h e a i r c r a f t

t o i n d i c a t e a n unsafe takeoff configuration and should be t r e a t e d

as such. Had t h e crew i n t h i s case aborted t h e . t a k e o f f , r a t h e r

than attempting t o l o c a t e t h e unsafe condition while continuing

t h e takeoff roll, they could have r e a d i l y i d e n t i f i e d t h e problem

and recommenced t h e i r departure s a f e l y a f t e r only a minor delay.

The UAL F l i g h t Operations Manual, as c o n s t i t u t e d a t t h e time

of t h e accident, s e t f o r t h i n s u f f i c i e n t d e t a i l t h e reasons why tile

takeoff warning horn will sound, and a l s o t h e means by which t h e

horn can be silenced. However, t h i s manual contained no s p e c i f i c

i n s t r u c t i o n s as t o what a c t i o n should be taken by t h e crew i f t h e

horn should become a c t i v a t e d during t h e takeoff roll. A review of

Boeing 727 F l i g h t Operations Manuals used by other c a r r i e r s revealed

similar d e f i c i e n c i e s .

With respect t o i n s t r u c t i o n s imparted during t r a i n i n g , it appears

t h a t p i l o t personnel again were taught t h e conditions which would

a c t i v a t e t h e warning horn, but t h a t no e x p l i c i t d i r e c t i v e s were

given t o abort t h e takeoff if t h e h o r n sounded before t h e a i r c r a f t

reached V speed. The crews apparently were permitted some degree

1
 - 31 -
' of discretion i n attempting t o c o r r e c t t h e unsafe takeoff condition,

rather than immediately aborting t h e takeoff. Indeed, r e p o r t s were

received from several a i r l i n e crews during t h e i n v e s t i g a t i o n r e l a t i n g

that they had been a b l e t o l o c a t e and correct t h e unsafe condition while

continuing t h e takeoff r o l l .

The Board recognizes that t h e simulator t e s t s conducted subsequent

i n Denver, c o n s t i t u t e examples of s i t u a t i o n s i n which flightcrews aborted

takeoffs upon a c t i v a t i o n of t h e warning horn. However, t h e value of t h e

simulator t e s t s as a r e l i a b l e i n d i c a t i o n of t h e r e a c t i o n s of flightcrews

i n general i s somewhat q u a l i f i e d by t h e f a c t t h a t t h e t e s t crews, although

unaware of t h e d e t a i l s of t h e subject accident, were informed that t h e

t e s t s were p a r t of t h e i n v e s t i g a t i o n , and t h e r e f o r e must have been "on

guard" with respect t o any takeoff emergencies. Similarly, t h e crews

involved i n t h e two operational i n c i d e n t s were no doubt a c u t e l y aware of

the cockpit of an FAA inspector. A t any r a t e , t h e Board i s unable t o

conclude that these examples provide s u f f i c i e n t assurance that a l l E727

flightcrews w i l l a b o r t a takeoff when t h e warning horn i s a c t i v a t e d .

I n view of t h e foregoing, t h e Board has recommended that s p e c i f i c

instructions be issued t o a l l Boeing 727 operators requiring t h a t

takeoffs be aborted i f t h e i n t e r m i t t e n t warning horn sounds during t h e

takeoff r o l l before t h e a i r c r a f t reaches V speed. L e t t e r s embodying

1
this recommendation have been transmitted t o t h e Administrator of

the FAA. These l e t t e r s , plus t h e respective responses of t h e

 - 32 -

Administrator, a r e discussed i n d e t a i l i n t h e Recommendations a n d

Corrective Action section.

Continuing with t h e chronological a n a l y s i s of F l i g h t 9963,

t h e explanation f o r t h e warning horn ceasing 2 seconds p r i o r t o

t h e first o f f i c e r c a l l i n g VR i s contained i n t h e c a p t a i n ' s statement.

He r e l a t e d t h a t as t h e a i r c r a f t reached r o t a t e speed, t h e nose

"came r i g h t off t h e ground ... w i t h abnormally light pressure."

This description closely corresponds t o t h e observation of t h e pre-

ceding crew who noted that t h e a i r c r a f t had a tendency t o o v e r r o t a t e .

It therefore appears l i k e l y t h a t , j u s t p r i o r t o reaching r o t a t e speed,

t h e nose gear s t r u t became s u f f i c i e n t l y extended t o a c t u a t e t h e

switch that c u t s out t h e ground operating mode of t h e warning horn.

I n analyzing t h e a c t i o n s of t h e captain during t h e b r i e f period

i n which t h e plane was airborne, it must be remembered t h a t he believed

t h e f l a p s were s e t a t 5", whereas i n f a c t they were i n t h e 2' position.

Accordingly, t h e r o t a t e and l i f t - o f f speeds of t h e a i r c r a f t were i n

f a c t considerably higher than t h e planned speeds, with t h e consequence

t h a t t h e a i r c r a f t was r o t a t e d and l i f t e d off prematurely. Further-

more, t h e s t a l l warning speed range was a t o r below 169 KTAS ( f o r 2'

of f l a p s ) r a t h e r than a t o r below 143 KIAS (for 5' of f l a p s ) , which
accounts f o r t h e s t i c k shaker becoming a c t i v a t e d i m e d i a t e l y a f t e r

lift-off.

The captain reacted t o t h e s t i c k shaker by pushing t h e nose over

and adding power, which i s t h e normal method of a v e r t i n g a s t a l l . At

 - 33 -
t h i s point, it should be noted that, when presented with a similar

s i t u a t i o n , t h e crews p a r t i c i p a t i n g i n t h e simulator t e s t s subsequent

t o t h e accident, took t h e same remedial s t e p s as t h e captain of

Flight 99'63. The difference, of course, i s t h a t t h e simulator f l i g h t s

were able t o a c c e l e r a t e through t h e s t i c k shaker speed range, while

on F l i g h t 9963 t h e s t i c k continued t o shake during t h e e n t i r e air-

borne period of t h e f l i g h t . It appears, however, t h a t t h e a i r c r a f t

must have c l o s e l y approached t h e s t i c k shaker speed of 169 knots

i n view of t h e f i r s t o f f i c e r ' s observation t h a t t h e airspeed i n d i c a t o r

passed through t h e 161 knot mark by 5" of t h e d i a l .

I n any event, t h e Board does not b e l i e v e t h e captain a c t e d

unreasonably i n deciding t o discontinue t h e climbout. Even a f t e r

adding power and pushing t h e nose over, t h e a i r c r a f t d i d not climb

or accelerate through t h e s t i c k shaker speed range, thereby present-

ing t h e captain with t h e r i s k of crashing i n t o t h e freeway off t h e

erld of t h e runway if he chose t o continue t h e f l i g h t . The Board

a l s o recognizes that, regardless of t h e r e s u l t s of t h e simulator

t e s t s , t h e captain of F l i g h t 9963 was presented with a s p l i t -

second decision under a c t u a l operational conditions which cannot be

recreated i n t o t o i n a simulator.

The various markings on t h e runway and runway shoulder, when

correlated t o t h e damage on t h e underside of t h e a i r c r a f t , provide

a c l e a r p i c t u r e of t h e manner i n which t h e a i r c r a f t s e t t l e d back t o

 - 34 -
t h e surface. While airborne, t h e a i r c r a f t was d r i f t e d t o t h e r i g h t

approximately 4” i n r e l a t i o n t o t h e runway c e n t e r l i n e , apparently due

t o t h e crosswind from t h e l e f t . I n i t i a l contact with t h e surface

was made by t h e t a i l skid and t h e No. 2 engine t h r u s t r e v e r s e r

f a i r i n g , which contacted t h e runway shoulder while t h e aircraft was

i n a nose-high a t t i t u d e . ’8’
- As t h e a i r c r a f t continued t o t r a v e l off

t h e runway, t h e l e f t main gear s e t t l e d t o t h e runway and, s h o r t l y

t h e r e a f t e r , t h e r i g h t gear made contact a short distance from t h e

runway edge i n t h e adjacent muddy t e r r a i n . This i n d i c a t e s t h a t ,

i n addition t o a nose-high a t t i t u d e , t h e a i r c r a f t s e t t l e d with t h e

lef’t wing s l i g h t l y down, which corresponds t o ground witness observa-

tions. The nosegear f i n a l l y touched down approximately 1,300 f e e t

beyond t h e point where t h e main gear contacted t h e surface. From

that point, t h e a i r c r a f t rode on a l l t h r e e gears u n t i l it impacted

with t h e drainage ditch.

I n regard t o t h e use of t h e a v a i l a b l e d e c e l e r a t i v e devices, t h e

captain s t a t e d that he used t h e wheel brakes and reverse t h r u s t , b u t

he could not r e c a l l whether he used t h e speed brakes. Several

witnesses supported h i s r e c o l l e c t i o n concerning reverse t h r u s t by

t h e i r statements that t h e a i r c r a f t sounded 86 if it went i n t o reverse

a f t e r touchdown. The evidence derived from t h e wreckage was incon-

clusive on t h i s point, i n d i c a t i n g only t h a t t h e No. 1 and No. 3

engine r e v e r s e r s were i n t h e “ i n transit” 0r”mstowed” p o s i t i o n .

%/
- I n order f o r these two p a r t s of t h e a i r c r a f t t o contact t h e
surface, t h e a i r c r a f t deck angle had t o be i n excess of 13”.
 - 35 -
Evidence did show, however, that t h e speed brake panels were stowed
ght
and thus were not u t i l i z e d . Their primary e f f e c t while t h e a i r c r a f t
y due
i s on t h e ground i s t o decrease lift, thereby increasing t h e effec-
.e
tiveness of t h e wheelbrakes. However, i n view of t h e f a c t that t h e

a i r c r a f t was r o l l i n g out over muddy t e r r a i n , it i s questionable

was
whether t h e increased effectiveness of t h e brakes, provided by
1 off
extension of t h e speed brakes, would have s i g n i f i c a n t l y reduced t h e
Y
impact forces w i t h which t h e a i r c r a f t struck t h e ditch.
he
From t h e vantage point of hindsight, it i s c l e a r that had t h e
9
captain been able t o keep t h e a i r c r a f t aligned with t h e runway while
the
airborne and during ground r o l l o u t , t h e degree of damage sustained
)serva-
by the a i r c r a f t would have been far l e s s severe. The f a c t that t h e
'eet
a i r c r a f t would have been r o l l i n g out over a paved surface, r a t h e r
rom
than muddy t e r r a i n , would have g r e a t l y increased t h e effectiveness
cted
of the wheelbrakes. Furthermore, even assuming that t h e a i r c r a f t

would nonetheless have overrun t h e end of t h e runway, t h e drainage

s t the
ditch would have presented no problem s i n c e that p o r t i o n of t h e
t , but
ditch which t r a v e r s e s t h e a r e a corresponding t o t h e extension of

Fanway 9R i s underground.
; by
The Board i s somewhat concerned with t h e f a i l u r e of t h e crew
reverse
of Flight 9963 t o wear t h e shoulder harnesses which were i n s t a l l e d
.neon-
on the a i r c r a f t . The Board recognizes t h a t , although shoulder harnesses
3
a r e required equipnent on a l l transport a i r c r a f t certificated a f t e r
on.

the
-
January 1, 1958, 19' neither t h e Federal Aviation Regulations nor
13". See Part 121.321 of t h e Federal Aviation Regulations
(14 CFR 12l.321).
 - 36 -
company policyrequiresflightcrews to wear them. Nevertheless, the

Board believes that shoulder harnesses are a proven safety factor

and should be worn during the critical periods of takeoff and landing.

This view is borne out by the circumstances of the subject accident.

The crewmembers most vivid recollection of the impact is one of being

violently tossed around inside the cockpit. The wearing of shoulder

harnesses would have held the upper parts of their bodies in a stationary

position and would therefore have tended to reduce the severity of

the injuries, which included lacerations and bruises on the chest,

face, and arms, as well as back injuries. Flightcrews should be

encouraged to wear shoulder harnesses, not only to enhance their own

safety, but also to assure that they will be available to assist

in the evacuation of passengers once the aircraft has come to rest.

In view of the foregoing, the Board recommends that the FAA and

air carriers re-examine their positions regarding shoulder harnesses

with a view toward requiring their use through appropriate revisions

of pre-takeoff and before-landing checklists.

2.2 Conclusions

(a) Findings
1. The aircraft was airworthy, and its gross weight and

center of gravity were within limits.

2. The flight crewmembers were properly certificated and

qualified for the operation involved.

 - 37 -
3. Weather was not a causal f a c t o r i n t h e accident.

4. There was no i n d i c a t i o n of a mechanical f a i l u r e o r

malfunction of t h e a i r c r a f t s t r u c t u r e , systems, o r

powerplants.

5. Evidence conclusively e s t a b l i s h e d that t h e f l a p s were

i n t h e 2' p o s i t i o n during takeoff, although it cannot

be determined when and how t h e f l a p s came t o be i n

t h i s position.

6. The 2' f l a p p o s i t i o n i s outside t h e takeoff range and

t h e r e f o r e a c t i v a t e d t h e takeoff warning horn s h o r t l y

a f t e r t h e commencement of t h e takeoff roll.

7. The f l i g h t crewmembers were unsuccessful i n t h e i r

attempts t o a s c e r t a i n t h e condition that a c t i v a t e d t h e

warning horn, which continued t o sound u n t i l j u s t

p r i o r t o r o t a t e speed.

a. The Operations Manual, as well as f l i g h t t r a i n i n g ,

were d e f i c i e n t i n t h a t t h e y d i d not impart t o p i l o t s

s p e c i f i c i n s t r u c t i o n s r e q u i r i n g them t o a b o r t t a k e o f f s

i f t h e takeoff warning horn i s a c t i v a t e d p r i o r t o

reaching V speed.
1
9. Immediately a f t e r l i f t - o f f , t h e s t i c k shaker was activated,

indicating that t h e a i r c r a f t was approaching a s t d l .

The captain lowered t h e nose and added power, but

t h e a i r c r a f t f a i l e d t o climb o r a c c e l e r a t e through

t h e s t i c k shaker speed range.

 - 38 -
11. The captain's decision t o discontinue t h e climbout

was reasonable under t h e circumstances.

12. The a i r c r a f t s e t t l e d back t o t h e surface on t h e r i g h t

shoulder of t h e runway i n a nose-high a t t i t u d e .

13. The a i r c r a f t was destroyed by t h e ground f i r e which

r e s u l t e d from t h e impact with a drainage d i t c h during

ground r o l l o u t .

(b) Probable Cause

The Safety Board determines that t h e probable cause

of t h i s accident was t h e f a i l u r e of t h e crew t o abort t h e

takeoff a f t e r being warned o f an unsafe takeoff condition.

i
 - 39 -
3. Recommendations and Corrective Action

As a r e s u l t of t h i s accident, t h e Safety Board, i n a l e t t e r t o

the Administrator of t h e FAA dated May 14, 1968, recornended t h a t

the FAA review t h e crew t r a i n i n g curriculum and t h e operating pro-

cedures r e l a t i v e t o (1)aircraft takeoff handling c h a r a c t e r i s t i c s

with various f l a p s e t t i n g s , and ( 2 ) t h e operations from a systems

standpoint of t h e i n t e r m i t t e n t warning horn i n t h e takeoff regime

and action expected of t h e crew when t h e horn i s heard during t h e

takeoff r o l l . Specifically, it was recornended t h a t t h e B e i n g 727

Operations Ma
nul be revised t o r e q u i r e t h a t t h e takeoff be aborted
a

should t h e i n t e r m i t t e n t warning horn sound during t h e takeoff roll

and that t h e reason f o r t h e horn sounding be determined and corrected

before another takeoff i s attempted.

The Administrator, i n h i s r e p l y of June 6, 1968, s t a t e d t h a t

each air c a r r i e r p i l o t receives ground i n s t r u c t i o n , as w e l l as

being checked by FAA inspectors, r e l a t i v e t o t h e operation o f t h e

takeoff warning system, including aborted takeoffs involving

activation of t h a t system. The Administrator f u r t h e r s t a t e d t h a t

each air c a r r i e r ' s m n u a l contains i n s t r u c t i o n s t o t h e e f f e c t t h a t ,

if a malf'unction (e.g., a c t i v a t i o n of t h e warning horn) occurs

prior t o V1, t h e takeoff should be aborted. The Administrator

therefore concluded t h a t " s u c c e s s M completion of an approved E727

t r a i n i n g program adequately prepares a p i l o t f o r operation o f t h a t
 -40-
a i r c r a f t , provided he adheres t o t h e operating procedures taught

i n t h e t r a i n i n g program and as o u t l i n e d i n t h e appropriate f l i g h t

operations manual."

The Administrator also noted t h a t , as a r e s u l t of t h e accident,

United A i r Lines issued an operations a l e r t b u l l e t i n re-emphasizing

t h e operational aspects of t h e takeoff warning horn. The

Administrator added t h a t FAA f i e l d personnel had been requested t o

place p a r t i c u l a r emphasis on that same subject during t r a i n i n g as

well as p i l o t c e r t i f i c a t i o n .

I n i t s response of August 19, 1968, t h e Safety Board expressed

t h e view that, while t h e emphasis on t h e takeoff warning system was

g r a t i f y i n g , M t h e r a c t i o n was required. The Board noted that t h e

operations manuals of air c a r r i e r s , although s t a t i n g t h e reasons

t h e horn would sound, contained no s p e c i f i c i n s t r u c t i o n s on a c t i o n s

t o be taken by t h e crew i f t h e warning horn should sound during takeoff

rolls. It was pointed out t h a t UAL personnel were apparently not

given e x p l i c i t i n s t r u c t i o n s t o abort t h e takeoff if t h e horn sounds

p r i o r t o reaching V
' but r a t h e r t h a t t h e crews had some prerogative
1
i n attempting t o c o r r e c t t h e cause thereof r a t h e r than t o a b o r t t h e

The referenced b u l l e t i n was a t e l e t y p e message s e n t t o UAL

f l i g h t domiciles on May 2, 1968, prescribing t h e following
procedures when t h e takeoff warning horn sounds:
"Normally, t h i s warning should occur very e a r l y i n t h e
takeoff roll when t h e takeoff run should obviously be discontinued
and t h e condition corrected p r i o r t o another attempt. Should
t h e warning occur near V when you a r e c o m i t t e d t o f l y , then a
1
higher r o t a t i o n speed i s obviously desirable."
 - 41 -
takeoff a t once. The l e t t e r a l s o c i t e d t h e admission of other

a i r l i n e crews that, during takeoff rolls, they had been a b l e t o l o c a t e

and correct t h e condition which caused t h e horn t o sound.

The Safety Board's l e t t e r a l s o expressed t h e b e l i e f t h a t the. pro-

cedure s e t f o r t h i n t h e UAL operations a l e r t should be required of

a l l Boeing 727 operators. It was t h e r e f o r e recomended " t h a t s p e c i f i c

instructions be issued t o a l l b e i n g 727 operators which r e q u i r e that

takeoffs be aborted i f t h e i n t e r m i t t e n t warning horn sounds during

takeoff rolls before reaching V1."

By l e t t e r dated September 10, 1968, t h e Acting Administrator

responded, i n p e r t i n e n t part, as follows:

"We have requested our f i e l d o f f i c e s t o review t h e procedures

prescribed i n t h e air c a r r i e r ' s manuals t o assure t h a t t a k e o f f s w i l l

be aborted whenever t h e takeoff warning horn sounds p r i o r t o reaching

eoff wiless t h e r e a r e other overriding f a c t o r s . If such i n s t r u c t i o n s

1'1'
are determined t o be inadequate o r nonexistent, t h e a i r c a r r i e r w i l l

be requested t o update t h e i r F l i g h t Operations Manuals o r i s s u e a n

re a l e r t bulletin." 20/-
3

- -
20/ Copies of t h e 4 l e t t e r s discussed above a r e contained i n t h e
Public Docket of Recommendations, which i s maintained i n
Safety Board's o f f i c e s i n Washington, D. C.

,inued

la
 - 42- .
The Safety Board believes that the corrective measures described

in the foregoing letter should, when effectuated, prevent the recurrence

of similar accidents in the future.

BY THE NATIONAL TRANSPORTATION SAFETY BOARD:

JOSEPH J. O'CONNELL, JR.

Chairman

OSCAR M. LAUREL
Member

JOHN H. REED
Member

LOUIS M. THAYER
Member

FRANCE? H. McADAMS
Member
i

APPENDIX A

;
@ewInformation

Captain Hudson, age 40, was employed by United A i r Lines on June 18,

1952, and was upgraded t o captain on June 30, 1966.

Captain Hudson s a t i s f a c t o r i l y completed t h e following:

Proficiency - 1/12/68 (B727) Initial

Line - 3/13/68 (E-727)
Pilot data from company records a r e as follows:

Approximate Hours

a. Total p i l o t time 10,500

b. Total p i l o t time i n E 7 2 7 ( c a p t a i n ) 33
C. Total p i l o t time i n E 7 2 7 ( f i r s t o f f i c e r ) 1,000

a. Total p i l o t time last 90 days 60

e. Total p i l o t time l a s t 30 days 60
f. Total p i l o t nighttime l a s t 30 days 21

g. C e r t i f i c a t e number and r a t i n g s held:

A i r l i n e Transport P i l o t No. 474665 with r a t i n g s nC-3/6/7,

CV 240/340/440, E 7 2 7 , a i r p l a n e multi-engine l a n d with
commercial p r i v i l e g e s single- engine land.

h. Date of last physical examination f o r first c l a s s medical

c e r t i f i c a t e - 1/15/68 with no l i m i t a t i o n s .

Hours and Minutes

i. C r e w rest past 24 hours 11:x)

3. Duty time last 24 hours 10:15

k. F l i g h t time last 24 hours p r i o r t o t h i s f l i g h t 4: 46

1. F l i g h t time t h i s f l i g h t 0:16
- i -
 I
,

i
F i r s t Officer Frederick D. Coleman

F i r s t Officer Coleman s a t i s f a c t o r i l y completed t h e following:

Proficiency - 12/6/67 (B-727)

Line - 1/10/@ (B-727)

P i l o t data from company records a r e as follows:

Approximate Hours

a. T o t a l p i l o t time 1,280

b. Total p i l o t time i n E 7 2 7 135

C. Total p i l o t time last 90 days 134
a. T o t a l p i l o t time last 30 days 52

e. T o t a l p i l o t nighttime last 30 days 27

f. T o t a l f l i g h t engineer time i n E 7 2 7 809

g. C e r t i f i c a t e number and r a t i n g s held:

Commercial P i l o t No. 1583019 with a i r p l a n e s i n g l e and multi-

engine land and instrument r a t i n g s .

h. k t e of last physical examination f o r f i r s t - c l a s s medical cer-

t i f i c a t e - 7/26/67 with no l i m i t a t i o n s .

Hours and Minutes

i. Crew r e s t past 24 hours 11:M

3. Duty time last 24 hours 10: 1 5

k. F l i g h t time last 24 hours p r i o r t o t h i s f l i g h t 4: 46

1. F l i g h t time t h i s f l i g h t 0: 16

Second Officer Donald N. Jackleg

Second Officer Jackley, age 34, was employed by United A i r Lines on

March 6, 1967, and was o r i g i n a l l y q u a l i f i e d as f l i g h t engineer on May 30, 1967,

- ii -

I
 in E-6 type equipment. Checkout as f l i g h t engineer i n B-727 a i r p l a n e was

accomplished on December 11, 1967.

Second Officer Jackley s a t i s f a c t o r i l y completed t h e following:

Proficiency - 12/11/67 (B727)

Line - 12/27/67 (E-727)

F l i g h t Engineer data from company records a r e as follows:

Approximate Hours

a. T o t a l second o f f i c e r time 303

b. T o t a l second o f f i c e r time i n E 7 2 7 160

C. T o t a l second o f f i c e r time l a s t 90 days 160

d. T o t a l second o f f i c e r time last 30 days 54

e. C e r t i f i c a t e number and r a t i n g s held:

F l i g h t Engineer No. 1764128 with r a t i n g s r e c i p r o c a t i n g engine

powered and t u r b o j e t powered.

f. k t e of last physical examination f o r f i r s t - c l a s s medical

c e r t i f i c a t e - 2/28/68 with no l i m i t a t i o n s .

Hours and Minutes

g. Crew r e s t past 24 hours 11:x)

h. Duty time last 24 hours 10:15

i. F l i g h t time last 24 hours p r i o r t o t h i s f l i g h t 4: 46

5. F l i g h t time t h i s f l i g h t 0 : 16

,
 APPENDIX B

Aircraft Information

a. Aircraft

Type - Boeing 727-22QC; I d e n t i f i c a t i o n - N7425U; Manufacturers S e r i a l No.

19200; UAL Plane No. 7425

Date of Manufacture - June 19, 1967

h t e of UAL Acceptance - June 19, 1967
Registered Owner - United A i r Lines, InC.

Total a i r c r a f t time 2208.04 hours

Time s i n c e #3 maintenance check 171.55 hours

Time since last s e r v i c e check 52.15 hours

Time s i n c e last terminating p r e f l i g h t check l7:ll hours

Time s i n c e last en r o u t e s e r v i c e 0O:OO hours

b. Engines - Fhtt & Whitney JT8&1

Time Since Last

Position S e r i a l No. Heavy Maintenance Time Since Overhaul

1 649018 2269 hours 5606 hours

2 653309 S7OO hours 4345 hours

3 6534U 172 hours 4831 hours

Note: A l l hours shown above a r e times as corrected by W OPBSP.

 APPENDIX C

COCKPIT VOICE RECORDER EXCERFTS

The following is a transcription of that portion of the cockpit

voice recording commencing with the issuance of takeoff clearance and

terminating with the end of the recording.

LEGEND

LC O'Hare Tower
f
RDO Aircraft radio channel

CAM Cockpit area microphone channel

-1 Captain's voice

-2 First officer's voice

-3 Second officer's voice

* Unintelligible word or phrase

Note 1 Words enclosed in parentheses are the best possible determination

Note 2 Times indicated are in minutes and seconds from beginning of

issuance of takeoff clearance.

 comm
-
TIME SOURCE

0:00 LC Seventy nine s i x t y t h r e e , t u r n l e f t heading two

seven zero, cleared for takeoff nine r i g h t

0:05 RDO-2 Left two seven zero t h e heading, cleared f o r takeoff

nine r i g h t , United seventy nine s i x t y three, good night

0: 15 CAM- 1 Final items

0: 16 CAM- 3 Ignition

0:18 CAM-2 Flight

CAM-3 Anti- skid

0:20.5 CAM- 2 Armed - nose r e l e a s e

0: 22 CAM-3 Oil cooler --- ground o f f , takeoff checklist complete

CAM-? *
0:46.5 CAM- ? Okay i t s

0: 49 CAM Sound of pulsating warning horn begins

0: 5 1 CAM- 2 Flaps, A N , f l a p s , speed brake, forward i n t h e detent,

f l a p s f i v e t o f i f t e e n degrees, t r i m up, i t ' s i n t h e

green band (1:02.5)

C
AM1
- Oh, ... it
1:07.5 CAM-1 I have it

W? (YOU going t o get i t ? )

1:16.5 CAM-1 It must be t h e t r i m

CAM-2 No, i t ' s i n t h e green band now

CAM-2 It can't be t h e trim

- _-- _--
~
.
~.-
-

- 2-
-
TIME SOURCE

1:20 CAM Sound of p u l s a t i n g warning horn ceases

1:22 CAM-2 Rotate

CAM-3 A N ' S (okay)

CAM-2 It's i n t h e green band

1:26 w Sound of s t i c k shaker begins

1:34 CAM Sound of breakup begins

1:45 End of recording

 NATIONAL TRANSPORTATION SAFETY BOARD
DEPARTMENT OF TRANSPORTATION
Washington, D.C.

TIRE TRACKS & WRECKAGE DISTRIBUTON CHART

DCA 68-A-3, UNITED AIRLINES B-727QC, N7425U
CHICAGO-O’HARE INTERNATIONAL AIRPORT
CHICAG0,ILL.
MARCH 21, 1968
L-