I thought I might have read this in 1968/’69, but the front page of the report suggests I couldn’t possibly have read it before 1972. So much for “infallible memory”. I was captivated by the detail in the report and the enormity of the investigation which led to it. Nothing like the Asiana 214 accident, nor N600XL, but pretty extensive. I was horrified at the fate of the crew.
Here’s an oddity. In almost all of the accident reports I’ve ever read, when an air carrier company was involved, the trip number was invariably used to describe not only the accident title, but internal references to the flight, as well. In this one, there’s no flight number reference on the title page, although the aircraft tail number (N785FT) is shown. In the sub-title page, neither is listed, although in the “Abstract” farther down the page, “Flight 45” suggests the trip number of the flight.
Notwithstanding the foregoing, when we finally get to see the transcript of the CVR (cockpit voice recorder) we find all references to the flight as “Flying Tiger 785”. Since Flying Tiger was solely a freight operation, there was no need for discrete trip numbers which passengers could choose (no passengers) and there were probably no scheduled (as in months in advance) operations. Freight flying is more of an ad hoc operation, sort of “when you ship, we fly”. Therefore, it would make sense to come up with a way to number flights when there wasn’t the necessity for a structured system. The tail number, largely unique, would be a good choice, and apparently was here, but nowhere in the report is it explained, nor where the “45” came from.
Reading this report from the perspective of >forty years experience in both the process as well as the industry, it strikes me as not as rigorous as later investigations seem to have been. We are not left with a compelling reason why this aircraft crashed, although the data suggests two things to me—lack of discipline in flying the airplane and poor ATC performance.
CRM (Crew Resource Management) was not an industry concept at the time—that would be born ≈twenty years later, and still not fully embraced as recently as the Asiana accident in 2013. In this accident, it was less a true CRM failure as it was distractions from the mission of the crew which was to get the airplane through a local environmental impediment and find the runway. Weather conditions were generally good VFR but there was a rainshower just short of the runway threshold. The PF (pilot flying— the FO, in this case) didn’t manage the approach parameters as well as an ATP (Air Transport Pilot) should have, and the PNF (pilot not flying—the Captain) wasn’t as rigorous in situational call outs as he should have been. Moreover, there was a radar altimeter on board, which should have been the Fail Safe, but clearly wasn’t
You may be surprised at my criticism of the GCA controller, given my own history. Nevertheless, poor ATC is indefensible, and my assessment of it as inferred from the report is that it was sub-standard in this case. Although I’ve never conducted a precision approach (GCA is the military term), I have conducted surveillance approaches, which are very similar but not done with an actual GCA display. Gross altitude guidance is given, but it’s given as calculated suggestions based on distance from the runway, all provided by the controller. Nevertheless, the azimuthal part is virtually identical to a GCA approach. The only difference is the display is based on the ordinary ASR (airport surveillance radar) which sweeps about every seven seconds. GCA scans are much more frequent, although I don’t have actual numbers.
In this case, I feel there weren’t frequent enough commands and it appears that altitude excursions (especially below the glide path) were not properly identified nor advertised. There is also a point at which the controller was not only authorized but obligated to command the execution of a missed approach, which he failed to do. I have no explanation other than the Bell curve. It’s exactly like the question, “what do you call the person who finished at the bottom of the class in medical school? Doctor.” ATC is exactly the same. Half of us were brilliant executors, the other half were below average. But, ATC is only part of the story.
Even though there wasn’t a precision, ground based instrument approach available, PARs (Precision Approach Radar, the civilian nomenclature of GCA) have been around for a long time, and in the early post war years were the precision approach available at busier airports. By 1970, they had largely disappeared from the civilian ATC system, although still available and conducted in joint use facilities such as CHS. I witnessed at least one while there on a visit, coincidentally, in 1970. The pilots of a carrier such as Flying Tiger, which was a frequently used contractor by the military, would have been exposed to PAR/GCA approaches far more frequently than the average line pilot of a scheduled passenger carrier in the U.S. at the time.
Another thing the report sort of glossed over was the cross tailwind component on approach—some ten knots. It was also reported that the wind changed direction shortly before the crash. This is functionally similar to the effects of windshear often cited as a factor in other accidents, and can be a real problem at the busiest point in the flight, as well as the most vulnerable. It certainly got my attention with my excellent hind sight.
Although not seen much any more, there was often a paragraph categorizing the survivability of a crash. In this case, three of the four occupants did survive and were even able to talk to early arriving rescuers/witnesses. Extraction proved impossible and the three survivors of the original impact succumbed to the tide—two drowned, the third was asphyxiated (a distinction without a difference, in my view). This was what was horrific to me.
Flying Tigers disappeared almost twenty years later, as they were bought out by Federal Express. I worked a lot of their aircraft into ORD back in the day, mostly over DBQ, although I’m not sure why. Likely because those flights probably originated in the SFO/OAK/SUU, all in the military staging chain for Vietnam (and return). Those flights were generally over DBQ.
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