F L I G H T S A F E T Y F O U N D AT I O N

Vol. 53 No.1 For Everyone Concerned with the Safety of Flight January 1996

Accident Prevention

Two Engines Separate from the Right Wing and

Result in Loss of Control and Crash of

Boeing 747 Freighter

marginal controllability, a safe landing became highly

improbable, if not virtually impossible."

The investigation was hampered because the cockpit voice

recorder (CVR) was never found. The digital flight data

recorder (DFDR) was severely damaged, but the data

concerning the accident flight were recovered.

The B-747-200 freighter was owned and operated by El Al

Israel Airlines. The accident aircraft arrived in Amsterdam at

1540 hours local time, after flying from John F. Kennedy

International Airport, New York, New York, U.S., the report

said. The accident crew (captain, first officer and flight

engineer) and a nonrevenue passenger boarded the aircraft after

it was fueled and loaded with cargo.

At 1921, the flight departed Amsterdam. The takeoff and initial

climb were normal until 1927:30, the report said. As the aircraft

climbed through 6,500 feet, the No. 3 and No. 4 pylons and

engines separated from the right wing. The first officer then

transmitted to air traffic control (ATC), "El Al 1862, Mayday,

Mayday, we have an emergency," the report said.

"The aircraft turned to the right and, according to witnesses

on the ground, started dumping fuel," the report said. The

Amsterdam Radar controller acknowledged the flight's

emergency call, and cleared the area of other traffic. After

confirming that the crew wanted to return to Schiphol Airport,

the controller instructed the flight to turn to a heading of 260

The crew of the Boeing 747-200 freighter made a normal

takeoff from Schiphol Airport, Amsterdam, Netherlands, on

an instrument flight rules (IFR) flight plan to Tel Aviv, Israel.

Seven and a half minutes later, while the aircraft was climbing

through 6,500 feet (1,982 meters), the No. 3 pylon and its

engine separated from the right wing and damaged part of the

wing's leading edge. The No. 3 engine then struck the No. 4

engine, causing it to also separate from the aircraft.

While attempting to return to Schiphol Airport, the crew lost

control of the aircraft, which crashed into an apartment building

in a suburb of Amsterdam. The three crew members and one

nonrevenue passenger were killed. In addition, 43 persons on

the ground were killed, 11 persons were seriously injured and

15 persons received minor injuries in the Oct. 4, 1992, accident.

The final report of the Netherlands Aviation Safety Board (NASB)

concluded that the probable causes of the accident were: "The

design and certification of the B-747 pylon was found to be

inadequate to provide the required level of safety. Furthermore,

the system [designed] to ensure structural integrity by inspection

failed. This ultimately caused - probably initiated by fatigue in

the inboard midspar fuse pin - the No. 3 pylon and engine to

separate from the wing in such a way that the No. 4 pylon and

engine were torn off, part of the leading edge of the wing was

damaged and the use of several systems was lost or limited."

The report concluded: "This subsequently left the flight crew

with very limited control of the airplane. Because of the 2

degrees. "At 1928:17, the crew reported a fire on engine No.

3 and, subsequently, they indicated [a] loss of thrust on engines

No. 3 and No. 4," the report said. [The report attributed the

flight crew's announcement of a fire on the No. 3 engine to a

"double fault indication of the (engine-fire detection) system,"

which, according to the system logic, triggered a fire warning,

and the crew's "limited field of view from the cockpit to the

wing area."]

"Witnesses heard one or more banging sounds, and saw a dark

plume of smoke trailing the aircraft," the report said. "Some

witnesses saw objects fall. Other witnesses also saw fire on

the right wing which eventually disappeared. When the aircraft

turned right, two vapor trails were seen to emerge from the

wingtips."

At 1928:57, the controller told the crew that Runway 6 was in

use, and that the wind was from 40 degrees at 21 knots. "The

flight crew, however, requested Runway 27 for landing," the

report said. "Because the aircraft was only seven miles [11.3

kilometers] from the airport, and still flying at an altitude of

5,000 feet [1,525 meters], a straight-in approach was not

feasible, and the crew was instructed to turn right to heading

360 and descend to 2,000 feet [610 meters]. The crew was

again informed about the wind (by then 50 degrees at 22

knots)."

About one minute later, the controller asked the crew about

the distance required for their approach. The crew replied that

they needed "12 miles [19.3 kilometers] final for landing,"

the report said. Together with this reply, the call "Flaps one"

could be heard in the background.

The controller instructed the crew to turn right to 100 degrees,

then asked the crew about the aircraft status. The crew replied,

"No. 3 and [No.] 4 are out and we have problems with our

flaps," the report said. The aircraft turned through 100 degrees,

maintaining a heading of 120 degrees. "No corrective action

was taken by the controller," the report said. The aircraft was

now maintaining 260 knots, and was in a gradual descent.

The flight was cleared for the approach, and given a heading

of 270 degrees to intercept the final approach course, the report

said. The aircraft was at approximately 4,000 feet (1,220

meters), and on a heading of 120 degrees. At this point, the

aircraft was three nautical miles (NM) (5.5 kilometers) north

of the extended centerline of Runway 27, and about 11 miles

(17.7 kilometers) from the runway. "According to the radar

plot, it took about 30 seconds before the aircraft actually

changed heading," the report said.

The controller noticed that the flight was going to overshoot

the localizer, and instructed the crew to turn further right to a

heading of 290 degrees, to intercept the localizer from the

south, the report said. Twenty seconds later, the controller

instructed the flight to turn to 310 degrees, and to descend to

1,500 feet (457 meters).

At 1935:03, the crew acknowledged the controller's instructions

and added, "and we have a controlling problem," the report said.

About 25 seconds later, the first officer radioed, "Going down

1862, going down ... ," the report said. "In the first part of this

transmission, commands from the captain to raise all the flaps

and to lower the landing gear could be heard. During the middle

part of this transmission, a sound was heard, and in the final

part of the transmission, another sound was audible. These

sounds were later analyzed and determined to be the stick shaker

and the ground-proximity warning system respectively," the

report said.

At 1935:42, the aircraft crashed into an 11-story apartment

building, approximately 13 kilometers (eight miles) east of

Schiphol Airport. "The impact was centered at the apex of two

connected and angled blocks of apartments, and fragments of

the aircraft and the buildings were scattered over an area

approximately 400 meters [1,320 feet] wide and 600 meters

[1,980 feet] long," the report said. The aircraft collided with the

two buildings while in a right bank of slightly more than 90

degrees, and in a nose-down attitude of approximately 70 degrees.

"Fire-fighting and rescue operations started shortly after the

crash," the report said. The aircraft was destroyed by the impact

and the ensuing fire. The two apartment buildings were partly

destroyed, and later demolished.

The report described the wreckage pattern: "The initial impact

area in the frontal face of the buildings was small. Pavement

and walkways along the initial impact area, and rather high

trees immediately in front of the building remained

undamaged. Most of the structure in front of the wings of the

aircraft was recovered from this area. Parts of the cockpit

section, cockpit interior, controls and human remains of the

crew were recovered at the right hand side of the apex [of the

two buildings]."

The report continued: "Ground water level, mud and [local]

repeatedly ensuing fires formed generally hazardous conditions,

seriously impairing the possibility of retrieving the flight

recorders, which were not found in the main wreckage area.

The DFDR was recovered after a scrutinous inspection of the

already removed mixture of debris of the aircraft and rubble.

The possibility has to be considered seriously that the CVR was

stolen from the area, as were several other parts, [e.g.], the left-hand

steering wheel."

The DFDR was heavily damaged by the crash impact and

postcrash fire, the report said. Nevertheless, the DFDR tape

was recovered. "The tape itself was found broken at four places,

where it was not wound on the reels. The tape exhibited cracks,

discoloration and contamination, particularly at the section that

contained the information of the last two and a half minutes of

the flight. A small amount of water was also found in the crash-protection

unit of the recorder. Notwithstanding the damage,

a readout was accomplished on some parameters."

When investigators examined the wreckage, they determined

that the "aircraft configuration at impact was TE [trailing-edge]

flaps up, LE [leading-edge] flaps partially extended, stabilizer

trim approximately 4.2 units aircraft nose-up, wing gears up,

body gears and nose gears in transit," the report said.

The No. 1 and No. 2 engines were found in the main impact

area near the apartment building. "Examination of the engine

fragments and analysis of the damage indicated that the engines

were operating at high power up to the impact with the ground,"

the report said. "No evidence was found of pre-existing damage

to the engines which might have been caused by an external or

internal source."

"Engines No. 3 and [No.] 4 were dredged from the lake located

below the aircraft's flight path, together with the engine pylons

and many parts of their nose cowls and thrust reversers," the

report said. "Internal rub marks and other witness marks

indicated that when the engines hit the water they were either

at a low rotating speed or had stopped. Internal examination

of engine [No.] 3 and [No.] 4 showed no abnormal signs of

pre-existing damage."

Investigators reviewed the possibility of a bird strike on the

accident aircraft, and found no evidence of bird impact on the

No. 3 and No. 4 engines or the engine cowlings, the report

said. The possibility of sabotage was also examined, and no

evidence was found that sabotage caused the accident, the

report said.

The maintenance records for the accident aircraft were reviewed,

and "all the required inspection and maintenance actions had

been completed, and all applicable airworthiness directives

(ADs) had been accomplished, or were in the process of being

accomplished within the specified time limits," the report said.

"Examination of the service records, crew write-ups, action

items, trend monitoring data and flight recorder data of previous

flights did not reveal any significant deviations."

The NASB determined that "the accident sequence was

initiated by the in-flight separation of the No. 3 engine pylon

from the wing," the report said. "Engine and pylon No. 3

separated from the wing and collided with engine No. 4, in an

outward and rearward direction. In view of the amount of LE

flaps and LE structure found, the right wing leading edge must

have been damaged up to the front spar of the right-hand wing,

over an area approximately one meter [3.3 feet] left of pylon

No. 3 to approximately one meter right of No. 4. It is assumed

that [because of] the speed of the aircraft, the aerodynamic

distortion and turbulence, some parts were blown off the

leading edge of the right-hand wing up to the front spar."

After the No. 3 and No. 4 pylons and engines separated,

investigators believed, the crew flew the aircraft under the

following conditions:

· The right wing leading edge was severely damaged;

· The right wing leading-edge flaps were partially damaged;

· The right outboard aileron was "floating" at five degrees

trailing edge­up;

· There was limited roll control because no outboard

aileron was available, and the spoiler system was only

partially available;

· There was limited rudder control because of a lagging

of the lower rudder for unknown reasons;

· The right inboard aileron was probably less effective

because of disturbed airflow created by the damaged

wing leading edge and the loss of the No. 3 pylon;

and,

· Engines No. 1 and No. 2 were at high thrust settings.

The NASB concluded that "the separation of the engine pylon

was caused by a failure of connecting components that attach

the pylon to the wing of the airplane," the report said. "To

determine the initial failure origin, a total of nine different

scenarios were identified, each of which could lead to the

separation of the engine pylon from the wing."

Investigators believed that the most likely sequence of events

that led to the separation of the engine pylon was "(1) a fracture

initiated by a fatigue crack of the shear face of the inboard

midspar fuse pin," the report said, " ... followed by (2) a

sequential failure of the outboard lug of the inboard midspar

fitting. Then (3), the outboard shear face. Finally (4), the

inboard shear face of the outboard midspar fuse pin. The

subsequent pylon engine separation occurred during the flight

out of Schiphol Airport at 6,500 feet and at an IAS [indicated

airspeed] of 367 knots."

The NASB analyzed the U.S. Federal Aviation

Administration's (FAA's) supervision of the continued

airworthiness of the B-747. "This organization [the FAA]

carries out its responsibility mainly by issuing airworthiness

directives [ADs], many of which were originally Boeing

service bulletins [SBs]," the report said. "In [the] case of the

Boeing 747, the FAA issued a large number of ADs addressing

numerous fatigue problems in the pylon structure, including

fuse pins, lugs and fittings. Nevertheless, new cracks and

failures were discovered frequently, giving doubt about the

ultimate strength of the structure."

The report continued: "In addition to the fatigue problems, a

static problem was identified in service. On several occasions,

so-called crank-shafting of fuse pins was reported. Apparently,

a plastic deformation of the fuse pins can occur at operational

load conditions. Over a time period of 15 months, three pylons

([on airplanes operated by] China Airlines, El Al and Evergreen)

have failed in flight, resulting in two fatal [accidents] and one

serious accident."

[The other fatal accident occurred on Dec. 29, 1991. While

passing through 5,200 feet (1,586 meters) on a climbout, a

China Airlines B-747-200 freighter experienced separation of

pylons and engines No. 3 and No. 4. All five crew members

were killed when the airplane collided with a hillside near

Taipei, Taiwan, while attempting to return to the airport. An

Evergreen International Airlines B-747-121 freighter

encountered severe turbulence at 2,000 feet (610 meters) during

climb after takeoff from Anchorage, Alaska, U.S. The No. 2

pylon and engine separated from the wing. Despite having

extreme difficulty in controlling the aircraft, the crew made a

successful emergency landing.]

The NASB concluded: "The original design together with the

continuous airworthiness measures and the associated inspection

system did not guarantee the minimum required level of safety

of the Boeing 747 at the time of the accident."

As a result of this accident, and other occurrences of wing-pylon

problems on the B-747, "Boeing developed a stainless

steel fuse pin with a considerably improved fatigue and crack

growth life," the report said. "Furthermore, the static strength

and fatigue, and crack growth analysis, will be supported by

tests."

The U.S. National Transportation Safety Board (NTSB)

recommended that the FAA take a number of actions relating

to the design of, and inspection procedures for, the B-747:

· Reduce the recurrent inspection interval for the old-style

fuse pins from 500 flight cycles to 100 flight cycles or

fewer, and specify a time for removing the old-style fuse

pins from service;

· Reduce the inspection intervals for the new-style fuse

pins if a need for reduction is indicated by inspections;

· Require an ultrasonic inspection, in place of visual

inspection, of the wing spar lug and pylon clevis of the

midspar attachments;

· Establish an inspection requirement for the upper-link

and diagonal-brace attachment hardware;

· Apply the inspection program for the new-style pins and

the pylon-attachment fittings to General Electric (GE)-powered

airplanes;

· Require Boeing to obtain flight test data to be used in

engineering analysis to validate that the pylon-to-wing

attachments have adequate safety margins for all flight

conditions and engine configurations; and,

· Require Boeing to make available a newly designed fuse

pin for the B-747 engine pylon-to-wing midspar

attachment to replace current fuse pins that are susceptible

to corrosion or fatigue cracking.

By the end of July 1995, the NTSB had classified the FAA's

responses to these recommendations "closed - acceptable

action," meaning that the recommendations had been

implemented or alternate actions taken to the same effect.

One other NTSB recommendation was:

· Require the installation of a midspar fuse pin­indicating

stripe on each side of the B-747 engine nacelle struts, in

accordance with a Boeing service bulletin, and require

a check for wing-to-pylon misalignment before each

flight.

The FAA disagreed with the recommendation to require preflight

inspections on the grounds that misalignment could be too small

to detect from the ground during visual inspection.

The background and qualifications of the flight crew were

reviewed. The captain, age 59, held an Israeli Airline Transport

License (ATPL), with type ratings in the B-747, Boeing 707

and McDonnell Douglas DC-3. He had 25,000 hours total flying

time, and 9,500 hours in the B-747. The captain had flown 233

hours in the B-747 in the 90 days preceding the accident. He

held a current first-class medical certificate, with a requirement

to wear corrective glasses while exercising the privileges of his

certificate, the report said.

The first officer, age 32, held an Israeli ATPL, with type ratings

in the B-707 and the B-747. He had 4,288 hours total flying

time, and 612 hours in the B-747. The first officer had flown

151 hours in the B-747 in the 90 days preceding the accident.

He held a first-class medical certificate with no limitations, the

report said.

The flight engineer, age 61, held an Israeli flight engineer license,

with ratings for the B-747 and B-707. He had 26,000 hours

total flying time, and 15,000 hours in the B-747. The flight

engineer had flown 222 hours in the B-747 in the 90 days

preceding the accident. He held a first-class medical certificate,

with the requirement to wear corrective glasses while exercising

the privileges of his certificate, the report said.

The day before the accident flight, all three crew members

had flown together on the route from Tel Aviv to London, then

to Amsterdam, the report said. The crew reported for duty on

the day of the accident flight after resting for 20 hours.

When the accident flight departed Amsterdam, the first officer

was the pilot flying, and the captain was communicating with

ATC, the report said. After the engines separated from the right

wing, the Mayday call and all following communications were

made by the first officer. "The captain clearly took over control

and kept control of the airplane throughout the remainder of

the flight," the report said.

Investigators reviewed the performance of the flight crew after

the engines separated. DFDR data revealed that the captain

was at times using full rudder pedal deflection, and control

wheel deflections from 20 degrees to 60 degrees to the left,

the report said. "The Boeing training manual states that in an

asymmetric flight condition with two engines inoperative on

one side, there should be enough rudder authority to allow the

control wheel to be almost neutral up to MCT [maximum

continuous thrust] at maneuvering speed," the report said.

During a flight in a B-747 simulator, "it was noted that with

flaps up (which locks out the outboard ailerons) under the

above-mentioned conditions and with maximum deflection,

approximately 30 degrees left wing­down control wheel

deflection was needed to maintain straight flight," the report said.

"In the case of El Al 1862, the damage to the right wing and

the up-floating right outboard aileron required even more left

wing­down control wheel deflection."

The report noted: "This supports the hypothesis that the crew

faced a very unusual situation. At 260 knots, the airplane

was almost out of control with full deflected rudder and 60

to 70 percent of maximum control. This was very different

from what the crew would expect from their knowledge of

an experience with an aircraft with two engines inoperative."

Investigators then evaluated the crew's handling of the aircraft

in the final moments of the flight. "Until the last phase of the

flight, aircraft control was possible, but extremely difficult,"

the report said. "The aircraft was in a right turn to intercept

the localizer, and the crew was preparing for the final approach,

and may have selected the leading edge flaps electrically ... .

The aircraft decelerated when the pitch attitude was increased,

probably to reduce the rate of descent."

The report continued: "The associated increase in angle-of-attack

caused an increased drag. Additional drag of a sideslip

and possible extended leading-edge flaps resulted in a further

speed decay. This speed decay was probably the reason to

increase thrust on the two remaining engines, No. 1 and [No.]

2."

Those conditions resulted in an increased roll moment to the

right caused by:

· asymmetric lift generation at an increased angle-of-attack;

· high-thrust asymmetry;

· a loss of aerodynamic efficiency of the right inboard

aileron at an increased angle-of-attack; and,

· possible asymmetric lift caused by leading-edge flaps

operation.

"The resulting roll moment exceeded the available roll

control," the report said. "Near the end of the flight, the crew

was clearly confronted with a dilemma. On the one hand, they

needed extra thrust to decrease the rate of descent and maintain

speed, [but] on the other hand the higher thrust increased the

control difficulties. In general, in case of degraded

performance, thrust should be confined to that level at which

aircraft control can be maintained."

Investigators reviewed the crew's immediate decision and

actions to return to Schiphol Airport. "The decision to land

as soon as possible committed the crew to perform under

extreme time constraints. The complexity of the emergency,

on the other hand, called for time-consuming and partly

conflicting checklist procedures. Warnings and indications

in the cockpit were most likely compelling and confusing.

Furthermore, the pilots were confronted with a controllability

and performance situation which was completely unknown

to them, and they were not in a position to make a correct

assessment."

The report concluded: "The [NASB] is of the opinion that given

the situation of the crew as described above, and the marginal

controllability, the possibility for a safe landing was highly

improbable, if not virtually impossible."

The performance of the air traffic controllers who handled

the accident flight was reviewed. The NASB believed that

the exchange of information during the emergency was at

times inadequate. "The crew only gave sparse information

concerning their problems and intentions," the report said.

"The controller occasionally used nonstandard phraseology

which was not as explicit or understandable as would be

desirable in an emergency situation ... . Pilots and ATC

personnel should be aware that for the adequate handling of

an emergency, it is vital to use standard phraseology, and to

exchange all necessary information about the urgency and

the severity of the situation."

In evaluating the radar vectors provided by ATC, the report

said: "The attempt of the controller to position the airplane

by radar vectoring to a point 12 NM on the localizer for

Runway 27 was not completely successful. A wider than

normal setup of the circuit would have better allowed for the

possible steering errors and slow reactions to heading changes

which occurred, and which may be expected in emergency

situations."

The NASB also commented on the controller's vectoring of

the accident flight over the city of Amsterdam during the

emergency. "The [NASB] feels that in the handling of

emergency situations, not only the safety of airplane and

passengers, but also the possible risk to third parties [on the

ground] should be taken into account," the report said.

The weather at the time of the accident was reviewed. The

conditions at Schiphol Airport at the time of the crash consisted

of 1 / 8 alto-cumulus clouds at 13,000 feet (3,965 meters), and

the visibility from the ground to 2,000 feet was 15 kilometers

(9.3 miles), the report said. The surface wind was from 40

degrees at 23 knots, with gusts to 33 knots, and the temperature

was 13 degrees C (55 degrees F). There was light-to-moderate

turbulence, the report said.

As a result of its investigation, the Netherlands Aviation Safety

Board concluded the following:

· "The airplane was inspected and maintained in accordance

with El Al and Boeing maintenance procedures;

· "The flight crew was trained and certificated in

accordance with appropriate Israeli CAA [Civil Aviation

Authority], El Al and industry standard procedures;

· "At an altitude of about 6,500 feet, the No. 3 pylon failed.

This pylon and No. 3 engine separated from the right wing;

· "The No. 3 engine struck the No. 4 engine, causing the

No. 4 pylon and engine to separate from the wing;

· "The leading-edge flaps and a portion of the fixed leading

edge of the wing back to the front spar were extensively

damaged. The No. 3 and [No.] 4 hydraulic systems were

completely [disabled] and the pneumatic system was

partially disabled;

· "The flight crew reported a fire on the No. 3 engine to

ATC. Given the system logic, a fire warning may have

been the result of a double fault indication of the system;

· "[Because of] the limited field of view from the cockpit

to the wing area, the flight crew was not able to observe

the separation of the No. 3 engine, [or] the damage to

the wing;

· "Performance and controllability were so severely

limited that the airplane was marginally flyable;

· "Current standard industry training requirements and

procedures do not cover complex emergencies like [that]

encountered by El Al 1862;

· "After declaring an emergency, the flight crew decided

to return to Schiphol Airport immediately and land on

Runway 27, although Runway 6 was in use for landing;

· "Because the airplane became too high and too close to

the airport to accomplish a straight-in landing, the flight

crew was vectored through an approximate 360-degree

pattern of descending turns to intercept the final approach

course;

· "During the vectoring to the final approach, the flight

crew stated to air traffic control that they were

experiencing a problem with the aircraft's flaps. Shortly

before intercepting the final approach, they reported

controlling problems;

ATC Transcript of El Al 1862's Final Moments

19:27:56 CREW: El Al 1862, Mayday, Mayday, we have

an emergency.

19:28:00 ATC: El Al 1862, roger. Break, KLM 237, turn

left heading 090.

19:28:06 ATC: El Al 1862, do you wish to return to

Schiphol?

19:28:09 CREW: Affirmative, Mayday, Mayday, Mayday.

19:28:11 ATC: Turn right heading 260, field eh ... behind

you eh ... in your - to the west eh ...

distance 18 miles.

19:28:17 CREW: Roger, we have fire on engine number

number 3, we have fire on engine number

3.

19:28:22 ATC: Roger, heading 270 for downwind.

19:28:24 CREW: 270 downwind.

19:28:31 ATC: El Al 1862, surface wind 040 at 21 knots.

19:28:35 CREW: Roger.

19:28:45 CREW: El Al 1862, lost number 3 and number 4

engine, number 3 and number 4 engine.

19:28:50 ATC: Roger, 1862.

19:28:54 CREW: What will be the runway in use for me at

Amsterdam?

19:28:57 ATC: Runway 6 in use, sir. Surface wind 040

at 21 knots, QNH 1012.

19:29:02 CREW: 1012, we request 27 for landing.

19:29:05 ATC: Roger, can you call Approach now, 121.2

for your line-up?

19:29:08 CREW: 121.2, bye bye.

19:29:08 ATC: Bye.

19:29:25 CREW: Schipol, El Al 1862, we have an

emergency, eh ... we're number t- ... eh

... 3 and 4 engine inoperative [badly

readable, probably: "intending" or

"returning"] landing.

19:29:32 ATC: El Al 1862, roger, copied about your

emergency, contact 118.4 for your line-up.

19:29:39 CREW: 118.4, bye.

19:29:49 CREW: Schiphol, El Al 1862, we have an

emergency, number 3 and number 4

engine inoperative, request 27 for landing.

19:29:58 ATC: You request 27, in that case heading 360,

360 the heading, descend to 2,000 feet

on 1012, mind, the wind is 050 at 22.

19:30:10 CREW: Roger, can you say again the wind please?

19:30:12 ATC: 050 at 22.

19:30:14 CREW: Roger, what heading for Runway 27?

19:30:16 ATC: Heading 360, heading 360 and [then]

give you a right turn on, to cross the

localizer first, and you've got only seven

miles to go from present position.

19:30:25 CREW: Roger, 36 copied.

19:31:17 ATC: El Al 1862, what is the distance you need

to touchdown?

19:31:27 CREW: 12 miles final we need for landing.

19:31:30 ATC: Yeah, how many miles final ... eh

correction ... how many miles track miles

you need?

19:31:40 CREW: ... Flap one ... we need ... eh ... a 12 miles

final for landing.

19:31:43 ATC: Okay, right right heading 100, right right

heading 100.

19:31:46 CREW: Heading 100.

19:32:15 ATC: El Al 1862, just to be sure, your engines

number 3 and 4 are out?

19:32:20 CREW: Number 3 and 4 are out and we have ...

eh ... problems with our flaps.

19:32:25 ATC: Problem with the flaps, roger.

19:32:37 CREW: Heading 100, El Al 1862.

19:32:39 ATC: Thank you, 1862.

19:33:00 CREW: Okay, heading ... eh ... and turning, eh ...

maintaining.

19:33:05 ATC: Roger, 1862, your speed is?

19:33:10 CREW: Say again?

19:33:12 ATC: Your speed?

19:33:13 CREW: Our speed is ... eh ... 260.

19:33:15 ATC: Okay, you have around 13 miles to go to

touchdown, speed is all yours, you are

cleared to land Runway 27.

19:33:21 CREW: Cleared to land 27.

19:33:37 ATC: El Al 1862, a right right turn heading 270

adjust on the localizer, cleared for

approach.

19:33:44 CREW: Right, right 270.

19:34:18 ATC: El Al 1862, you're about to cross the

localizer due to your speed, continue the

right turn heading 290, heading 290, 12

track miles to go, 12 track miles to go.

19:34:28 CREW: Roger, 290.

19:34:48 ATC: El Al 1862, further right, heading 310,

heading 310.

19:34:52 CREW: 310.

19:34:58 ATC: El Al 1862, continue descent 1,500 feet,

1,500.

19:35:03 CREW: 1,500, and we have a controlling problem.

19:35:06 ATC: You have a controlling problem as well,

roger.

19:35:25 CREW: Going down 1862, going down, going

down, copied going down. [Background:

"Raise all the flaps, all the flaps raise,

lower the gear."]

19:35:47 ATC: Yes, El Al 1862, your heading.

· "During preparation for final approach, speed reduction

made the airplane exceed the limits of its remaining

control capability. The airplane crashed into an apartment

complex;

· "Exchange of information between El Al 1862 and ATC

was not always adequate;

· "The effectiveness of the fused-pylon concept in

protecting the wing structure and fuel tank against the

consequences of pylon overloads was based on the history

of the similar fuse-pin design of the Boeing 747;

· "Certification of the B-747 pylon included a fail-safe

analysis of the nacelle and pylon concept. At that time,

this analysis, however, did not address the specific fail-safe

requirement assuming a fatigue failure or partial

failure of a single structure element;

· "A then state-of-the-art fatigue analysis of the pylon

structure was made to establish the maintenance

requirements. In real life, this did not turn out to be

sufficiently reliable. From August 1979 on, a large

number of SBs and ADs were issued addressing

numerous fatigue problems in the pylon structure

including fuse pins, lugs and fittings;

· "Inspection and analysis performed by specialists on

recovered parts of the pylon construction revealed severe

damage [caused by] fatigue;

· "No firm conclusion could be drawn whether or not

the fatigue crack in the outboard midspar fuse pin was

detectable at the last ultrasonic inspection;

· "After analyzing the possibilities, it is assumed that the

separation was initiated by a fatigue crack in the inboard

shear face of the fuse pin in the inboard midspar fitting;

[and,]

· "Over a period of 15 months, three pylons have failed

in flight, resulting in two fatal [accidents] and one serious

accident. The original type design together with the

continuous airworthiness measures and associated

inspection system did not guarantee the minimum

required level of safety of the Boeing 747."

The NASB issued the following recommendations as a result

of its investigation:

· "Redesign the B-747 pylon structure, including

attachment to engine and wing. All SBs and ADs should

be terminated after the redesign;

· "The redesign program for the pylon should include a

full-scale fatigue and fail-safe test; Source: Netherlands Aviation Safety Board

8 FLIGHT SAFETY FOUNDATION · ACCIDENT PREVENTION · JANUARY 1996

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ACCIDENT PREVENTION

Copyright © 1996 FLIGHT SAFETY FOUNDATION INC. ISSN 1057-5561

Suggestions and opinions expressed in FSF publications belong to the author(s) and are not necessarily endorsed by Flight Safety

Foundation. Content is not intended to take the place of information in company policy handbooks and equipment manuals, or to

supersede government regulations.

Staff: Roger Rozelle, director of publications; Girard Steichen, assistant director of publications; Rick Darby, senior editor; Russell Lawton,

editorial consultant; Karen K. Ehrlich, production coordinator; and Kathryn Ramage, librarian, Jerry Lederer Aviation Safety Library.

Subscriptions: US$80 (U.S.-Canada-Mexico), US$85 Air Mail (all other countries), twelve issues yearly. · Include old and new addresses when

requesting address change. · Flight Safety Foundation, 601 Madison Street, Suite 300, Alexandria, VA 22314 U.S. · Telephone: (703) 739-6700 ·

Fax: (703) 739-6708

· "A large-scale in-flight fleetwide fatigue load

measurement program should be carried out, both on wing,

fuselage and fin-mounted engines in order to establish

more realistic load spectra for fatigue evaluations;

· "Review present methods of controlling structural

integrity, such as nondestructive inspection techniques

and airworthiness directive requirements, in the current-design

B-747 pylon assembly;

· "If a structural design concept is used as the basis for

the certification of another design, in-service safety

problems for both designs should be cross-referenced;

· "Evaluate and where necessary improve the training and

knowledge of flight crews concerning factors affecting

aircraft control when flying in asymmetrical conditions

such as with one or more engines inoperative, including:

­ advantages and disadvantages of direction of turn;

­ limitation of bank; [and,]

­ use of thrust in order to maintain controllability;

· "Evaluate and where necessary improve the training

and knowledge of flight crews in cockpit resource

management in order to prepare them for multiple

systems failures, conflicting checklist requirements and

other beyond-abnormal situations;

· "Expand the information on in-flight emergencies in

appropriate guidance material to include advice [on] how

to [ensure] that pilots and air traffic controllers are aware

of the importance to exchange information in case of

in-flight emergencies. The use of standard phraseology

should be emphasized;

· "Evaluate and where necessary develop common

guidelines on emergency procedures and phraseology

to be used between ATC, fire brigade, airport authorities

and RCC [rescue coordination center];

· "Expand the training of pilots and ATC personnel to

include the awareness that in the handling of emergency

situations, not only the safety of airplane/passengers, but

also the risk to third parties, especially residential areas,

should be considered;

· "Review design philosophy of fire-warning systems, to

preclude false warnings upon engine separation;

· "Review flight control design to ensure that flight control

surfaces do not contribute adversely to airplane control

in case of loss of power to a control surface;

· "Fire resistance of DFDR and CVR should be improved;

· "Investigate the advantages of [the] installation [of]

cameras for external inspection of the airplane from the

flight deck."©

Editorial note: This article was adapted from El Al Flight 1862,

Boeing 747-285F, 4X-AXG, Bijlmermeer, Amsterdam, October

4, 1992, Aircraft Accident Report no. 92-11, prepared by the

Netherlands Aviation Safety Board. The 81-page report, which

was published in February 1994, is in English and includes

diagrams and illustrations.

Boeing 747 EL AL and China Airline Boeing 747 crash
JAL46Econtents.html
Contents
Boeing 747-131
Trans World Airlines Flight 800
Debriefing
Boeing 747-237B
Air India Flight 182
Debriefing
Boeing 747-121A
Pan Am Flight 103
Debriefing
Boeing 747-122
United Airlines Flight 811
Debriefing
The Type Airplane
The Damage Starts
The Radar Blips
The Sudden Loud Sounds
The Abrupt Power Cuts
The Fodded Engines
The Inflight Damage
The Missing Bodies
The Torn Off Noses
The Wreckage Plots
More Similarities
The Red Herring: Bomb!
Inadvertent Opening of the Forward Cargo Door in Flight
Forward Cargo Door Section
Introduction
Introduction Photograph
Introduction Page
Big picture
More pictures.
(larger picture with DC-10 door also)
Boeing 747.html
747historycontents.html
747-121dimensions.html
747cargo door and nose
747specsheet.html
747seating.html
747crashes.html
cargodoorfaraway.html
pressurization1.html
pressurization9.html
aerodynamics.html
crashchart0.html
crashchart1.html
Airworthiness Directive 79-17-02.html
Airworthiness Directive 88-12-04
Airworthiness Directive 90-09-06
800summary
variousdooraccidents.html
forwardcargodoorpict.html
Boeing 747 nose picts right side cargo door
cargodoorfaraway.html
Bibliography:
DC-10page146.html
DC-10page147.html
DC-10photorippeddoor.html
DC-10page148.html
DC-10page151.html
DC-10photowreckage.html
DC-10cargodoorcrashp15.html
DC-10crashcontents.html
AI182essentials.html
182summary.html
AirIndiareportcontents.html
125sum.html
PA103essentials.html
103radarblip1.html
103cvrtext1.html
103scancvr1.html
103scandraw0.html
103blipsani.html
103drawrightleftani.html
103reportcontents.html
UAL811essentials.html
811bigholephotobetter.html
811page92conclusions3cause.html
811PS.html
811picture
More pictures of UAL 811 cargo door hole
811reportcontentpage.html
811skiesdoorcontents.html
811page65uncommandeddoor.html
811page67uncommdooranly1.html
811page68uncommdoranly2.html 800streakexplained.html
800radarbipdoor.html
800cargodoor.html
ntsbcommentlatches.html
800avweekintrigue.html
TWA800essentials.html
800newsreports.html
800newsreports1.html
800newsreport2.html
800newsreport3.html
800crashsitemap.html
800wxradar.html
800partsphoto
800engine3.html
800publicappeal.html .
800doorversusfire.html
TBA.html
crashsimilarvariables.html
TWA800PA103UA811.html
747jetroutes.html
747contrails.html
ejection.html
314summary.html
314accidentreport.html

barry@corazon.com