/ \ PB91-910404 .J$~ 3 u:y: ?$ia NTSB/AAR-9 l/04 NATIONAL TRANSPORTATION’ SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT AVIANCA, THE AIRLINE COLUMBIA BOEING 707=321B, HK 2016 FUEL EXHAUSTION COVE NECK,NEWYORK JANUARY 25, 1990 pl r 5255B The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by the Independent Safet Board Act of 1974 to investigate transportation accidents, determine the progable cause of accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safet recommendations, and statistical reviews. Copies of these documents may be pureKased from the National Technical Information Service, 5285 Port Royal Road, Springfield, Virginia 22161. Details on available publications may be obtained by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 800 Independence Avenue, S.W. Washington, D.C. 20594 (202)382-6735 NTSB/AAR-91/04 PB91-910404 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON. D.C. 20594 AIRCRAFT ACCIDENT REPORT AVIANCA, THE AIRLINE OF COLUMBIA BOEING 707-321 B, HK 2016 FUEL EXHAUSTION COVE NECK, NEW YORK JANUARY 25,199O ADOPTED: APRIL 30,199l NOTATION: 52558 Abstract: This report explains the crash of an Avianca Airlines Boeing 707-321B in Cove Neck, Long Island, New York, on Januar 25, 1990. The safety issues discussed in the report are pilot responsibilities anJ dispatch responsibilities regarding planning, fuel requirements, and flight following during international fli hts; pilot- to-controller communications; air traffic control flow control. rote8ures; and flightcrew coordination and English language proficiency oPforeign crews. Recommendations concerning these issues were addressed to the Federal Aviation Administration and the Department0 Administrativo de Aeronautic0 Civil (DAAC), Columbia. 1 CONTENTS EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V 1. FACTUAL INFORMATION 1.1 History of Flight ............................................. 1 1.2 Injuries to Persons ........................................... 1.3 Damage to Airplane ............................................ :: 1.4 Other Damage .................................................. 1.5 Personnel Information ......................................... ii! 1.5.1 The Captain ................................................... 14 1.5.2 The First Officer ............................................. 1.5.3 The Flight Engineer ........................................... :i 1.5.4 Cabin Crew .................................................... 1.5.5 The Flight Dispatcher ......................................... :i 1.5.6 Air Traffic Controller ........................................ 1.6 Airplane Information ........................................... :7 1.6.1 General ....................................................... 1.6.2 Flight Plan and Performance Information ....................... ;: 1.6.3 Fuel System ................................................... 27 1.7 Meteorological Information .................................... 29 1.8 Aids to Navigation ............................................ 31 1.9 Communications ................................................ 31 1.9.1 Flight Following, Dispatching, and En Route Services .......... 31 1.10 Aerodrome Information ......................................... 32 1.11 Flight Recorders .............................................. 33 1.12 Wreckage and Impact Information ............................... 33 1.13 Medical and Pathological Information .......................... 38 1.14 Fire .......................................................... 38 1.15 Survival Aspects .............................................. 39 1.15.1 Rescue ........................................................ 39 1.15.2 Location of Crew and Passengers in Relation to Injuries ....... 39 1.16 Tests and Research ............................................ 1.17 Additional Information ......................................... t : 1.17.1 Airline Procedures ............................................ 42 1.17.2 Air Traffic Control Facilities and Procedures ................. 43 1.17.3 Traffic Management ............................................ 44 1.17.4 Expect Further Clearance (EFC) Times .......................... 46 1.17.5 Air Traffic Control of Emergencies ............................ 47 1.17.6 Regulations and Airline Policies on Weather and Fuel ........... 48 2. ANALYSIS 2.1 General ....................................................... 51 2.2 Flight Planning ............................................... 2.3 Communications--Flightcrew (CVR) .............................. :P Flight Data Recorder (FDR) .................................... 59 22:: Communications--Controllers ................................... 60 Pilot and ATC Communications--General ......................... 63 i:; Flightcrew Performance--The ILS Approach ...................... 66 Central Flow Control Facility (CFCF)--Traffic Management ...... 68 E Survivability .................................................. 71 2:9.1 Emergency Response ............................................ 73 iii CONCLUSIONS i-1 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 3:2 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 4. RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 5. APPENDIXES Appendix A--Investigation and Hearing ......................... Appendix B--CVR Transcript .................................... ii: Appendix C--FAA Traffic Management ............................ 152 Appendix D--ATC Transcript .................................... 162 Appendix E--Surface Weather Observations ...................... 276 Appendix F--Comments on Draft Report From the Administrative Department of Civil Aeronautics, Colombia .................... 282 iv 1 On July 19, 1989, at approximately 2134 eastern standard time, Avianca Airlines flight 052, a Boeing 707-321B with Colombian registration HK 2016, crashed in a wooded residential area in Cove Neck, Long Island, New York. AVA052 was a scheduled international passenger flight from Bogota, Colombia, to John F. Kennedy International Airport, New York, with an intermediate stop at Jose Maria Cordova Airport, near Medellin, Colombia. Of the 158 persons aboard, 73 were fatally injured. Because of poor weather conditions in the northeastern part of the United States, the flightcrew was placed in holding three times by air traffic control for a total of about 1 hour and 17 minutes. During the third period of holding, the flightcrew reported that the airplane could not hold longer than 5 minutes, that it was running out of fuel, and that it could not reach its alternate airport, Boston-Logan International. Subsequently, the flightcrew executed a missed approach to John F. Kennedy International Airport. While trying to return to the airport, the airplane experienced a loss of power to all four engines and crashed approximately 16 miles from the airport. The National Transportation Safety Board determines that the probable cause of this accident was the failure of the flightcrew to adequately manage the airplane's fuel load, and their failure to communicate an emergency fuel situation to air traffic control before fuel exhaustion occurred. Contributing to the accident was the flightcrew's failure to use an airline operational control dispatch system to assist them during the international flight into a high-density airport in poor weather. Also contributing to the accident was inadequate traffic flow management by the Federal Aviation Administration and the lack of standardized understandable terminology for pilots and controllers for minimum and emergency fuel states. The Safety Board also determines that windshear, crew fatigue and stress were factors that led to the unsuccessful completion of the first approach and thus contributed to the accident. The safety issues raised in this report include: 1. Pilot responsibilities and dispatch responsibilities regarding planning, fuel requirements, and flight following during international flights. 2. Pilot to controller communications regarding the terminology to be used to convey fuel status and the need for special handling. 3. ATC flow control procedures and responsibilities to accommodate aircraft with low fuel state. 4. Flightcrew coordination and English language proficiency of foreign crews. Recommendations concerning these issues were addressed to the Federal Aviation Administration and the Director, Department0 Administrativo de Aeronautic0 Civil (DAAC), Columbia. vi NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT AVIANCA, THE AIRLINE OF COLOMBIA BOEING 707-321B, HK 2016 FUEL EXHAUSTION COVE NECK, NEW YORK JANUARY 25, 1990 1. FACTUAL INFORMATION 1.1 History of the Flight On Thursday, January 25, 1990, at approximately 2134 eastern standard time,' Avianca Airlines flight 052 (AVA052), a Boeing 707-321B with Colombian registration HK 2016, crashed in a wooded residential area in Cove Neck, Long Island, New York. AVA052 was a scheduled international passenger flight from Bogota, Colombia, to John F. Kennedy International Airport (JFK), New York, with an intermediate stop at Jose Maria Cordova Airport, near Medellin, Colombia. Of the 158 persons aboard, 73 were fatally injured. The flight was operating under the regulations of Colombia, and was certified to operate in the United States under the provisions of Title 14 of the Code of Federal Regulations (CFR) Part 129.2 AVA052 departed Bogota International Airport at 1310, 5 minutes ahead of schedule. The flight landed at Medellin at 1404, and was refueled and prepared for departure to JFK. There was no flightcrew change at Medellin. The cockpit crew consisted of a captain, a first officer, and a flight engineer (second officer). AVA052 departed Medellin at 1508. The flight plan for AVA052 was via an oceanic route over Bimini, Bahama Is1 ands, and then northbound toward the East Coast of the United States. The flight was cleared into U.S. airspace by Air Traffic Control (ATC) via Atlantic route 7 to Dixon, North Carolina, jet airway 174 to Norfolk, Virginia (ORF), direct to Sea Isle, New Jersey, and then via the CAMRN TWO ARRIVAL to JFK, at flight level 370 (FL370).3 ’ Unless otherwise indicated, all times shown are eastern standard time, based upon the 24-hour clock. 2 14 CFR Part 129 governs the operations of foreign air carriers and foreign operators of United States-registered aircraft engaged in common carriage. 3 Flight Level is a level of constant atmospheric pressure related to a reference datum of 29.92 inches of mercury. Each is stated in three digits that represent hundreds of feet. For example, flight level 370 represents a barometric altimeter indication of 37,000 feet. 2 AVA052 entered the airspace of Miami Air Route Traffic Control Center (ARTCC) at approximately 1728 at FL350. While in Miami airspace, the flight was given clearance to climb from FL350 to FL370, in the vicinity of URSUS navigational intersection, and was level at that altitude by the time it reached ADOOR intersection. As the flight proceeded northward, it was placed in holding three times by ATC. AVA052 was instructed to enter holding first over ORF. This period of holding was from 1904 to 1923 (19 minutes). The flight was placed in holding a second time at BOTON intersection, near Atlantic City, New Jersey. This period of holding was from 1943 to 2012 (29 minutes). The flight was placed in holding a third time at CAMRN intersection. CAMRN intersection is 39 nautical miles south of JFK. This third period of holding was from 2018 to 2047 (29 minutes). Between the ORF and CAMRN intersections, AVA052 was cleared to descend to several lower altitudes. The flight entered the holding pattern at CAMRN, at 14,000 feet mean sea level (msl). The flight was subsequently descended to 11,000 feet while in the holding pattern. Figure 1 depicts the track of AVA052 beginning at 2042:59. At 2044:43, while holding at CAMRN, the New York (NY) ARTCC radar controller advised AVA052 to expect further clearance (EFC) at 2105. The flight had previously been issued EFC times of 2030 and 2039. The first officer responded, ' . ..ah well I think we need priority we're passing [unintelligible]." The evidence showed that the first officer was making all AVA052's radio transmissions to U.S. controllers.4 The radar controller inquired, ' . ..roger how long can you hold and what is your alternate [airport]?" At 2046:03, the first officer responded, "Yes sir ah we'll be able to hold about five minutes that's all we can do. "The controller replied, ' . ..roger what is your alternate." The first officer responded at 2046:13, "ah we said Boston but ah it is ah full of traffic I think." The controller said, ' . ..say again your alternate 4 Voice recordings are taken from the U.S. Air Traffic Control tape recordings for Neu York Center, Neu York TRACON, and JFK Touer. Yhere intracockpit conversations of the crewmembers are quoted herein, the transcript was taken from the cockpit voice recorder (CVR) aboard the flight. The CVR-recorded tape covered the period from 2053:09 to 2133:34. The recording revealed that the first officer uas the only crewmember who spoke to ATC. The first officer received instructions from the ground controllers in English and repeated the instructions in Spanish in the cockpit. The cockpit creu speakers could not be heard on the area microphone, e x c‘e p t when the crew received the Kennedy touer automatic terminal information service (ATIS) broadcast, information Zulu, at 2100:26. The first officer was using a headset instead of the cockpit speakers to receive the radio transmissions. A l l t h r e e of t h e CVR’s radio channels contained identical signals, but it could not be determined whether the captain or the second officer (flight engineer) were uearing headsets. 21 Feet) J 72 (2.500 Feet) - 2 64 67 (3,200 Feet) North 1 012345 III I I I I Scale in N.M. .* . Recorded by FAA: @I = Event Location : l = Radar Return : AVA052 = Flt. 052 radio transmission 1 in. = 5 n.m. : CAMRN,R67 = Controller transmission : : .= .* Recorded by CVR: .-* Z CAM 1, 2, 3 = Flightcrew comments . .** APPR,TWR = Controller transmissions .* . RDO 1, 2, 3 = Flightcrew radio transmissions 14 .= 7 1 - Captain, 2 - First Officer, 3 - Flight Engineer BEGIN .=. B : GPWS = Ground Proximity Warning System 1 ’ 2 ifLo .s . (11,000 Feet) 3 .’ 5 @b...*:* Figure 1. --AVA052 flight reconstruction based on CVR, ATC radar data, and ATC communications.