Gander : The Untold Story - Canadian Aviation Safety Board Majority Report

TABLE OF CONTENTS
(title page)

FACTUAL INFORMATION

History of the Flight
Injuries to Persons
Damage to Aircraft
Other Damage
Personnel Information
Aircraft Information
Meteorological Information
Aids to Navigation
Comm.
Aerodrome Information
Flight Recorders
Wreckage and Impact Information
Medical Information
Fire
Survival Aspects
Tests and Research
Additional Information
ANALYSIS

Introduction
Performance Analysis
Pre-Impact Condition of the Aircraft
Aircraft Weight
Weather Factors
Sequence of Events
Load Planning and Control
Arrow Air Maintenance and Operating Practices
Flight Crew Fatigue
Flight Recorder Requirements
FAA Surveillance
CONCLUSIONS

Findings
Causes
SAFETY ACTION

Action Taken
Action Required
Other Safety Concerns - Air Carrier Maintenance and Operating Procedures - Inadequate Regulatory Control
APPENDICES

ESTIMATED FLIGHT PROFILE
EXTRACTS FROM ATMOSPHERIC ENVIRONMENT SERVICE MANUAL OF SURFACE OBSERVATIONS
AERODYNAMIC EFFECTS OF ICING
LIST OF WITNESSES - PUBLIC INQUIRY
LIST OF LABORATORY REPORTS AND STUDIES
GLOSSARY

CASB Majority Report

Findings

During the approach to land at Gander, the existing meteorological conditions were conductive to ice accretion on the leading edge of the wing.
While on the ground at Gander, the aircraft was exposed to freezing and frozen precipitation capable of producing roughening on the wing upper surface.
While the aircraft was on the ground at Gander, the difference between the wing surface temperature and the outside temperature was conducive to the formation of frost on the surface of the wing.
The aircraft was not de-iced prior to take-off.
The aircraft stalled at a higher than normal airspeed after leaving ground effect.
There was insufficient altitude available to effect a recovery from the stall.
The performance of the aircraft after lift-off was below that expected and was consistent with the reduced aerodynamic efficiency and resultant high drag associated with wing ice contamination. It was also consistent with the effects of wing ice contamination combined with a partial loss in engine thrust.
The ground impact rpm of the number four engine was lower than that of the other three engines.
No evidence was found of a pre-impact mechanical failure of the number four engine.
It could not be determined if the lower ground impact rpm of the number four engine was the result of an in-flight power loss, either before or after the stall, or was the result of tree fragment ingestion prior to ground impact.
The integrity of a Class D cargo compartment was compromised because flight was undataken with two missing side panels in the number three cargo pit.
The take-off weight at Gander calculated by the crew was about 14,000 pounds less than the actual take-off weight of the aircraft.
The take-off reference speeds believed to have been used by the crew during the accident take-off were applicable to a take-off weight at least 14,000 pounds less than the actual takeoff weight and may have been applicable to a take-off weight as much as 35,000 pounds less than the actual take-off weight.
Although the use of actual passenger weights was required by the Arrow Air Operations Manual, the crew used a standard average weight to calculate the weight of passengers. This average passenger weight did not accurately reflect the actual weight of the passengers carried on the flight.
Guidance material available to Arrow Air flight crew did not include direction concerning the requirement or method to determine total passenger weight using actual passenger weights when calculating weight and centre of gravity.
Accurate weight and centre of gravity calculations were not being performed by Arrow Air flight crew for every flight.
Inconsistencies existed in the load-planning material that was available to Arrow Air personnel, MFO personnel, and U.S. Army personnel.
The quantity and accuracy of documentation regarding the number and weight of passengers and weight of cargo carried on the MFO rotation flights were inadequate.
The maximum design zero fuel weight of the aircraft was exceeded on each of the MFO rotation flights conducted in December 1985.
Arrow Air's contractual obligations with respect to allowable payload exceeded the authorized payload capability (maximum design zero fuel weight) of the aircraft being used.
Arrow Air flight crews were not recording all aircraft unserviceabilities in the aircraft journey log and on occasion were accepting for flight aircraft with known defects.
A life-limited repair resulting from a previous occurrence had not been replaced in accordance with the recommendations of the aircraft manufacturer.
The potential of the flight crew's December flight schedule to produce fatigue was high.
There are no flight-time and crew-rest limitations for United States FAR Part 121 air carrier operations conducted under FAR Part 91.
The accident investigation mto the causes and factors that led to this occurrence was severely hampered by the lack of information that a serviceable cockpit voice recorder and enhanced-capability digital flight data recorder could have provided.
The United States Federal Aviation Administration Master Minimum Equipment List for aircraft such as the DC-8 allowed aircraft to be released for flight with an unserviceable cockpit voice recorder and flight data recorder.
Routine FAA surveillance of Arrow Air did not identify existing deficiencies with respect to Arrow Air's ability to comply with applicable FARs and FAA approved procedures. These deficiencies were identified in a special inspection conducted in January 1986, one month after the accident.
The balance of evidence did not support the occurrence of a pre-impact fire or explosion either accidental or as a result of sabotage.
The evidence did not support the occurrence of an uncommanded deployment of a thrust reverser.
The flight crew was certified and qualified for the flight in accordance with existing regulations.
The aircraft was certified in accordance with existing regulations.
The take-off weight and centre of gravity position were within prescribed limits.