Rancho Cordova, California
February 16, 2000
NTSB Number: AAR-03-02
NTIS Number: PB2003-910402
Adopted August 5, 2003
On February 16, 2000, about 1951 Pacific standard time, Emery Worldwide Airlines, Inc., (Emery) flight 17, a McDonnell Douglas DC-8-71F (DC-8), N8079U, crashed in an automobile salvage yard shortly after takeoff, while attempting to return to Sacramento Mather Airport (MHR), Rancho Cordova, California, for an emergency landing. Emery flight 17 was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 as a scheduled cargo flight from MHR to James M. Cox Dayton International Airport (DAY), Dayton, Ohio. The flight departed MHR about 1949, with two pilots and a flight engineer on board. The three flight crewmembers were killed, and the airplane was destroyed. Night visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan.
The National Transportation Safety Board determined that the probable cause of the accident was a loss of pitch control resulting from the disconnection of the right elevator control tab. The disconnection was caused by the failure to properly secure and inspect the attachment bolt.
The safety issues discussed in this report include DC-8 elevator position indicator installation and usage, adequacy of DC-8 maintenance work cards (required inspection items), and DC-8 elevator control tab design. Safety recommendations are addressed to the Federal Aviation Administration.
As a result of the investigation of the Emery Worldwide Airlines flight 17 accident, the National Transportation Safety Board recommends that the Federal Aviation Administration:
Require all DC-8 operators to train DC-8 flight crewmembers to look for symmetry between the right and left side elevators, control tabs, and geared tabs during preflight inspection, consistent with Boeing's June 2001 flight operations bulletin guidance. (A-03-22)
Require the development of DC-8 80-knot elevator check procedures that will ensure that pilots are clearly made aware of whether the elevator is functioning properly before the airplane lifts off, then require all DC-8 operators to incorporate these procedures into their training and normal operations. The procedures should contain specific guidance regarding an expected range of elevator position indicator (EPI) needle movement (including EPI needle movement well below the neutral mark with forward control column movement) and specific criteria for aborting a takeoff as a result of an inadequate elevator movement indication. (A-03-23)
Require all DC-8 operators to incorporate periodic elevator position indicator (EPI) calibration inspections into their maintenance programs to ensure that the EPI indications observed by pilots accurately represent the condition of the elevator. (A-03-24)
Require DC-8 elevator position indicators to be located and sized so that they are visible and usable for both the captain and first officer. (A-03-25)
Require Boeing to redesign DC-8 elevator control tab installations and require all DC-8 operators to then retrofit all DC-8 airplanes with these installations such that pilots are able to safely operate the airplane if the control tab becomes disconnected from the pushrod. (A-03-26)
Evaluate airplanes other than the DC-8 certificated to Civil Aviation Regulations 4b standards to evaluate whether disconnection or failure of critical flight control systems could have catastrophic results and, if so, require that they also be redesigned and retrofitted and/or equipped with dual-locking devices to preclude such catastrophic results. (A-03-27)
Require all DC-8 operators to replace all DC-8 aluminum elevator geared tab crank arms on their DC-8 airplanes with stainless steel elevator geared tab crank arms. (A-03-28)
Require all DC-8 operators to create or revise DC-8 work cards to ensure they specifically include a postrigging inspection of the elevator assembly, including verifying the security of elevator control tab attachments. (A-03-29)
Require all DC-8 operators to review their work cards related to critical flight controls, and revise them as necessary to ensure that appropriate tasks are identified as discrete tasks with individual inspection signoff requirements. (A-03-30)
Require all 14 Code of Federal Regulations Part 121 air carrier operators to revise their task documents and/or work cards to describe explicitly the process to be followed in accomplishing maintenance tasks. (A-03-31)
Require all air carrier operators to either: 1) provide all pertinent maintenance personnel with the manufacturer's current installation drawings for pertinent airplanes, update those installation drawings as needed, and require use of those drawings during installation and/or assembly of that airplane's components; or 2) list the IPC on that operator's operation specifications, provide maintenance personnel with up-to-date IPCs for reference, continue to update those IPCs as needed, and require maintenance personnel to use the pertinent updated IPCs during installation and/or assembly of an airplane's components. (A-03-32)
Require operators of airplanes manufactured before August 18, 2000, that have been retrofitted with additional flight data recorder (FDR) parameters in compliance with Federal requirements and for which an operator maintains a common correlation document for that airplane type to conduct a full correlation of all such airplanes' FDR parameters at the airplanes' next required FDR maintenance inspection to verify accurate FDR system documentation and sensor function. (A-03-33)
Require all operators of airplanes equipped with Loral Fairchild Model F-800 flight data recorders to comply with Loral Fairchild Field Service Bulletins digital flight recorder (DFR) 011 and DFR 027 for recorders with applicable part numbers and installed component numbers. (A-03-34)
Require overhaul facilities that service Loral Fairchild Model F-800 flight data recorders to monitor those recorders to determine whether abnormal track switching is occurring and to report any such findings to the Federal Aviation Administration and the manufacturer. (A-03-35)
Modify the list of safety-sensitive functions described in 14 Code of Federal Regulations Part 121, Appendixes I and J, to include all personnel with direct access to the airplane and a direct role in the handling of the flight, including cargo handlers, load planners, and ramp supervisors. (A-03-36)