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Safety Recommendation Details

Safety Recommendation A-72-002
Details
Synopsis: A PAN AMERICAN BOEING 747 STRUCK THE APPROACH LIGHT STRUCTURE (ALS) FOR RUNWAY 19L WHILE TAKING OFF FROM RUNWAY 01R AT THE SAN FRANCISCO INTERNATIONAL AIRPORT. THE CREW CONTINUED THE TAKEOFF AND, AFTER AN INFLIGHT INSPECTION FOR DAMAGE, DUMPED FUEL AND RETURNED FOR A LANDING AT SAN FRANCISCO. TWO PASSENGERS WERE INJURED DURING THE IMPACT WITH THE ALS AND EIGHT OTHERS SUSTAINED SERIOUS BACK INJURIES DURING THE EVACUATION AFTER THE LANDING. THE AIRCRAFT HAD BEEN DISPATCHED FOR A DEPARTURE FROM A CLOSED RUNWAY AND, UPON CHANGING TO AN OPEN RUNWAY, THE CREW DID NOT RECOMPUTE THE PROPER REFERENCE SPEEDS FOR TAKEOFF UNDER THE EXISTING CONDITIONS.
Recommendation: REQUIRE THAT V REFERENCE SPEED CHECKS BE INCLUDED ON THE LAST CHECKLIST USED IMMEDIATELY PRIOR TO TAKEOFF.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: San Francisco, CA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: 79468
Accident Reports: Pan American World Airways, Inc., Boeing 747, N747PA, Flight 845
Report #: AAR-72-17
Accident Date: 7/30/1971
Issue Date: 12/8/1971
Date Closed: 9/16/1977
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 9/16/1977
Response: Closed.

From: FAA
To: NTSB
Date: 2/24/1972
Response: THE PROCEDURES USED BY THE AIRLINES FOR SETTING AND CROSS-CHECKING TAKEOFF V REFERENCE SPEEDS HAVE BEEN CONSIDERED ACCEPTABLE. TRAINING PROGRAMS SHOULD EMPHASIZE THE NECESSITY FOR FLIGHT CREWS TO ASSURE THAT THESE SPEEDS INCLUDE ACCURATE RESOLUTION OF ALL PERTINENT FACTORS PRIOR TO INITIATING A TAKEOFF. ACCORDINGLY, FAA PLANS TO ISSUE AN OPERATIONS BULLETIN TO FIELD INSPECTORS TO ACCOMPLISH THIS. PAN AMERICAN PLANS TO INCLUDE "V REFERENCE SPEEDS" ON THE BEFORE TAKEOFF CHECKLIST FOR ALL OF THEIR AIRPLANES.