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Safety Recommendation Details

Safety Recommendation A-72-003
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 THE INSTALLATION OF RUNWAY DISTANCE MARKERS AT ALL CIVIL AIRPORTS WHERE AIR CARRIER AIRCRAFT ARE AUTHORIZED TO OPERATE.
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--unacceptable action.

From: FAA
To: NTSB
Date: 2/24/1972
Response: DISTANCE MARKERS HAVE BEEN EVALUATED IN THE PAST AND FOUND LACKING IN VALUE FOR TAKEOFF PURPOSES. THE FOLLOWING SIGNIFICANT PROBLEMS WERE LISTED: A. THE PILOT NOT IN CONTROL WOULD BE REQUIRED TO MONITOR PASSAGE OF THE MARKERS. THIS WOULD DIVERT HIS ATTENTION FROM ADEQUATELY MONITORING ENGINE AND FLIGHT INSTRUMENTS. THIS WOULD INCREASE THE PROBABILITY OF HIS FAILING TO CALL OUT THE V SPEEDS AT THE PROPER TIME DURING A MOST CRITICAL PERIOD OF THE TAKEOFF AND ONLY AGGRAVATE THE PROBLEM WHICH WE ARE TRYING TO SOLVE. B. WHEN A THRESHOLD IS TEMPORARILY DISPLACED, AS WAS THE CASE AT SANFRANCISCO, THE MARKERS WOULD NOT PROVIDE CORRECT VALUES. C. MISREADING OF A MARKER IN REDUCED VISIBILITY COULD RESULT IN A REJECTED TAKEOFF TOO FAR DOWN THE RUNWAY TO MAKE A SAFE STOP. D. USE OF DISTANCE MARKERS PRESENTS THE SAME PROBLEMS WITH RESPECT TO ACCELERATION, RUNWAY CONDITIONS, WEIGHT, ETC., AS DISCUSSED UNDER RECOMMENDATION NO. 4.