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Safety Recommendation Details

Safety Recommendation A-72-004
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 USE OF TAKEOFF PROCEDURES WHICH WILL PROVIDE THE FLIGHTCREW WITH TIME AND DISTANCE REFERENCE TO ASSOCIATE WITH ACCELERATION TO V1 SPEED.
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: 6/7/1974
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 FAA AGREED WITH RECOMMENDATION IN PRINCIPLE. HOWEVER, THE MANY VARIABLES INVOLVED PRECLUDE PRACTICAL APPLICATION. AN ACCELERATION CHECK WAS USED BY THE AIRLINES IN THE BEGINNING OF JET OPERATIONS BUT WAS DISCONTINUED FOR THE FOLLOWING REASONS: A. THE ACCELERATION CHECK IS INVALID WHERE SLUSH OR STANDING WATER IS PRESENT. DRAG RISE DUE TO SLUSH OR WATER OFTEN DOES NOT FULLY DEVELOP UNTIL THE SPEED IS NEAR OR JUST GREATER THAN V1. B. SOME OF THE VARIABLES WHICH AFFECT ACCELERATION ARE ALTITUDE, WEIGHT, WIND, FLAP SETTING, RUNWAY SLOPE, THRUST SETTING AND RUNWAY CONDITIONS. NEITHER WIND NOR RUNWAY SLOPE CAN BE ASSUMED TO BE CONSTANT THROUGH THE TAKEOFF. IN ADDITION, THE WIND AND/OR TEMPERATURE AT THE TIME OF TAKEOFF MAY NOT COINCIDE WITH THE VALUES USED TO COMPUTE THE ACCELERATION CHECK. C. INHERENT INACCURACIES IN ACCELERATION DATA, I.E., ROLLING TAKEOFF VS. BRAKE RELEASE TAKEOFF AND RATE OF THRUST APPLICATION COULD RESULT IN MISUSE OF ACCELERATION CHECKS AND LEAD TO UNNECESSARY REJECTED TAKEOFFS AND INCREASED EXPOSURE TO OVERRUNS. FINALLY THIS ACCIDENT, IN FAA'S VIEW, WOULD NOT HAVE BEEN PREVENTED BY AN ACCELERATION CHECK. THE USE OF SYSTEMS TO MONITOR TAKEOFF PERFORMANCE ARE BEING INVESTIGATED BY VARIOUS SEGMENTS OF THE INDUSTRY. THE FAA IS FOLLOWING THE DEVELOPMENTS OF THESE SYSTEMS AND THEIR POSSIBLE APPLICATION TO EVERYDAY OPERATIONS.