On August 18, 1993, at 1656 easte daylight tirne, a Douglas DC-8-61 freighter, N814CK, registered to American lnternational Airways, Inc., doing business as Connie Kalitta Services. Inc., and operating as AIA flight 808, collided with level terrain approxirnately 1/4 rnile from the approach end of run way 10, after the captain lost control of the airplane ,while approaching the Leeward Point Airfield at the U.S. Naval Air Station, Guantanarno Bay, Cuba. The airplane was destroyed by impact forces and a postaccident fire, and the three flight crewmembers sustained serious injuries. Visual metteorological conditions prevailed, and an instrument flight rules flight plan had been filed. The flight was conducted under 14 Code of Federal Regulations, Part 121, Supplernental Air Carriers, as an international, nonscheduled, rnilitary contract flight.
We determined that the probable causes of this accident were the impaired judgmenl, decision-making, and flying abilities of the captain and flightcrew due to the effects of fatigue; the captain's failure to properly assess the conditions for landing and rnaintaining vigilant situational awarencess of the airplane while maneuvering onto final approach; his failure to prevent the loss of airspeed and avoid a stall while in the steep bank turn; and his failure to execute immediate action to recover from a stall.
Additional factors contributing to the cause were the inadequacy of the flight and duty tirne regulations applied to 14 CFR, Part 121, Supplemental Air Carrier, international operations, and the circumstances that resulted in the extended flight/duty hours and fatigue of the flightcrew members.
Also contributing were the inadequate training and guidance by American International Airways, Inc., to the flightcrew for operations al special airports. such as Guantananmo Bay: and the Navy's failure to provide a system that would assure that the local tower controller was aware of the inoperative slrobe light so as to provide the flightcrew with such information.
As a result of this investigation, the National Transportation Safety Board makes the following new safety recommendation.
To the Federal Aviation Administration:
- Revise the applicable subpart of 14 CFR, Part 121, to require that flight time accumulated in noncommercial "tail end" ferry flights conducted under 14 CFR, Part 91, as a result of 14 CFR, Part 121, revenue flights, be included in the flight crewmembers total flight and duty time accrued during those revenue operations. (A-94-105)
- Expedite the review, and upgrade of Flight/Duty Time Lirnitations of the Federal Aviation Regulations to ensure that they incorporate the results of the latest research on fatigue and skep issues. (A-94-106)
- Revise 14 CFR, Section 121.445. to elirninate subparagraph (c), and require that all flight crewmernbers rneet the requirernents for operation to or from a special airport either by operating experience or pictorial means. (A-94-107)
lo American International Airways Inc.:
- Revise the AIA training prograrn to ensure that all pilots receive crew resource management (CRM) training that conforms to the guidelines set forth in FAA Advisory Circular 120-51 A. (A-94-108)
- Review and revise the AIA special airports training program to require, in addition to flightcrew members, flight engineers to participate in the AIA special airports training prograrn. The revised program should ensure that all flightcrew members who operate airplanes with high approach speeds are aware and understand the effects of high bank angles and increased load factors, adverse wind conditions. and required flightpath profiles necessary to perform the approach. (A-91-109)
- Provide to all civilian contract operators and flightcrew members either verbal and/or written airfield briefing information regarding normal and emergency operations and flight restrictions pertaining to those airfields classified as 'specialized airports.The briefing information would contain special considerations for airplanes with high approach speeds and emphasize the effocts of high bank angles and increased load factors adverse wind conditions, and required flightpath profiles necessary to perform the approach. This information would be provided in additions to the regularly published notices to airman (NOTAMS) (A-94-110)
Previously Issued Recommendations Reiterated in this Report
- Require U.S. air carriers operating under 14 CFR Part 121, to provide for flightcrews not covered by Advanced Qualifications Program, a comprehensive crew resource managment (CRM) program as described in Advisory Circular 120-51A. (A-94-2)
- Require U.S. air carriers operating under 14 CFR, Part 121, to include, as part of pilot training, a program to educatino pilots about the determental effects of fatiguq, and strategies for avoiding fatigue and countering its effects. (A-94-5)
