On Tuesday, February 16, 1995, at 2027 central standard time, a Douglas DC-S-63, N782AL, operated by Air Transport International, was destroyed by ground impact and fire during an attempted takeoff at the Kansas City International Airport, Kansas City, Missouri. The three flight crewmembers were fatally injured. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The flight was being conducted as a ferry flight under Title 14 Code of Federal Regulations Part 91.
Safety issues discussed in the report focused on three-enginc takeoff training and procedures, flightcrew fatigue, company crew assignment decisionmaking, and Federal Aviation Administration oversight of the company. Safety recommendations concerning these issues were made to the Federal Aviation Administration and Air Transport International. Also, as a result of the investigation of this accident, on March 30, 1995, the Safety Board issued Urgent Action Safety Recommendations A-95-38 and -39 to The Federal Aviation Administration concerning practices at Air Transport International.
We determined that the probable causes of this accident were:
- the loss of directional control by the pilot in command during the takeoff roll, and his decision to continue to takeoff and initiate a rotation below the computed rotation airspeed, resulting in a premature liftoff, further loss of control and collision with the terrain.
- the flightcrew's lack of understanding of the three-engine takeoff procedures, and their decision to modify those procedures.
- the failure of the company to ensure that the flightcrew had adequate experience, training, and rest to conduct the nonroutine flight.
Contributing to the accident was the inadequacy of FAA oversight of ATI and FAA flight and duty time regulations that permitted a substantially reduced flightcrew rest period when conducting a nonrevnue ferry flight under 14 CFR Part 91.
As a result of its investigation of this accident, we made the following recommendations:
to the Federal Aviation Administration:
- Review the effectiveness of the geographic unit oversight program, with particular emphasis on the oversight of supplemental air carriers and their international operations, and the improvement • of overall communications between principal operations inspectors and geographic inspectors. (A-95-110)
- Evaluate the surveillance programs to ensure that budget and personnel resources are sufficient and used effectively to maintain adequate oversight of the operation and maintenance of both passenger and cargo air carriers, irrespective of size. (A-95-111)
- Require airplane manufacturers to revise one-engine inoperative takeoff procedures to provide adequate rudder availability for correcting directional deviations during the takeoff roll and provide perfonnance figures and runway requirements compatible with the achievement of maximum asymmetric thrust at an appropriate speed greater than ground minimum control speed. (A-95-112)
- Finalize the review of current flight and duty time regulations and revise the regulations, as necessary, within 1 year to ensure that flight and duty time limitations take into consideration research findings in fatigue and sleep issues. The new regulations should prohibit air carriers from assigning flightcrews to flights conducted under 14 Code of Federal Regulations (CFR) Part 91 unless the flightcrews meet the flight and duty time limitations of 14 CPR Part 121 or other appropriate regulations. (A-95-113)
to Air Transport International:
- Review the A TI DC-8 operating manual discussion on three-engine takeoffs to ensure that it is understandable to all pilots who must accomplish such takeoffs. This section of the manual should emphasize the specifics of proper throttle application technique. (A-95-114)
- Discontinue the company policy of routinely assigning line flightcrews for three-engine feny operations. Allow only specifically designated, highly experienced crewmembers to perfonn such operations. (A-95-115)
