Portal:Civil Aeronautics Board

“ In this case, the only logical explanation for conducting the approach at such low engine power settings would have been an attempt by the pilot to expedite airspeed reduction to the appropriate approach/flap extension speeds. However, it can be seen that if the downwind leg altitude had been maintained or if a considerably lesser descent rate had been used while extending flaps in conformance with normal flap extension speeds, airspeed bleed-off would have been more rapid and the appropriate flap extensions could have been achieved further back on the base leg. ”

“ These and other indeterminable factors may or may not have presented additional distractions to the crew but must be considered in the final evaluation. It is clear, however, that a rapidly deteriorating visibility situation and increasingly heavy cockpit workload compounded with all or any combination of the other influencing conditions may have distracted from the full attentiveness of flight instruments and the proper monitoring of the aircraft's altitude. ”

“ Because the water flow over the windshield acts as an aid in spreading the repellent and in eliminating the possibility of fluid residue obscuration on the windshield, it is recommended that the system be utilized only in moderate to heavy rain conditions. This system is designed for use, with the same effectiveness, during either day or night operations. American Airlines operating procedures recommend that the repellent be used on only one windshield at a time, normally on the windshield of the pilot not flying the aircraft. ”

“ After an exhaustive review and evaluation of the available evidence, the Board has become convinced that the cause of the accident is directly related to the manner in which the crew operated the flight and indirectly related to certain specific factors that may have influenced or affected the crew during the landing approach. ”

“ At idle thrust and 40 degrees of flap the Boing 727 descent flightpath at the minimum approach speed was about two degrees steeper than the average descent paths for the other models in the full flap landing configuration. It is recognized that the approach speed is lower for the B-727 than the other models with full flaps and idle power and that steeper descent paths in this configuration should, therefore, be expected. It was also found that the 727, with its hydraulically powered flight control system, has lighter control forces and is more responsive to control input than the other models. ”

“ An approach wherein an aircraft on an IFR flight plan, operating in VFR conditions and having received an Air Traffic Control authorization, may deviate from the prescribed instrument approach procedures and proceed to the airport of destination by visual reference to the surface. ”

“ It can be seen that in reading this altimeter the pilot must first look at the number below the index on the "drum" to identify the thousand-foot level, and then to the radial pointer to determine the hundred feet indication. Two separate readings are required to assess altitude. At stabilized altitudes, or at low rates of climb/descent where the drum is moving slowly or not at all, the pilot must be certain to associate the proper thousand feet indication in relationship to the hundred feet reading. ”

“ For other time intervals during the approach many combinations of these variables would have been consistent with the flight recorder data, and the actual configuration of N1996 for these time intervals could not be conclusively established. However, the study did indicate that with the exception of the level off at 2,000 feet where some thrust would have been required to correlate with the recorder data, the entire descent, 7,000 feet to impact, could have been made at or near idle thrust, gear up and with wing flap extension at or near the AA normal operating flap extension speed schedule. ”

“ It should be stressed that because of the high drag characteristics of the aircraft in the 40-degree flap configuration, high descent rates and airspeed reduction, in response to decreased thrust, can develop more rapidly than in the less sophisticated models and that this flight regime should be avoided close to the ground. ”

“ Prior to departure from LaGuardia the captain of Flight 383 was provided with a dispatch packet which included the company forecast for the Cincinnati terminal for the period 1600-2000. This forecast called for 1,200 feet broken, 3,500 feet overcast, visibility 4 miles, light rain, fog, variable to 1,000 feet overcast, visibility 2 miles, thunderstorm, moderate rain showers.
A weather information display board is also installed at the LaGuardia American Airlines Operations office. Company employees observed Captain Teelin briefing himself at this board at approximately 1600. ”

“ It is doubtful that the center (No. 3) altimeter would have been used on the approach as it would not have been indication absolute altitude over the airport as were the Nos. 1 and 2 altimeters.
It is reasonable to assume that the flight engineer would have been engaged in duties attendant to completing the landing checklist and would not have had time to devote his full attention to the monitoring of flight instruments during the descent along the base leg. ”

“ The Board would be remiss if it did not take cognizance of the concern that existed in the minds of many elements of the aviation community and traveling public regarding the three Boeing 727 fatal accidents that occurred within a short period of time. ”

“ The published airport elevation is 890 feet above sea level.
1.11 Flight Recorder The aircraft was equipped with a United Data Control model F-542 series flight recorder which scribes traces of inflight pressure altitude, indicated airspeed, magnetic heading and vertical acceleration as a function of time. Examination of the flight recorder record for that portion of the flight from takeoff at LaGuardia to the initial descent into Cincinnati area revealed no abnormalities or unusual occurrences. ”

“ Another facet of this part of the investigation was a review of the Boeing 727 flight crew training programs as conducted by the major air carriers utilizing this type aircraft. Because the several major 727 accidents which were reviewed occurred during the descent or landing position of the flight the examination of the various training programs was concentrated on the descent, approach, landing, and landing abort flight regimes. ”

“ It is also recognized that high performance aircraft operations are becoming increasingly complex especially in the critical flight regimes such as takeoff, approach, and landing. The Board therefore encourages acceleration of the program designed to improve data presentation. ”

“ The knob also positions an index on the periphery of the instrument face which is used for setting field pressure altitude (QFE) . [12] The procedures for setting altimeters, as applicable in this case, are set forth in the AA Flight Manual as follows:
" (3) Descent Approach:
" (a) Aircraft descending through FL 180 (15,000' in Mexico) shall have the No. 1 and 2 altimeters change to appropriate QNH [13] settings. Once again, all three altimeters will be set to the same setting and the No. 1 altimeter becomes the master. ”

“ Weather conditions at the time of initial contact with AA 383 were described by the tower controllers as being clear to the east and northeast with "clouds" and "lighting" observed to the northwest. As the aircraft proceeded on the base leg the clouds had moved over the field with light rain blowing on the west and north quadrants of the tower cab windows. ”

“ Station barometric pressure which when set in the altimeter allows for an altimeter reading of zero feet at the airport elevation. ↑ QNH – Local atmospheric pressure which when set in the altimeter allows for the appropriate mean sea level altitude reading at the airport elevation. ↑ The NASA VGH program is a continuing research project whereby recorded airspeed – acceleration – altitude data is collected for many different aircraft models and for different types of operation. ”

“ Evidence of rotation on the No. 2 engine was established by mud and debris which was wiped in the track of the first stage fan blades. There was no significant damage to the compressor or turbine assemblies and the engine was free to rotate. ”

“ He had accumulated a total of 16,387 flying hours including a total of 225 hours in Boeing 727 type aircraft.
On the subject flight Captain Teelin, in accordance with Federal Aviation Regulations (FAR) 121.425 (a) (l) , [5] was acting as check airman for Captain O'Neill who had completed 9 hours and 30 minutes of the programmed 25 flight hours as pilot-in-command under the observation of a check airman. As the check airman assigned to this flight Captain Teelin was the designated pilot-in-command of the aircraft. ”

“ The copilot's (No. 2) altimeter was found at a barometric scale setting of 29.03 inches with the index marker positioned at 815 feet. Only portions of the center instrument panel (No. 3) altimeter were recovered and no barometric, index marker, or drum position information could be obtained. A discussion of the American Airlines procedures for altimeter utilization and related procedures will be found in section 1.15 under the heading of AA altimeter procedures.
1.13 Fire Following impact an intense ground fire erupted which completely destroyed the aircraft cabin forward of the tail section. ”