Status: | Accident investigation report completed and information captured |
Date: | Tuesday 24 December 1968 |
Time: | 20:12 |
Type: |  Convair CV-580 |
Operator: | Allegheny Airlines |
Registration: | N5802 |
MSN: | 410 |
First flight: | 1957 |
Total airframe hrs: | 29173 |
Engines: | 2 Allison 501-D13 |
Crew: | Fatalities: 3 / Occupants: 6 |
Passengers: | Fatalities: 17 / Occupants: 41 |
Total: | Fatalities: 20 / Occupants: 47 |
Aircraft damage: | Destroyed |
Aircraft fate: | Written off (damaged beyond repair) |
Location: | 4 km (2.5 mls) SE of Bradford Airport, PA (BFD) ( United States of America)
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Phase: | Approach (APR) |
Nature: | Domestic Scheduled Passenger |
Departure airport: | Erie International Airport, PA (ERI/KERI), United States of America |
Destination airport: | Bradford Airport, PA (BFD/KBFD), United States of America |
Flightnumber: | 736 |
Narrative:Allegheny Airlines Flight 736 departed Detroit, MI for a flight to Washington, DC with intermediate stops at Erie, Bradford and Harrisburg, PA. The Convair CV-580 took off from Erie at 19:46.
At 20:06 Flight 736 reported over the VOR outbound at the beginning of the instrument approach procedure. Erie Approach Control then told the crew to contact the Braford Flight Service Station (FSS). At 20:08 the flight reported that they were doing the procedure turn inbound for runway 32 and Bradford FSS told them wind was 290 degrees at 15 knots. The Convair descended in light snow showers until the aircraft contacted trees along terrain which had an average upslope of 1.5 degrees some 4 km short of the runway. The airplane cut a swath through the trees and impacted the ground at a point 800 feet from the initial tree contact. The fuselage came to rest inverted.
Probable Cause:
PROBABLE CAUSE: "The continuation of the descent from the final approach fix through the Minimum Descent Altitude and into obstructing terrain at a time when both flight crewmembers were looking outside the aircraft in an attempt to establish visual reference to the ground. Contributing factors were the minimal visual references available at night on the approaches to the Bradford Regional Airport; a small but critical navigational error during the later stages of the approach; and a rapid change in visibility conditions that was not known to the crew."
Accident investigation:
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Investigating agency: | NTSB  |
Status: | Investigation completed |
Duration: | 1 year and 1 months | Accident number: | NTSB/AAR-70-04 | Download report: | Final report
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Sources:
» ICAO Accident Digest Circular 107-AN/81 (303-328)
Follow-up / safety actions
On January 17, 1969 13 safety recommendations were issued to the FAA regarding approach and landing accidents in poor weather conditions. The NTSB a.o. recommended expediting development and installation of audible and visible altitude warning devices and the implementation of procedures for their use. The FAA replied that a rule became effective on September 28, 1968, which will require by February 28, 1971, both visual and aural altitude alerting signals to warn pilots of jet aircraft when approaching selected altitudes during climbs, descents, and instrument approaches.
The FAA also reported that an Instrument Landing System (ILS) was installed at the Bradford Regional Airport in the fall of 1969.
NTSB issued 2 Safety Recommendations
Issued: 17-JAN-1969 | To: FAA | A-69-2 |
1. PILOTS, OPERATORS AND REGULATORY AGENCIES SHOULD RENEW EMPHASIS ON, AND IMPROVE WHEREVER POSSIBLE, COCKPIT PROCEDURES, CREW DISCIPLINE AND FLIGHT MANAGEMENT. 2. BOTH THE AIR CARRIER INDUSTRY AND THE FAA SHOULD REVIEW POLICIES PROCEDURES, PRACTICES, AND TRAINING TOWARD INCREASING CREW EFFICIENCY AND REDUCING DISTRACTIONS AND NONESSENTIAL CREW FUNCTIONS DURING THE APPROACH AND LANDING PHASE OF A FLIGHT.3. CREW FUNCTIONS NOT DIRECTLY RELATED TO THE APPROACH AND LANDING SHOULD BE REDUCED OR ELIMINATED, ESPECIALLY DURING THE LAST 1,000 FEET OF DESCENT. 4. DURING THE FINAL APPROACH, ON PILOT SHOULD MAINTAIN CONTINUOUS VIGILANCE OF LIGHT INSTRUMENTS INSIDE THE COCKPIT UNTIL POSITIVE VISUAL REFERENCE IS ESTABLISHED.5. DURING APPROACHES WERE LESS THAN FULL PRECISION FACILITIES EXIST, THERE SHOULD BE A REQUIREMENT THAT DURING THE LAST 1,000 FEET OF FINAL APPROACH, THE PILOT NOT FLYING CALL OUT ALTITUDE IN 100-FOOT INCREMENTS ABOVE AIRPORT ELEVATION. 6. THERE SHOULD BE A REQUIREMENT TO REPORT INDICATED ALTITUDES TO AIR TRAFFIC CONTROL AT VARIOUS POINTS IN THE APPROACH PROCEDURE, SUCH AS THE OUTBOUND PROCEDURE TURN AND AT THE OUTER MARKER POSITION. 7. THE AVIATION COMMUNITY SHOULD CONSIDER EXPEDITING DEVELOPMENT AND INSTALLATION OF AUDIBLE AND VISIBLE ALTITUDE WARNING DEVICES AND THE IMPLEMENTATION OF PROCEDURES FOR THEIR USE. 8. ALTIMETRY SYSTEMS SHOULD BE REASSESSED WITH PARTICULAR REGARD TO THEIR SUSCEPTIBILITY TO INSIDIOUS INTERFERENCE BY FORMS OF PRECIPITATION. 9. THE POSSIBILITY OF DEVELOPMENT OF ADDITIONAL ALTITUDE WARNING SYSTEMS, EXTERNAL TO THE AIRCRAFT, SHOULD BE EXPLORED. ONE POSSIBILITY IS A HIGH-INTENSITY VISUAL WARNING RED LIGHT BEAM, PROJECTED UP ALONG AND SLIGHTLY BELOW THE DESIRED APPROACH GLIDE SLOPE, TO WARN OF FLIGHT BELOW THE DESIRED PATH. 10. DEVELOPMENT IS NEEDED IN THE FIELDS OF RADIO/ RADAR, AND INERTIAL ALTIMETRY AND CRT/MICROWAVE PICTORIAL DISPLAY APPROACH AIDS AS POSSIBLE IMPROVED REPLACEMENTS FOR THE BAROMETRIC ALTIMETRY SYSTEM IN THE NEAR FUTURE. 11. MODIFIED USE OF EXISTING APPROACH RADAR SHOULD BE FURTHER STUDIED WITH REGARD TO ITS ADAPTABILITY AS A SURVEILLANCE (ACCIDENT PREVENTION) TOOL FOR NONPRECISION INSTRUMENT APPROACHES (E.G., TO MONITOR AUTOMATICALLY AND WARN AGAINST THE DESCENT BELOW DESIRED GLIDEPATH OF ANY AIRCRAFT IN THE FINAL DESCENT MODE). 12. THERE SHOULD BE INCREASED SURVEILLANCE AND MORE FREQUENT AND MORE RIGOROUS INSPECTION AND MAINTENANCE OF ALTIMETRY SYSTEMS BY BOTH THE AIR CARRIERS AND THE FAA. 13. CERTIFICATION REQUIREMENTS AND PROCEDURES SHOULD BE REEXAMINED TO DETERMINE IF THERE IS A POSSIBILITY OF A SINGLE FAILURE MODE OF NOMINALLY DUAL SYSTEMS WHICH, WHEN COMBINED WITH AN ALREADY EXISTENT PASSIVE FAILURE OR INADEQUATE COCKPIT PROCEDURES, CAN INVALIDATE DUAL FAILURE PROTECTION FEATURES. (Closed - Acceptable Action) |
Issued: 04-MAR-1970 | To: FAA | A-70-12 |
1. THE BOARD URGED THE FAA TO EXPEDITE THE INSTALLATION OF ILS AT QUALIFIED FIELDS CURRENTLY EQUIPPED WITH NON-PRECISION APPROACHES WITHIN THE LIMITS OF AVAILABLE RESOURCES, AND 2. TO CONSIDER INSTALLATION OF APPROACH LIGHTS TO IMPROVE SAFETY OF NON-PRECISION INSTRUMENT APPROACHES AT THOSE AIRPORTS WHERE THE INSTALLATION OF A FULL ILS IS NOT FEASIBLE. (Closed - Acceptable Action) |
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Photos
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Erie International Airport, PA to Bradford Airport, PA as the crow flies is 130 km (81 miles).
Accident location: Approximate; accuracy within a few kilometers.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.