Estado: | Accident investigation report completed and information captured |
Fecha: | miércoles 18 agosto 1993 |
Hora: | 16:56 |
Tipo: | McDonnell Douglas DC-8-61 |
Operador: | Connie Kalitta Services |
Registración: | N814CK |
Numéro de série: | 46127/510 |
Año de Construcción: | 1969 |
Horas Totales de la Célula: | 43947 |
Ciclos: | 18829 |
Motores: | 4 Pratt & Whitney JT3D-3B (Q) |
Tripulación: | Fatalidades: 0 / Ocupantes: 3 |
Pasajeros: | Fatalidades: 0 / Ocupantes: 0 |
Total: | Fatalidades: 0 / Ocupantes: 3 |
Daños en la Aeronave: | Anulado |
Consecuencias: | Written off (damaged beyond repair) |
Ubicación: | Guantánamo NAS (NBW) ( Cuba)
|
Fase: | Aproximación (APR) |
Naturaleza: | Carga |
Aeropuerto de Salida: | Norfolk NAS Chambers, VA (NGU/KNGU), Estados Unidos de América |
Aeropuerto de Llegada: | Guantánamo NAS (NBW/MUGM), Cuba |
Número de Vuelo: | 808 |
Descripción:Flight 808 took off from Norfolk at 14:13 for a cargo flight to Guantanamo Bay. The flight and arrival into the Guantanamo terminal area was uneventful. At 16:34, while the flight was descending from FL320, radio contact was established with the Guantanamo radar controller. The radar controller instructed flight 808 to maintain VFR 12 miles off the Cuban coast and report at East Point. The runway in use was runway 10. The flight crew then requested a runway 28 approach, but changed this back to a runway 10 approach a couple of minutes later.
Clearance was given at 16:46 with wind reported at 200deg./7 knots. The runway 10 threshold was located 0,75 mile East of Cuban airspace, designated by a strobe light, mounted on a Marine Corps guard tower, located at the corner of the Cuban border and the shoreline. On the day of the accident, the strobe light was not operational (both controller and flight crew were not aware of this). The aircraft was approached from the south and was making a right turn for runway 10 with an increasing angle of bank in order to align with the runway. At 200-300 feet agl the wings started to rock towards wings level and the nose pitched up. The right wing appeared to stall, the aircraft rolled to 90deg. angle of bank and the nose pitched down. The aircraft then struck level terrain 1400 feet west of the approach end of the runway and 200 feet north of the extended centreline.
Probable Cause:
PROBABLEÂ CAUSES: "The impaired judgement, decision-making, and flying abilities of the captain and flight crew due to the effects of fatigue; the captain's failure to properly assess the conditions for landing and maintaining vigilant situational awareness of the airplane while manoeuvring 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 time 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 flight crew members. Also contributing were the inadequate crew resource management training and the inadequate training and guidance by American International Airways, Inc., to the flight crew for operations at special airports such as Guantanamo Bay; and the Navy's failure to provide a system that would assure that local tower controller was aware of the inoperative strobe light so as to provide the flight crew with such information."
Accident investigation:

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Investigating agency: | NTSB |
Status: | Investigation completed |
Duration: | 265 days (9 months) | Accident number: | NTSB/AAR-94-04 | Download report: | Final report
|
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Fuentes:
» NTSB Safety Recommendation A-94-105/110
» NTSB/AAR-94/04
Subsiguiente / acciones de seguridad
NTSB issued 6 Safety Recommendations
Issued: 18-MAY-1994 | To: FAA | A-94-105 |
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 result of 14 CFR, Part 121, revenue flights be included in the flight crewmember\'s total flight and duty time accrued during those revenue operations. (Superseded by A-95-110 through -113) (Closed - Acceptable Action/Superseded) |
Issued: 18-MAY-1994 | To: FAA | A-94-106 |
Expedite the review and upgrade of flight/duty time limitations of the federal aviation regulations to ensure that they incorporate the results of the latest research on fatigue and sleep issues. (Superseded by A-95-110 through -113) (Closed - Acceptable Action/Superseded) |
Issued: 18-MAY-1994 | To: FAA | A-94-107 |
Revise 14 CFR, section 121.445, to eliminate subparagraph (C), and require that all flight crewmembers meet the requirements for operation to or from a special airport, either by operating experience or pictorial means. (Open - Acceptable Response) |
Issued: 18-MAY-1994 | To: American International Airways, Inc. | A-94-108 |
REVISE THE AIA TRAINING PROGRAM TO ENSURE THAT ALL PILOTS RECEIVE CREW RESOURCE MANAGEMENT (CRM) TRAINING THAT CONFORMS TO THE GUIDELINES SET FORTH IN FAA ADVISORY CIRCULAR 120-51A. (Closed - Acceptable Action) |
Issued: 18-MAY-1994 | To: American International Airways, Inc. | A-94-109 |
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 PROGRAM. THE REVISED PROGRAM SHOULD ENSURE THAT ALL FIGHTCREW MEMBERS WHO OPERATE AIRPANES 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. (Closed - Acceptable Action) |
Issued: 18-MAY-1994 | To: US DoD | A-94-110 |
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 "SPECIAL AIRPORTS." THE BRIEFING INFORMATION WOULD CONTAIN SPECIAL CONSIDERATIONS FOR AIRPLANES WITH HIGH APPROACH SPEEDS AND EMPHASIZE THE EFFECTS 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 ADDITION TO THE REGULARLY PUBLISHED NOTICES TO AIRMEN (NOTAMS). (Closed - Acceptable Action) |
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Fotos
Ground track of flight 808
accident date:
18-08-1993type: McDonnell Douglas DC-8-61
registration: N25UA
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 Norfolk NAS Chambers, VA to Guantánamo NAS as the crow flies is 1884 km (1177 miles).
Accident location: Exact; deduced from official accident report.
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.