ASN Aircraft accident McDonnell Douglas DC-8-61F N27UA Miami International Airport, FL (MIA)

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Accident description

Last updated: 22 September 2017

Status:	Final
Date:	Thursday 7 August 1997
Time:	12:36
Type:	McDonnell Douglas DC-8-61F
Operator:	Fine Air
Registration:	N27UA
C/n / msn:	45942/349
First flight:	1968
Total airframe hrs:	46825
Cycles:	41688
Engines:	4 Pratt & Whitney JT3D-3B
Crew:	Fatalities: 3 / Occupants: 3
Passengers:	Fatalities: 1 / Occupants: 1
Total:	Fatalities: 4 / Occupants: 4
Ground casualties:	Fatalities: 1
Airplane damage:	Destroyed
Airplane fate:	Written off (damaged beyond repair)
Location:	Miami International Airport, FL (MIA) ( United States of America)
Crash site elevation:	2 m (7 feet) amsl
Phase:	Initial climb (ICL)
Nature:	Cargo
Departure airport:	Miami International Airport, FL (MIA/KMIA), United States of America
Destination airport:	Santo Domingo-Las Américas International Airport (SDQ/MDSD), Dominican Republic
Flightnumber:	101A

Narrative:
Fine Air Flight 101 was originally scheduled to depart Miami for Santo Domingo at 09:15 using another DC-8 airplane, N30UA, to carry cargo for Aeromar. Due to a delay of the inbound aircraft, Fine Air substituted N27UA for N30UA and rescheduled the departure for 12:00. N27UA arrived at Miami at 09:31 from San Juan, Puerto Rico, and was parked at the Fine Air hangar ramp. The security guard was not aware of the airplane change, and he instructed Aeromar loaders to load the airplane in accordance with the weight distribution form he possessed for N30UA. The first cargo pallet for flight 101 was loaded onto N27UA at 10:30 and the last pallet was loaded at 12:06. The resulting center of gravity (CG) of the accident airplane was near or even aft of the airplane’s aft CG limit. After the three crew members and the security guard had boarded the plane, the cabin door `was closed at 12:22. Eleven minutes later the flight obtained taxi clearance for runway 27R. The Miami tower controller cleared flight 101 for takeoff at 12:34. Takeoff power was selected and the DC-8 moved down the runway. The flightcrew performed an elevator check at 80 knots. Fourteen seconds later the sound of a thump was heard. Just after calling V1 a second thump was heard. Two seconds later the airplane rotated. Immediately after takeoff the airplane pitched nose-up and entered a stall. The DC-8 recovered briefly from the stall, and stalled again. The airplane impacted terrain in a tail first, right wing down attitude. it slid west across a road (72nd Avenue) and into the International Airport Center at 28th Street and burst into flames.
Investigation showed that the center of gravity resulted in the airplane’s trim being mis-set by at least 1.5 units airplane nose up, which presented the flightcrew with a pitch control problem on takeoff.

Probable Cause:

PROBABLE CAUSE: "The National Transportation Safety Board determines that the probable cause of the accident, which resulted from the airplane being misloaded to produce a more aft center of gravity and a correspondingly incorrect stabilizer trim setting that precipitated an extreme pitch-up at rotation, was (1) the failure of Fine Air to exercise operational control over the cargo loading process; and (2) the failure of Aeromar to load the airplane as specified by Fine Air. Contributing to the accident was the failure of the FAA to adequately monitor Fine Airs operational control responsibilities for cargo loading and the failure of the FAA to ensure that known cargo-related deficiencies were corrected at Fine Air."

Accident investigation:

Investigating agency:	NTSB
Status:	Investigation completed
Duration:	10 months
Accident number:	NTSB/AAR-98-02
Download report:	Final report

Classification:

Centre of Gravity outside limits
Loss of control

Sources:

» NTSB/AAR-98/02

Follow-up / safety actions

NTSB issued 15 Safety Recommendations

Issued: 10-JUL-1998	To: FAA	A-98-44
Require all 14 Code of Federal Regulations Part 121 air carriers to provide flightcrews with instruction on mistrim cues that might be available during taxi and initial rotation, and require air carriers using full flight simulators in their training programs to provide flightcrews with special purpose operational training that includes an unanticipated pitch mistrim condition encountered on takeoff. (Open - Acceptable Response)
Issued: 10-JUL-1998	To: FAA	A-98-45
Conduct an audit of all Code Federal Regulations Part 121 supplemental cargo operators to ensure that proper weight and balance documents are being used, that the forms are based on manufacturer\'s data or other approved data applicable to the airplane being operated, and that FAA principal inspectors confirm that the data are entered correctly on the forms. (Closed - Acceptable Action)
Issued: 10-JUL-1998	To: FAA	A-98-46
Require carriers operating under 14 Code of Federal Regulations Part 121 to develop and use checklists to positively verify that all loading steps have been accomplished for each loaded position on the airplane and that the condition, weight, and sequencing of each pallet is correct. (Closed - Acceptable Alternate Action)
Issued: 10-JUL-1998	To: FAA	A-98-47
Requiring training for cargo handling personnel and develop advisory material for carriers operating under 14 Code of Federal Regulations Part 121 and principal operations inspectors that addresses curriculum content that includes but is not limited to, weight and balance, cargo handling, cargo restraint, and hazards of misloading and require all operators to provide initial and recurrent training for cargo handling personnel consistent with this guidance. (Open Acceptable Alternate Response)
Issued: 10-JUL-1998	To: FAA	A-98-48
Review the cargo loading procedures of carriers operating under 14 Code of Federal Regulations Part 121 to ensure that flightcrew requirements for loading oversight are consistent with the loading procedures in use. (Closed - Acceptable Action)
Issued: 10-JUL-1998	To: FAA	A-98-49
Evaluate the benefit of the STAN (sum total aft and nose) and similar systems and require, if warranted, the installation of a system that displays airplane weight and balance and gross weight in the cockpit of transport-category cargo airplanes. (Closed - Acceptable Action)
Issued: 10-JUL-1998	To: FAA	A-98-50
Require all principal inspectors assigned to 14 Code of Federal Regulations part of their annual work program requirements, the complete loading operation including cargo weighing, weight and balance compliance, flight following, dispatch of an airplane. (Closed - Acceptable Action)
Issued: 10-JUL-1998	To: FAA	A-98-51
Review its national aviation safety inspection program and regional aviation safety inspection program inspection procedures to determine why inspections preceding these accidents failed to identify systemic safety problems at Valujet and Fine Air and, based on the findings of this review, modify these inspection procedures to ensure that such systemic indicators are identified and corrected before they result in an accident. (Closed - Unacceptable Action)
Issued: 10-JUL-1998	To: FAA	A-98-52
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 carriers, irrespective of size. (Closed - Acceptable Action)
Issued: 10-JUL-1998	To: FAA	A-98-53
Require an immediate readout of all 11-parameter retrofitted flight data recorders (FDRs) to ensure that all mandatory parameters are being recorded properly; that the FDR system documentation is in compliance with the range, accuracy, resolution, and recording interval specified in 14 Code of Federal Regulations, Part 121, Appendix B; and require that the readout be retained with each airplane\'s records. (Closed - Acceptable Action)
Issued: 10-JUL-1998	To: FAA	A-98-54
Require maintenance checks for all FDRs of aircraft operated under 14 Code of Federal Regulations Part 121, 129, 125, and 135 every 12 months or after any maintenance affecting the performance of the FDR system, until the effectiveness of the proposed advisory circular and new FAA inspector guidance on continuing FDR airworthiness (maintenance and inspections) is proven; further, these checks should require air carriers to attach to the maintenance job card records a computer printout, or equivalent document, showing recording data, verifying that the parameters were functioning properly during the FDR maintenance check and require that this document be part of the permanent reporting and recordkeeping maintenance system. (Closed - Acceptable Action)
Issued: 10-JUL-1998	To: FAA	A-98-55
Provide FAA principal avionics inspectors with training that addresses the unique and complex characteristics of flight data recorder systems. (Closed - Acceptable Action)
Issued: 10-JUL-1998	To: FAA	A-98-56
Create a national certification team of flight data recorder (FDR) system specialists to approve all supplemental type certificate changes to FDR systems. (Closed - Acceptable Action)
Issued: 10-JUL-1998	To: FAA	A-98-57
Direct the principal maintenance inspector assigned to fine air to reexamine the airline\'s continuing analysis and surveillance program take action, if necessary to ensure that repetitive maintenance discrepancies are being identified and corrected. (Closed - Acceptable Action)
Issued: 10-JUL-1998	To: FAA	A-98-58
Amend 14 Code of Federal Regulations Part 121.563 to specifically require that all discrepancies be logged when they occur and be resolved before departure through repair or deferral in consultation with (the certificate holder\'s or contracted) maintenance personnel. (Closed - Reconsidered)

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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 Miami International Airport, FL to Santo Domingo-Las Américas International Airport as the crow flies is 1357 km (848 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.

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DC-8

556 built
77^th loss
48^th fatal accident
36^th worst accident

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