Narrative:The Pan American Boeing 747 struck the Approach Light Structure (ALS) at the departure end of runway 01R while taking off from the San Francisco International Airport. Two passengers, in seats 47G and 48G, were seriously injured by parts of the Approach Light System structure which penetrated the
passenger compartment. The flightcrew continued the takeoff and then flew the aircraft for 1 hour and 42 minutes while assessing the structural damage and dumping fuel before landing on runway 28L. After landing, the aircraft veered off the right side of runway 28L and came to a stop in the unpaved area approximately 5,300 feet from the approach end of the runway. The passengers and crew evacuated the aircraft using the emergency evacuation slides.
Upon activation of the slides for evacuation, four of the 10 passenger slides failed to function properly and were not useable. During the evacuation the aircraft tilted slowly back onto the rear section of the fuselage.
The aircraft had been dispatched for a departure from a closed runway and, upon changing to an open runway, the crew did not recompute the proper reference speeds for takeoff under the existing conditions.
Probable Cause:
PROBABLE CAUSE: "The National Transportation Safety Board determines that the probable cause of this accident was the pilots use of incorrect takeoff
reference speeds. This resulted from a series of irregularities involving: (1) the collection and dissemination of airport information; (2) aircraft dispatching; and (3) crew management and discipline; which collectively rendered ineffective the air carriers operational control system."
Accident investigation:
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Investigating agency: | NTSB  |
Status: | Investigation completed |
Duration: | 299 days (10 months) | Accident number: | NTSB-AAR-72-17 | Download report: | Final report
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Classification:
Collision with approach or runway lights
Forced landing on runway
Sources:
» NTSB AAR-72-17
Follow-up / safety actions
NTSB issued 9 Safety Recommendations
Issued: 08-DEC-1971 | To: | A-72-1 |
REVIEW THE PROCEDURES FOR THE ISSUANCE OF NOTAM AND AIRAD FOR STANDARDIZED IMPLEMENTATION WITHIN THE APPROPRIATE FAA FACILITIES AND MODIFY THE PROCEDURES TO ASSURE THAT INFORMATION PERTINENT TO "SAFETY OF FLIGHT" IS DISSEMINATED WITHOUT DELAY. (Closed - Acceptable Action) |
Issued: 08-DEC-1971 | To: | A-72-2 |
REQUIRE THAT V REFERENCE SPEED CHECKS BE INCLUDED ON THE LAST CHECKLIST USED IMMEDIATELY PRIOR TO TAKEOFF. (Closed - Unacceptable Action) |
Issued: 08-DEC-1971 | To: | A-72-3 |
REQUIRE THE INSTALLATION OF RUNWAY DISTANCE MARKERS AT ALL CIVIL AIRPORTS WHERE AIR CARRIER AIRCRAFT ARE AUTHORIZED TO OPERATE. (Closed - Unacceptable Action) |
Issued: 08-DEC-1971 | To: | A-72-4 |
REQUIRE THE USE OF TAKEOFF PROCEDURES WHICH WILL PROVIDE THE FLIGHTCREW WITH TIME AND DISTANCE REFERENCE TO ASSOCIATE WITH ACCELERATION TO V1 SPEED. (Closed - Unacceptable Action) |
Issued: 08-DEC-1971 | To: | A-72-5 |
REQUIRE MANUFACTURERS TO INCLUDE INFORMATION IN THE AIRCRAFT FLIGHT MANUAL CONCERNING THE AIRCRAFT CONTROLLABILITY AND PERFORMANCE CHARACTERISTICS WITH THE LOSS OF ANY SYSTEM THAT INVOLVES FLIGHT CONTROLS. CONSIDERATION SHOULD BE GIVEN TO INCORPORATING TRAINING IN SUCH IN-FLIGHT EMERGENCIES IN ALL APPROVED SIMULATOR PROGRAMS AT THE EARLIEST POSSIBLE DATE." (Closed - Unacceptable Action) |
Issued: 24-MAY-1972 | To: | A-72-141 |
THE FAA REQUIRE ALL AIR CARRIER AIRCRAFT TO BE EQUIPPED WITH AN AUDIO AND VISUAL EVACUATION ALARM SYSTEM. THIS SYSTEM SHOULD BE CAPABLE OF BEING ACTIVATED IN THE COCKPIT AND AT EACH FLIGHT ATTENDANT\'S STATION. THE ALARM SYSTEM SHOULD BE SELF-POWERED SO THAT INTERRUPTION OF THE AIRCRAFT ELECTRICAL SYSTEMS WILL NOT INTERFERE WITH USE OF THE EVACUATION ALARM. (Closed - Unacceptable Action) |
Issued: 24-MAY-1972 | To: | A-72-142 |
THE FAA REVIEW THE SLIDE PACK MOUNTING DESIGN, GAS GENERATOR RETENTION DESIGN, AND THE PROTECTION OF THE WHEEL WELL MOUNTED GAS GENERATOR INSTALLATION. THIS REVIEW SHOULD BE MADE TO DETERMINE WHAT ACTIONS CAN BE TAKEN TO IMPROVE THESE COMPONENTS AND MAKE THEM MORE RELIABLE. (Closed - Acceptable Action) |
Issued: 24-MAY-1972 | To: | A-72-143 |
THE FAA TAKE ADDITIONAL STEPS TO ENSURE THAT ALL CABIN CREWMEMBERS ARE PROPERLY INFORMED REGARDING THE SAFETY EQUIPMENT INSTALLED IN THE CABIN AND THAT THE EMERGENCY EQUIPMENT USED FOR PASSENGER DEMONSTRATION IS THE SAME AS THAT PROVIDED FOR THE PASSENGERS\' USE. (Closed - Acceptable Action) |
Issued: 24-MAY-1972 | To: | A-72-144 |
THE FAA REVIEW THE CRITERIA APPLIED TO THE INSTALLATION OF THESE PANELS AND EFFECT WHATEVER ACTION IS APPROPRIATE TO IMPROVE THE INSTALLATION SO THAT THE PANELS WILL STAY IN POSITION DURING SURVIVABLE IMPACT LOAD IMPOSED ON THE CABIN STRUCTURE. (Closed - Acceptable Action) |
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accident date:
30-07-1971type: Boeing 747-121
registration: N747PA
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.