Factual Information 54 Aircraft Accident Report

D. The elevator position indicator should move to the “UP” mark.

+ -Pull control column aft until it reaches full travel against the [aft] stop.

The [EPI] needle will remain pointing to the UP mark. The elevator control
tabs. will move to command aircraft nose up condition (trailing edge down).
The force required to position the control column aft will be relatively light,
since the elevators already have their trailing edge up and only the control tabs
are being deflected. Variations of required force may, however, be expected,
contingent upon wind conditions.

¢ Push control column forward until it reaches full travel against [the forward]
stop.

Barring unusual wind conditions, the force required on the control column is
initially light while only the control tabs are being deflected to command
aircraft nose-down condition (tabs trailing edge up). The control tabs having
reached their full throw, a substantial increase in required force to move the
control column can be noted as the elevator itself deflects to a trailing edge
down condition.[’°] The elevator position indicator needle should now point
between the [neutral] mark and the [down] mark. Movement of the elevator’s
trailing edge to the full down position is not possible. Therefore, the position
indicator needle will not reach the [down] mark. Freedom of the elevator to
move is established by the indicator needle moving from the UP mark to a

position just more than half-way between the [neutral] mark and the [down]
mark,

NOTE: If tailwinds prevail during control check and no elevator movement is
indicated, turn the aircraft into the wind and repeat this procedure.

Emery’s DC-8 AOM section titled “Takeoff, General, Takeoff Roll,” dated
November 11, 1995, contained the following guidance regarding the 80-knot elevator
check:

Between 80 and 100 knots, the pilot flying shall exert a forward pressure on the
elevator to the stop and then release the yoke to slightly forward of neutral. The
crew should confirm a nose down response. Depending on weight and loading,
the pilot flying may need to apply the nose down elevator more than once to get a
satisfactory response. Once the check is complete the pilot flying should state,
“Elevator checks.” The first officer looks for the EPI to respond to yoke
movement when the elevator check is made. The captain must know the elevator
is working properly early in the takeoff roll. If he is in doubt, he should consider
aborting the takeoff.

TM During the Safety Board’s public hearing on this accident, the chief pilot for Boeing’s Douglas
Product Division stated that forces up to about 100 pounds could be required to move the control column as
specified during this check.



Factual Information 20 Aircraft Accident Report

A review of the work cards provided by Emery to TTS for this job revealed that
the overhauled control and geared tabs were installed on the overhauled elevator in
accordance with instructions on work card 3502D, titled “Install Right Elevator Tabs.”
This work card stated the following:

NOTE: Use applicable DC-8 M/M [Maintenance Manual], Chapter 27, when

performing this card.

1. Inspection OK to install serviceable elevator control and gear tab to elevator.
2. Lube all tab hinge bearings prior to tab installation....

3. Install overhauled elevator control tab to elevator.

4. Install overhauled elevator gear tab to elevator.

5. Inspector verify control and geared tab installation and security.

The Safety Board’s review of the completed work card indicated that the required
signatures and stamps were present. All five steps were signed off by a mechanic; the first
and third steps involved in the installation of the elevator tabs were signed off by a
mechanic and stamped by an inspector; and the final step, an inspection verifying the
proper installation and security of the elevator control and geared tabs, was stamped by
two inspectors. There was no indication of the date of completion of the individual steps,
nor did the card call for such an indication; however, the date listed on the completed work
card was October 14, 1999.

When TTS received the overhauled elevator components from CCI, the hardware
required for installation of the elevator control and geared tabs was not included. TTS
personnel indicated that, as a result, they used hardware from TTS stock in accordance
with the DC-8 MM chapter 27 guidance (referenced on work card 3502D).* Chapter 27
of the DC-8 MM, section 3, subpart D of 27-32-06, titled “Tab, Elevator Control—
Removal/Installation,” contained instructions to “connect [the control] tab pushrod to the
tab crank [fitting] and secure.” However, this section of the Emery DC-8 MM did not
contain a list of (or other guidance specifically detailing) the required hardware for the
proper installation and security of the control tab crank fitting/pushrod attachment or
detailed steps regarding the inspection of this attachment. Likewise, the Douglas Master
DC-8 MM did not contain this information. An index associated with an illustration in
Emery’s DC-8 MM, chapter 27-32-06, referenced a figure from Emery’s DC-8 Illustrated
Parts Catalog (IPC),*° chapter 27-30-01. This IPC figure then referenced another IPC

%3 The TTS “Repair Station Inspection Procedures Manual” included the following description of TTS’
procedures for receiving overhauled components, “...[aJny repaired or overhauled components received
from an FAA certificated repair station require a receiving inspection for shipping damage, traceability of
life limits, if applicable, and traceability of overhaul record and or maintenance release tag before being
returned to service. Repaired or overhauled components that are received from other than an FAA
certificated repair station may not be used on an airplane and must be returned to the vendor.”

4 Work card 3502D did not identify the specific hardware required for this installation.

35 Although the Emery and Douglas DC-8 IPCs are not FAA-approved items individually, they were

included on a list of reference documents that was approved by the FAA as part of Emery’s continuous
airworthiness maintenance program.



Aircraft Accident Report

Loss of Pitch Control on Takeoff
Emery Worldwide Airlines, Flight 17
McDonnell Douglas DC-8-71F, N8079U
Rancho Cordova, California

February 16, 2000
DISTRIBUTION STATEMENT A
Approved for Public Release
Distribution Unlimiteg
a,
NTSB/AAR-03/02 7y 30
PB2003-910402 National Transportation Safety Board
Notation 72994

490 L’Enfant Plaza, S.W.

Adopted August 5, 2003 Washington, D.C. 20594



Factual Information 63 Aircraft Accident Report

Additionally, Boeing indicated that it examined more than 180 attachment points
on the DC-8 elevator, aileron, and rudder flight control systems to determine the effect of
a separation of the securing hardware (that is, the castellated nut and cotter pin) at those
attachment points. According to Boeing, this evaluation indicated that a disconnection at
any of these attachment points would result in “mostly minor or no degradation in the
control system operation.”

Boeing also conducted an evaluation of tab-driven flight controls on its other
airplanes, including the DC-9, MD-80/90, and 717, to determine whether similar
unanticipated failure modes might exist in those airplanes. Specifically, Boeing tried to
identify other “previously unanticipated adverse consequences of a single joint disconnect
in the tab mechanisms of tab-driven flight control systems.” (Boeing’s evaluation of the
tab-driven flight controls on the 707 was ongoing at the time of this writing. The primary
flight controls on all other Boeing airplanes are hydraulically actuated (not tab-driven)
and, therefore, were not evaluated.) Boeing described the results of its evaluations in its
May 14, 2003, letter to the Safety Board, stating “[t]he only tab surface that can pose a
loss-of-control disconnect concern is the elevator control tab.”

1.18.2 Party Submissions Regarding Contact/Possible Contact
with the Bolt

In its submission on this accident, Emery stated that although Emery maintenance
personnel performed maintenance on the accident airplane after TTS performed the
D inspection, these maintenance activities did not result in contact with the bolt at the
control tab crank fitting to pushrod attachment. Further, Emery proposed the following
probable cause for the accident:

..loss of elevator control that resulted from the loss of the bolt connecting the
right-hand elevator pushrod to the elevator control tab crank fitting. The loss of
the bolt was due to the failure of the TTS mechanics conducting the D check to
install the cotter pin, or the nut and cotter pin, to safety the bolt properly.
Contributing to the accident was the failure of the TTS inspector to identify the
missing hardware at the time that the work on the elevator control tab installation
was completed during the D check installation.

In contrast, TTS stated in its submission on this accident that several maintenance
actions performed by Emery after TTS completed the D inspection could have resulted in
contact with the bolt connecting the right elevator control tab pushrod to the elevator
control tab crank fitting. Specifically, TTS cited Emery’s troubleshooting efforts during
damper-related maintenance, work performed as a result of repeated pilot writeups about
PTC anomalies, and the B-2 inspection. The TTS submission proposed the following
probable cause for the accident:



Analysis 74 Aircraft Accident Report

The Safety Board notes that 14 CFR 121.369[b][2] requires operators to designate
“items of maintenance...that must be inspected. ..including at least those that could result
in a failure, malfunction, or defect endangering the safe operation of the airplane, if not
performed properly.” Although the instructions and steps contained on Emery’s DC-8
work card 3504D were consistent with industry standards that have been in use for
decades, the Board is concerned that the lack of specificity regarding a postrigging
inspection could result in a hazardous condition. As demonstrated in this accident, if a
missing securing device at a critical attachment goes undetected, it can have catastrophic
consequences. Although the Board did not determine whether the lack of specific
information on Emery’s work cards was directly related to the improper securement of the
bolt in this case, the addition of discrete inspection items, specifically identifying the
attachments/fittings to be inspected, could only help ensure the security of this critical
flight control” attachment. (The Board is aware of one carrier that included in in its
maintenance documents a specific “safety check” work card, requiring inspection of all
previously installed/assembled/inspected components.)

The Safety Board concludes that DC-8 elevator rigging procedures should be fully
addressed in a separate work card that specifically lists required inspection items,
including verifying the security of elevator control tab attachments after the rigging is
completed. Therefore, the Safety Board believes that the FAA should require all DC-8
operators to create or revise DC-8 work cards to ensure they specifically include a

postrigging inspection of the elevator assembly, including verifying the security of
elevator control tab attachments.

Because carriers customarily base their maintenance programs on the
manufacturer’s recommendations, Emery’s DC-8 work card 3504D was most likely based
on a generic work card originally prepared by the manufacturer as part of an overall
recommended DC-8 maintenance program. Therefore, the Safety Board is concerned that
other DC-8 work cards based on that set of generic work cards may contain a similar level
of detail, or lack thereof. The Safety Board concludes that all DC-8 work cards related to
critical flight controls should identify required inspection items as discrete tasks with
individual inspection signoff requirements. Therefore, the Safety Board believes that the
FAA should require all DC-8 operators to review their work cards related to critical flight
controls, and revise them as necessary to ensure that appropriate tasks are identified as
discrete tasks with individual inspection signoff requirements.

2.6.2 Emery’s B-2 Inspection

The B-2 inspection conducted by Emery between the November 1999
D inspection and the accident included instructions for maintenance personnel to “visually
inspect elevators and tabs for general condition, corrosion, leakage, and security of
attachment.” However, when the control tab fairing is installed, it prevents any visual
examination of the control tab crank fitting to pushrod attachment or the inboard hinge

% The DC-8 elevator control tab is a critical flight control because certain failures of this flight control
can be catastrophic.



Factual Information 10 Aircraft Accident Report

accident airplane was altered (different engines and nacelles were installed) and the
airworthiness certificate was amended accordingly to indicate an airplane model DC-8-71.
The accident airplane was converted to a freighter in April 1993, and the airworthiness
certificate was amended to indicate an airplane model DC-8-71F. The documentation for
the freighter conversion included several FAA Form 8110-3s, “Statement of Compliance
with the Federal Aviation Regulations.”

Emery purchased the airplane from Aero USA, Inc., on March 27, 1994. The
airplane was added to Emery’s operating certificate on March 31, 1994. According to
Emery records, the accident airplane had 84,447 total hours of operation and 33,395 flight
cycles”! at the time of the accident. The accident airplane was equipped with four CFM
International (CFMI)”? CFMS56-2-C1 engines.

According to Emery’s dispatch documents for the accident flight, the airplane’s
takeoff weight was calculated to be 279,231 pounds,’ including 63,764 pounds of cargo
and 66,700 pounds of fuel. The dispatch documents indicated that the airplane’s takeoff
c.g. was calculated to be 28.9 percent of the mean aerodynamic chord (MAC) and that the
aft c.g. limit was 33.6 percent MAC for the DC-8-71F airplane. Dispatch documents
indicated that the takeoff flap setting was 15°, and the takeoff horizontal stabilizer trim
setting was 1.6 units ANU.

1.6.1 Cargo Load Information

Postaccident interviews with the cargo-handling personnel who worked on the
accident airplane revealed that the airplane arrived at MHR about 1815. The MHR
cargo-handling personnel indicated that they removed the cargo that was on the main
cargo compartment when the airplane arrived, then loaded 4 pallets and 14 containers of
cargo into the main cargo compartment positions. They also loaded 3 cases of mail and
several pieces of long freight to the existing 1,784 pounds of cargo in the belly cargo
compartments. According to Emery records, the weight of the cargo that was loaded in
the accident airplane at MHR was as follows: 59,290 pounds in the main cargo
compartment and 2,690 pounds in the belly cargo compartments.

The cargo-handling personnel told investigators that there were no problems
during the unloading or loading, and several cargo handlers commented that the operation
went “smooth” that night. Additionally, the cargo-handling personnel, including the load
planner, reported that the airplane’s load was lighter than usual—the load planner
estimated that a typical load would involve about 75,000 pounds of cargo. He further
stated that his usual load planning goal was to obtain a c.g. of about 23 percent MAC; the

21 A flight cycle is one complete takeoff and landing sequence.

” CFMI is a company jointly owned by General Electric Aircraft Engines of the United States and
Societe Nationale d’Etude et de Construction de Moteurs d’ Aviation of France.

3 According to the manufacturer’s airplane flight manual, the maximum certificated takeoff gross
weight for the accident airplane was 328,000 pounds.



Analysis 69 Aircraft Accident Report

(to address a pilot report of increased control column forces) about 1 week after the
accident airplane’s D inspection was completed.

Emery’s DC-8 MM contained troubleshooting procedures for the reported problem
that included inspecting the control tab pushrods and their linkage; had Emery mechanics
followed these procedures, their work could have involved contact with the bolt at the
inboard control tab fitting. However, during postaccident interviews, Emery’s lead
mechanic stated that they identified and corrected the reversed elevator damper
installation early in their troubleshooting efforts and, therefore, never accessed the control
tab pushrods.

2.4 Preflight Inspection and Flight Control/EPI Checks

2.4.1 Preflight Inspection

Emery’s procedures required the flight engineer to examine the elevator control
surfaces twice during his preflight inspections of the airplane—once with the elevator gust
lock engaged and once with the gust lock disengaged. Although it was not possible to
determine what position the control tabs were in during the flight engineer’s preflight
inspection of the airplane, if the right elevator control tab was disconnected when the
preflight inspections were conducted, an asymmetry between the right and left control tabs
would likely have existed.

Emery’s AOM instructed pilots to check the elevator and tabs for “alignment and
condition” and specified “with gust lock off, elevator should be up, control tabs up, and
geared tabs down.” Although this guidance is accurate, it should more strongly emphasize
the importance of pilots ensuring that the right and left side elevators and tabs are
deflected symmetrically during the preflight inspection. After the accident, Boeing
emphasized flight control symmetry in its June 19, 2001, FOB, which stated the
following:

The proper functioning of the flight controls should be verified before every
flight. If the exterior walk-around is made...with the gust lock released, the
elevators and control tabs should be positioned toward UP (symmetrically), and
the geared tabs DOWN (again symmetrically).

The Safety Board concludes that DC-8 operators’ procedures and training should
more clearly emphasize that DC-8 flight crewmembers need to verify symmetry between
the right and left side elevators, control tabs, and geared tabs during the preflight
inspection. Therefore, the Safety Board believes that the FAA should require all DC-8
operators to train DC-8 flight crewmembers to look for symmetry between the right and
left side elevators, control tabs, and geared tabs during the preflight inspection, consistent
with Boeing’s June 2001 FOB guidance.



Factual Information 27 Aircraft Accident Report

However, during his public hearing testimony, the lead mechanic for TTS stated
that although the work card did not specifically call for removal of the inboard control tab
fairing, TTS mechanics “would remove the fairings on the elevator itself...and the control
tab...and the geared tab...to accomplish all of that card.” The president of TTS also stated
that the company’s maintenance personnel would remove the fairings on the elevator,
control tab, and geared tab to visually inspect each attachment to accomplish the work
card tasks.

The Safety Board is aware that several air carrier operators have tried to provide
their mechanics with additional guidance regarding the proper accomplishment of a work
card item by enumerating the necessary steps or tasks on that item’s work card.

1.7 Meteorological Information

The automated weather observation system (AWOS) weather observation taken at
MHR on February 16, 2000, at 1950 stated the following:

Winds calm; visibility 10 miles plus; scattered clouds at 2,000 feet, ceiling
7,000 feet broken; temperature 46° Fahrenheit (F); dew point 46° F; altimeter
setting 30.01 inches of Hg [mercury].

According to postaccident interviews with witnesses, the ceiling and nighttime
visibility at MHR at the time of the accident were such that the witnesses could clearly
observe the airplane as it taxied from the ramp to the tunway, took off, climbed out, and
tumed to return to the airport. The CVR did not record any pilot comments regarding the
weather conditions at the time of the accident.

1.8 Aids to Navigation

No difficulties with the navigational aids were known or reported.

1.9 Communications

No difficulties with communications were known or reported.

1.10 Airport Information

MRR is a former U.S. Air Force Base that is currently operated by the County of
Sacramento and located about 12 miles east of downtown Sacramento, California. The
airport has an elevation of 96 feet and two parallel runways; runway 4L/22R is 6,040 feet
long and 150 feet wide and runway 4R/22L is 11,301 feet long and 150 feet wide. The
accident airplane departed from runway 22L.



Aircraft Accident Report

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Factual Information 34 Aircraft Accident Report

The FAA had previously notified Emery of deficiencies with its DC-8 FDR
documentation. On December 1, 1998 (about 11 months before the accident airplane’s
FDR was upgraded to 17 parameters), the FAA’s principal avionics inspector for Emery

sent a letter to Emery’s Director of Quality Control, in which he listed the following
FDR-related findings:

There are no correlation documents required by FAR 121.343(j) on file for any of
Emery Worldwide Airlines DC-8 aircraft. As discussed with you and Mr. Robbins
the minimum correlation requirement is derived from FAR 25.1459(c).[°7]

There is no current maintenance manual procedure for the upgraded 11 parameters
of each make/model of DFDR [digital flight data recorder] in use.

1.11.2.4 FDR Control Column Position Data

In the original correlation measurements (intended to establish a relationship
between the geometry of the accident airplane’s control column and the corresponding
data recorded by the FDR), the FDR recorded the airplane’s control column position at 15°
forward of vertical when the gust lock was engaged. The control column correlation also
showed that the total range of control column position at the time of the FDR upgrade was
29.6° (nearly the DC-8 design control column maximum range of 30.25°) and fell within
the design range of forward and aft movement.

However, the recorded control column range of motion at the time of the accident
was less than that observed during the original correlation. Although the recorded forward
and neutral control column positions came close to those indicated by the original
correlation, the maximum recorded aft control column range was significantly reduced
from that indicated by the original correlation. The Safety Board did not determine the
cause of this reduction in recorded control column range.

1.11.2.5 Previous FDR Data-Related Safety Recommendations

The Safety Board has previously encountered problems related to the absence of
reliable FDR data® and has made a series of safety recommendations regarding these
issues since the early 1970s. In its correspondence with the FAA regarding these safety
recommendations, the Board has noted that the FDR-related problems were especially
prevalent for airplanes that were originally equipped with six-parameter FDRs and
subsequently retrofitted to record additional parameters in accordance with

* As previously discussed, Emery personnel were able to provide the Safety Board with conversion
documentation for the accident airplane and the airplanes involved in the other incidents. L2 Consulting
Services, Inc., the company that correlated and verified the FDR parameter upgrades on Emery’s DC-8s,
provided Emery with the documentation.

53 Accidents in which unreliable or missing FDR data were discovered included four accidents
involving DC-9 airplanes operated by ValuJet in 1996; the February 16, 1995, accident involving an ATI
DC-8; the November 12, 1996, accident in Orebro, Sweden, involving an Express One Boeing 727; the
August 7, 1997, accident involving a Fine Airlines DC-8-61, and the February 9, 1998, accident involving
an American Airlines 727. Other accidents are discussed later in this section.



Factual Information 59 Aircraft Accident Report

tab pushrod to the tab crank fitting. The DC-8 IPC provided by Emery identified the
control tab crank/pushrod attachment point hardware except for the cotter pin. The DC-8
OHM provided by Emery did contain such information.

1.17.2.2 TTS DC-8 Elevator Control Tab Inspection Memorandum

On October 24, 2001, based on information learned during this investigation, the
TTS Director Of Quality Assurance issued a memorandum to all inspection personnel,
requiring them, on an ongoing basis, to remove the inboard fairings on the right and left
elevator control tabs on all DC-8s. The memorandum instructed personnel to do the
following before an airplane leaves the facility:

* . Ensure that the correct hardware, per aircraft effectivity, is installed and
properly safetied on each control tab pushrod to drive crank fitting. Use the
appropriate Illustrated Parts Catalog.

* Ensure that the bolt is installed with the head of the bolt being inboard, as
illustrated in the Douglas Overhaul Manual 27-16-1, page 13/14.

* Any discrepancies will be documented and corrected prior to the airplane
departing our facility.

1.17.3 FAA Oversight of Emery Worldwide Airlines’ Certificate

FAA oversight responsibility for the company’s certificate was located with the
San Jose FSDO until December 1999, when Emery’s certificate was transferred to the
Cincinnati FSDO." Because the transfer of FAA oversight responsibility occurred about
2 months before the accident, investigators interviewed FAA personnel at the San Jose and
Cincinnati FSDOs during this investigation.

The San Jose FSDO principal operations inspector (POI) indicated that most of the
violations and issues discovered during the inspections conducted by that FSDO were
maintenance/airworthiness related; he did not remember any specific operational changes
as a result of these inspections. Emery’s POI from the Cincinnati FSDO indicated that
managing Emety’s certificate was a heavy workload; he stated that he interacted
frequently with Emery management personnel at DAY, oversaw the rewriting of several of
Emery’s manuals, and was extremely busy conducting checkrides.

The San Jose FSDO principal maintenance inspector (PMI) was responsible for
the Emery certificate from September 1997 until the certificate was transferred in
December 1999. He stated that he thought FSDO personnel were working productively
with Emery personnel to address ongoing maintenance issues, including repetitive

® According to Emery personnel, the company requested that the certificate be transferred from the San
Jose FSDO because that FSDO was unable to provide adequate checkride support. According to FAA
personnel, the oversight responsibility was reassigned to the Cincinnati FSDO because that FSDO was
closer to Emery’s corporate offices and main base of operation and, thus, was better able to support/oversee
the air carrier.



Factual Information 30 Aircraft Accident Report

airplane in November 1999, after the airplane was upgraded to record 17 parameters.)*
The documentation for elevator position provided a relationship between elevator position
data recorded by the FDR and the degrees of elevator travel that data represents. The
Board’s subsequent conversion of the data based on this relationship resulted in a potential
range of elevator positions from 12.8° TEU to 26.6° TED; the elevator’s normal operating
range is from 27° TEU to 16.5° TED.

The accident airplane’s FDR data indicated that the elevator surfaces were
deflected 11° TED relative to the horizontal stabilizer when the airplane was on the ground
with the elevator gust lock engaged. However, by design, when the gust lock is engaged,
the elevators are physically locked in their neutral, or 0°, position. Additionally, the FDR
data recorded during the accident airplane’s climb out from RNO (the flight immediately
preceding the accident flight) showed the elevators in a significant TED deflection when
the control columns were near their rigged neutral position, which normally corresponds
to a neutral elevator position of about 0°. The elevator’s total range of motion was slightly
smaller than and offset from its normal range. Therefore, an 11° offset (based on the
elevator’s position with the gust lock engaged) in the TEU direction was applied to the
elevator recorded position data.

Figure 6 shows the elevator, pitch, and control column plots recorded by the
accident airplane’s FDR during ground operations before the accident flight. On this plot,
the uncorrected data on the far left side of the plot shows an 11° TED elevator deflection
when the gust lock was engaged (and the elevator was in its neutral, or 0°, position).

46 According to the FAA’s advisory circular (AC) on this subject (AC 20-141), “a correlation describes
the relationship between two variables. In this case the two variables are the raw data stored in the digital
FDR and the engineering units or discretes that this raw data represents.” The work card provided by L2
Consulting Services, Inc., titled “F800 [FDR] Correlation Test Procedure—17 Parameters,” documented the
ground test performed on the accident airplane to collect correlation data for Emery’s upgrade configuration
for that airplane model. For additional information regarding this documentation, see “Addendum 2 to the
Digital Flight Data Recorder Factual” in the docket for this accident.



Factual Information 62 Aircraft Accident Report

1.18 Additional Information

. 1.18.1 Design and Certification of DC-8 Elevator System

As previously discussed, the DC-8 was originally type-certificated in 1959 under
CAR 4b (dated December 31, 1953). (The DC-8 type certificate [TC No. 4425] was
amended on April 13, 1982, to include DC-8-71F model airplanes.) For example, CAR
Section 4b.320, “Control Systems, General,” states the following:

[A] controls and control systems shall operate with ease, smoothness, and
Positiveness appropriate to their function. The elements of the flight control
system shall incorporate design features, or shall be distinctively and permanently
marked to minimize the possibility of incorrect assembly which could result in
malfunctioning of the flight control system. Tab control systems shall be such
that disconnection or failure of any element...cannot jeopardize the safety of

flight.

CAR Section 4b.303, “Standard Fastenings” (the predecessor to FAR 25.607),
States, “self-locking nuts shall not be used on bolts which are subject to rotation in
operation.” FAR 25.607® states, in part, the following:

(a) Each removable bolt, screw, nut, pin, or other removable fastener must
incorporate two separate locking devices if —

(1) _ Its loss could preclude continued flight and landing within the
design limitations of the airplane using normal pilot skill and
strength; or

(2) Its loss could result in reduction in pitch, yaw, or roll control
capability.

In its submission on this accident, Boeing stated that a failure/disconnection of the
control tab crank fitting/pushrod attachment was considered by the manufacturer and the
FAA during DC-8 development and certification. The submission noted, however, that
“the TED [control] tab motion and the subsequent [pushrod end escape from between the
crank [fitting] lugs was a mode that had not been anticipated, nor had it been experienced
prior to this accident.”

Boeing indicated it has “begun developing an enhanced design of the control tab
pushrod that will prevent the pushrod from dropping or otherwise moving in front of the
control tab crank should the bolt migrate out of the connecting joint. The front end of the
pushrod is also being reviewed for consequences should it become disconnected.” In a
letter to the Safety Board dated May 14, 2003, Boeing stated that a “prototype part has
been built. The design and installation will be ground tested on a DC-8.”

86 FAR 25.607 did not apply to the certification of the DC-8.



Aircraft Accident Report

100

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NOLLVOINNWINOD GNNOYS-OL-LaveoulV 99929 NOILVOINNWWOD LidHSO9-VULNI



Factual Information 40 Aircraft Accident Report

(See figure 2, in section 1.6.2, for a diagram of the elevator control tab installation.) The
right control tab pushrod was recovered separately, with its aft rod end (which would
normally have been bolted to the tab crank fitting) intact. Examination of the forward
edges of the elevator control tab crank fitting lugs revealed evidence of repeated contact
damage (including gouge marks and indentations). (Figure 9 is a photograph of damage to
this area.) The internal surfaces of the pushrod aft rod end bearing and the bushings in the
crank fitting lugs showed no visible signs of damage or deformation. The bolt and
associated hardware that normally secures the right elevator control tab pushrod to the tab
crank fitting®' was missing and not recovered.

Although the inboard portions of the left elevator, control tab, crank fitting, and
attachment hardware were not recovered and were presumed consumed by postcrash fire,
the left elevator control tab pushrod was recovered. Unlike the right control tab pushrod,
the left control tab pushrod’s aft rod end (normally attached to the tab crank fitting) was
fractured and about 75 percent of it and its associated bearing were missing. The forward
end of this pushrod was fractured at its rod end attachment holes, and the pushrod had

about an approximately 90° bend at its midpoint. No fire damage was observed on the left
control tab pushrod assembly.

Control Tab Hinge Line

Outboard Crank Lug

Contact Damage ===

Forward

Figure 9. A photograph of the accident airplane's right elevator control tab
crank fitting. Note damage on forward face of control tab crank fitting lugs.

°! As previously stated, the hardware required to secure the elevator control tab pushrod to the tab crank
fitting at this location includes a 5/16-inch drilled-shank alloy steel bolt, a washer, a steel castellated nut, and
a cotter pin. The bolt has a rated shear strength of 7,300 pounds; if properly installed, the attachment
hardware has a tensile strength of 3,250 pounds. The alloy steel hardware had a melting temperature of

about 2,700° F, whereas the aluminum crank fitting and pushrod aft rod end had a melting temperature of
about 1,000° F.



Conclusions 82 Aircraft Accident Report

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

DC-8 operators, including Emery, do not use the elevator position indicator (EPI) to
confirm elevator movement indications above and below the neutral range during the
80-knot elevator check and, thus, do not take full advantage of the EPI’s capabilities
to provide pilots with an indication of an abnormal elevator condition.

The elevator position indicator needs to be periodically calibrated to ensure that it
provides the most accurate information possible to the pilots.

The elevator position indicator gauge should be readily visible to both pilots.

The circumstances of the Emery flight 17 accident show that the current DC-8 design
does not preclude a catastrophic result from a disconnection or failure of the existing
control tab crank fitting to pushrod attachment.

There may be airplanes that were certificated to Civil Aviation Regulations 4b
standards other than the DC-8 on which the disconnection of a critical flight control
could have catastrophic results.

Replacement of the DC-8 aluminum elevator geared tab crank arms on DC-8
airplanes with stainless steel elevator geared tab crank arms would likely eliminate
the possibility of a jam resulting from fractured geared tab crank arms.

DC-8 elevator rigging procedures should be fully addressed in a separate work card
that specifically lists required inspection items, including verifying the security of
elevator control tab attachments after the rigging is completed.

All DC-8 work cards related to critical flight controls should identify required
inspection items as discrete tasks with individual inspection signoff requirements.

All air carrier operators should provide maintenance personnel with more detailed
information regarding the steps or actions that are necessary to satisfactorily
accomplish a maintenance task.

The use of outdated, incomplete, or otherwise unsuitable reference materials by
maintenance personnel during the installation and/or assembly of airplane
components can occur and is a potentially unsafe practice.

The use of a single airplane’s flight data recorder (FDR) parameter correlation for all
airplanes of the same type is inadequate to ensure accurate correlations for older
airplanes that have been retrofitted to record additional FDR parameters.

Loral Fairchild Model F-800 flight data recorders with unaddressed or unidentified
tracking-switching anomalies may currently be in operation.

The current regulatory definition of safety-sensitive functions is too narrow for the
issue of postaccident testing because it does not include cargo handlers, load planners,

and ramp supervisors, all of whom have a demonstrated potential to affect the safety
of a flight.



Factual Information 3 Aircraft Accident Report

left...center...right...center” and the captain stating, “ready on the rudders?...left
rudder...center...right rudder...center.” About 1942:27, the captain stated, “elevator
forward...coming back,” and the first officer responded, “EPI [elevator position
indicator]'° checks.”

According to the CVR, about 1942:31, the flight crew began the taxi checklist.
About 1942:43, the flight engineer stated, “controls, EPI;” the first officer responded,
“checked;” and the flight engineer repeated, “checked.” Flight data recorder (FDR) data
indicate that, during the elevator control check, the accident airplane’s control column
moved from 10.8° forward of its vertical position to 17.3° forward of vertical. During this
time, the FDR recorded the elevator surfaces moving from 16.6° trailing edge up (TEU) to
2.8° TEU. No trailing edge down (TED) deflection was recorded during this elevator
check. About 1943:23, the flight engineer indicated that the taxi checklist was complete.

According to the CVR, about 1946:58, the first officer contacted Sacramento
terminal radar approach control (TRACON), advising the air traffic controllers that Emery
flight 17 was number one for takeoff and requesting the flight’s IFR release for the flight
to DAY." About 1947:14, the controllers at Sacramento TRACON stated, “Emery [17...],
Sacramento...you’re released for departure, report airborne.” The first officer responded,
“...we’ll call you in the air.”

Between 1947:28 and 1948:10, the pilots performed the before takeoff checklist,
during which they advised the local airport traffic that they would be taking off on
runway 22L with a left downwind departure. About 1948:15, the CVR recorded a sound
similar to increasing engine rpm. About 1948:44, the captain stated “airspeed’s alive” and
the first officer responded “alive here.” According to FDR data, as the airplane
accelerated through about 60 knots, the control column was moving forward from about
13.7° forward of vertical while the elevator was about 6.4° TEU.” About 1948:50, the
captain stated “eighty knots” and the first officer responded, “eighty knots...elevator
checks.” FDR data indicate that, during this elevator check (which occurred between
1948:48 and 1948:53), the control column and elevator positions moved from about 14.4°
forward of vertical and 5.4° TEU, respectively, to about 19.0° forward of vertical and 2.2°
TEU then returned to their previous values.'* Also during this time, the airplane’s pitch
attitude moved from about 0.2° airplane nose up (ANU) to 0.6° airplane nose down
(AND), then back to 0.2? ANU.

'Emery’s before takeoff checklist procedures included an EPV/elevator check. For additional
information regarding the EPI, see sections 1.6.2.1, 1.16.1.2, and 1.17.1.2.2.

TM Because there is no on-airport ATC facility at MHR to provide pilots with instrument clearances,
pilots departing from MHR on IFR flight plans contact Sacramento TRACON for an IFR release before they
depart.

“ FDR data showed that, during the previous takeoff (at RNO), as the airplane accelerated through
about 60 knots, the control column position was steady at 13.4° forward of vertical while the elevator
remained fairly steady above neutral, about 6.0° to 6.4° TEU.

® FDR data showed that, during the previous takeoff (at RNO), as the pilots performed the 80-knot
elevator check, the elevator moved below neutral to about 7.8° TED when the control column position
moved forward slightly less than it did during the accident flight.



Contents iv Aircraft Accident Report
2. Analysis .............. Boece eee e ect eect cee ee ences 65
2.1 General . - 65

2.2 The Accident Sequence . - 65
2.2.1 Disconnection of the Right Elevator Control Tab . . - 66

2.3 Role of Aircraft Maintenance in the Accident ..... - 68

2.4 Preflight Inspection and Flight Control/EPI Checks - 69

24.1 Preflight Inspection ...................6
2.4.2 Elevator Checks/Use of the EPI Gauge
2.5 Elevator Design Issues..............
2.5.1 Elevator Geared Tab Crank Arm Fractures . .
2.6 Emery’s DC-8 Maintenance Documents and Guidance...............000eeeeeee 7B
2.6.1 Required Inspection Items .
2.6.2. Emery’s B-2 Inspection .
2.6.3 DC-8 MM Information.
2.7 FDR-Related Issues ..

3. Conclusions . .

81
3.1 Findings .. 81
3.2 Probable Cause.... 2.0... cece cece cece ee cen cece ceeeneeeeeeauns 83
4, Recommendations. ........ 00.0... 0 cece cece cc cce eee eceenneeeeees 84
5. Appendixes
A: Investigation and Hearing ©... 0.0.2... cec cece ccc cenneeeeeanecs 89
B: Cockpit Voice Recorder Transcript ...... 0.0.0.2... cece cc ccceececceeuneeeeees 90


Factual Information 37 Aircraft Accident Report

Safety Recommendation A-98-54 asked the FAA to do the following:

Require maintenance checks for all...flight data recorders (FDR) of aircraft
operated under...14 CFR Parts 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 recorded 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.

On October 5, 1999, the FAA issued AC 20-141, “Airworthiness and Operational
Approval of Digital Flight Data Recorder Systems,” which addressed design, installation,
and continued airworthiness of FDR systems. AC 20-141 instructs operators to “establish
a schedule for accomplishing an operational and functional [FDR] ground check at
intervals not to exceed 12 calendar months.” As previously mentioned, the FAA indicated
that it would conduct a survey of all FDR-equipped airplanes by February 2001. In part,
this survey was intended to determine the effectiveness of AC 20-141 and whether any
changes were needed. Pending the results of the FAA’s survey, on March 12, 2001, the
Safety Board classified Safety Recommendation A-98-54 “Open—Acceptable Response.”

There has been no further correspondence from the FAA regarding Safety
Recommendation A-98-54.

Safety Recommendation A-98-55 asked the FAA to do the following:

Provide FAA principal avionics inspectors with training that addresses the unique
and complex characteristics of flight data recorder systems.

In response to Safety Recommendation A-98-55, the FAA developed a training
course in evaluating the certification and maintenance of FDRs for all FAA PAIs. The
implementation of this course began in October 2000. The curriculum addresses FDR
regulatory requirements, flight recorder systems specifications, certification records and
documentation, maintenance program requirements, and maintenance program data
analysis. The course is intended to help PAIs determine whether FDR systems comply
with the FAR requirements and evaluate an operator's FDR maintenance/inspection and
training program. The course should train PAIs to identify whether FDR recorded values
are within required specifications and to evaluate the reasonableness and quality of the
recorded data.”* On March 12, 2001, the Safety Board classified Safety Recommendation
A-98-55 “Open—Acceptable Response,” pending the completion of this training by all of
the FAA’s PAIs.

5 According to the FAA, as of May 8, 2003, all active FAA PAIs had completed the required training;
three non-active PAls had not completed the FAA’s training because of other commitments.



Analysis 68 Aircraft Accident Report

2.3 Role of Aircraft Maintenance in the Accident

The FDR data and the physical evidence indicated that the bolt that normally
attaches the right elevator control tab pushrod to the control tab crank fitting separated
before the accident takeoff. There was no physical damage or other evidence indicating
that the bolt failed or fractured, and failure of an installed castellated nut and/or cotter pin
during normal operation would be very unlikely. Therefore, the bolt must have separated
because it had not been properly secured; that is, the required castellated nut was either
never installed, or it was improperly installed (for example, installed without a cotter pin).
The Safety Board reviewed the accident airplane’s maintenance history to determine when
and where the improper installation of the attachment bolt may have occurred. On the
basis of its review, the Safety Board concludes that the bolt attaching the accident
airplane’s right elevator control tab was improperly secured and inspected, either during
the most recent D inspection or subsequent maintenance; however, the Board was unable
to determine when this improper securement and inspection occurred.

The installation of the overhauled elevator assembly during the D inspection
completed by TTS in November 1999 was the last documented maintenance action
involving attachment of the right elevator control tab to the pushrod. According to
documentation and postaccident interviews, TTS maintenance personnel installed the
overhauled elevator assembly in accordance with work cards and the maintenance manual
MM that were provided by Emery. TTS maintenance personnel told the Safety Board that
they were aware that this connection should be secured with a drilled-shank bolt, a
castellated nut, and a cotter pin.

TTS maintenance personnel had another opportunity to come into contact with the
bolt at that attachment during the postinstallation testing and rigging procedures. If
adjustments to the pushrod length were required during the rigging process (as they
commonly are), the aft rod end bolt, nut, and cotter pin might have been removed and the
bolt reinstalled upon completion of the rigging. However, because the forward rod end is
designed to be the adjustable end of the pushrod, it is possible to adjust the rod length
without removing the aft rod end hardware; therefore, an experienced mechanic might not
have removed this bolt during the rigging process.®®

In its submission on this accident, Emery contends that TTS mechanics failed to
properly secure the bolt during the D inspection. However, submissions received from
several other parties to the investigation suggested that there was an opportunity for
Emery maintenance personnel to access this bolt/attachment after TTS completed the
D inspection. Specifically, these submissions referenced work accomplished by Emery

® Emery’s postaccident inspection of its DC-8 fleet (which was maintained and inspected by both TTS
and Emery personnel) revealed that control tab attachment hardware (including cotter pins) was installed at
the forward and aft ends of each control tab pushrod on each airplane. In addition, physical damage to the
accident airplane’s left control tab pushrod (the only piece of wreckage from that attachment that was
recovered) indicated that the bolt at the left control tab crank fitting to pushrod attachment was in place at
the time of impact.



Analysis 77 Aircraft Accident Report

range of elevator travel, including the elevator neutral position, was not accurately
identified during the original correlation.

Fortunately, the Board was able to adjust the conversion for use in this
investigation; however, the Board’s identification of the incorrect elevator conversion
delayed a thorough evaluation of the elevator’s behavior during the accident and previous
flights. This problem could have been identified and corrected at the time of the upgrade
if L2 Consulting Services, Inc. (the company that performed the correlation after the
upgrade) or Emery had verified that the accident airplane’s original correlation reflected
the elevator’s actual (design) range of travel during the correlation or after the correlation
was completed.

The subsequent readout and evaluation of three other Emery DC-8 FDRs (two of
which were installed at different times on the Emery DC-8 used in postaccident tests) also
indicated problems with the elevator data conversions. According to documentation the
Safety Board received from Emery and L2 Consulting Services, Inc., the accident
airplane’s FDR system was the only FDR system on which a complete correlation of
recorded FDR data to actual elevator position was accomplished. The other two airplanes
examined were only subjected to a verification test during which the elevator was moved
to its neutral, full up, and full down positions, then the measured values from the
accident airplane’s correlation were applied. Unfortunately, the elevator position
correlation for the accident airplane, which was used by Emery for the remainder of its
upgraded DC-8 fleet, was incorrect. The FARs (specifically, Section 121.343 iJ) permit
the use of a single correlation for airplanes of the same type if they have the same FDR
and sensors, presumably because full correlations on similar equipment would be
expected to be similar. However, the Board observed significant differences in the
conversions required for Emery’s DC-8s. The correlation problems observed during this
investigation raise concerns about the use of a single correlation for a fleet of airplanes.

The Safety Board’s discovery of a shift in the control column range of travel
between the time of the original correlation and the accident provides further evidence of
inconsistencies with the FDR-to-actual position correlations. Although the shift in control
column range of travel did not result in a change to the control column conversion, the
Board is concerned about the cause of the shift, which was not determined.

The Safety Board has found that FDR correlation inconsistencies occur more
frequently on airplanes manufactured on or before August 18, 2000, that have been
retrofitted to record additional parameters (in compliance with Federal regulations).
Consequently, the use of a single correlation document for an existing fleet, while
permitted by regulation, may be more problematic when applied to older airplanes that
have been retrofitted to record additional FDR parameters. These difficulties have often
resulted in more difficult and time-consuming investigations.*

°% These elevator movements were not physically measured; rather, the erroneous correlations from the
accident airplane were applied to data obtained from the other two airplanes.



Loss of Pitch Control on Takeoff
Emery Worldwide Airlines, Flight 17
McDonnell Douglas DC-8-71F, N8079U
Rancho Cordova, California

February 16, 2000

Aircraft Accident Report
NTSB/AAR-03/02

PB2003-910402
Notation 7299A

20031126 054

National
Transportation
Safety Board

Washington, D.C.



Aircraft Accident Report

104

Appendix B

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iti Aircraft Accident Report

Contents

Figures 0.0.0.0. ccc een cence tenet teen entrees v
Abbreviations ........0. 0.0 n teen ene enenee vi
Executive Summary ............ 00.00 cece cece cece eee een een e nee neee viii

1. Factual Information .........0..00 0.0 e eee e teen e eens
1.1 History of Flight...
1.2 Injuries to Persons. .
1.3. Damage to Aircraft...............
1.4 Other Damage...................
1.5 Personnel Information.

1.5.1 The Captain ...
1.5.2 The First Officer. .
1.5.3. The Flight Engineer
1.6 Airplane Information . .
1.6.1 Cargo Load Information. . .
1.6.2 DC-8 Longitudinal Flight Control System.
1.6.3 Maintenance Information
1.7 Meteorological Information .
1.8 Aids to Navigation
1.9 Communications
1.10 Airport Information.
1.11 Flight Recorders
1.11.1 Cockpit Voice Recorder. ...... 0.0... cece cece e een eee teen ences
1.11.2 Flight Data Recorder ........
1.12 Wreckage Recovery and Documentation ................
1.12.1 Longitudinal Flight Control Surfaces ................
1.13 Medical and Pathological Information .
1.13.1 Flight Crew Information .......
1.13.2 Cargo Handlers—Postaccident Drug and Alcohol Testing
1.14 Fire/Explosion ....
1.15 Survival Aspects
1.16 Tests and Research.

1.16.1 DC-8 Elevator Flight Control Tests. - 42
1.16.2 Airplane Performance Studies . . . .47
1.17 Operational and Management Information - 50
1.17.1 Emery Worldwide Airlines, Inc. - 50

1.17.2 Tennessee Technical Services
1.17.3 FAA Oversight of Emery Worldwide Airlines’ Certificate
1.18 Additional Information
1.18.1 Design and Certification of DC-8 Elevator System..............0.0ee0eeeee 62
1.18.2 Party Submissions Regarding Contact/Possible Contact with the Bolt.......... 63



Aircraft Accident Report

105

Appendix B

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Factual Information 25 Aircraft Accident Report

) Maintenance personnel reported that after the damper exchange, they noted no
excessive control column forces or elevator binding; the damper exchange was examined
by an inspector and signed off, and the airplane was returned to service. The maintenance
logbooks contained no further pilot complaints regarding this anomaly.

Chapter 27-00-37 of Emery’s DC-8 MM, “Mechanical Controls—Trouble
Shooting,” listed the following procedures, in part, for troubleshooting elevator/tab issues:

A. Part 1

1. Clean and lubricate elevator cable cabin pressure seals per MM....

2. With airplane out of the wind (in hangar), gust lock off, check elevator
controls for binding and roughness. Cause of any roughness or binding is to
be located. Experience has shown that tab torque tube bearings inside the
elevator inboard hinge fitting are very susceptible to binding and rough
operation.

Check elevator control cable tensions, per MM...and record them.
4. Check cable on elevator autopilot servo drum for binding or damage.

Check top and bottom surface contours of elevators outboard of tabs. Top and
bottom surfaces to be flat and trailing edge should not bow up or down....

6. Repeat check “5,” but on all four elevator tabs.

B. Part2

1. Check that elevator trailing edge forward of tabs fairs with tab leading edges.
Correct any discrepancies.

2. Check control tab pushrods in elevators for clearance per MM....Correct
conditions not within limits.

3. Check that elevator servo support rig holes...are aligned per MM....Record
any discrepancies.

4. Check elevator controls rigging per MM...record any out-of-tolerance
conditions.

5. Remove the RH pilot seat and floorboards and check the MPT (mach pitch
trim) controls for evidence of binding....Operate the MPT to the extend
position and check elevator controls for binding. Correct any binding.

6. Check end play (looseness) of the elevator load feel/centering mechanism
shaft relative to the mechanism housing....If end play exceeds 0:010 inch the
mechanism should be replaced. The mechanism can be removed, checked
and reinstalled without disturbing its adjustment.

7. Check that elevator control system friction is within the limits of [the MM].

C. Part 3



84 Aircraft Accident Report

4. Recommendations

As a result of the investigation of the Emery Worldwide Airlines flight 17
accident, the National Transportation Safety Board recommends that the Federal Aviation
Administration:

Require all DC-8 operators to train DC-8 flight crewmembers to look for
symmetry between the right and left side elevators, control tabs, and geared
tabs during preflight inspection, consistent with Boeing’s June 2001 flight
operations bulletin guidance. (A-03-22)

Require the development of DC-8 80-knot elevator check procedures that
will ensure that pilots are clearly made aware of whether the elevator is
functioning properly before the airplane lifts off, then require all DC-8
operators to incorporate these procedures into their training and normal
operations. The procedures should contain specific guidance regarding an
expected range of elevator position indicator (EPI) needle movement
(including EPI needle movement well below the neutral mark with forward
control column movement) and specific criteria for aborting a takeoff as a
result of an inadequate elevator movement indication. (A-03-23)

Require all DC-8 operators to incorporate periodic elevator position
indicator (EPI) calibration inspections into their maintenance programs to
ensure that the EPI indications observed by pilots accurately represent the
condition of the elevator. (A-03-24)

Require DC-8 elevator position indicators to be located and sized so that
they are visible and usable for both the captain and first officer. (A-03-25)

Require Boeing to redesign DC-8 elevator control tab installations and
require all DC-8 operators to then retrofit all DC-8 airplanes with these
installations such that pilots are able to safely operate the airplane if the
control tab becomes disconnected from the pushrod. (A-03-26)

Evaluate airplanes other than the DC-8 certificated to Civil Aviation
Regulations 4b standards to evaluate whether disconnection or failure of
critical flight control systems could have catastrophic results and, if so,
require that they also be redesigned and retrofitted and/or equipped with
dual-locking devices to preclude such catastrophic results. (A-03-27)

Require all DC-8 operators to replace all DC-8 aluminum elevator geared
tab crank arms on their DC-8 airplanes with stainless steel elevator geared
tab crank arms. (A-03-28)



Analysis 79 Aircraft Accident Report

components of the accident FDR were subject to modifications per any of the FSBs
regarding track switching.

The Safety Board considered two possible explanations for the accident airplane’s
tracking-switching anomaly: 1) the accident FDR’s tracking-switching condition was a
previously unidentified condition for which no remedy had been developed, and therefore
none of the FSBs applied, or 2) one or more of the existing FSBs were applicable to the
accident FDR, but Emery’s paperwork did not reflect installation of the relevant
components (whether accomplished or not). Regarding the second scenario, although the
FSB’s targeted replacement of one or more specific components on a board in the FDR
and such component revisions should be marked on the boards, a mechanic could easily
temove one board and replace it with another without documenting the components on the
replacement board if slight differences exist. Thus, it is possible that one or more of the
FSBs designed to address track switching applied to the accident airplane’s FDR but this
was not indicated in Emery’s documentation for that FDR. (The condition of the recorder
prevented the Board from physically verifying the components installed on the accident
FDR.)

The Safety Board concludes that Loral Fairchild Model F-800 FDRs with
unaddressed or unidentified tracking-switching anomalies may currently be in operation.
Therefore, the Safety Board believes that the FAA should require all operators of airplanes
equipped with Loral Fairchild Model F-800 FDRs to comply with Loral Fairchild FSBs
DFR 011 and DFR 027 for recorders with applicable part numbers and installed
component numbers. Further, the Safety Board believes that the FAA should require
overhaul facilities that service Loral Fairchild Model F-800 FDRs to monitor those
recorders to determine whether abnormal track switching is occurring and to report any
such findings to the FAA and the manufacturer.

2.8 Drug and Alcohol Testing of Ground Personnel

The FARs require that all employees who perform a “safety-sensitive” function be
tested for drugs or alcohol if their performance could have contributed to or could “not be
completely discounted as a contributing factor to the accident.” Drug testing and alcohol
testing are required to be accomplished as soon as possible but no later than 32 and
2 hours after the accident, respectively. However, the ground personnel at MHR who
were involved with the accident airplane (including cargo handlers, load planners, and
ramp supervisors) were not required to submit to drug or alcohol testing promptly after the
accident, in part because the applicable regulations (specifically 14 CFR Part 121,
Appendixes I and J) do not define their duties as “safety-sensitive.”

Although not required, voluntary drug tests were eventually conducted on eight
cargo handlers, a load planner, and the ramp supervisor involved with the accident flight.
Samples were taken from the 10 tested employees between 1 and 6 days after the accident;
2 of the 10 employees tested positive for drugs and were subsequently relieved of their
duties.



Factual Information 7 Aircraft Accident Report

19:49:08 C Sound similar to stabilizer trim In m

SEE ae a eG;

—
Oe
19:50:37 C2 what I'm trying to do is make the airplane's position ® ”
match the elevator. That's why I'm putting It in a bank.

19:50:32 C2 we're gonna have to land fest

18:49:51 C.... whoop pull up [GPWS. voice] Fama ’ 19:60:11 C1 roll out to the right
— ¥
19:49:58 C1 roll out

Note: C1=recorded on the captain’s CVR channel, C2=recorded on the first officer’s CVR channel,
C=recorded on the cockpit area microphone channel.

Figure 1. The airplane's ground track, with selected CVR comments, during the accident
flight.

1.2 Injuries to Persons

Table 1. Injury chart

Injuries Flight Crew Cabin Crew Passengers Other Total
Fatal 3 0 0 0 3
Serious i) 0 0 0 0
Minor 0 0 0 0 0
None 0 0 0 0 0

Total 3 0 0 0 3



Factual Information 49 Aircraft Accident Report

Emery Flight 17

Aft

—o—FDR 748
Required to reach tab stop 7 6.0

cale (deg)

4-10.52

Column - design scale (deg)

Forward 4 22.5

-10 T T T T
19:49:00 19:49:30 19:50:00 19:50:30 19:51:00 19:51:30
Time (sec)

Figure 12. The control column position required for the left elevator control
tab to reach its TEU physical stop (for the recorded elevator position) and the
actual recorded control column position for the accident flight.

The study also showed that the stabilizer moved in an ANU direction at the same
time that the pilot pushed the control column forward to resume the descent after a brief
period of level flight at 10,000 feet. The direction of this stabilizer movement was
opposite that which would be expected when the pilot provided a forward control column
input. The study showed that the slight ANU stabilizer shift balanced the effect of the
change in the relationship between the recorded elevator and control column movements
and that the elevator remained responsive to pilot input. Figure 13 shows plots of the
control column and elevator for the accident takeoff roll and the previous takeoff roll
(from RNO).



Aircraft Accident Report

92

Appendix B

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Analysis 70 Aircraft Accident Report

2.4.2 Elevator Checks/Use of the EPI Gauge

FDR and CVR evidence indicates that the pilots attempted to verify elevator
movement (presumably using the EPI) during the elevator taxi check. However, the EPI
gauge would not have provided the pilots with an indication of a restricted control tab
during this check (regardless of the range or direction of control column input).

CVR evidence indicates that the pilots also attempted to verify the elevator’s
proper operation during the 80-knot elevator check by checking the EPI indication in
accordance with Emery’s procedures and practices. The flight crew appeared satisfied
with the results of the 80-knot elevator check and continued the takeoff roll. However,
because the aerodynamic forces acting on the elevator and control tabs would have been
significant as the airplane accelerated during the takeoff roll, the abnormal control tab
condition would have prevented the elevator from moving to its full TED position.
Therefore, under the circumstances of this accident, the EPI needle would not have moved
below the neutral mark during the 80-knot elevator check, thus providing an indication
that the elevator was not fully operational.

Emery’s AOM regarding the use of the EPI during the 80-knot elevator check
instructed pilots to apply “full forward” control column pressure, then “release slightly
forward of neutral...confirm nose DN response...look for EPI to respond to yoke
movement.” Although the AOM did not explicitly describe the expected EPI indications
during the 80-knot elevator check, Emery’s AOM guidance for the ground taxi check
stated that, with the control columns full forward, the EPI needle “should now point
between [neutral] mark and the [down] mark.” On an airplane with a properly functioning
elevator, a similar indication would be expected during the 80-knot elevator check. AOM
guidance to this effect might have been helpful to the pilots because when the accident
airplane’s EPI needle did not move below the neutral mark, they might have been alerted
to the elevator’s abnormal operation.

Review of other DC-8 operator’s procedures indicated that Emery’s guidance
regarding EPI usage was among the most thorough in the industry. The AOMs of five of
the other six DC-8 operators surveyed did not mention using the EPI during the 80-knot
elevator check.” Postaccident interviews with Emery personnel and FDR data indicate
that Emery’s pilots used the EPI but only to confirm elevator response in the proper
direction. Observation of EPI needle movement below the neutral mark during the

80-knot elevator check would provide a more quantitative determination that the elevator
was functioning properly.

The Safety Board found that there is no standardization of EPI guidance and EPI
use across DC-8 operators. The 80-knot elevator check provides flight crews with their
last chance to detect abnormal elevator performance (which could result from foreign
object damage, fractured geared tab arms, mechanical failure [as with the accident flight],
and/or damage to components that might have occurred since the earlier elevator checks)

® AD 78-01-15 did not require operators to use the EPI during 80-knot elevator checks.



Factual Information 31 Aircraft Accident Report

Emery Worldwide Airlines Flight 17 Ground Operations

airplane nose down (-)

trailing edge up (+)[°
25-+|trailing edge up 25
m n
@ 20 Elevator Position (corrected) 20 &
5 Fi
2 ts 8 e
> 0 0
& 5 5 8
3 o- Elevator Position (uncorrected) o 8
3. 5 =
2-10. -10 =
tralling edge down (-)
“5: “By
airplane nose up (+30 5
20
trailing edge down ‘0 2
Pitch Attitude 5
e
cs

luuinjog joxu0D
i
a

forward

10 Control! Column Position
15:
s

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Ov6e:6L
ostee:6t
00:08:61
osiorer
00zP6L

orzrer

Ov-08:61

Pacific Standard Time (hh:mm:ss)

Figure 6. Elevator, pitch, and contro! column plots recorded by the accident
airplane’s FDR during ground operations before the accident flight. The first 20
seconds of data were recorded while the gust lock was engaged.

The Safety Board’s examination of the corrected elevator position data revealed
that the airplane’s elevator never traveled below its neutral position to a TED deflection
during the accident flight, although recorded forward control column inputs should have
resulted in a TED elevator deflection. For example, although the FDR data indicated that,
during the 80-knot elevator check at MHR, the control columns were moved to about 6°
forward of their rigged neutral position, the elevators did not deflect below 2.2° TEU. In
contrast, during the 80-knot elevator check on the previous takeoff (at RNO) the FDR
recorded elevator movement to 8° TED, with less forward control column movement.
Figure 7 shows plots of the pitch attitude, control column position, and elevator position
FDR data for the accident flight. Elevator position is shown using the conversion that
corrected for the 11° offset. Figure 7 also shows when the 80-knot elevator check and
takeoff occurred. Figure 8 shows the same information for the takeoff from RNO.



Factual Information 43 Aircraft Accident Report

During these tests, the Safety Board also examined the fractured geared tab crank
arms and surrounding test airplane structure to determine whether the fractures might have
occurred before the accident. For additional information regarding the geared tab crank
arm fractures, see section 1.16.1.3. For information regarding other tests conducted, see
Airworthiness Group Chairman’s Factual Report, dated February 28, 2002, in the docket
for this accident.

1.16.1.1 Disconnected Elevator Control Tab/Interference Tests

After the test airplane’s baseline deflections were measured, investigators removed
the right elevator control tab aft pushrod attachment bolt from its crank fitting. With no
additional manual input, the right elevator control tab moved to a 29° TED deflection,
where it contacted the geared tab linkage fairing. With this control tab movement, the aft
end of the pushrod moved free of the crank fitting.

When the aft end of the test airplane’s pushrod cleared the crank fitting, it shifted
slightly inboard so that it was aligned with the inboard leg of the forward face of the crank
fitting. When the test airplane’s control tab was manually raised TEU (simulating the
effects of aerodynamic forces that would be experienced during the takeoff roll), the crank
fitting contacted the aft rod end, obstructing any attempt to further deflect the elevator
control tab in the TEU direction. Figure 10 shows the test airplane’s pushrod in this
position.

Figure 10. Photograph of the test airplane's right elevator contro! tab pushrod
contacting the crank fitting.



Aircraft Accident Report

113

Appendix B

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Factual Information 48 Aircraft Accident Report

The results of this portion of the performance study were consistent with a left
elevator control tab at or near its TEU stop throughout the accident flight. The
performance study further indicated that the right control tab position required to match
the recorded elevator position and airplane motion with a left control tab deflected fully
TEU was about 17° TED to 25° TED. The results of the study were consistent with a 25°
to 33° difference between the left and right control tab positions when the left control tab
was at its TEU stop. As previously discussed, physical testing with a fully functioning
and responsive left control tab and a disconnected right control tab, with movement
restricted by contact with the free end of the control tab pushrod (see figure 10), showed a
differential between the left and right control tabs of about 25° at all control column
positions. The results of the performance study were consistent with a large split between
the left and right control tabs, which is consistent with the physical evidence.

1.16.2.3 Control Column and Elevator Position Data

The FDR data showed that the control columns were positioned forward of their
neutral position throughout most of the accident flight, and the airplane performance study
showed that the flight crew maintained a forward force on the control column throughout
the accident flight. The performance study also indicated that the left control tab was at its
TEU physical stop throughout most of the accident flight. After the control column
moved forward to the point where the left control tab’s TEU stop was reached, the pilots
could force the control columns further forward because of cable stretch; however, no
additional nose-down elevator input would result.

Figure 12 shows the control column position required for the left elevator control
tab to reach its TEU physical stop (with no cable stretch) and the recorded control column
position for the recorded elevator position during the accident flight. The plot indicates
that at most points during the accident flight, the flight crew was trying to command
additional forward control column.

The Safety Board’s examination of the FDR data for the flights preceding the
accident flight revealed that a change in the relationship of control column movement to
elevator response occurred about 8 minutes and 20 seconds before the accident airplane
landed at MHR. The Board’s performance study derived the control tab positions at the
time of this change. The study showed that the change in FDR data could be explained by
a shift of about 3° to 4° in the TEU direction of the right control tab, assuming that the
right control tab’s pushrod to crank fitting attachment bolt separated at this time. This
change in the FDR data was evident until the airplane landed at MHR. As previously
discussed, a scenario in which a disconnected pushrod remained between the lugs of the

aft crank fitting (shown in figure 11) resulted in a 3° to 4° control tab shift in the TEU
direction.


Factual Information 44 Aircraft Accident Report

When the test airplane’s elevator surfaces were manually moved to their TEU limit
(about 27° TEU) in this condition, the control columns moved aft from 15.0° forward of
vertical (the position in which they were held by the centering device) to about 8.8°
forward of vertical, and both elevator geared tabs moved to 27.5° TED. The left elevator
control tab deflected fully to about 8.5° TEU; however, the right elevator control tab could
not be moved further in the TEU direction than 15.9° TED because of interference with
the disconnected pushrod.

The test airplane’s elevator surfaces were then moved manually to various TEU
deflections (simulating the range of elevator travel that occurred during the accident
flight), and measurements were taken to document the right and left elevator control tab
deflections and control column positions at those elevator deflections. Based on the
Safety Board’s test and measurements, an average mismatch of 25° was noted between the
left and right elevator control tabs (or about 8 inches of vertical separation if measured at
the trailing edge), with TEU movement of the right elevator control tab restricted by
contact between the pushrod and the crank fitting. This mismatch between the left and

tight elevator control tab positions existed regardless of elevator or control column
position.

Because a free elevator control tab pushrod might not necessarily always displace
itself inboard into alignment with the crank fitting as it did on the test airplane (especially
if the pushrod is disconnected while the airplane is in flight and aerodynamic forces are
acting on the flight control surfaces), the Safety Board examined other potential
interference modes between a free elevator control tab pushrod and crank fitting. These
tests revealed that in general, contact between a free pushrod and the forward face of
either crank fitting lug (accounting for rod end misalignment, etc.) resulted in a mismatch
of approximately 25° between the left and right control tabs. These tests also revealed that
a disconnected control tab could be rotated about 3° to 4° in the TEU direction if the crank
fitting remained centered about the pushrod; however, further movement was restricted by
contact between the crank fitting and shoulders of the aft end of the pushrod. Figure 11 is
a photograph of the test airplane’s control tab in this position.



Analysis 73 Aircraft Accident Report

2.5.1 Elevator Geared Tab Crank Arm Fractures

During this investigation, the Safety Board reviewed the history of fractured DC-8
geared tab crank arms, which, though not a factor in this accident, have been involved in
other elevator jam events over the years. Although AD 78-01-15 required DC-8 operators
to modify the clearances for the geared tab crank arms, DC-8 elevator system jams caused
by fractured aluminum geared tab crank arms are still occurring. The Board notes
that AD 78-01-15 does not require operators to replace the existing aluminum crank arms
with forged stainless steel crank arms, as suggested by Douglas in SB 27-262. The SB
stated that “replacing the existing aluminum geared tab crank assemblies with forged
stainless steel crank assemblies and improving the crank assembly clearance will
minimize the possibility of crank failure.”

Stainless steel is stronger than aluminum and the Safety Board is not aware of any
fractures of stainless steel DC-8 geared tab crank arms that have occurred in normal
operation. In fact, although both elevator geared tab aluminum crank arms on the accident
airplane (the inboard crank arms) fractured as a result of the impact forces, the elevator
geared tab stainless steel crank arms were twisted but not fractured. Therefore, the Safety
Board concludes that replacement of the DC-8 aluminum elevator geared tab crank arms
on DC-8 airplanes with stainless steel elevator geared tab crank arms would likely
eliminate the possibility of a jam resulting from fractured geared tab crank arms.
Therefore, the Safety Board believes that the FAA should require all DC-8 operators to
replace all DC-8 aluminum elevator geared tab crank arms on their DC-8 airplanes with
stainless steel elevator geared tab crank arms.

2.6 Emery’s DC-8 Maintenance Documents and
Guidance

2.6.1 Required Inspection Items

The Safety Board notes that Emery’s work cards for installation of the right
elevator tabs (work card 3502D) and right elevator assembly (work card 3504D)
contained specific instructions for verification of proper “installation and security” and
that an inspector stamp/signoff was required for these steps. However, Emery’s work card
3504D contained another step after the inspector verification of installation and security—
“rig R/H elevator [assembly] per DC-8 MM chapter 27.” Although an inspector
stamp/signoff was required for this task and the MM cited inspection of elevator
“mechanism rods secure and safetied,” there was no discrete work card step requiring an
inspector to re-verify the security of attachments after the rigging work was completed.
Thus, it is possible that a once-properly secured bolt, which was inspected and signed off
during the installation inspection, could be returned to service after the postinstallation
rigging process without a properly secured bolt or subsequent inspection.



Conclusions 83 Aircraft Accident Report

3.2 Probable Cause

The National Transportation Safety Board determines that the probable cause of
the accident was a loss of pitch control resulting from the disconnection of the right
elevator control tab. The disconnection was caused by the failure to properly secure and
inspect the attachment bolt.



Factual Information 38 Aircraft Accident Report

Safety Recommendation A-98-56 asked the FAA to do the following:

Create a national certification team of flight data recorder (FDR) system
specialists to approve all supplemental type certificate changes to FDR systems.

In response to Safety Recommendation A-98-56, the FAA trained a team of
electrical systems engineers and avionics inspectors to approve all STC changes to FDR
systems and to determine if the modified FDR installations would record the required
FDR parameters effectively. As a result of the FAA’s actions, on January 11, 2000, Safety
Recommendation A-98-56 was classified “Closed—Acceptable Action.”

1.12 Wreckage Recovery and Documentation

The airplane wreckage was located in an automobile salvage yard about 1 mile
east of MHR. The wreckage path was oriented approximately on a heading of 295 and
was strewn over an area about 1,500 feet long by 450 feet wide. Examination of the
wreckage revealed that the main fuselage was broken into several sections. Several pieces
of airplane wreckage were located along the wreckage path to the southeast of the main
wreckage, including the engines, engine components, nacelles, pylons, landing gear
assemblies, flight control surfaces, sections of each wing, stabilizers, the tail cone, and
numerous systems components.

Portions of all major sections of the airplane were accounted for in the wreckage.
However, significant portions of the airframe, its associated systems, and onboard cargo
were severely damaged and/or consumed by fire. Continuity of the flight control cables
and components, including those that control the elevator tabs, could not be established
because of the breakup of the airplane and postaccident fire.

The cockpit wreckage and portions of the fuselage nose section were located about
30 feet south of the center of the main wreckage and exhibited evidence of severe impact
and fire damage, with much of the associated structure missing. Additional
cockpit/forward fuselage components, including the control column torque tube, pitch
trim compensator (PTC) motor and actuator, throttle quadrant, throttle handles, flap
handle, spoiler handle, and thrust reverser levers, were located beneath a section of
cockpit floor. The PTC actuator was found in its retracted position.”

The flap handle was found with its lever latched in the third detent aft of its stowed
position, which corresponded to 15° of flap extension. The flap position gauge was
recovered but was unreadable because of mechanical and fire damage. The spoiler handle
was found in its retracted position, and the thrust reverser levers were found in their

* The PTC system is installed to prevent the airplane’s tendency to nose-down while operating at higher
Mach numbers. According to the system design, when the airplane is operating at low altitudes and

airspeeds, such as during takeoff and landing, the PTC actuator is retracted and exerts no force on the control
columns.



Aircraft Accident Report

109

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National Transportation Safety Board. 2003. Loss of Pitch Control on Takeoff, Emery
Worldwide Airlines, Flight 17, McDonnell Douglas DC-8-71F, N8079U, Rancho Cordova, California,
February 16, 2000. Aircraft Accident Report NTSB/AAR-03/02. Washington, D.C.

Abstract: This report explains the accident involving Emery Worldwide Airlines flight 17, a
McDonnell Douglas DC-8-71F, which crashed in an automobile salvage yard shortly after takeoff,
while attempting to return to Sacramento Mather Airport, Rancho Cordova, California, for an
emergency landing. Safety issues discussed in this report include DC-8 elevator position indicator
installation and usage, adequacy of DC-8 maintenance work cards (required inspection items),

and DC-8 elevator control tab design. Safety recommendations are addressed to the Federal
Aviation Administration.

‘The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,
pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board
Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study
transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board

makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and
statistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also
may be obtained from the Web site or by contacting:

National Transportation Safety Board
Public Inquiries Section, RE-51

490 L’Enfant Plaza, S.W.
Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To
purchase this publication, order report number PB2003-910402 from:

National Technical Information Service
5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports
related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.



Aircraft Accident Report

102

Appendix B

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Factual Information 61 Aircraft Accident Report

of an unapproved/unaccepted “part number cross reference” manual and an out-of-date
MPPM in the stores area, an unqualified company technical representative, an untrained
company technical representative, and Emery’s use of contract facilities not listed in the
then-current MPPM.*4

The FAA indicated that the RASIP conducted from January 18 to 28, 2000, was
intended to evaluate the condition of the Emery certificate when it was transferred from
the San Jose FSDO to the Cincinnati FSDO. This RASIP resulted in 98 findings, 81 of
which were maintenance related. There were multiple findings in many areas, including
the following: operations manuals and procedures (4 findings), maintenance manuals and
procedures (11 findings), training program (6 findings), MEL/deferred maintenance
(3 findings), reliability program (7 findings), and maintenance inspection system and
required inspection items (9 findings). The report on this inspection noted that some
company manuals had not been properly updated, instructions in manuals were not always
followed, there was no AD compliance list, there was no traceability on C inspection work
cards for non-routine items, Emery’s maintenance training program lacked sufficient
formal training courses, and maintenance logbook entries were inadequate (specifically,
they lacked detailed descriptions of work performed and/or lacked a reference for
compliance).

1.17.3.2 FAA Inspection of TTS

The FAA conducted a RASIP inspection of TTS between February 14 and 18,
2000. The RASIP focused on management and administration, certificate and operation
specifications, manuals and procedures, training program, records system, maintenance
facilities, contractual arrangements, AD compliance, maintenance inspection system and
required inspection items, mechanical reporting procedures, major repair and alteration
conformity, aging aircraft program, and part traceability and documentation. The FAA’s
RASIP inspection report, dated July 25, 2000, noted findings in the following areas:
manuals and procedures (1 finding), records systems (5 findings), maintenance facilities
(4 findings), and maintenance inspection system and required inspection items
(2 findings). The report indicated that all findings had been closed satisfactorily. The
RASIP inspection report indicated that the FAA reviewed a random sample of training
files for 10 mechanics and 10 inspectors for proper training and authorizations and that no
discrepancies were noted in this area.

® TTS was listed in Emery’s MPPM.

85 The TTS employee numbering system was clarified and an explanatory memorandum was issued;
information regarding proper maintenance documentation and signoffs was disseminated; lapses in parts
documentation were corrected; shop test stand instruments were calibrated; and calibration of precision tools
in the shop was confirmed.



Factual Information 47 Aircraft Accident Report

Because the Emery accident airplane’s elevator geared tab inboard crank arms
were found fractured and because interference from such a fracture could have resulted in
restricted movement of the elevators, the Safety Board evaluated the fractures on the
recovered right elevator geared tab inboard crank arm from the accident airplane relative
to the surrounding structure on a test airplane to determine the possible effects of various
interference modes. Investigators installed the forward end of the accident airplane’s
fractured right elevator geared tab crank arm to the link assembly on the horizontal
stabilizer rear spar on the test airplane. Tests on this airplane and further examination of
the accident airplane wreckage revealed no evidence of damage on the horizontal
stabilizer or the right geared tab crank arm itself that was consistent with any observed
interference position.

1.16.2 Airplane Performance Studies
1.16.2.1 Center of Gravity Calculations

Because the Emery flight 17 accident involved a nose-up pitch anomaly,® the
Safety Board conducted an airplane performance study to evaluate whether an aft c.g.
problem was involved in the accident. The Safety Board extracted the aerodynamic forces
and moments that acted on the airplane to produce the recorded aircraft motion then used
the pitching moment and lift to calculate the accident airplane’s pitch stability, which can
be related directly to c.g. The study concluded that the basic stability of the aircraft during
the accident flight was consistent with a c.g. within the c.g. limits.°” The study also found
that the airplane’s motion was consistent with elevators in a highly deflected nose-up
position.

1.16.2.2 Elevator Control Tab Deflection Study

Although the FDR recorded the elevator position, it did not record the left and
right elevator control tab positions. Therefore, the Safety Board conducted an airplane
performance study (assuming a disconnected right control tab) to determine which
position(s) of the right® control tab would match the elevator positions and airplane
motions recorded during the accident flight. To determine the left elevator control tab’s
position during the accident flight, investigators used the recorded control column and
elevator position data and the known relationship between the control tab, the control
column, and the elevator on a properly functioning system.

® Potential indications of an aft c.g. problem included the first officer’s statement, recorded by the CVR
almost immediately after takeoff, that the airplane’s c.g. was “way out of limits” and FDR data showing
excessive nose-up pitching and unusual elevator positions.

© Further, the Safety Board’s review of the loading reports and dispatch records for the accident flight,
examination of the airplane wreckage, and postaccident statements from cargo loading personnel revealed
no evidence indicating that the airplane was improperly loaded or that a c.g. shift occurred.

% The performance study could not differentiate between failures of the right or left control tab.
However, a disconnected right elevator control tab was assumed because physical evidence (for example,
the missing aft pushrod attachment bolt at impact) indicated that the accident airplane’s right elevator
control tab linkage was disconnected.



Aircraft Accident Report

97

Appendix B

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Factual Information 21 Aircraft Accident Report

figure, which identified the drilled-shank alloy steel bolt, washer, and castellated nut
required for this installation by part number but did not identify the cotter pin required to
secure the bolt in this installation.

On May 8, 2002, Boeing issued temporary revisions 27-207, 27-208, 27-561, and
27-562 to the Master DC-8 MM. These temporary revisions instructed DC-8 operators to
connect the control tab pushrod to the tab crank fitting by installing a bolt, washer, and nut
and tightening and securing with a cotter pin. These temporary revisions also included an
illustration depicting the hardware to be installed when connecting the elevator control tab
pushrod to the tab crank fitting. In a June 17, 2002, letter to the Safety Board, Boeing
stated that it did not plan to issue a similar revision to the DC-8 IPC because the IPC “was
not intended to be used for installation and assembly...the IPC does, however, relate the
specific part to the appropriate installation drawing, which is what the mechanic should be
using to assemble and/or install components on an airplane.” Emery did not list Boeing’s
DC-8 installation drawings in its DC-8 maintenance policy and procedures manual as a
reference document, and TTS personnel stated that Emery did not provide them with
Boeing’s DC-8 installation drawings.

In an August 19, 2002, letter to the Safety Board, the FAA stated “if the air carrier
chooses to incorporate the manufacturer’s IPC and/or the manufacturer’s drawings in its
program, then the carrier must define the use of the information with regard to its own
aircraft.” In a subsequent letter to the Safety Board, dated January 21, 2003, the FAA
stated that during surveillance and inspections, it ensures that the maintenance information
being used by an operator or repair station is “current and part of the information
incorporated into the operator’s program.” Additional commentary and discussion of
FAA, manufacturer, and related correspondence concerning the use of IPCs is included in
the public docket of this report.

When properly installed, the cotter pin is inserted through the castellations on the
nut and a hole in the bolt’s shank, then one leg of the cotter pin is bent up and over the top
of the nut and the end of the bolt, while the other leg of the cotter pin is bent down, parallel
with the bolt. This method of installation prevents the loosening of the nut during
operation. According to the DC-8 overhaul manual (OHM), chapter 27-16-1, the hardware
required to secure the elevator control tab’s aluminum pushrod end to the aluminum tab
crank fitting at this location includes a drilled-shank alloy steel bolt, a washer, a steel
castellated nut, and a cotter pin. The Emery work cards and DC-8 MM did not cite the
DC-8 OHM as a reference for installing the elevator assemblies.

TTS maintenance records indicate that the installation of the elevator assembly on
the horizontal stabilizer was performed in accordance with work card 3504D, titled
“Install Right Elevator Assembly.” This work card stated the following:

NOTE: Use applicable DC-8 M/M, Chapter 27, when performing this card.

1. Inspection OK to install right elevator assembly to horizontal stabilizer.

2. Hoist overhauled elevator into position, install eyebolt nuts...



Factual Information 17 Aircraft Accident Report

Douglas has developed check procedures involving control yoke movement to
check for elevator movement and jamming prior to takeoff. FAA issued an
operations alert on [December 1, 1970] outlining this check procedure and
requested all principal inspectors to bring this to the attention of all operators
utilizing DC-8 aircraft. This pre-takeoff check made by the pilot in accordance
with the operations alert will provide adequate assurance to the pilot that there is
proper elevator control for the flight.

Compliance with the operations alert, we believe, will be consonant with your
first three recommendations made in your [October 28, 1970] letter. In regard to
your fourth recommendation for the installation of an elevator position indicator
in the cockpit, we believe that due to the design of the aircraft’s elevator controls,
the usefulness and value of such a position indicator would not justify the large
cost and complexities of this installation. The information provided by the
elevator position indicator during the pre-takeoff check specified in the operations
alert would, at best, only duplicate the information the pilot obtains by moving the
control yoke between full forward and full aft.

On February 18, 1972, the Safety Board classified Safety
Recommendation A-70-54 “Closed—Acceptable Action.” ”°

As previously mentioned, on March 5, 1975, Douglas issued SB 27-254, titled
“Flight Controls—Elevator and Tabs—Install Position Indicator,” which recommended
that operators install an EPI and associated transmitters and circuitry in their DC-8s to
help flight crews detect restricted elevator movement. Douglas indicated that the SB was
released because of two instances of insufficient or abnormal elevator travel that were
discovered by flight crews during preflight checks. SB 27-254 instructed DC-8 operators
to install the EPI on the first officer’s instrument panel, in a location selected by the
operator, such that the first officer’s view of the indicator was not obstructed by the
full-forward position of the control column.

The FAA subsequently issued AD 78-01-15 (effective June 1, 1978), which
required DC-8 operators to install an EPI system within 18 months, unless already
accomplished in accordance with Douglas SB 27-254.

1.6.3 Maintenance Information

Emery’s continuous airworthiness maintenance program for its DC-8 fleet
included the following major inspections and intervals:2°

Although Safety Recommendation A-70-54 contained four distinct subparts, only one
recommendation number was assigned. Therefore, the classification “Closed—Acceptable Action” applied
to all four parts of Safety Recommendation A-70-54.

3° Emery’s continuous airworthiness maintenance program for its DC-8 fleet also included transit,
terminating, and service inspections. For additional information regarding transit, terminating, and service
inspections, see the Maintenance Group Chairman’s Factual Report, dated October 27, 2000, in the docket
for this accident.



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Aircraft Accident Report

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Appendix B



Factual Information 29 Aircraft Accident Report

Despite this damage, the FDR installed on the accident airplane yielded data of good
quality for the accident flight without any losses of data synchronization.”!

1.11.2.1 Track-Switching Anomaly

The Safety Board’s examination of the transcribed FDR data revealed that the
FDR erroneously switched to the first track of the tape every time electrical power to the
FDR stopped. Thus, the FDR did not record data throughout the length of its 25-hour loop
tape (and would not have, unless the FDR was powered nonstop during that 25 hours). As
a result of this anomaly, only the last 8 hours and 11 minutes of data for the accident
airplane were available; these data included information from portions of the three
previous flights (the arrival at DAY and the flights from DAY to RNO and RNO to MHR)
and the accident flight. These data were recorded on one complete track and portions of
two other tracks; other portions of the tape contained data from various previous flights,
including some that took place before the FDR was upgraded in November 1999. As a
result of this tracking-switching anomaly, only limited FDR data was available to the
Board from flights that occurred in the days leading up to the accident.”

Because of previously identified instances of tracking-switching anomalies in
F800 FDR systems, Loral Fairchild’ has identified several potential causes for
tracking-switching problems and has issued three field service bulletins (FSB) since
February 1988 to address these anomalies. Although two of these FSBs“ appeared to
address anomalies like the one observed in the accident airplane’s FDR, Emery personnel
stated that its maintenance records showed that the FSBs were not applicable to the
accident airplane’s FDR unit. The FSBs only applied to F800 FDRs with particular
components installed; maintenance records indicated that those components were not
installed on the accident airplane’s FDR.** The FDR damage sustained during the accident
precluded physical confirmation of the specific components that were installed on the
accident airplane’s FDR.

1.11.2.2 Elevator Position Data Conversion Anomaly

The Safety Board’s examination of the FDR data also revealed an anomaly with
the accident airplane’s recorded elevator position data. The Board converted the recorded
FDR data to engineering units appropriate to each parameter (for example, feet for
altitude, knots for airspeed, and degrees for heading, pitch, roll, etc.) using conversion
formulas based on documentation provided by Emery through L2 Consulting Services,
Inc. (L2 Consulting Services performed the FDR parameter correlation on the accident

“A loss of synchronization can result from either a mechanical or electrical interruption of the data.

“ During the FDR correlation check in November 1999, maintenance personnel evaluated real-time
data from the FDR system through a download and diagnostic tool. Because the FDR history was not
examined during this check, the tracking-switching anomaly would not have been detected.

 Loral Fairchild is now L3 Communications.
“ Loral Fairchild FSBs Digital Flight Recorder (DFR) 011 and DFR 027.

* According to Emery records, the accident FDR contained components addressed by Loral Fairchild
FSBs DFR 015, 016, 017, 020, 021, and 029.



Aircraft Accident Report

111

Appendix B

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Factual Information 53 Aircraft Accident Report

Horizontal stabilizer and elevator. «CHECK.
Check between trailing edge of stabilizer and elevator for foreign objects, ice or
snow. Check all access plates for security. Check condition of static dischargers.

1.17.1.2.2 Emery’s DC-8 Flight Control Operational Checks

Emery’s DC-8 AOM section titled “Ground Operations, Taxi Procedures,” dated
November 15, 1995, contained the following guidance regarding elevator checks:

After the ailerons and rudder are checked, the captain and the first officer will
check the elevator together. It is important that both pilots exert pressure on their
yokes [control columns] to prevent excessive stress on either yoke. The normal
indication of the [EPI] when the gust lock is off shows the elevator full nose up. If
there is a strong headwind or a substantial amount of power is coming from the
engines, [the EPI] may indicate a position between full nose up and neutral.

To check the elevator, both pilots will push forward on their respective yokes until
they reach the forward stop. This will require a substantial force, especially if
there is a tailwind. The first officer should monitor the EPI during the check.
When the yokes are full forward, expect to see the EPI indicate between neutral
and very slightly nose up. Then both pilots should pull the yokes to the aft stop;
expect to see the EPI move to full nose up.

Additionally, in its section titled “Normal Operations, Taxi Checklist,” dated
October 25, 1999, Emery’s DC-8 AOM stated the following:

Check control freedom about all three axes. Aileron and rudder reversion light
should remain off during the check. When checking the ailerons, check for
spoiler pressure drop indicating spoiler operation. The first officer should call out
“EPI checks” after the elevator check.

Further, the Emery DC-8 AOM section titled “Normal Operation, Flight Control
System, Elevator—Elevator Position Indicator Operative—Captain and First Officer
(Perform Check Together),” dated May 1, 1989, stated the following:

* Ensure that gust lock is disengaged.

Disengagement of the gust lock should cause the following:

A. The elevators will move to command aircraft nose-up condition (trailing edge
up), due to their static balance characteristics.

B. The elevator control tabs will have trailing edge up.

C. The...control column moves slightly aft.

TM Postaccident interviews confirmed that the flight engineer conducted at least one preflight
walkaround inspection of the airplane. The Safety Board reviewed the CVR and FDR information to further
document the preflight inspections; however, such documentation was not possible because electrical power
to the recorders was interrupted for about 50 of the more than 60 minutes that the airplane was parked on the
ramp at MHR.



Aircraft Accident Report

108

Appendix B

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Analysis 71 Aircraft Accident Report

before the airplane lifts off the runway.”' However, the procedures and practices currently
in use appear to make minimal use of the EPI’s potential as a go/no-go tool during the
80-knot check, resulting in pilots continuing a takeoff with a potentially unsafe elevator
condition.

The Safety Board concludes that DC-8 operators, including Emery, do not use the
EPI to confirm elevator movement indications above and below the neutral range during
the 80-knot elevator check and, thus, do not take full advantage of the EPI’s capabilities to
provide pilots with an indication of an abnormal elevator condition. Therefore, the Safety
Board believes that the FAA should require the development of DC-8 80-knot elevator
check procedures that will ensure that pilots are clearly made aware of whether the
elevator is functioning properly before the airplane lifts off, then require all DC-8
operators to incorporate these procedures into their training and normal operations. The
procedures should contain specific guidance regarding an expected range of EPI needle
movement (including EPI needle movement well below the neutral mark with forward
control column movement) and specific criteria for aborting a takeoff as a result of an
inadequate elevator movement indication.

The Safety Board’s review also indicated that there is no ongoing calibration
requirement for the EPI gauge/system. Although the Board could not determine the
calibration of the accident EPI, it notes that the EPI installed on the test airplane was not
accurately calibrated when the ground tests were performed. The Safety Board concludes
that the EPI needs to be periodically calibrated to ensure that it provides the most accurate
information possible to the pilots. Therefore, the Safety Board believes that the FAA
should require all DC-8 operators to incorporate periodic EPI calibration inspections into
their maintenance programs to ensure that the EPI indications observed by pilots
accurately represent the condition of the elevator.

Finally, the Board noted that the small (1-inch diameter) EPI gauge was installed
in a location on the accident airplane (the lower left side of the first officer’s instrument
panel) that was not ideally visible for either pilot. The Safety Board concludes that the
EPI gauge should be readily visible to both pilots. Therefore, the Safety Board believes
that the FAA should require DC-8 EPIs to be located and sized so that they are visible and
usable for both the captain and first officer.

2.5 Elevator Design Issues

CAR 4b.320 amendment 4b-3, under which the DC-8 was certificated, stated that
“Tab control systems shall be such that disconnection or failure of any element...cannot
jeopardize the safety of flight.” According to Boeing’s submission on this accident, the
company and the FAA considered the possibility of a failure of the crank fitting/pushrod
attachment during the development and certification of the DC-8; however, subsequent

°! For example, during the December 12, 2002, Tampa Airlines aborted takeoff, the pilots performed an
80-knot elevator check and observed that the EPI did not respond to their control column inputs. See
section 1.16.1.3 for more information on this event.



Factual Information 23 Aircraft Accident Report

7. Perform elevator geared tab mechanism clearance check.

All seven steps were signed off by a TTS mechanic and stamped by a TTS
inspector; the overall work card completion date listed on the card was October 14, 1999.

Work card 3601D, titled “L/H and R/H Horizontal Stabilizer and Elevator Close,”
contained three steps—one step instructing an inspector to verify the inspection areas
before access plates and fairings were reinstalled and secured and fairing seams were
sealed (this step required an inspector signature) and two closure steps for a mechanic to
perform (a mechanic signature was required). This work card contained no specific
reference to inspection of the elevator control tab crank fitting/pushrod attachment area.
All required signatures were present on the completed work card 3601D for the accident
airplane; the completion date listed on the card was October 26, 1999.

During this investigation, the Safety Board interviewed personnel from TTS,
including the general manager, vice president, director of quality control, a lead mechanic,
and two of the three inspectors involved in the installation of the elevator assembly.**
Subsequently, the Board conducted formal interviews with the president of TTS, the
director of quality control, and one inspector; these individuals were also witnesses at the
Board’s public hearing on this accident. None of the mechanics/inspectors interviewed
specifically recalled the work they performed on the accident airplane.

For example, one of the TTS inspectors involved in the installation of the right
elevator assembly stated that the elevator control tab crank fitting/pushrod attachment area
on the accident airplane would have been inspected at least three or four times (including
at the end of the elevator installation and twice during the elevator rigging process) before
the fairing would have been replaced. Specifically, he said that TTS mechanics were not
allowed to close a panel/fairing unless an inspector was there to inspect the area and
witness the closing of that panel/fairing. The TTS inspector stated that he would only
stamp the work card for the elevator control tab installation after he had touched the cotter
pin to ensure proper installation.

1.6.3.1.2 Reversed Installation of Elevator Dampers

The accident airplane’s maintenance records revealed that on November 25, 1999,
eight days after the D inspection was completed (which included the installation of the
elevator assemblies), a pilot reported that he had to apply “more back pressure than
normal” on the control column to flare during the preceding landing and during the
elevator check before the previous takeoff. The corrective action for this pilot report
(performed by Emery maintenance personnel) was described in the accident airplane’s
maintenance logbook as follows: “Found [left/right] elevator dampers reversed, moved
[left to right] side, [right to left] side, ops ck’d good, no defects noted.” Figure 5 shows
the elevator damper’s location on the right elevator of a DC-8.

38 The third inspector who was involved with the elevator assembly installation was no longer working
at TTS and was unavailable when the Safety Board conducted its interviews.



90 Aircraft Accident Report

Appendix B
Cockpit Voice Recorder Transcript

The following is an excerpted transcript of the Sundstrand AV557 cockpit voice
recorder (CVR) installed on the accident airplane. Only radio transmissions to and from
the accident airplane were transcribed. The full CVR transcript (available in the public
docket for this accident) reflects the 33 minutes and 24 seconds before power was lost to
the CVR. All times are Pacific standard time, based on a 24-hour clock.

LEGEND

CAM Cockpit area microphone voice or sound source

RDO Radio communications transmitted to and from N8079U

APR _ Radio transmission from Sacramento approach controller
GND —_Radio transmission from Mather Field ramp personnel
4 Voice identified as the Captain

Voice identified as the First Officer

3 Voice identified as the Second Officer
Unidentified female voice
2 Voice unidentified

Unintelligible word

# Expletive

@ Non-pertinent word
() Questionable insertion
0] Editorial insertion

” Pause

Note 1: Times are expressed in pacific standard time (PST).
Note 2: Generally, only radio transmissions to and from the accident aircraft were transcribed.

Note 3: Words shown with excess vowels, letters, or drawn out syllables are a phonetic representation of the words
as spoken.

Note 4: A non-pertinent word, where noted, refers to a word not directly related to the operation, control or condition
of the aircraft.



Factual Information 4 Aircraft Accident Report

As the takeoff roll continued, the CVR recorded the captain stating, “V one”!*
about 1949:02 and “rotate” about 1949:06. Information from the FDR confirmed that the
airplane pitched from 0.2? ANU about 1949:02 to 5.3° ANU at 1949:08; the pitch
continued to increase despite the forward movement of the control column. FDR data
indicated that, during this time, the control column position moved forward (from 14.5°
forward of vertical to 17.4° forward of vertical), and the elevators’ TEU deflection
increased from about 5.5° to 8.6° TEU.'° About 1949:08, the CVR began to record a sound
similar to the airplane’s stabilizer trim-in-motion alert,!° which continued to sound as the
captain stated, “...watch the tail,” about 1949:09. (This sound was recorded by the CVR
intermittently until 1949:14.) Between 1949:08 and 1949:15, the airplane’s pitch rate
increased to about 2° per second.

By 1949:12, the airplane’s pitch had increased to 11.7? ANU, while the control
column and elevators had moved to 15.7° forward of vertical and 15.3° TEU, respectively.
About 1949:13, the CVR recorded the captain stating, “V two”!” then “positive rate,”
1 second later; FDR data show the airplane’s altitude was increasing at this time. By
1949:15, the airplane’s pitch had increased to 18.3° ANU and the control column position
was at 16.2° forward of vertical. About 1949:16, the first officer stated, “I got it,” the
captain asked, “you got it,” and the first officer responded, “yep.”

FDR data indicated that, almost immediately after the accident airplane lifted off
the runway (beginning about 1949:12), it entered a left turn that steepened to about 35°
within about 10 seconds. Between 1949:12 and 1949:15, the control column position
moved forward from 15.7° to 16.2° forward of vertical and the elevator deflection
decreased, moving from about 15.7° TEU to 9.0° TEU. About 1949:19, the CVR recorded
the first officer stating, “we’re going back...c.g.’s waay [sic] out of limits.”

About 1949:25, about 6 seconds after the first officer announced that they would
return to the airport, the flight engineer asked, “do you want to pull the power back.” Two
seconds later, the CVR recorded a sound similar to decreasing engine rpm, followed by a
sound similar to the airplane’s stick shaker. About 1949:30, the first officer stated, “oh
[expletive],” and the captain stated, “push forward.” About 1949:36, the CVR recorded
the captain advising Sacramento TRACON that the flight had an emergency. During this

'4'V, is the takeoff decision speed, which was 126 knots for the accident flight. Rotation speed for the
accident flight was 146 knots.

15 In contrast, the FDR data from the accident airplane’s previous departure (from RNO) indicated that
when the pilots moved the control column aft (from 14.4° forward of vertical to about 7.8° forward of
vertical), the elevator moved from about 5.1° TED to about 7.8° TEU, and the airplane’s pitch began to
increase during the takeoff.

16 CVR information indicates that the pilots began adding nose-down stabilizer trim about 4 seconds
before the airplane lifted off the runway at 1949:11 and that the stabilizer reached full nose-down trim about
3 seconds after liftoff. There was no evidence that the pilots changed the trim setting during the remainder
of the accident flight. Physical evidence was consistent with full nose-down trim at impact. According to
the manufacturer, a cable motion sensor connected to the stabilizer detects horizontal stabilizer motion and
commands the stabilizer warning horn to sound for 1/2 second when it detects 1° of continuous stabilizer
movement; it then sounds repeatedly for every additional 1/2 degree of continuous stabilizer travel.

17, is the takeoff safety speed, which was 158 knots for the accident flight.



Analysis 72 Aircraft Accident Report

control tab and pushrod end movements, such as those that likely occurred on the accident
airplane, and the resultant jam/restricted movement of the control tab were not considered.
The submission further stated that Boeing has “begun developing an enhanced design of
the control tab pushrod that will prevent the pushrod from dropping or otherwise moving
in front of the control tab crank should the bolt migrate out of the connecting joint. The
front end of the pushrod is also being reviewed for consequences should it become
disconnected.”

Boeing also conducted a postaccident review of more than 180 additional
attachment points on the DC-8 elevator, aileron, and rudder flight control systems to
identify other potentially vulnerable attachments. In a letter to the Safety Board dated
May 14, 2003, Boeing stated that its review showed that a disconnection at any of these
other attachment points would result in “minor or no degradation” in the associated
system’s operation. Further, Boeing stated that its survey of flight control attachment
points on other tab-driven airplanes (including the DC-9, MD-80/90, and 717)” indicated
that the DC-8 elevator control tab was the “only tab surface that can pose a loss-of-control
disconnect concern.”

The Safety Board concludes that the circumstances of the Emery flight 17 accident
show that the current DC-8 design does not preclude a catastrophic result from a
disconnection or failure of the existing control tab crank fitting to pushrod attachment.
Therefore, the Safety Board believes that the FAA should require Boeing to redesign
DC-8 elevator control tab installations and require all DC-8 operators to then retrofit all
DC-8 airplanes with these installations such that pilots are able to safely operate the
airplane if the control tab becomes disconnected from the pushrod.

Current Federal regulations (14 CFR Section 25.607) require manufacturers of
transport-category airplanes to incorporate two separate locking devices at every
removable bolt (or other fastener) if the loss of the bolt could result in reduction in pitch,
yaw, or roll control capability. The use of dual-locking devices at critical flight control
attachments was intended as additional protection against a catastrophic result from
disconnection of a flight control. However, airplanes certificated under CAR 4b were not
required to incorporate dual-locking devices. The Safety Board concludes that there may
be airplanes that were certificated to CAR 4b standards other than the DC-8 on which the
disconnection of a critical flight control could have catastrophic results. Therefore, the
Safety Board believes that the FAA should evaluate airplanes other than the DC-8
certificated to CAR 4b standards to evaluate whether disconnection or failure of critical
flight control systems could have catastrophic results and, if so, require that they also be

redesigned and retrofitted and/or equipped with dual-locking devices to preclude such
catastrophic results.

* Boeing’s evaluation of the flight controls on the 707 was ongoing at the time of the letter.



Analysis 78 Aircraft Accident Report

Because older airplanes with retrofitted FDRs are not required to record as many
parameters as newly manufactured airplanes,” the loss of data from just one parameter on
an older retrofitted airplane can significantly hamper and slow progress in an
investigation. Although investigators are often able to estimate the values for the lost or
invalid data using data from other parameters and sources of information, this
reconstruction of the data takes time and can delay the identification of potentially critical
safety issues (and can potentially lead to incorrect conclusions regarding the recorded
data). When more recorded data is available during an investigation, it is more likely that
investigators will be able to identify critical safety issues early in the investigation and not

spend a significant amount of investigative time compensating for lost or unreliable FDR
data.

The Safety Board concludes that the use of a single airplane’s FDR parameter
correlation for all airplanes of the same type is inadequate to ensure accurate correlations
for older airplanes that have been retrofitted to record additional FDR parameters.
Therefore, the Safety Board believes that the FAA should require operators of airplanes
manufactured before August 18, 2000, that have been retrofitted with additional FDR
parameters in compliance with Federal requirements and for which an operator maintains
a common correlation document for that airplane type to conduct a full correlation of all
such airplanes’ FDR parameters at the airplanes’ next required FDR maintenance
inspection to verify accurate FDR system documentation and sensor function.

Additionally, a thorough evaluation of the accident airplane’s elevator behavior
was further complicated by the abnormal FDR track switching. As previously noted, the
FDR switched to the first track every time electrical power to the FDR stopped. The
process of viewing all 25 hours of data recorded on the FDR’s six tracks, identifying the
locations of track switching, and identifying the data that corresponded to the airplane’s
most recent operations was time consuming. Further, because of the tracking-switching
anomaly, the Safety Board had only the most recent 8 hours 11 minutes of elevator data to
examine instead of the required 25 hours of recent data. (The remaining data recorded by
the FDR was from unidentified previous flights, some of which occurred at least 3 months
prior to the accident [before the FDR was upgraded to 17 parameters].)

The Safety Board has previously observed tracking-switching anomalies with
other F800 model FDRs. The F800 manufacturer, Loral Fairchild,®” identified several
potential causes of tracking-switching anomalies and issued three FSBs to correct them.
Two of the three FSBs appear to address a condition like that of the accident FDR
(S/N 04018, P/N 17M303-282). However, according to Emery’s records, none of the

The Safety Board has issued many related safety recommendations to the FAA to remedy these
difficulties throughout the years and has included improvements in on-board recording devices on its list of
most wanted safety improvements since 1997.

% Airplanes manufactured on or before August 18, 2000, are required to be upgraded as necessary to
record 17 parameters (as with the accident airplane) or 34 parameters, while newly manufactured airplanes
are required to record 57 or 88 parameters (depending on the date of manufacture).

°” Loral Fairchild is now L3 Communications.



viii Aircraft Accident Report

Executive Summary

On February 16, 2000, about 1951 Pacific standard time, Emery Worldwide
Airlines, Inc., (Emery) flight 17, a McDonnell Douglas DC-8-71F (DC-8), N8079U,
crashed in an automobile salvage yard shortly after takeoff, while attempting to return to
Sacramento Mather Airport (MHR), Rancho Cordova, California, for an emergency
landing. Emery flight 17 was operating under the provisions of 14 Code of Federal
Regulations (CFR) Part 121 as a scheduled cargo flight from MHR to James M. Cox
Dayton International Airport (DAY), Dayton, Ohio. The flight departed MHR about
1949, with two pilots and a flight engineer on board. The three flight crewmembers were
killed, and the airplane was destroyed. Night visual meteorological conditions prevailed
for the flight, which operated on an instrument flight rules flight plan.

The National Transportation Safety Board determined that the probable cause of
the accident was a loss of pitch control resulting from the disconnection of the right
elevator control tab. The disconnection was caused by the failure to properly secure and
inspect the attachment bolt.

The safety issues discussed in this report include DC-8 elevator position indicator
installation and usage, adequacy of DC-8 maintenance work cards (required inspection
items), and DC-8 elevator control tab design. Safety recommendations are addressed to
the Federal Aviation Administration.



Aircraft Accident Report

107

Appendix B

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Analysis 76 Aircraft Accident Report

primary U.S. operators (that is, those who operate multiple DC-8s) have all adopted this
revision in their MMs.

Boeing did not issue a similar revision to the DC-8 IPC because it was not
intended to be used as a reference for installation and/or assembly of components; rather,
Boeing intended that mechanics use its installation drawings for installation and assembly
tasks. However, the Safety Board notes that Emery did not list the manufacturer’s
installation drawings as a reference to be used in Emery’s maintenance program, and
Emery did not provide TTS with Boeing’s DC-8 installation drawings. In the absence of
installation drawings, it is possible that a mechanic would use the IPC as a reference for
installation and/or assembly of components. Because the IPC is not required to be
updated, the information contained in that document might be incomplete or might not
accurately reflect an airplane’s configuration. The Safety Board concludes that the use of
outdated, incomplete, or otherwise unsuitable reference materials by maintenance
personnel during the installation and/or assembly of airplane components can occur and is
a potentially unsafe practice. Therefore, the Safety Board believes that the FAA should
require all air carrier operators to either: 1) provide all pertinent maintenance personnel
with the manufacturer’s current installation drawings for pertinent airplanes, update those
installation drawings as needed, and require use of those drawings during installation
and/or assembly of that airplane’s components; or 2) list the IPC on that operator’s
operation specifications, provide maintenance personnel with up-to-date IPCs for
reference, continue to update those IPCs as needed, and require maintenance personnel to
use the pertinent updated IPCs during installation and/or assembly of an airplane’s
components. ,

2.7 FDR-Related Issues

The elevator data conversion problems encountered with the accident airplane’s
FDR complicated this investigation and delayed the Safety Board’s recognition of the
significance of the elevator movement during the accident sequence. Observing
abnormalities in the recorded elevator data, the Board reviewed the data more thoroughly
and determined that the elevator’s neutral position was not accurately identified during the
original correlation. Specifically, the Board noted that an 11° TEU adjustment to the
elevator conversion value resulted in an elevator position of 0° when the gust lock was
engaged.

In compliance with Federal regulations, the accident airplane’s FDR was upgraded
to record additional parameters (including elevator position) during its most recent heavy
maintenance inspection in November 1999. The accident airplane was the first of Emery’s
DC-8 fleet to be so upgraded, and a full correlation of the data recorded by the FDR to the
actual elevator positions was performed and documented. Given that the total range of
elevator travel from the documented data from the accident airplane’s original correlation
was similar to the elevator’s normal operating range and that the recorded travel above and
below neutral (when corrected) was consistent with its design, it is apparent that the entire



Aircraft Accident Report

103

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Appendix B

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87 Aircraft Accident Report

Board Member Statements

Member John J. Goglia’s Statement

I concur with the findings and probable cause of the accident; but I would like to
emphasize the significance of information contained in the public docket for this accident
that is not included in the report.

This is clearly a maintenance accident, related to many operations of each of the
organizations involved. There is concern regarding the accuracy of company and aircraft
manufacturer manuals, poor quality of task documentation and job cards, and a lack of
sufficient detail to satisfactorily complete the tasks.

Both the report and the public docket identify deficiencies that are not unique.
There are similar examples in the recent past contained within the NTSB accident
database.

The Board has made recommendations in this report which attempt to focus
attention on the inconsistent use of and responsibility for maintenance manuals, illustrated
parts catalog, and task documents used to accomplish maintenance on aircraft.

Detailed task descriptions, well trained mechanics, thorough inspection of work,
along with complete and accurate documentations is the only method for ensuring that a
maintenance task is properly completed.

Chairman Engleman, Vice Chairman Rosenker, and Members Carmody and
Healing concurred with this statement.



Factual Information 55 Aircraft Accident Report

In addition, this section of the DC-8 AOM contained a table titled “Takeoff Roll—
Callouts or Duties of Flight Crew” that included the following guidance regarding pilot
duties during and after the 80-knot check:

Table 2. Takeoff Roll—Callouts or Duties of Flight Crew (from DC-8 Aircraft Operating
Manual).

Captain First Officer Pilot Not Flying Pilot Flying
At 80 [knots | Watch for nose Watch EPI 1. Callout “80 1. Callout “80 here”
indicated strut compression. | during the knots” 2. Push forward on the
airspeed] elevator check. yoke
3. Callout “elevator
checks”

1.17.1.3 Manufacturer’s Guidance Regarding Flight Control Operational
Checks

As previously mentioned, on March 5, 1975, Douglas issued SB 27-254, titled
“Flight Controls — Elevator and Tabs — Install Position Indicator,” which recommended
that operators install an EPI and associated transmitters and circuitry in their DC-8s to
help flight crews detect restricted elevator movement. Douglas indicated that the SB was
issued because of two instances of insufficient or abnormal elevator travel that were
discovered by flight crews during preflight checks.”* SB 27-254 instructed DC-8 operators
to install the EPI on the first officer’s instrument panel, in a location selected by the
operator, such that the first officer’s view of the indicator was not obstructed by the full
forward position of the control column.

Another Douglas ASB (SB A27-264, issued on May 14, 1977) stated “Douglas is
of the opinion that had [SB] 27-254...been accomplished on the aircraft involved, flight
crews would have determined that the elevator surfaces were not moving normally.
Therefore, Douglas strongly recommends prompt incorporation of DC-8 [SB] 27-254.”
With regard to flight control checks, the SB stated the following:

If it is not possible to check the elevator control with the aircraft turned into the
wind, an optional procedure can be used during the initial takeoff roll (60 — 80
knots) by checking the response of the aircraft in relation to small up and down
elevator inputs. The optional procedure should not be used when the takeoff is
made on wet or icy runways or when moderate crosswind conditions exist.
Incorporation of SB 27-254 constitutes terminating action for this alert Service
Bulletin.

TM The SB was also partially responsive to Safety Recommendation A-70-54, which the Safety Board
issued on October 28, 1970, as a result of the September 8, 1970, accident involving a Trans International
Airlines Corporation DC-8-63, which crashed during takeoff from John F. Kennedy International Airport.
See section 1.6.2.2 for further discussion of this accident.



Factual Information 51 Aircraft Accident Report

because several inspectors reported observing numerous apparent violations of the FARs.
After more than 1 1/2 years under this heightened oversight, on August 13, 2001, Emery
signed an interim agreement with the FAA stating that it would immediately cease

operating until it satisfactorily resolved the safety issues identified by the FAA during a
series of inspections.”

According to the FAA’s news release regarding the interim agreement:

Emery...has been under a heightened state of oversight by the FAA since
January 2000. The FAA has conducted several special inspections of the airline,
most recently in May and June. Those inspections uncovered more than 100
apparent violations of the Federal Aviation Regulations, including:

+ — Improper/inadequate repairs to mechanical irregularities, including numerous
repetitive pilot write-ups of the same problem on the same aircraft over
extended time periods;

* Unapproved aircraft installations/alterations;

* Operating unairworthy aircraft;

* Not following the policies and procedures in their manuals;

+ Inadequate record keeping;

¢ Failure to distribute and use current manuals.

The interim agreement indicated that a final settlement agreement must be signed
within 30 days of the interim agreement. On September 17, 18, and 19, 2001, Emery and
FAA representatives signed the final settlement agreement, stating that both parties would
“use their best efforts...to conclude the process described [in the agreement—including
disposition of aircraft and other assets, etc.], on an expedited basis.” However, Emery and
FAA representatives subsequently signed an amendment (dated December 4, 2001) to the
final settlement agreement, which indicated that Emery had informed the FAA that it did
not wish to resume commercial air carrier flight operations and that it intended to dispose
of its airplanes. On December 4, 2002, in accordance with the December 2001 agreement,
Emery returned its operating certificate to the FAA.

1.17.1.1 Emery’s MMs and Practices

Emery’s continuous airworthiness maintenance program was governed by a series
of manuals, including the maintenance policy and procedures manual (MPPM), the
reliability program manual, the inspection program manual, the time limits manual,
maintenance manuals from the airplane’s former operators, the manufacturer’s
maintenance manual, the structural repair manual, original equipment manufacturer
manuals, the fueling manual, the minimum equipment list (MEL) manual, FAA-approved
STCs, the airplane flight manual, and the airplanes’ weight and balance documentation.”

® For additional information regarding the FAA’s inspections of Emery, see section 1.17.3.1.



Factual Information 13 Aircraft Accident Report

During normal operation in flight, the elevator flight controls work as follows:
when a pilot moves the control column forward (commanding an AND movement), the
left and right elevator control tabs deflect in a TEU direction and the resultant
aerodynamic forces drive the elevator surfaces in the opposite (that is, TED) direction
causing the airplane to pitch nose down. When a pilot moves the control column aft
(commanding an ANU movement), the left and right elevator control tabs deflect in a
TED direction and the resultant aerodynamic forces drive the elevator surfaces in the
opposite (TEU) direction causing the airplane to pitch nose up.

When the airplane is on the ground with the gust lock engaged,” the centering
device positions the control columns about 15° forward of vertical, the elevators are
locked in their neutral position, the elevator geared tabs are in line with the elevator
surfaces, and the control tabs are deflected slightly above neutral (about 2° TEU). When
the gust lock is disengaged (assuming no pilot input), the elevators rotate in a TEU
direction because of their leading-edge-heavy balance condition; depending on the wind
conditions, the elevators might rotate to their maximum TEU position. Because of the
mechanical linkages between the flight control cables and the control tabs, the control tabs
rotate to their maximum TEU position. The elevator geared tabs deflect toward their
maximum TED position.

1.6.2.1 DC-8 Elevator Position Indicator Information

The DC-8 EPI is a 1-inch diameter circular cockpit gauge with a pointer needle
and index markings for UP, DN (down), and NEUT (neutral) positions to indicate the
position of the elevators. When the EPI is properly calibrated, the up index mark should
correspond to the maximum TEU elevator surface position of 27° and the down index
mark should correspond to the maximum TED elevator surface position of 16.5° TED. A
narrow white band adjacent to the NEUT index mark indicates an elevator surface
position between 0° and 5° TEU. Figure 3 is a photograph of an EPI gauge similar to that
on the accident airplane.

> The gust lock holds the elevator surfaces in a fixed, faired position to prevent damage from gusty
winds, etc. The lever for the elevator (and rudder) control surface gust lock is located on the right side of the
pilot’s center control pedestal. To engage the gust lock, the lever is moved to its aft (down), latched position.



Factual Information 42 Aircraft Accident Report

Appendixes I and J specify “safety-sensitive” functions to which the postaccident
drug and alcohol testing requirements apply. These functions include the duties of flight
crewmembers, flight attendants, flight instructors, aircraft dispatchers, aircraft
maintenance or preventive maintenance personnel, ground security coordinators, aviation
screeners, and air traffic controllers. Cargo handler duties are not included under
“safety-sensitive” functions, nor are load planners or ramp supervisors.” Although testing
was not required, voluntary drug tests were conducted on eight cargo handlers, the load
planner, and the ramp supervisor who were involved with the cargo loaded on the accident
airplane; all tests were conducted between February 17 and February 22, 2000. The load
planner tested positive for amphetamines and was relieved of duties on February 25. A
cargo handler who was tested on February 22 tested positive for amphetamines and
cocaine metabolites and was relieved of duties on March 2, 2000.

1.14 Fire/Explosion

A fuel-fed fire occurred after impact.

1.15 Survival Aspects

The airplane was destroyed by impact and postimpact fire. According to the
Sacramento County Coroner’s Office, the captain and flight engineer died as a result of
thermal and traumatic injuries, and the first officer died of thermal injuries and inhalation
of combustion products.

1.16 Tests and Research

1.16.1 DC-8 Elevator Flight Control Tests

Using an Emery DC-8-71F that was equipped and had been operated similarly to
the accident airplane, the Safety Board conducted tests to document the deflections of the
test airplane’s elevator, control columns, and control tabs (with the right elevator control
tab disconnected from its pushrod) while the elevators were moved to duplicate a range of
travel consistent with that recorded by the FDR from the accident airplane. The Board
also conducted tests to determine the test airplane’s EPI indication during elevator checks
before taxi, during taxi, and at 80 knots during a simulated takeoff roll to identify what a
flight crew might see at various elevator deflections under normal conditions.

® The Safety Board notes that on May 8, 2003, the FAA proposed rulemaking that would broaden its
existing regulations regarding hazardous materials training by requiring such training for all personnel who

might be involved in the handling of hazardous materials; this proposal reinforces the safety-sensitive nature
of these functions.



Factual Information 46 Aircraft Accident Report

1.16.1.3 DC-8 Elevator Geared Tab Crank Arm Fractures

As a result of several elevator jam events in which the jams were caused by
interference from a fractured geared tab crank arm, in April 1977, Douglas issued Alert
Service Bulletin (ASB) 27-262, titled “Flight Controls—Elevator and Tab—Inspect
Elevator Geared Tab Mechanism and Gust Lock Crank Assembly.” The ASB advised all
DC-8 operators of an aborted takeoff incident that resulted from the failure of the elevator
geared tab pushrods (inboard and outboard) and recommended that the elevator gust lock
be engaged at all times when the airplane is parked to prevent elevator damage caused by
high/gusting winds and/or jet blast.

In July 1977, Douglas issued SB 27-262, titled “Flight Controls—Elevator and Tab
Modify Elevator Geared Tab Mechanism,” which indicated that “replacing the existing
aluminum geared tab crank assemblies with forged stainless steel crank assemblies and
improving the crank assembly clearance will minimize the possibility of crank failure
when the aircraft is parked in high gusty wind.”

Subsequently, the FAA issued AD 78-01-15 (effective June 1, 1978), which
required, in part, all DC-8 operators to modify the clearances in the elevator geared tab
crank assembly in accordance with Douglas SB 27-262 and to inspect and replace
fractured geared tab crank arms; however, it did not require DC-8 operators to replace all
existing aluminum crank assemblies with stainless steel crank assemblies.

The Safety Board’s review of DC-8 elevator-related service difficulty reports
(SDR) submitted to the FAA during the 5 years preceding the Emery flight 17 accident
revealed six SDRs involving fractured elevator geared tab crank arms. One of these was
detected during an elevator ground check, one was detected in flight, and four were
detected during elevator checks during the takeoff roll, resulting in aborted takeoffs.
(Although the SDRs did not always reference an EPI gauge, it is likely that all airplanes
involved were equipped with EPIs because AD 78-01-15 required DC-8 operators to
install an EPI system within 18 months of the AD’s June 1978 issuance unless an EPI had
already been installed in accordance with SB 27-254.)

Additionally, the Safety Board investigated a December 12, 2002, aborted takeoff
event involving a Tampa Airlines DC-8-71F that did not rotate/lift off normally during the
takeoff roll. According to Tampa Airlines personnel, the pilots performed an 80-knot
elevator/EPI check and observed that the EPI did not respond to the control column. The
pilots indicated that they aborted the takeoff when the airplane failed to rotate normally
once it reached rotation speed. Subsequent examination revealed that the elevator
jammed because the inboard and outboard aluminum crank arm assemblies on the left
geared tab had fractured (which Tampa Airlines personnel believed to be the result of jet
blast from a DC-10 while the DC-8 was waiting to takeoff).

§ This anomalous behavior is consistent with an elevator jam/restriction in a position near or below
neutral.



Analysis 75 Aircraft Accident Report

fitting, making it impossible to inspect either attachment point for “security of
attachment,” as called for by the B-2 inspection work card.

During postaccident interviews, Emery maintenance personnel stated that they did
not remove the control tab fairing or inspect the crank fitting/pushrod attachment during
the B-2 inspection. In public hearing testimony, witnesses from Emery indicated that its
B-2 inspection was intended to be a general visual inspection, to be accomplished without
removing access or inspection panels or fairings. However, witnesses from TTS stated
that, although not specifically listed as a step, removal of the control tab fairing was
necessary to satisfactorily perform the tasks described in Emery’s B-2 work card. Further,
the Safety Board’s survey of several other DC-8 operators revealed inconsistent
interpretation and application of the work card task regarding the inspection of the
elevator and control tab for security of attachment.

Emery’s interpretation of its B-2 work card was consistent with Boeing’s position
that the manufacturer’s recommended program work cards “do not call for the removal of
the inboard control tab fairing during the B [inspections]. The inboard control tab fairing
is not removed until the [heavy maintenance inspection equivalent to Emery’s C- and
D-inspections]...Therefore, the Emery B-2 inspection work card...would be...an
inspection to be accomplished without removing access or inspection panels, fairings, or
the like.” (Emery performed C inspections about every 2 years and D inspections about
every 12 years.)

The Safety Board notes that several air carrier operators have tried to clarify the
intended scope of maintenance tasks by including in work cards an enumeration of the
actions that are necessary for the proper accomplishment of the associated work task.
Although this additional detail on work cards is not required by the FAA, its inclusion
should result in more consistent accomplishment of maintenance tasks. The Safety Board
concludes that all air carrier operators should provide maintenance personnel with more
detailed information regarding the steps or actions that are necessary to satisfactorily
accomplish a maintenance task. Therefore, the Safety Board believes that the FAA should
require all 14 CFR Part 121 air carrier operators to revise their task documents and/or
work cards to describe explicitly the process to be followed in accomplishing maintenance
tasks.

2.6.3 DC-8 MM Information

The information regarding the control tab installation that was in Emery’s DC-8
MM and IPC in use at the time of this accident did not specify that a cotter pin was
required. However, the Safety Board has no evidence that the lack of specific reference to,
or depiction of, a cotter pin at this attachment in the DC-8 MM and/or IPC was a factor in
this accident. In fact, that information had been used for years with no other known
instance of an incorrectly safetied bolt separating. Boeing subsequently improved the
related information in its DC-8 MM, revising it to explicitly state that a cotter pin is
needed to secure the elevator control tab crank fitting to pushrod attachment. The five



Factual Information 8 Aircraft Accident Report

1.3 Damage to Aircraft

The airplane was destroyed by impact forces and postcrash fire.

1.4 Other Damage

The accident airplane’s left wing tip contacted a concrete and steel support column
for an overhang attached to a two-story building, located adjacent to the southeast edge of
the salvage yard. The airplane subsequently impacted the vehicles and pavement in the
salvage yard; many vehicles in the salvage yard were damaged or destroyed by impact and
postimpact fire.

1.5 Personnel Information

The National Transportation Safety Board reviewed the flight crew’s flight- and
duty-time limits and rest records and found no evidence that they were not within the
limits established by Federal regulations. According to Emery records, the accident flight
crewmembers flew together on two previous trip sequences in February 2000—one that
began on February 4 and another that began on February 8.

1.5.1 The Captain

The captain, age 43, was hired by Emery on October 19, 1994. He held an airline
transport pilot (ATP) certificate with multiengine land and instrument ratings. He had
type ratings in five airplane types, including the DC-8 (issued August 5, 1998). The
captain’s most recent DC-8 proficiency check was completed on June 30, 1999, and his
most recent recurrent training was completed on February 11, 2000. His most recent
Federal Aviation Administration (FAA) first-class airman medical certificate was issued
on February 15, 2000, and contained the limitation that he “must wear corrective lenses
for near and distant vision.” According to Emery records, at the time of the accident, the

captain had flown about 13,329 total flight hours, including 2,128 hours as a DC-8
captain.

According to company records and postaccident interviews, the captain left his
home in New York about 1430 on February 15 to commute to MHR, where his duty
period was scheduled to begin the next day. Interviews indicated that the captain likely
traveled from Albany, New York, to DAY by jumpseat then rode on the jumpseat of
Emery flight 18, which was scheduled to fly to MHR, then to RNO, and return to DAY.
However, the flight from DAY to MHR was delayed while maintenance personnel
completed work on one of the cockpit windows, and the trip sequence was subsequently
modified to land at RNO first, then MHR. The captain’s flight duty began with the flight
from RNO to MHR.



Factual Information 50 Aircraft Accident Report

Pitch Control Comparison

Att Accident and Previous Takeoff

36>

12 End, Pitch = 10 degrees

164 Column Position

Fwd

0 5 10 15 20 25 30
Airplane Nose Up

Corrected Elevator Position

|-4— Accident Takeoff
[-®— Previous Takeoff

bhodvKONAROASD

FDR Elevator Position (deg) FDR Column Position (deg)

JAirplane Nose Down

0 5 10 15 20 25 30
Time Since 60 kts (sec)

3

Figure 13. Plots of the contro! column and corrected elevator position
recorded by the accident FDR during the accident takeoff roll and the
previous takeoff roll (from RNO).

1.17 Operational and Management Information

1.17.1 Emery Worldwide Airlines, Inc.

Emery received its initial air carrier certification in May 1987 under the name of
Air Train, Inc. When Emery began operating, its corporate offices were located in
Redwood City, California, and its hub operations were located at DAY. In January 1990,
the company name was changed to Emery Worldwide Airlines, Inc. Emery held air carrier
certificate number RRXA558B and was authorized to conduct operations in accordance
with 14 CFR Part 121, as a domestic and international airfreight carrier. Emery relocated
its corporate offices from Redwood City to DAY in 1990. However, the FAA oversight
responsibility for the airline remained with the San Jose Flight Standards District Office
(FSDO) until December 1999, when Emery’s certificate was transferred to the FSDO in
Cincinnati, Ohio. At the time of the accident, Emery operated 43 DC-8 and 2 DC-10
freighters, with most of its airplanes based at its main hub and corporate headquarters at
DAY.

The FAA’s August 13, 2001, news release indicated that in January 2000, about a
month before the accident, the FAA placed Emery under a “heightened state of oversight”



v Aircraft Accident Report

Figures

1, The airplane’s ground track, with selected CVR comments, during the accident flight............ 7
2. A diagram of the elevator control tab installation .............000cccccceeeeecceeeeeecees 12
3. A photograph of an EPI gauge similar to the gauge installed on the accident airplane ........... 14
4. EPI installation on the lower left side of the first officer’s instrument panel

(shown by the yellow arrow), similar to that on the accident airplane...................00005 15
5. Photograph showing the elevator damper’s location on the right elevator ofa DC-8 ............ 24
6. Elevator, pitch, and control column plots recorded by the accident airplane’s FDR

during ground operations before the accident flight. The first 20 seconds of data

were recorded while the gust lock was engaged... 6.00.0... cece cece cece cece eee eeeeeees 31

10.

i.

12.

13.

. Pitch attitude, control column position, and (corrected) elevator position FDR.

data from the accident flight. About the first 20 seconds of data were recorded
while the gust lock was engaged...

. Pitch attitude, control column position, and (corrected) elevator position FDR

data for the previous takeoff from RNO. About the first 1 minute 20 seconds

of data were recorded while the gust lock was engaged . 32
. A photograph of the accident airplane’s right elevator control tab crank

fitting. Note damage on forward face of control tab crank fitting lugs ..............00000eeee 40

Photograph of the test airplane’s right elevator control tab pushrod contacting

the crank fitting... 0.6... e cece c eee n cece eee eee eteseeeeresenannere 43

Photograph of the test airplane’s disconnected right elevator control tab

pushrod centered between the lugs of the crank fitting with the control

tab rotated 3° to 4° in the TEU direction after the attachment bolt was removed..............05 45

The control column position required for the left elevator control tab to

teach its TEU physical stop (for the recorded elevator position) and the

actual recorded control column position for the accident flight ...............000ccccceeeeee 49

Plots of the control column and corrected elevator position recorded
by the accident FDR during the accident takeoff roll and the previous takeoff roll (from RNO) ... 50



Analysis 67 Aircraft Accident Report

FDR data revealed abnormal elevator movements during the accident takeoff roll,
indicating that the bolt had certainly migrated free by this time and was no longer securing
the pushrod end bearing. Specifically, FDR data indicated that during the accident flight’s
80-knot check, the pilots moved the control column forward significantly, but the
elevators moved relatively little (from about 5.5° TEU to about 2.2° TEU). By contrast,
during the accident airplane’s previous takeoff (from RNO), when the pilots applied less
forward control column motion, the elevators moved from about 5.4° TEU to about 7.8°
TED. Further, FDR data showed that as the airplane rotated during the accident takeoff,
the control columns were positioned to command a nose-down elevator deflection while
the elevators remained in an extreme nose-up deflection.

When the aerodynamic forces on the airplane increased as it accelerated during the
accident takeoff roll, the right control tab would have moved to a point where the crank
fitting lugs contacted the end of the disconnected pushrod (about 16° to 17° TED). From
that point on, the right control tab’s TEU motion would have been restricted to a deflection
that was about 25° lower than the left control tab positions. This scenario is consistent
with evidence of contact damage observed on the forward edges of the accident airplane’s
right control tab crank fitting and would have resulted in the abnormal nose-up pitching
observed in the FDR data as the airplane neared rotation speed. Therefore, the Safety
Board concludes that at some time after the previous takeoff (from RNO) and before the
accident takeoff roll, the bolt connecting the right elevator control tab crank fitting to the
pushrod migrated out of the fitting, allowing the control tab to disengage from its pushrod
and shift to a TED position.

DC-8 ground tests conducted with a disconnected right control tab pushrod
showed that the pilots’ nose-down control column inputs resulted in a full (about 8°) TEU
left control tab deflection and an extreme (about 16° to 17°) TED right control tab
deflection. During the accident flight, the aerodynamic forces acting on the extreme
TED-deflected right control tab would have driven both elevator surfaces abnormally
TEU, resulting in a strong airplane nose-up elevator effect throughout the accident flight,
regardless of the flight crew’s inputs. This TEU elevator movement was consistent with
the elevator data recorded by the accident FDR.

Therefore, the Safety Board concludes that when the aerodynamic forces increased
as the airplane accelerated during the takeoff roll, the right elevator control tab crank
fitting contacted the disconnected pushrod, restricting that control tab’s further TEU
movement and leaving it in an extreme TED deflection. The Safety Board further
concludes that as a result of the right elevator control tab’s extreme TED deflection, the
accident airplane’s elevator surfaces were driven to command an extreme airplane nose-up
Pitch attitude; despite the large nose-down forces the pilots applied to the control columns,
the pilots were unable to overcome the effects of the restricted right elevator control tab.



Factual Information 22 Aircraft Accident Report

Torque elevator hinge eyebolt nuts.

Install bolts and shims to inboard elevator hinge fitting.
Torque inboard hinge fitting bolts and check clearance.
Install control tab drive crank and outboard drive torque tube.
Connect and safety control tab pushrod to drive crank.[°*]

2eN AKA w

Connect and safety inboard and outboard geared tab drive cranks to horizontal
stabilizer rear spar links.

9. Connect inboard elevator damper crank to horizontal stabilizer rear spar
fittings.

10. Remove sling and install screws in hoist points of elevator surface.
11. Inspector check elevator assembly for proper installation and security.
12. Rig RVH elevator [assembly] per DC-8 M.M. Chapter 27. [°7]

The required signatures and stamps were present on the completed 3504D work
card. The first step on work card 3504D was stamped by a TTS inspector and steps 2
through 10 were signed by a TTS mechanic. Steps 11 and 12 were stamped by a TTS
inspector; step 12 was also signed by a mechanic. As with work card 3502D, there was
no indication of the date of completion of the individual steps, nor did the work card call
for such an indication. The completion date listed on the card was November 4, 1999.

TTS’s time card database indicated that 19 mechanics/inspectors performed tasks
described on work card 3504D between September 27 and November 2, 1999. TTS
personnel did not document the specific tasks performed by individual
mechanics/inspectors, nor was such documentation required by Emery or the FAA.

Maintenance records indicated that TTS personnel performed a functional check
of the right elevator and tab in accordance with work card 3506D, titled “Functionally
Check Right Elevator and Tab.” This work card stated the following:

NOTE: Use applicable DC-8 M/M, Chapter 27, when performing this work card.
(This card to be worked in conjunction with 3504D.)

Perform elevator and tab travel check. See work card #3501.
Perform elevator and tab system for excessive friction check.
Perform geared tab mismatch check.
Perform control tab mismatch check.

Perform elevator mismatch check.

AwPPrYR

Perform elevator and tab clearance check.

36 This instruction refers to the forward end of the pushrod.

37 Chapter 27-30-03 of the DC-8 MM contains information regarding elevator assembly rigging and
includes after-rigging instructions to “inspect and check...mechanism rods secure and safetied.”



65 Aircraft Accident Report

2. Analysis

2.1 General

The captain, first officer, and flight engineer were properly certificated and
qualified and had received the training and off-duty time prescribed by Federal regulations
and company requirements. No evidence indicated any preexisting medical or behavioral
conditions that might have adversely affected the flight crew’s performance during the
accident flight.

The accident airplane was certificated, equipped, and dispatched in accordance
with applicable regulations and industry practices. Cargo loading for the accident flight
was routine, and the airplane was operating within prescribed c.g. limits.

At the time of the accident, light winds and scattered clouds were in the area; no
significant meteorological conditions were present that might have disrupted the flight.
The Safety Board’s review of air traffic control (ATC) information revealed no evidence
of any ATC problems or issues related to the accident. Therefore, weather and ATC were
not factors in this accident.

2.2 The Accident Sequence

There was no indication that the pilots were concerned about the airworthiness of
the accident airplane as they prepared to depart from MHR. The airplane’s performance
during ground operations and CVR evidence indicated that the initial takeoff roll did not
appear to cause the pilots any concern and the takeoff continued in an apparently routine
manner through the 80-knot elevator check.®”

However, FDR and CVR evidence indicate that as the airplane reached its rotation
speed, it began to pitch nose-up although neither pilot had moved his control column aft to
command this movement, as would normally be expected at this time in the takeoff. To
the contrary, CVR and FDR evidence indicates that the first officer began to move the
control column forward, countering the airplane’s unusual nose-up pitch rate, about the
time the airplane reached its rotation speed. Further, CVR evidence indicates that the first
officer began to add nose-down stabilizer trim about 4 seconds after the airplane passed its
rotation speed and attained full nose-down trim about 3 seconds after liftoff.

CVR and FDR evidence indicates that as the pilots maneuvered the airplane in the
traffic pattern in an attempt to return to the airport to land, the first officer primarily
worked to maintain nose-down force on the control column, while the captain primarily
tried to bank the airplane in an apparent attempt to control the pitch. The flight engineer

®” The pilots actions during the airplane’s ground operations and takeoff are discussed in section 2.4.



Factual Information 58 Aircraft Accident Report

was awarded the FAA’s “Diamond Certificate of Excellence Award” in 1998, 1999, 2000,
and 2001, for actively participating in the FAA Aviation Technician Training Program.””
The Board’s review of the training records for the mechanics that participated in the
installation of the elevator assembly on the accident airplane during its most recent
D inspection revealed no discrepancies.

1.17.2.1 Reference Documents/Maintenance Manuals Provided by Emery

TTS and Emery personnel indicated that when TTS maintenance personnel
worked on Emery’s DC-8s, they followed the guidance on the work cards provided by
Emery. However, the work cards provide only general guidance regarding the steps
involved in a procedure and typically referred the mechanic to other DC-8 documents or
manuals for more specific guidance regarding procedures and/or components. In
accordance with its MPPM and FAA requirements, Emery provided TTS with pertinent
DC-8 manuals and documents, including the Douglas Master DC-8 MM; the Douglas
DC-8 Aircraft OHM; the Douglas DC-8 IPC, 60/70 series; and temporary revisions to
manuals, as applicable, when Emery added TTS to its list of approved maintenance
facilities. Emery also provided TTS with the DC-8 MM and IPC that were applicable for
the accident airplane.

According to TTS personnel, mechanics working on the accident airplane would
have used the United Airlines DC-8 MM as the primary reference for their work cards,
using other available manuals and documents to augment as necessary. TTS personnel
indicated that there is no consolidated list/description for these manuals and documents;
however, because of their experience, mechanics would know that the manuals and
documents existed and would know the information each item contained.” According to
TTS personnel, if a mechanic did not know about all the available reference materials, his
lead mechanic/supervisor would.

The Safety Board’s examination of the documents and manuals available to TTS
revealed that the DC-8 MMs provided by Emery did not contain detailed drawings, lists,
or other specific instructions indicating the hardware and actions required for the proper
installation and securement of the pushrod attachment bolt connecting the elevator control

76 When Emery added TTS to its list of approved repair stations/vendors, Emery sent quality control
representatives to TTS to train TTS inspectors regarding Emery’s procedures and processes. The
Emery-trained TTS inspectors were then the only inspectors designated to work on Emery’s airplanes.

7 In an attempt to improve the training of maintenance technicians and employers, the FAA set up an
award-oriented training program that maintenance technicians and organizations could participate in
voluntarily. The “Diamond Award” is the highest recognition from the FAA for technicians and employers
that participate in available initial and recurrent maintenance training courses. According to TTS
management personnel, the company designed its training program around the FAA’s program.

78 Emery’s DC-8 MM for the accident airplane was formerly a United Airlines DC-8 MM.

® According to postaccident interviews and information contained in the TTS party submission for this
investigation, the TTS workforce was very stable. All maintenance personnel who performed work on
Emery’s DC-8s had years of experience working on DC-8s (the lead mechanics and inspectors who worked
on the accident airplane had between 20 and 40 years of maintenance experience, mostly on DC-8s), and all
such work was performed under the oversight of at least one Emery technical representative.



Factual Information 15 Aircraft Accident Report

a

Figure 4. EPI installation on the lower left side of the first officer's instrument
panel (shown by the yellow arrow), similar to that on the accident airplane.

Further, AD 78-01-15 did not include any guidance for DC-8 operators regarding
incorporation of EPI checks into the operator’s processes and procedures, such as
manuals, checklists, cockpit procedures, and training. The Safety Board’s survey of the
elevator check procedures used by seven DC-8 operators”® and those recommended by
Boeing revealed a variety of practices regarding EPI usage. Of the seven DC-8 operators,
only two (Emery and Arrow Air) specifically referenced use of the EPI during the 80-knot
elevator check. Emery’s 80-knot check procedure calls for “full forward elevator pressure
then release slightly forward of neutral...confirm nose DN response...[first officer] looks
for EPI to respond to yoke movement.” Arrow Air’s 80-knot check procedure calls for
“full forward yoke and note and feel airplane response, nose strut compression, EPI partial
DN.” Ina flight operations bulletin (FOB) issued on June 4, 2001, Boeing recommended
EPI use during the preflight and taxi elevator checks; however, regarding the 80-knot
check, Boeing stated “pitch response may be useful as a check for weight distribution, but
[the 80-knot check] is not a valid substitute for a properly conducted flight control
check.”?7

*° The seven DC-8 operators were Emery, Air Transport International, Arrow Air, United Air Lines,
Airborne Express, DHL, and United Parcel Service.

77 For additional information regarding Boeing’s FOB, see section 1.17.1.3.



Factual Information 32 Aircraft Accident Report

Emery Worldwide Airlines Flight 17
= |traling edge up (+)

20, Elevator Position (corrected) i

trailing edge down (-) 80 knot—;

airplane nose up (+)
20. pl 1p
. Pitch Attitude 4

airplane nose down (-)

Control Column Position

(60p) uwnjop [0.1409 (Sep) PMY Yotld (Gap) UoRIseg s0;eAe1g,

$ ¢@ @ ¢ @ @ @ 6 $ 8 ¢
8 ¢ £ € € &§ & & 2 € 6
@ 8 Fa ep 8 fF B 8 © ¢ ¢§
= 2 8 og 2 2 2 2
oo 3 o o so °o rc) 5 ° ° °

Pacific Standard Time (hh:mm:ss)

Figure 7. Pitch attitude, control column position, and (corrected) elevator
position FDR data from the accident flight. About the first 20 seconds of data
were recorded while the gust lock was engaged.

Emery Worldwide Airlines Previous Takeoff

305
25 ‘falling edge up (+)
201 Elevator Position (corrected)

(®2p) vowjsod s0,eA013
oad

5
40 tailing edge down (-)

80 knot — Takeoff

30 check
pe hose up (+)

20
Pitch Attitude |

10+
oO
airplane nose down (-)

Control Column Posit

104

aa
_golforward

{0p} uunjeg ronueg (Sep) epMINIY HOH
°

00:82:20
00:62:20
00:06:20
00120
00:26:20
ooee:20
‘EO
10:S€:20

& 00:96:20
00:26:20
00'86:20
00:68:20
00:0%:20

8
lapsed FDR Time (hh:mm:

Figure 8. Pitch attitude, control column position, and (corrected) elevator
position FDR data for the previous takeoff from RNO. About the first 1 minute
20 seconds of data were recorded while the gust lock was engaged.



Factual Information 52 Aircraft Accident Report

More than 300 full-time mechanics who worked at various Emery facilities at the
time of the accident performed airplane transit, terminating, service, and B inspections.
Emery used contract repair facilities (including TTS) for heavy maintenance (C and D
inspections) and major alterations of airframes, aircraft engines, and other components. A
list of approved overhaul and repair facilities was contained in Emery’s MPPM.”!

1.17.1.2 Operational Guidance Regarding the DC-8 Elevator
1.17.1.2.1 Emery’s DC-8 Preflight Inspection Procedures

Emery’s DC-8 Aircraft Operating Manual (AOM), “Normal Operations,” stated, in
part, the following regarding the flight engineer’s preflight inspection:”

Initial exterior inspection, elevators and tabs — with gust lock on

Elevators. . CHECK
Ensure elevators locked in faired position (gust lock on). If the gust lock is not on,
contact maintenance for possible inspection requirement.

Initial pilots’ station preflight

Gust lock... .OFF

Exterior preflight, elevators and tabs

[Left and right side] elevators............./ TAB ALIGNMENT AND CONDITION
With gust lock off, elevator should be up, control tabs up, and geared tabs down.

TM Title 14 CFR Part 121.369(b), states, in part, “the certificate holder’s manual must contain the
programs required by §121.367 that must be followed in performing maintenance, preventive maintenance,
and alterations of that certificate holder’s airplanes, including airframes, aircraft engines, propellers,
appliances, emergency equipment, and parts thereof and must include the following...a designation of the
items of maintenance and alteration that must be inspected (required inspections), including at least those
that could result in a failure, malfunction, or defect endangering the safe operation of the aircraft, if not

performed properly or if improper parts or materials are used... [and] procedures to ensure that all required
inspections are performed.”

7 According to Section 121.363, “Responsibility for airworthiness:”
(a) Each certificate holder is primarily responsible for —

(1) The airworthiness of its aircraft, including airframes, aircraft engines, propellers, appliances, and
parts thereof; and

(2) The performance of the maintenance, preventive maintenance, and alteration of its aircraft,
including airframes, aircraft engines, propellers, appliances, and parts thereof, in accordance with its
manual and the regulations of this chapter.

(b) A certificate holder may make arrangements with another person for the performance of any mainte-
nance, preventive maintenance, and alterations. However, this does not relieve the certificate holder of the
responsibility specified in paragraph (a) of this section.



Factual Information 18 Aircraft Accident Report

* B Inspections. B inspections were conducted as a series of four segmented
inspections (B-1, B-2, B-3, and B-4), accomplished at 136-hour intervals at
Emery maintenance stations, unless a C inspection was accomplished. The
B inspections were accomplished by Emery maintenance personnel and by
contract maintenance personnel under supervision of Emery personnel,
whereas heavier maintenance inspections were accomplished for Emery by
FAA-approved repair/overhaul facilities. B inspections included inspections
of the wings; main landing gear assemblies, wheel wells, doors, and wing root;
the nose section, nose landing gear, nose landing gear wheel well area and
tunnel; turbo compressor compartment; external center fuselage; aft fuselage
and empennage area; cabin area; time-limited components; main aircraft
battery; and main cargo door. Additionally, during a B inspection, the airplane
was thoroughly cleaned, flight controls were lubricated, the engines were run,
and pressurization was checked. For additional information regarding the
accident airplane’s most recent B inspections, see section 1.6.3.2.

* C Inspections. C inspections were accomplished at 24-month intervals by
FAA-approved repair/overhaul vendors that were contracted to conduct
maintenance on Emery airplanes. Emery defined a C inspection as “a high
level check to insure [sic] the integrity and airworthiness of airframe, fluid
quantities, security of components, operational checks of specified
components, filter changes, lubrication, overhaul of specific components,
systems checks and the accomplishment of principle structural elements per
the structural inspection document, or supplemental structural inspection
document.” (The accident airplane’s most recent C inspection was completed
as part of the most recent D inspection.)

* D Inspections. D inspections were accomplished at 12-year intervals; Emery
defined a D inspection as “a high level check to include all of the same checks
described in the [B and] C check[s], to include overhaul of the aircraft.” For
additional information regarding the accident airplane’s most recent
D inspection, see section 1.6.3.1.

Emery maintenance records indicated that, from November 17, 1999 (the
completion date of the accident airplane’s most recent D inspection), to the accident date
the company had complied with all applicable FAA ADs and accomplished all scheduled
maintenance items on the accident airplane in accordance with the provisions of its
continuous airworthiness maintenance program.

1.6.3.1 Accident Airplane’s Most Recent D Inspection

Tennessee Technical Services (TTS),*! in Smyma, Tennessee, performed the
accident airplane’s most recent D inspection between August 27 and November 17, 1999,
at an airplane total time of 84,050 hours (33,180 cycles). Emery provided TTS with
workscope information and guidance. In general, Emery specified that the inspection
include fleet campaign directives (FCD) and other special inspections, applicable ADs,

3! For additional information regarding TTS, see section 1.17.2.



Recommendations 85 Aircraft Accident Report

Require all DC-8 operators to create or revise DC-8 work cards to ensure
they specifically include a postrigging inspection of the elevator assembly,
including verifying the security of elevator control tab attachments.
(A-03-29)

Require all DC-8 operators to review their work cards related to critical
flight controls, and revise them as necessary to ensure that appropriate
tasks are identified as discrete tasks with individual inspection signoff
requirements. (A-03-30)

Require all 14 Code of Federal Regulations Part 121 air carrier operators to
revise their task documents and/or work cards to describe explicitly the
process to be followed in accomplishing maintenance tasks. (A-03-31)

Require all air carrier operators to either: 1) provide all pertinent
maintenance personnel with the manufacturer’s current installation
drawings for pertinent airplanes, update those installation drawings as
needed, and require use of those drawings during installation and/or
assembly of that airplane’s components; or 2) list the IPC on that operator’s
operation specifications, provide maintenance personnel with up-to-date
IPCs for reference, continue to update those IPCs as needed, and require
maintenance personnel to use the pertinent updated IPCs during
installation and/or assembly of an airplane’s components. (A-03-32)

Require operators of airplanes manufactured before August 18, 2000, that
have been retrofitted with additional flight data recorder (FDR) parameters
in compliance with Federal requirements and for which an operator
maintains a common correlation document for that airplane type to conduct
a full correlation of all such airplanes’ FDR parameters at the airplanes’
next required FDR maintenance inspection to verify accurate FDR system
documentation and sensor function. (A-03-33)

Require all operators of airplanes equipped with Loral Fairchild Model
F-800 flight data recorders to comply with Loral Fairchild Field Service
Bulletins digital flight recorder (DFR) 011 and DFR 027 for recorders with
applicable part numbers and installed component numbers. (A-03-34)

Require overhaul facilities that service Loral Fairchild Model F-800 flight
data recorders to monitor those recorders to determine whether abnormal
track switching is occurring and to report any such findings to the Federal
Aviation Administration and the manufacturer. (A-03-35)

Modify the list of safety-sensitive functions described in 14 Code of
Federal Regulations Part 121, Appendixes I and J, to include all personnel
with direct access to the airplane and a direct role in the handling of the
flight, including cargo handlers, load planners, and ramp supervisors.
(A-03-36)



Factual Information 39 Aircraft Accident Report

stowed positions. The landing gear lever was not recovered; however, CVR data and
physical evidence indicate that the landing gear were extended throughout the accident
flight.

The left and right wings were fractured; portions of the wings were recovered
separate from the fuselage and exhibited severe impact, heat, and fire damage. Portions of
the left aileron and the flap surfaces and spoiler panels from both wings were found
scattered throughout the debris.

All four engines were recovered and examined; FDR data and engine damage were
consistent with a high power setting at impact. There was no indication of any preimpact
engine damage, fire, or uncontainment.

The tail section wreckage was located aft of the rear fuselage. Portions of the
vertical stabilizer rear spar were located adjacent to the tail structure. However, the
remaining vertical stabilizer and rudder structures were not recovered and were presumed
consumed by fire based on the presence of previously melted and resolidified aluminum
adjacent to the tail section wreckage. The horizontal stabilizer center section and
surrounding tail structure exhibited evidence of heat and fire damage. The horizontal
stabilizer jackscrew and associated drive mechanisms exhibited severe heat damage. Both
jackscrews were fully extended, corresponding to a full nose-down trim position.

1.12.1 Longitudinal Flight Control Surfaces

The right horizontal stabilizer was recovered largely intact, whereas the right
elevator was recovered in several pieces. The inboard section of the right elevator, with
the control tab and the inboard 2 feet of the geared tab, remained mostly intact and
attached to the stabilizer. The right elevator geared tab inboard crank arm, which connects
the geared tab pushrod to the horizontal stabilizer, was manufactured of aluminum and
was found fractured.

Portions of the left horizontal stabilizer (about 75 percent, including the inboard
portions of the left stabilizer, elevator, and control tab surfaces) were not recovered;
because they were located in an area that was exposed to intense fire, they were presumed
consumed by postcrash fire. The left elevator inboard geared tab crank arm was
manufactured of aluminum and was found fractured, similar to the inboard geared tab
crank arm on the right elevator. (Although the left and right geared tab outboard crank
arms, which were manufactured of steel, exhibited severe twisting and other
impact-related damage, they were recovered intact.)

1.12.1.1 Flight Control Connections at the Elevator Control Tabs

The right elevator control tab crank fitting was found structurally intact and
attached to the control tab inboard hinge fitting on the inboard section of the right elevator.

® For additional information regarding fractured elevator geared tab crank arms, see section 1.16.1.3.



Analysis 80 Aircraft Accident Report

Although it was determined that the performance of cargo-handling personnel was
not a factor in this accident, improper loading of the airplane’s cargo and/or a cargo shift
during takeoff have been involved in previous accidents and were considered possibilities
during the early stages of this investigation. As evidenced by the history of cargo-related
accidents, the way cargo-handling personnel conduct their duties (whether those duties
involve the loading of cargo in cargo compartments; the loading/packing of the containers,
pallets, and other items for placement within the cargo compartments; or planning the
placement of the load) can have a significant effect on the safety of a flight. This potential
effect is no less serious than several of the functions that are currently defined as
safety-sensitive by the FARs, including aircraft dispatcher duties, ground security
coordinator duties, aviation screening duties, and aircraft maintenance or preventive
maintenance duties.

Therefore, the Safety Board concludes that the current regulatory definition of
safety-sensitive functions is too narrow for the issue of postaccident testing because it
does not include cargo handlers, load planners, and ramp supervisors, all of whom have a
demonstrated potential to affect the safety of a flight. Therefore, the Safety Board believes
that the FAA should modify the list of safety-sensitive functions described in 14 CFR
Part 121, Appendixes I and J, to include all personnel with direct access to the airplane
and a direct role in the handling of the flight, including cargo handlers, load planners, and
ramp supervisors.



Factual Information 57 Aircraft Accident Report

the pushrod and orientation of the bolt used to attach the aft end of the pushrod to the
control tab crank fitting.

On March 22, 2001, Emery issued FCD A27-8, Revision 1, titled “Elevator
Push/Pull Rod End Bolt Installation Inspection and Clearance Check,” which was required
to be accomplished on the Emery DC-8 fleet no later than April 12, 2001. Revision 1 to
FCD A27-8 changed the part number of the bolt and corrected a figure. It also added a
parts list and extended the time limit to accomplish the FCD by 10 days. The title was
also changed to reflect the clearance check not incorporated into FCD A27-8.

The findings from the inspections that followed the issuance of FCD A27-8
indicated that the attachment hardware, including cotter pins, were installed at the forward
and aft ends of each control tab pushrod on each airplane in Emery’s DC-8 fleet.
Although orientation of the pushrod attachment bolts was not consistent across Emery’s
fleet or from one side to the other on some airplanes, the manufacturer has indicated that
orientation of the bolt is not critical if the bolt is properly installed and secured. One
control tab pushrod was found installed incorrectly, and three control tab pushrods were
replaced because of wear and/or suspected damage.

1.17.2 Tennessee Technical Services

TTS, located in Smyrna, Tennessee, has been an FAA-approved 14 CFR Part 145
Repair Station since May 29, 1998, when it was issued Air Agency Certificate number
T64R1640. TTS’s certificate was reissued on January 26, 2000, with the following
limited ratings: airframe, powerplant, accessories, radio, instrument, non-destructive
testing, and specialized services. This certificate allowed TTS to perform inspections,
maintenance, modifications, and alterations on several airplane models, including
DC-8-50/-60/-70 airplanes. TTS’s certificate stated that all work was to be accomplished
in accordance with the customer’s 14 CFR Part 121 requirements for continuous
airworthiness per 14 CFR Section 145.2, the manufacturer’s current technical data, or
other data acceptable to the FAA administrator.

In October 1998, upon successful completion of an Emery audit, TTS was added
to Emery’s list of approved repair stations/vendors. TTS performed a variety of services
for Emery, including heavy maintenance, special maintenance services (such as lighter
maintenance [B] inspections, off-site maintenance assistance with ramp checks and ramp
damage, and short- and long-term airplane storage), and off-base maintenance support for
Emery. At the time of the Safety Board’s review of TTS facilities in 2001, TTS operated
from a hangar that would accommodate four DC-8 airplanes and from another building in
which it overhauled various components. Examination of TTS records indicated that from
the time the company began operating as a repair station until March 1, 2001, TTS had
performed maintenance on 173 airplanes, including many of Emery’s airplanes (TTS
records contained 99 invoices for Emery airplanes).

At the time of the accident, TTS employed about 91 certificated mechanics and
3 repairmen. Emery had designated 20 TTS inspectors to work on its airplanes.”© TTS



81 Aircraft Accident Report

3. Conclusions

3.1 Findings

1.

The captain, first officer, and flight engineer were properly certificated and qualified
and had received the training and off-duty time prescribed by Federal regulations and
company requirements. No evidence indicated any preexisting medical or behavioral
conditions that might have adversely affected the flight crew’s performance during
the accident flight.

The accident airplane was certificated, equipped, and dispatched in accordance with
applicable regulations and industry practices.

Cargo loading for the accident flight was routine, and the airplane was operating
within prescribed center of gravity limits.

Weather and air traffic control were not factors in this accident.

At some time after the previous takeoff (from Reno, Nevada) and before the accident
takeoff roll, the bolt connecting the right elevator control tab crank fitting to the
pushrod migrated out of the fitting, allowing the control tab to disengage from its
pushrod and shift to a trailing edge down position.

When the aerodynamic forces increased as the airplane accelerated during the takeoff
roll, the right elevator control tab crank fitting contacted the disconnected pushrod,
restricting that control tab’s further trailing edge up movement and leaving it in an
extreme trailing edge down deflection.

As a result of the right elevator control tab’s extreme trailing edge down deflection,
the accident airplane’s elevator surfaces were driven to command an extreme airplane
nose-up pitch attitude; despite the large nose-down forces the pilots applied to the
control columns, the pilots were unable to overcome the effects of the restricted right
elevator control tab.

The bolt attaching the accident airplane’s right elevator control tab crank fitting to the
pushrod was improperly secured and inspected, either during the most recent D
inspection or subsequent maintenance; however, the Board was unable to determine
when this improper securement and inspection occurred.

DC-8 operators’ procedures and training should more clearly emphasize that DC-8
flight crewmembers need to verify symmetry between the tight and left side
elevators, control tabs, and geared tabs during the preflight inspection.



Factual Information 26 Aircraft Accident Report

1. Disconnect elevator control cables and control tab pushrods from tab torque
tubes at the elevator inboard end. Check the torque tube bearings for binding
or roughness. If bearings do not operate smoothly, replace the elevator hinge
fitting. Rerig elevator controls.

2. Correct all discrepancies recorded during accomplishment of parts 1 and 2,
preceding.
Additional commentary and discussion of the troubleshooting procedures used to

address pilot write-ups regarding elevator controls is included in the public docket of this
report.

1.6.3.2 Most Recent B-2 Inspection of the Accident Airplane

The accident airplane’s most recent B-2 inspection was conducted overnight at
Emery’s DAY facility, on January 21-22, 2000. One of Emery’s DC-8 work cards (B009)
for the B-2 inspection of the right elevator control tab stated the following:

RH AND LH HORIZONTAL STABILIZER EXTERNAL SURFACE
INSPECTION

1. Inspect external surface of RH and LH horizontal stabilizers for signs of
damage, deformation, fluid leakage, and security of attachment. Inspect static
dischargers for general condition and security.

RH AND LH ELEVATOR AND TAB INSPECTION

1. Visually inspect elevators and tabs for general condition, corrosion, leakage,
and security of attachment. Inspect static dischargers for general condition
and security.

Both steps were signed off by an Emery mechanic.

Because of the DC-8 elevator assembly design, the elevator control tab inboard
fairing would have to be removed for maintenance personnel to inspect the inboard hinge
fitting and crank fitting/pushrod attachment. During the Safety Board’s public hearing on
this accident, there was conflicting testimony regarding the intended depth and scope of
the B-2 inspection. For example, Emery’s Director of Engineering and Director of Line
Maintenance indicated that the general visual inspection dictated by the B-2 inspection
work cards would not require the removal of any panels or fairings and, therefore, would
not include a visual inspection of the elevator control tab inboard hinge fitting or crank
fitting/pushrod attachment. Boeing supported this interpretation of the B-2 inspection
work card tasks. In a letter to the Board dated June 14, 2002, Boeing’s Chief Engineer,
Air Safety Investigation, stated that the manufacturer’s recommended program work cards
“do not call for the removal of the inboard control tab fairing during the B [inspections].
The inboard control tab fairing is not removed until the [C- and D-inspection
equivalent]...Therefore, the Emery B-2 inspection work card...would be...an inspection
to be accomplished without removing access or inspection panels, fairings, or the like.”



Factual Information 2 Aircraft Accident Report

the investigation revealed that minor maintenance discrepancies existed (for example, an
inoperative fuel valve indication and a malfunctioning navigation light), neither the flight
engineer nor the mechanics reported observing any significant airplane anomalies during
the preflight inspections. Further, the cockpit voice recorder (CVR) did not record any
discussion of airplane anomalies while the airplane was on the ground at MHR.°

According to CVR information and postaccident interviews, the loading
supervisor gave the final load planning information to the accident flight crew after the
outbound cargo was loaded. According to Emery’s procedures, the pilots were to review
this information and use it to calculate the airplane’s weight and center of gravity (c.g.)’
for the accident flight. Postaccident interviews indicated that the cargo loading supervisor
received a copy of the signed load planning sheet and the completed weight and balance
form from the pilots just before the airplane’s doors were closed for departure; there were
no anomalies or irregularities with the paperwork or procedures. Postaccident interviews
with the cargo loading supervisor, load planner, and cargo loaders who worked on the
accident airplane indicated that the unloading/loading process on the night of the accident
was routine and that the airplane’s load was lighter than usual.®

According to the CVR, about 1927:25, the first officer (the flying pilot for the
accident flight) performed the takeoff briefing, stating, in part, “[w]e’re cleared up to
[3,000 feet]. ...Standard Emery procedures if there’s a problem, we’ll come back here and
land on [runway 22L].” The captain responded, “Sounds good.” About 1932:32, the CVR
recorded the flight engineer confirming that the airplane’s cargo doors were closed and,
about 1932:36, the flight crew began the prestart checklist. About 1939:19, the flight
engineer advised ground personnel “we have four good [engine starts], you can go ahead
and pull the [auxiliary] air and power.”

According to the CVR transcript, the flight crew began the after start/before taxi
checklist about 1940:00 and, about 1940:39, advised local airport traffic that Emery
flight 17 was taxiing from the southwest cargo area to runway 22L.° As the pilots taxied
the airplane toward the runway, the captain called for 15° of flaps and a flight control
check. The CVR subsequently recorded the first officer stating, “ailerons

5 It was dark at the time these tasks and inspections were conducted; however, ground personnel set up
light stands along the left side of the airplane, illuminating that portion of the airplane for cargo
loading/unloading and inspection operations. Ground personnel reported that there was no significant direct
light on the right side of the airplane. (National Transportation Safety Board investigators noted similar
lighting conditions during their observation of loading operations on February 21, 2000.)

The CVR recorded the last 33 minutes and 24 seconds of cockpit communications before the
accident. See appendix B for an excerpted portion of the CVR transcript.

7 The position of the c.g. is directly related to the stability of the airplane (that is, the tendency of the
aircraft to return to a trimmed equilibrium) and the pitch control input required to maintain a given flight
condition.

® For additional information regarding the cargo loading on the accident airplane, see section 1.6.1.
Also, see the Operational Factors/Human Performance Group Chairman’s Factual Report, dated April 13,
2001, and Attachments 1 (interview summaries), 7, and 8 in the public docket for this accident.

° Because there is no air traffic control (ATC) facility at MHR, pilots typically broadcast their
intentions to other area traffic on a common radio frequency.



Factual Information 41 Aircraft Accident Report

1.13 Medical and Pathological Information

1.13.1 Flight Crew Information

Tissue specimens from the captain, first officer, and flight engineer were sent to
the FAA’s Civil Aerospace Medical Institute in Oklahoma City, Oklahoma, for
examination. The specimens tested negative for all drugs of abuse,” as well as
prescription and over-the-counter medications.

1.13.2 Cargo Handlers—Postaccident Drug and Alcohol Testing

The FARs do not require postaccident drug or alcohol testing of cargo handlers.
The provisions of 14 CFR Part 121, Appendix I, titled “Drug Testing Program,” state the
following:

Each employer shall test each employee who performs a safety-sensitive function
for the presence of marijuana, cocaine, opiates, phencyclidine (PCP), and
amphetamines, or a metabolite of those drugs in the employee’s system if that
employee’s performance either contributed to an accident or can not be
completely discounted as a contributing factor to the accident. The employee
shall be tested as soon as possible but not later than 32 hours after the accident.
The decision not to administer a test under this section must be based on a
determination, using the best information available at the time of the
determination, that the employee’s performance could not have contributed to the
accident.

Additionally, the provisions of 14 CFR Part 121, Appendix J, titled “Alcohol
Misuse Prevention Program,” state the following:

As soon as practicable following an accident, each employer shall test each
surviving covered employee for alcohol if that employee's performance of a
safety-sensitive function either contributed to the accident or cannot be
completely discounted as a contributing factor to the accident. The decision not to
administer a test under this section shall be based on the employer’s
determination, using the best available information at the time of the
determination, that the covered employee's performance could not have
contributed to the accident.

Ifa test required by this section is not administered within 2 hours following the
accident, the employer shall prepare and maintain on file a record stating the
reasons the test was not promptly administered. If a test required by this section is
not administered within 8 hours following the accident, the employer shall cease
attempts to administer an alcohol test and shall prepare and maintain the same
record. Records shall be submitted to the FAA upon request of the Administrator
or his or her designee.

“The five drugs of abuse for which specimens are tested in postaccident analysis are marijuana,
cocaine, opiates, phencyclidine, and amphetamines.



1 Aircraft Accident Report

1. Factual Information

1.1 History of Flight

On February 16, 2000, about 1951 Pacific standard time,! Emery Worldwide
Airlines, Inc., (Emery) flight 17, a McDonnell Douglas’ DC-8-71F (DC-8), N8079U,
crashed in an automobile salvage yard shortly after takeoff, while attempting to return to
Sacramento Mather Airport (MHR), Rancho Cordova, California, for an emergency
landing. Emery flight 17 was operating under the provisions of 14 Code of Federal
Regulations (CFR) Part 121 as a scheduled cargo flight from MHR to James M. Cox
Dayton International Airport (DAY), Dayton, Ohio. The flight departed MHR about
1949, with two pilots and a flight engineer on board. The three flight crewmembers were
killed, and the airplane was destroyed. Night visual meteorological conditions prevailed
for the flight, which operated on an instrument flight rules (IFR) flight plan.

On the day of the accident, Emery had operated the accident airplane on two
cargo-carrying flight segments before the accident flight. The first was flight 18 from
DAY to Reno/Tahoe International Airport (RNO), Reno, Nevada, which arrived at RNO
about 1642, and the second flight segment was the first leg of flight 17, from RNO to
MHR. Emery flight 17 departed RNO for MHR about 1755. The accident captain was
aboard the airplane for both previous flight segments. He rode the jumpseat as he
commuted from DAY to RNO to begin his duty day in RNO and was the flying captain
from RNO to MHR?

According to postaccident interviews and company records, the airplane arrived at
MHR about 1815 and reached the MHR cargo ramp about 1832. Records indicated that
cargo-handling personnel unloaded the inbound cargo from the main and belly cargo
compartments then loaded the outbound cargo, finishing about 1930.

Postaccident interviews indicated that while cargo-handling personnel were
working, the accident flight engineer conducted a preflight inspection of the exterior of the
accident airplane.’ Additionally, during this time, mechanics from Emery and a contract
maintenance company performed routine maintenance inspections and service items (such
as servicing the engines with oil, checking the tires and brakes, and refueling). Although

1 Unless otherwise indicated, all times are Pacific standard time, based on a 24-hour clock.

2 Douglas Aircraft Company and McDonnell Aircraft Company merged in April 1967 and formed the
McDonnell Douglas Company. The Boeing Company and McDonnell Douglas merged in August 1997 and
operate under the Boeing name. Subsequent references to Boeing as the manufacturer reflect this merger.

3 The captain and flight engineer who flew from DAY to RNO were replaced by the accident captain
and flight engineer for the flight from RNO to MHR. The first officer who flew to RNO continued on the
accident airplane to MHR, where he was replaced by the accident first officer.

‘For detailed information regarding Emery’s DC-8 preflight inspection procedures, see
section 1.17.1.2.1.



Factual Information 35 Aircraft Accident Report

Section 121.343(c).4 As a result of its ongoing concerns, the Board issued Safety
Recommendations A-97-29 and A-97-30 on May 22, 1997.55 Safety Recommendation
A-97-29 asked the FAA to do the following:

Take action within 180 days to ensure compliance of the U.S. carriers subject to
14 CFR 121.343(c). Actions should include (a) performing a readout of each
retrofitted airplane’s 11-parameter flight data recorder (FDR) to determine that all
required FDR parameters are being recorded and to verify that each parameter is
working properly; and (b) reviewing the FDR system documentation to determine

compliance with the range, accuracy, resolution, and recording interval specified
in 14 CFR Part 121, Appendix B.

In a letter to the Safety Board dated July 14, 1997, the FAA stated that it agreed
with the intent of this safety recommendation. In response, the FAA issued Flight
Standards Handbook Bulletin for Airworthiness (HBAW) 97-13C, which became
effective on December 15, 1997. HBAW 97-13C provided FAA airworthiness inspectors
with “policy/guidance to ensure continued proper operation and recording of data” by
FDRs. The bulletin outlined items inspectors should look for in a comprehensive FDR
maintenance program, defined time requirements for addressing identified discrepancies
in FDR maintenance programs, and described a functional evaluation as a “recorded data
dump, conversion to engineering units and assessing that the [FDR] is receiving,
transcribing and decoding sensor information properly.”

In a July 10, 1998, safety recommendation letter to the FAA (regarding the
August 1997 accident involving Fine Airlines flight 101 in Miami, Florida®), Safety
Recommendation A-97-29 was classified “Closed—Unacceptable Action/Superseded”
(the recommendation that superseded A-97-29 is discussed later in this section). The
Board indicated that this classification was based on “the continued discovery of
malfunctioning 11-parameter FDRs” and the findings of the Fine Air investigation, which
indicated that “it is advisable to require air carriers to maintain the records of FDR
readout.”

* There have been two required FDR upgrades that apply to Emery’s DC-8s (which were manufactured
before May 26, 1989, and type certificated before September 30, 1969). The first upgrade, which became
effective on May 26, 1995, required that the following additional parameters be recorded: pitch attitude, roll
attitude, longitudinal acceleration, control column or pitch control surface position, and N, (rotational speed)
of each engine. The second upgrade required the affected airplane to be upgraded to record 17 parameters;
this upgrade had to be completed by the airplane’s first heavy maintenance inspection after August 18, 1999,
As previously mentioned, the accident airplane was modified to record these additional parameters during
its most recent D inspection in November 1999.

** Tn this safety recommendation letter, the Safety Board listed a series of recent accidents and incidents
that involved malfunctioning FDRs, including the October 22, 1996, accident involving a Millon Air Boeing
707 and the May 28, 1995, accident involving a Millon Air DC-8.

56 See National Transportation Safety Board, Uncontrolled Impact with Terrain, Fine Airlines
Flight 101, Douglas DC-8-61, N27UA, Miami, Florida, August 7, 1997, Aircraft Accident Report
NTSB/AAR-98/02 (Washington, DC: NTSB, 1998).



Factual Information 14 Aircraft Accident Report

oe up?

ELEY cure
pos

~

ON.

Figure 3. A photograph of an EPI gauge similar to the gauge
installed on the accident airplane.

The EPI on the accident airplane was located on the lower left side of the first
officer’s instrument panel. (Figure 4 shows an EPI installation similar to that on the
accident airplane.) The EPI gauge was installed in 1979 by the then-operator of the
accident airplane, United Airlines, in compliance with Airworthiness Directive
(AD) 78-01-15, which required DC-8 operators to install an EPI system in accordance
with Douglas Service Bulletin (SB) 27-254, dated March 5, 1975. The FAA issued
AD 78-01-15 as a result of a series of accidents and incidents involving DC-8 jammed or
restricted elevator surfaces that began in 1970. (For additional information regarding
these instances of jammed/restricted DC-8 elevators, see section 1.6.2.2)

AD 78-01-15 specified that operators install the EPI gauge on the first officer’s
instrument panel such that full forward movement of the control column and wheel would
not obstruct the first officer’s view of the gauge. The AD did not comment regarding
visibility of the gauge from the captain’s seat. As a result, DC-8 operators installed the
EPI where they found room for it and where the first officer could see it on an airplane’s
existing instrument panel. Because Emery purchased its DC-8s from several other
operators and EPI placement was not standardized, EPI gauges in Emery’s fleet were
installed in several different locations; according to Emery personnel, however, they were
generally installed on the lower portion of the first officer’s instrument panel.


Factual Information 9 Aircraft Accident Report

The first officer who was the flying pilot for the flight from DAY to RNO (on
which the captain rode jumpseat) and was the non-flying pilot while the accident captain
flew the flight from RNO to MHR indicated that he had not flown with the accident
captain before. He indicated that the accident captain smoothly hand-flew the airplane to
their cruising altitude of 14,000 feet msl, then (again hand-flying) made a normal descent
and a “nice” landing at MHR. The first officer stated that he did not note any problems
with the airplane during the flight from RNO to MHR, nor did the accident captain
indicate to the first officer that there were any problems with the airplane.

1.5.2 The First Officer

The first officer, age 35, was hired by Emery on September 15, 1996. He held an
ATP certificate with multiengine land and instrument ratings. His most recent DC-8
recurrent training and proficiency checks were completed on October 27 and 29, 1999,
respectively. The first officer’s most recent FAA first-class airman medical certificate was
issued on June 24, 1999, with no restrictions or limitations. According to Emery records,
at the time of the accident, the first officer had flown about 4,511 total flight hours,
including 2,080 hours as a DC-8 first officer.

The first officer lived in Placerville, California, about 33 miles northeast of MHR,
where he joined the accident captain and flight engineer for the accident flight. According
to Emery records, the first officer’s duty day began with the accident flight.

1.5.3 The Flight Engineer

The flight engineer, age 38, was hired by Emery on September 15, 1998. He held
an ATP certificate with multiengine land rating and a flight engineer rating for
turbojet-powered airplanes. The flight engineer’s most recent DC-8 recurrent training and
proficiency checks were completed on September 2, 1999. His most recent FAA
first-class airman medical certificate was issued on June 22, 1999, with no restrictions or
limitations. According to Emery records, at the time of the accident, the flight engineer
had accumulated about 9,775 total flight hours, including 675 hours as a DC-8 flight
engineer.

The flight engineer lived in Sparks, Nevada, a suburb of Reno, where he joined the
accident captain for the flight from RNO to MHR. According to Emery records, the flight
engineer’s duty day began with the flight from RNO to MHR.

1.6 Airplane Information

The DC-8 was originally certificated in 1959, under Civil Aviation Regulations
(CAR) Part 4b.” The accident airplane, N8079U, serial number (S/N) 45947, was issued a
standard airworthiness certificate as a DC-8-61, on March 21, 1968. In July 1983, the

° For additional information regarding the DC-8’s certification under CAR 4b, see section 1.18.1.



vi

Aircraft Accident Report

Abbreviations
AC advisory circular
AD airworthiness directive
ALPA Air Line Pilots Association
AND airplane nose down
ANU airplane nose up
AOM aircraft operating manual
ASB alert service bulletin
ASOS automated surface observation system
ATC air traffic control
ATP airline transport pilot
c.g. center of gravity
CAR Civil Aviation Regulations
CFR Code of Federal Regulations
CVR cockpit voice recorder
DAY James M. Cox Dayton International Airport
DFR digital flight recorder
EPI elevator position indicator
FAA Federal Aviation Administration
FAR Federal Aviation Regulations
FCD fleet campaign directive
FDR flight data recorder
FOB flight operations bulletin
FSB field service bulletins
FSDO flight standards district office
GPWS ground proximity warning system



Aircraft Accident Report

106

Appendix B

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Factual Information 64 Aircraft Accident Report

...a mechanical failure in the elevator control system. The likely cause was a
failure at the control tab clevis fitting due to either a failure of or improper
securing of the nut, bolt, and/or cotter pin. This resulted in the pilot’s inability to
control the aircraft. Improper and inadequate maintenance performed by [Emery]
likely caused the bolt/nut assembly to come loose or fail during the fatal takeoff.

In its submission on this accident, the Air Line Pilots Association (ALPA) stated
that the accident “was the result of a disconnect and subsequent jam in the linkage of the
pitch control system, which rendered the aircraft uncontrollable.” ALPA’s submission
further stated the following:

Evidence and analysis indicates that the bolt which attaches the pushrod to the tab
crank fitting for the right-hand. ..elevator control tab was jammed in the airplane
nose up (ANU) position....Although the root cause for the loss of the bolt is
unknown, the most likely scenario is that the bolt’s locking hardware was either
never or improperly installed after maintenance activity by Emery....given
the...vague and/or ambiguous work card and maintenance guidance, the sparse
aircraft logbook write-ups...regarding both the damper reversal and the B-checks,
it seems highly likely that the elevator system linkage was parted by [Emery]
during one of those maintenance actions, and that locking hardware was either
never or improperly reinstalled.

In its submission on this accident, Boeing stated the following:

Based on the factual evidence and the analytical studies conducted for this
investigation, Boeing believes that the probable cause of this accident was
improper maintenance practices that led to the separation of the control tab
pushrod from the control tab crank [fitting], a subsequent restriction of the control
tab in an extreme trailing edge down position, and the subsequent loss of control
of the airplane.” Boeing’s submission also stated “the right elevator
control-rod-to-control-tab-crank joint was improperly installed either during
the...‘D’ check at TTS, or during troubleshooting at Emery for the flight
crew-reported difficulty with flaring the aircraft.



Factual Information 19 Aircraft Accident Report

components that were due to be changed or recertified, powerplant tasks, and
supplemental type certificate (STC) modifications to expand the parameters of the FDR.
Emery provided TTS with the following work cards for the inspection:

* D inspection work cards for DC-8-50/-60 series airplanes from Emery’s
Inspection Program Manual—Volume III, revision 17, dated November 15,
1995.

* C inspection work cards for DC-8-50/-60 series airplanes from Emery’s
Inspection Program Manual—Volume II, revision 19, dated October 18, 1996.

* C supplemental inspection work cards for DC-8-70 series airplanes from
Emery’s Inspection Program Manual—Volume II, revisions 16 and 19, dated
January 15, 1995, and October 18, 1996, respectively.

Emery also provided an amendment to the workscope information, dated
September 14, 1999, which stated that the accident airplane’s primary flight controls
would be removed and replaced with overhauled units during the D inspection work.

1.6.3.1.1 Removal/Replacement of the Right Elevator

Examination of the documentation for the D inspection confirmed that the
airplane’s existing elevators and their associated (control and geared) tabs were replaced
with overhauled assemblies. At Emery’s request, TTS sent the removed elevator, control
tab, and geared tab surfaces and their associated hardware to Willis Aeronautical Services
(Willis), in Tempe, Arizona, in exchange for overhauled components.” (The accident
airplane’s right elevator, control, and geared tabs were removed in accordance with work
card 3103D, titled “Remove R/H Elevator and Tabs.” This work card instructed
maintenance personnel to remove the right elevator, control tab, and geared tab and to bag
and attach all loose parts, including hardware, to their respective subassemblies.)

Willis then provided TTS (through Emery) with a replacement elevator, control
tab, and geared tab surfaces (with no associated hardware), which had been overhauled by
Complete Controls, Inc. (CCI), in Tucson, Arizona. According to the attached work
orders and documentation, CCI inspected and overhauled the elevator, control tab, and
geared tab surfaces in accordance with the DC-8 overhaul manual.

Records indicate that TTS received the replacement overhauled elevator geared tab
on August 20, 1999, and the replacement overhauled elevator and elevator control tab on
September 9, 1999. According to testimony presented at the public hearing for this
accident, TTS’ standard receiving inspection procedure consisted of a general visual
inspection (to identify shipping damage, etc.) and confirmation that the necessary
documentation was with the part? TTS representatives indicated that the components
were inspected in accordance with TTS’ standard receiving inspection procedure and that
no anomalous condition was noted during this inspection.

2 According to public hearing testimony, Emery arranged for TTS to receive replacement parts, which
typically were used/overhauled components that Emery obtained through brokers. Willis Aeronautical
Services was one such airplane parts broker.



Factual Information 5 Aircraft Accident Report

time (between 1949:30 and 1949:40), the FDR recorded the following: the airplane’s
altitude increased to 1,037 feet mean sea level (msl) then began to decrease; the airplane’s
left bank decreased from more than 30° to about 13°, then increased to 25°, then decreased
to about 12°; the control column position varied between about 17° forward of vertical and
19.5° forward of vertical;'® and the elevator surface deflections decreased from about 12°
TEU to about 5° TEU then increased to about 7.5° to 8.5° TEU.

About 1949:40, the CVR recorded the first officer stating, “you steer, I’m pushing”
while Sacramento TRACON asked the pilots of Emery flight 17 to repeat their radio
message. About 1949:44, the captain again advised the TRACON controllers that the
flight had an emergency.

Also about 1949:44, the flight engineer stated, “we’re sinking...we’re going down,
guys.” Two seconds later, the CVR recorded a sound similar to increased engine rpm,
followed almost immediately by the ground proximity warning system’s (GPWS)
“whoop, whoop, pull up” audible alert and the first officer’s call for “power.” According
to FDR data, at this time the airplane was descending through 679 feet msl in a steepening
left bank of about 11°. The recorded control column position was about 14° forward of
vertical and the elevator surface deflection was about 10° TEU. FDR data showed that the
airplane continued to descend until about 1949:50, when it reached about 601 feet msl and
began to climb again. About 1949:52, as the airplane climbed through 625 feet msl, the
GPWS audible alert ceased and the captain stated, “all right, all right...all right.” About
1949:54, as the airplane climbed through 673 feet msl, the first officer stated, “push” and
the flight engineer stated, “okay, so...we’re going back up.”

As the airplane’s altitude was increasing (after 1940:50), its left bank also
increased, reaching about 45° between 1949:55 and 1949:56, then began to decrease.
About 1949:57, the CVR recorded the flight engineer stating, “there you go,” then the
captain stating, “roll out,” followed by an unidentified crewmember saying, “roll out,” and
the sound of a strained exhale.

About 1950:04, the FDR data indicated that the airplane was ina left bank of about
33°, at an altitude of 901 feet msl. About this time, the CVR recorded the captain advising
Sacramento TRACON that, “Emery [17 has an] extreme c. g. problem.” FDR data
indicated that the airplane continued to climb and its bank continued to decrease during
the next 6 to 7 seconds. About 1950:10, as the airplane was rolling out of its left bank on
a heading of about 022" at 947 feet msl, the CVR recorded the sound of another strained
exhale. About 1950:11, the flight engineer stated, “anything I can do, guys,” and the
captain stated, “roll out to the right.” About 1950:12, the CVR recorded the first officer
stating, “okay...push.”

‘S This control column position (19.5° forward of vertical) was the most forward control column
position recorded by the FDR during the accident flight. For additional information on the recorded control
column position, see section 1.11.2.4.

All headings presented in this report are in degrees relative to the Earth’s magnetic north pole.



Factual Information 24 Aircraft Accident Report

Figure 5. Photograph showing the elevator damper’s location on the right elevator of a
DC-8.

Emery’s third-shift lead mechanic at DAY described the troubleshooting efforts
that led to the discovery of the reversed dampers. He stated, in part, that he and another
Emery mechanic moved the control column in the airplane through its range of motion
while other maintenance personnel (including his supervisor) watched the elevator
assembly’s motion from the ground at the rear of the airplane. The lead mechanic told
investigators that during this exercise, his supervisor “noted that there was a problem with
the [elevator] dampers and that the mechanical operation wasn’t correct.” Maintenance
personnel confirmed that the dampers were installed in the wrong positions and removed
and swapped the dampers. According to the lead mechanic, maintenance personnel did
not check cable tensions, access the elevator control tab pushrod fairing, rig the elevator
control or geared tabs, or discover any obstructions to control column movement during
the troubleshooting efforts.

Postaccident interviews with the mechanics involved in the maintenance action
indicated that they had nearly finished swapping the elevator dampers at the end of the
third shift when there was a change in lead mechanic personnel. According to the Emery
mechanic who moved the contro! column during the initial troubleshooting efforts (and
stayed on duty to complete the elevator damper work), “once the dampers were placed
into the correct position, no further maintenance was done...beyond a visual inspection
and checking the feel of the flight controls. It seems to me that the flight controls, after
swapping of the dampers, felt smoother.”



Aircraft Accident Report

Appendix B

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Recommendations 86 Aircraft Accident Report

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

ELLEN G. ENGLEMAN CAROL J. CARMODY
Chairman Member

MARK V. ROSENKER JOHN J. GOGLIA
Vice Chairman Member

RICHARD F. HEALING
Member

Adopted: August 5, 2003



Factual Information 6 Aircraft Accident Report

For the next 4 seconds, the airplane continued to fly on a north-northeasterly
heading, approximately parallel to the departure runway at an altitude of about 1,000 feet
msl. About 1950:16, the CVR recorded a crewmember stating, “push forward” then the
first officer saying, “awww.” During the next 10 seconds, the airplane banked right to an
east-northeasterly heading then climbed, reaching 1,087 feet msl (the maximum altitude
obtained for the accident flight) about 1950:18, before it began to descend again. About
1950:26, as the airplane’s right bank and altitude were decreasing, the flight engineer
asked, “you got the trim maxed?” About 1950:28, the first officer stated, “power;” the
flight engineer asked, “more;” and, about 1950:29, the first officer said, “yeah.” From
1950:29 to about 1950:35, as the airplane’s right bank decreased, the GPWS audible alert
sounded again. About 1950:32, as the GPWS alert continued to sound, the first officer
stated, “we’re gonna have to land fast.” Between 1950:33 and 1950:34, the airplane
transitioned from a right bank into a left bank.

About 1950:37, the first officer stated, “what I’m trying to do is make the
airplane’s pitch match the elevator. That’s why I’m putting it in a bank.” According to
FDR data, as the first officer spoke, the airplane continued a left turn back toward the
airport; the airplane’s left bank steepened to about 30°, and its heading shifted from about
071 through about 047. About 1950:45, the captain replied, “all right...left turn” and,
about 1950:46, the first officer added, “so we’re gonna have to land it in...a turn.” As the
airplane turned through a heading of about 035, the captain stated, “bring it around.”
About 1950:48, the CVR recorded a sound similar to the airplane’s stick shaker activating;
about 1 second later, the captain repeated, “bring it around.”

The CVR transcript indicated that “grunt” and “rustling” sounds were recorded
about 1950:51, as the airplane descended through 774 feet and turned through a heading of
about 016. About 1950:54, the first officer asked, “you got the airport.” About 1950:56,
as the airplane turned through a northerly heading, the captain again stated, “bring it
around.” At 1951:00, the first officer requested more power; 2 seconds later, the CVR
recorded the GPWS audible alert again briefly.

According to FDR data, about 1951:03, the accident airplane was at an altitude of
430 feet msl in about a 24° left bank, passing through a heading of about 325. Two
seconds later, the airplane was at 423 feet msl in about a 28° left bank, passing through a
heading of about 312. At 1951:07, the FDR recorded the airplane at 224 feet msl, in a
left turn through a heading of about 308. Also, at 1951:07, the CVR recorded the first
officer stating, “power...aww [expletive].” One second later, at 1951:08, the CVR
recorded a sound similar to impact. The accident airplane’s FDR stopped recerding about
1951:08, and the CVR stopped recording about 1951:09; the cessations were consistent
with an impact-related loss of electrical power.

The airplane impacted the ground in a left-wing-low, slightly nose-up attitude in an
automobile salvage yard, about 1 mile east of the departure runway. Figure 1 shows the
airplane’s ground track, with selected CVR comments, during the accident flight. (For
additional information regarding CVR comments, see the CVR transcript in appendix B).



Aircraft Accident Report

93

Appendix B

“sseuuey Jepjnoys eWVD

EO-EV6L

“x{S @UO eWVvo

LO-€r:6b

“XIS yuJod uO jes zwvo

00°€r:61

“xIs qujod auo -WVS

8S:2r-6L

“soziIG2)S f-WVO

SS:Zy-6L

“uo ZWVO

9S:2P'6L

“sedwep mek ewvo

€S:2p-6L

uajepuluo—_ Z-WW9.

2S:2y'6L

“S1BAQ] [ONY f-WVO

bS:ZP-6L

ANSLNOD aOYgNOS AN3LNOD aouNOS

(1S) ew, (1S) ew,
NOLLVSINNIWINOD GNNOYS-OL-LAVeuIV 9940 SF NOILVSINNWWOD LiddD09-VaLNI



Aircraft Accident Report

98

“uojAeq “ye 0} aseejaJ JNO paau “JeyVeW Yo] OMY OM} BUD
Jequinu Aaeay ueajueres Aiew3 eunyedep ojueweies 2-008
8:97:61

“we,e2s}|OU ¢-WVO
bELP6b

“uooeeq au yeyyysn{ yee 2-IWWD

80-27-61

qb seep -WWW9
20:27:61

ésiy6y uoyisod, —Z-WWO
LO:L¢:64

*. “yeak NWS
€S:97°61

“s} ey e104) YO Z-WV9

Appendix B

2S:97'61L
[pedyey you 0} )xe} 40} yo} OMY OMY
40} suaquunu ey} Bulssoso Sulu euO UeAes Ja}doo}}ey penb] oay
ey:or'6L
[6ulpeey
Q48Z aulU O18Z 0} WN} pueYy Yo] U} eAY AYY OUlU SM] oau
ZEOV'6L
4LN3LNOD a9YNOS 4AN3LNOD a9yNOS
(Lsd) eu. (Lsd) owt
sopoe NOILVOINNWWOD LidtOOS-VULNI

NOLLVOINNWWOD GNNOUS-OL-LIVaOUIV



Aircraft Accident Report

114

Buypsozey Jo pug
yduosued jo pug
60°1S-6b

foeduy 0} se)1wWis punos] WYO
80:15:61

‘w= GW
80:15:61

“ume Z-VS
20:15:6b

uemod = 7-9

Appendix B

20:15:61
LN3LNOD aogNos LN3LNOD aouNoSs
(1S¢) owLL (1Sd) owl,
NOLLVOINNWNOD GNNOYS-OL-LAVeoUIV 99" 99 NOILLVOINNWINOD Lidw90D-VU_LNI



Factual Information 60 Aircraft Accident Report

write-ups and instances of possible improper maintenance sign-offs. However, he
characterized Emery as a “troubled carrier,” adding that “[t]here were a lot of issues.”

When the Emery certificate was transferred, Cincinnati FSDO PMI personnel met
with the San Jose FSDO PMI to become familiar with the issues involved with
management of Emery’s certificate. Further, in January 2000, the Cincinnati FSDO
conducted a Regional Aviation Safety Inspection Program (RASIP) inspection of Emery
to evaluate the company. (For additional information regarding this RASIP, see section
1.17.3.1.) The Cincinnati FSDO PMI noted that of the 98 initial findings, 81 were
maintenance related.

1.17.3.1 FAA Inspections of Emery

Before the accident, the FAA conducted the following inspections of Emery: a
National Aviation Safety Inspection Program (NASIP) inspection in June 1992; a RASIP
inspection in June 1995;*! a focused RASIP in February 1999,®? and another RASIP
inspection in January 2000. The FAA also conducted several postaccident inspections of
Emery, including a surveillance inspection from May 11 to May 18, 2000; another RASIP
inspection from October 16 to November 2, 2000; and a logbook review inspection in
May/June 2001.8

The NASIP inspection, conducted June 8 to 26, 1992, resulted in 50 findings, 24 of
which were maintenance-related, including multiple findings in the following areas:
manuals and procedures (3 findings), records systems (2 findings), contractual agreements
(5 findings), and MEL/deferred maintenance (3 findings). Several of these findings cited
improper maintenance manual revisions. Other findings cited lengthy periods of operation
with a maintenance discrepancy, inadequate corrective actions for repetitive flight crew
write-ups in aircraft maintenance logbooks, and inconsistent/conflicting guidance in
maintenance manuals. There were no discrepancies noted in Emery’s maintenance
training program.

The RASIP inspection conducted June 12 to 23, 1995, resulted in 18 findings, 12
of which were maintenance related, including multiple findings in the following areas:
maintenance facilities (5 findings), training programs (2 findings), and maintenance
manuals and procedures (3 findings). Specific maintenance-related findings included use

81 A RASIP is initiated by the FAA regional office with oversight responsibility for the operator being
inspected and involves FAA personnel from that region, whereas a NASIP is initiated by FAA headquarters
and involves both FAA headquarters and regional personnel. NASIP inspections are generally lengthier,
involve more inspectors and are, therefore, more thorough than RASIP inspections. NASIP and RASIP
inspections are conducted to evaluate whether an operator is in compliance with all applicable FARs,
approved company procedures and policies, and other written FAA guidance.

® The San Jose FSDO POI stated that a focused RASIP is one in which the inspectors look at specific
areas within the airline. During the 1999 focused RASIP, the FAA examined loading procedures and the
condition of unit loading devices (ULD). This focused RASIP resulted in 21 findings, 18 of which were
maintenance related (including manuals/procedures, deferred maintenance, and maintenance program

findings). There was no evidence to indicate that loading procedures and ULD condition were involved in
this accident.

®3 Emery’s responses to the FAA’s NASIP/RASIP findings are in the docket for this accident.



Analysis 66 Aircraft Accident Report

adjusted the engine power in response to the first officer’s requests. Throughout the
accident flight, the airplane rolled and pitched and climbed and descended, as the pilots
tried different combinations of flight control inputs and engine power settings to counter
the airplane’s uncommanded pitch-up while they attempted to maneuver back to the
runway. The investigation focused on discovering the reason for this pitch-up anomaly.

2.2.1 Disconnection of the Right Elevator Control Tab

The Safety Board’s examination of the airplane wreckage revealed that the bolt
that usually attaches the right elevator control tab crank fitting to its pushrod was missing.
This bolt and its attaching hardware were not recovered.®® The aluminum control tab crank
fitting and the aft end of the pushrod were intact and exhibited no evidence of internal
damage, indicating that the bolt was not in place at impact. By contrast, the aft end of the
left control tab pushrod (the only piece of the left control tab crank fitting/pushrod
attachment that was not consumed by fire) showed evidence of damage consistent with the
bolt having been in place until impact; it was fractured and about 3/4 of the aft pushrod
end and its associated bearing were missing.

The Safety Board tried to determine when the right elevator control tab bolt
separated, disconnecting that control tab from its pushrod. Examination of FDR data for
the accident airplane’s previous departure (from RNO) revealed no evidence of anomalous
elevator movement—elevator deflections followed control column movements
proportionally throughout that takeoff roll and rotation. Therefore, it is likely that the
tight elevator control tab bolt was still in place at that time.

However, FDR data revealed that a 1° to 2° change in the relationship between the
airplane’s control column movement and elevator response began about 8 minutes
20 seconds before the airplane landed at MHR and continued until touchdown. The Safety
Board’s subsequent airplane performance study indicated that the change observed in the
FDR’s control column and elevator data at this time could be explained by a 3° to 4° TEU
shift in the airplane’s right control tab position relative to the left control tab. This shift in
control tab position is consistent with one of the scenarios considered by the Board during
this investigation—specifically, a scenario in which an elevator control tab disconnected
in flight and shifted in a TEU direction (with the disconnected pushrod remaining between
the lugs of the crank fitting), resulting in about a 3° to 4° TEU mismatch with respect to
the left control tab.

Postaccident ground tests conducted on an Emery DC-8 similar to the accident
airplane showed that when the right elevator control tab bolt was removed and no
aerodynamic loads were present, the right control tab deflected to about 29° to 30° TED,
which allowed the pushrod to disengage from the lugs of the crank fitting. Assuming the
bolt separated before the accident airplane landed at MHR, the control tab would likely
have shifted TED when the aerodynamic loads decreased as the airplane decelerated after
landing.

88 For additional discussion regarding the maintenance-related issues in this accident, see section 2.3.



Factual Information "1 Aircraft Accident Report

accident airplane’s c.g. was slightly aft of this (though still forward of its aft c.g. limit of
33.6 percent MAC) because two of the forward-loaded cargo containers were light.

1.6.2 DC-8 Longitudinal Flight Control System

The DC-8’s elevator flight control system is “tab-driven’”—that is, the control
columns are mechanically linked to the elevator control tabs, and deflection of the control
tabs in flight results in deflection of the elevators, which results in changes in the
airplane’s pitch attitude. This system includes two linked sets of components (one on the
left side and one on the right side), each of which include control columns, cables and
linkages, a horizontal stabilizer, and an elevator surface with a control tab and a geared
tab.

Pitch trim is provided by the adjustable horizontal stabilizer. The elevator surfaces
are hinged to the rear spar of the horizontal stabilizer and are connected to each other by
drive rods and a torque tube so that they operate in unison. According to chapter 27 of the
DC-8 maintenance manual (MM), when the DC-8 elevator surfaces are properly installed
and rigged, they have a maximum TEU deflection of 27.0° + 0.5° and a maximum TED
deflection of 16.5° + 0.5° from their neutral position, which is in line (or faired) with the
horizontal stabilizer.

Each elevator control tab is hinged to the inboard trailing edge of the associated
elevator surface, then connected by a mechanical linkage (including a crank fitting,
pushrod, and bellcrank assembly) at the inboard edge of the tab to the flight control system
on that side of the airplane. Figure 2 is a diagram of the elevator control tab installation.
The elevator control tabs are in their neutral position when they are in line with the
elevator surfaces and should have a maximum TEU deflection of 8.5° + 0.5° and a
maximum TED deflection of 26.5° + 0.5° from that neutral position.

The elevator geared tabs are hinged to the middle of the trailing edge of each
elevator, immediately outboard of the elevator control tabs. Two longitudinally aligned
pushrods, attached to the inboard and outboard ends of the elevator geared tabs, connect
the geared tabs to the horizontal stabilizers’ rear spar. The geared tabs are in their neutral
position when they are in line with the elevator surfaces in their neutral position and are
designed (or rigged) to deflect about 4.75° TEU and 26.75° TED from that position. As
the elevators’ positions change in relation to the horizontal stabilizer, linkages move the
elevator geared tabs in the opposite direction, providing an aerodynamic boost to assist the
control tabs in moving the elevators. (This reduces the amount of control force required
from the pilots.)



Aircraft Accident Report

95

Appendix B

Lueyyew 0} odes uonisod —

@ulu euO UaAes Xs eUO Ja}doo}}ey paenB Woy uoIsswsuen] OGY

92-Er6b

‘ysuep BuywiumM = WV.
6E-Er61

‘eBessew e Bumeb sey ey) spunos = Z-WW9
ZEEP6L

[teyy6ne| Jo punos] = WD
O:er'61

‘GVO
O€:€p:61

“ayeduoo ysipjoeyo xe} “WD.
€2:€¢'6b

wou yes Z-WVO
@er'6l

“Yel yes b-wWvd
be-€r'6b

[joo Jo punos] — WV9
Oz:eh:61

ANSLNOD

NOILVOINNIWINOD GNNOYS-OL-LavVeouIV

a9YNOS

9940 Lb

(1Sd) owl

INSLNOD 3OuNOS
(1Sd) ow,

NOLLVOINNWWOD LiIdM909-VULNI



Factual Information 16 Aircraft Accident Report

1.6.2.2 History of the DC-8 EPI Requirement

On September 8, 1970, a Trans International Airlines Corp., DC-8-63, N4863T,
crashed on takeoff at John F. Kennedy International Airport, Jamaica, New York. The
Safety Board determined that the probable cause of the accident was a loss of pitch control
caused by the entrapment of a pointed (asphalt-covered) object between the leading edge
of the right elevator and the trailing edge of the horizontal stabilizer, which the flight crew
did not detect in time to reject the takeoff.* As a result of its initial findings during this
investigation, on October 28, 1970, the Board issued Safety Recommendation A-70-54 to
the FAA, in which the Board expressed its concern that “an elevator jammed by a foreign
object would not be detected by the crew” and could result in an accident. Safety
Recommendation A-70-54 recommended the following to the FAA:

A. All DC-8 operators be advised of the hazardous condition that can be created
by foreign object jamming of the aircraft’s elevators.

B. Until adequate procedures are developed for positive check of elevator
position, all DC-8 operators be advised that takeoff should be aborted

whenever premature or unacceptable rotation of the aircraft occurs during
takeoff.

C. The DC-8 flight control system be evaluated by the FAA in the interest of
developing a standard procedure for checking the system from the cockpit.
The procedure should provide for positive detection of a jammed elevator.

D. Consideration be given for a requirement to install an elevator position
indicator in the cockpit of all DC-8 aircraft.

The FAA responded to Safety Recommendation A-70-54 in a letter dated
November 20, 1970, stating that “additional time is needed to complete the engineering
evaluation” and that the FAA would advise the Safety Board of any further action when
the evaluation was completed. The FAA’s November 1970 letter further stated that the
FAA needed clarification on some sections of A-70-54. The FAA addressed some of these
issues in a letter to the Safety Board dated March 8, 1971, which stated:

Following our request for the above clarification, NTSB and FAA representatives
met on [December 18, 1970] to discuss the intent of the NTSB
recommendation....NTSB personnel fully concurred with FAA representatives
that the decisions to abort should be left to the judgment of the pilot.

8 For additional information regarding this accident, see National Transportation Safety Board, Trans
International Airlines Corp., Ferry Flight 863, Douglas DC-8-63F, N4863T, John F. Kennedy International

Airport, New York, September 8, 1970. Aircraft Accident Report NTSB/AAR-71/12 (Washington, DC:
1971).



Factual Information 45 Aircraft Accident Report

Figure 11. Photograph of the test airplane’s disconnected right elevator control
tab pushrod centered between the lugs of the crank fitting with the control tab
rotated 3° to 4° in the TEU direction after the attachment bolt was removed.

1.16.1.2 EPI Indication Checks

The Safety Board also conducted tests to document the test airplane’s elevator
movements and the corresponding EPI indications during the 80-knot elevator check
during a simulated takeoff roll. During the 80-knot elevator check, the horizontal
stabilizer trim was set to approximate the accident airplane’s trim setting for takeoff.
When the test airplane accelerated to 80 knots, the right seat pilot (provided by Emery)
moved the control column to its maximum forward position; the EPI needle immediately
deflected to a position about 45 percent of the distance between the neutral and nose-down
index marks, corresponding to about 10° of TED elevator travel. The pilot then relaxed
the forward pressure on the control column and rejected the takeoff. A review of the data
recorded by the test airplane’s FDR during this test confirmed an elevator deflection of
about 10°.

“The EPI on the test airplane was located on the lower left side of the first officer’s instrument panel,
like that on the accident airplane. During these tests, the Safety Board noted that the EPI installed on the
ground test airplane was not accurately calibrated such that when full down elevator was applied, the EPI
needle moved about 75 percent of the distance between the neutral and nose-down marks,



Aircraft Accident Report

91

Appendix B

‘syey ida Z-INWO

62:27:61

“yoeq Buluioo “p1eMuoy 1OyeA9}9 ——F-INWO

LEZY6L

‘peyeys WO

S226)

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vezpeL

“pexoeyo wv

€2Zh'6L

‘yequeo “Jeppru ye} LV.

Le-Zp-6b

‘WyBu seep “ye eunok = Z-WV9

02:26

‘dek WO

Sb:Zr7'6b

esieppnu ey uo Apeas = “WW

Lh2v'6L

4IN3LNOD BOyNOS 4INSLNOOD a0yuNOS

(1Sd) ew, (1Sd) ew,
9959 & NOILVOINNINNOD LidM90O-VULNI

NOILVSINNWAWOS GNNONS-O1-LaveONlVY



Factual Information 28 Aircraft Accident Report

1.11 Flight Recorders

1.11.1 Cockpit Voice Recorder

The CVR installed on the accident airplane was a Sundstrand AV557, S/N 7286.
Examination of the exterior of the CVR revealed evidence of severe fire and heat damage,
while the interior exhibited heat damage. When the crash-survivable case containing the
CVR tape drive assembly was opened, its contents exhibited no sign of severe heat
damage; however, the CVR magnetic tape that was outside of the spool showed some
signs of shrinkage, which can be the result of exposure to heat. The sections of tape that
had shrunk were permanently damaged, resulting in small areas of unusable audio at the
beginning and end of the recording. The overall recording, however, was in playable
condition and was successfully downloaded.

The CVR recording consisted of four channels of good quality audio
information. One channel contained audio information recorded by the cockpit area
microphone, and the other three channels contained audio information recorded through
the radio/intercom selector panels at the captain, first officer, and flight engineer positions.
The recording began at 1917:45 and ended at 1951:09, 1 second after it recorded a sound
similar to impact. A transcript was prepared of the entire 33-minute 24-second recording.
See appendix B for a complete transcript of the CVR recording.

1.11.2 Flight Data Recorder

The FDR was a Loral Fairchild digital FDR model F800, S/N 04018, part number
(P/N) 17M303-282, which recorded 17 parameters” of airplane information on a 450-foot
long, 1/4-inch wide magnetic tape. The tape is divided width-wise into 6 equally sized
tracks, which record a total of 25 hours of data (4 hours 10 minutes of data on each track).
The 17 recorded parameters included time, altitude, indicated airspeed, magnetic heading,
vertical acceleration, pitch attitude, roll attitude, VHF microphone keying for two VHF
channels, engine N1 (rotational fan speed) for all four engines, autopilot engage,
longitudinal acceleration, control column position, elevator position, control wheel
position, aileron position (left), rudder pedal position, and rudder position.

Visual examination of the FDR revealed evidence of internal and external heat and
fire damage, including heat damage to some of the tracks on the tape recording medium.

* The Safety Board uses the following categories to classify the levels of CVR recording quality:
excellent, good, fair, poor, and unusable. A good recording is one in which most of the crew conversations
can be accurately and easily understood. The transcript that is developed may indicate several words or
phrases that are not intelligible. Any loss in the transcript can be attributed to minor technical deficiencies
or momentary dropouts in the recording system or to a large number of simultaneous cockpit/radio
transmissions that obscure each other.

“Title 14 CFR Section 121.344 required all airplane FDR systems to be upgraded to record more
parameters (airplanes with more than two engines, like the accident airplane, had to be upgraded to record
17 parameters) by August 2001. The accident airplane’s FDR was upgraded during the D inspection that
was completed in November 1999.



Factual Information 12 Aircraft Accident Report

FAIRING

CONTROL
faa

Figure 2. A diagram of the elevator control tab installation.

Dampers are installed in each elevator leading edge at the inboard hinge location
and provide an opposing force proportional to the rate of elevator movement to prevent
elevator flutter. For additional information regarding the elevator dampers on the accident
airplane, see section 1.6.3.1.2.

The airplane is also equipped with an elevator load-feel and centering device,
which increases the forces felt by the pilots at the control columns above those resulting
from the aerodynamic forces acting on the control tabs and helps return the columns to
their neutral position when control column force is removed. The control columns are
rigged to travel between 23.75° forward and 6.50° aft of a vertical reference positionTM and
are connected by cables to the left and right elevator control tab drive linkages. The
control column’s rigged neutral position is 13.5° forward of the control column’s vertical
reference position.

4 The vertical reference position is perpendicular to the cockpit floor. Physical stops prevent control
column movement beyond 23.75° forward and 6.50° aft of vertical.



Factual Information 56 Aircraft Accident Report

Subsequently, the FAA issued AD 78-01-15 (effective June 1, 1978), which required all
DC-8 operators to install an EPI system in accordance with Douglas SB 27-254.

On June 4, 2001, as a result of the Emery flight 17 accident, Boeing issued a FOB,
restating the recommendations contained in the DC-8 AOM and SB A27-264 for the
elevator portion of the preflight control check. Specifically, the FOB stated the following:

The proper functioning of the flight controls should be verified before every
flight. If the exterior walk-around is made with the gust lock engaged, the flight
crew should verify that the elevators and the tabs are faired, and that the Elevator
Position Indicator (EPI) indicates in the white neutral band. If the check is made
with the gust lock released, the elevators and control tabs should be positioned
toward UP (symmetrically) and the geared tabs DOWN (again symmetrically).
Then, during the flight control rollout check elevator function should be verified
by first applying full up elevator and confirming that the needle on the EPI moves
in the UP direction; followed by full down elevator to the [control] column
mechanical stop and verifying that the needle moves through the faired position to
a point below the white band. Because the elevator system’s viscous dampers
resist rapid surface movement, flight crews should be aware that rapid application
of full forward [control] column, followed by an immediate release, is not an
effective check in that the [control] column release will interrupt elevator travel
well short of its limit travel. Also, since the forces on the [control] column during
these checks are high, Boeing recommends that a downward (forward) force be
applied to both columns by both pilots simultaneously.

Service Bulletin A27-264 (issued May 14, 1977 and mandated by AD 78-01-15),
and “Know your DC-8” letter No. 53A, issued on May 25, 1977, state that if the
[elevator control] checks cannot be made into the wind such that satisfactory
elevator movement is verified, an optional procedure to check for airplane
response to small up and down elevator movements during initial takeoff roll
(60-80 knots) was allowed. Upon reviewing this procedure with the FAA, Boeing
has determined that although the pitch response may still be useful as a check for
weight distribution, it is not a valid substitute for a properly conducted flight
control check as described above. Boeing no longer recommends it as an
alternative to the rollout check. Operators who wish to continue the 60-80 knot
check may do so, but are advised that the only acceptable alternative to a
satisfactory flight control check is a positive visual check.[”>]

1.17.1.4 Emery’s Postaccident Fleetwide Campaign Directive

After discussions with Safety Board investigators, on March 16, 2001, Emery
issued FCD A27-8, titled “Elevator Push/Pull Rod End Bolt Installation Inspection,” to
ensure that on each of the 29 DC-8s Emery operated at the time, the elevator control tab
pushrods were properly installed and secured at the crank fitting with a bolt, washer, nut,
and cotter pin. The FCD also called for inspections of Emery’s DC-8 fleet for damage to

5 According to ASB A27-264, subpart E, this alternative was only acceptable on airplanes on which the
EPI was inoperative.



Aircraft Accident Report

110

Appendix B

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SZ:0S-6b

# eWVd
22:05:61

| GVO
64:05:61

[6upjeeso jo punos] = WWD
61:05:61

“MAME Z-NWD
81:05:61

‘pienuogy ysnd — é-WV9.

91:09:61
‘ysnd = Z-WV9
SL:0S:61
“heyo  Z-INWO
Z4:0S:61

qyBu Ou 0} 30 [ON FINO

bb:0S:61

INSLNOD aoOuNnos INALNOO 3OuNOS
(1Sd) ow, (1Sq) owl

99 4029 NOLLVOINNWINOD Ld4D09-VULNI

NOILVOINNWNOD GNNOUS-O1-LaveoulV



Aircraft Accident Report

112

Appendix B

“#poB ZNO
67:08:61

“punowe yj Buiq = }-WW9
6Y:0S:61

[ueyeys yons 0} zeyws punos] = WW9
8¢:0S:61

“punowe y Buuq = }-WW9
2v:0S:61

“uuny & ©» Ul}! PUB] 0} BABY BUCH a4,eM0S Z-WYO
9b:0S:61

“Wm Ye] -WvS
9b:0S:61

“heyo Z-WWO
Sv:0S'61

wou we | WO
Sv:0S:6L

“yueg e ul}! Bumnd Ww, Aym sey) “JoyeAg|e Ou}
yoyew uopisod s,euejdire ey) eye si op 0} BuiAn Wy) eUM = Z-WW9

2:05:61
INSINOD 3OuNoSs INSLNOD BOuNOS
(1Sd) ow, (1d) owl
NOLLVOINNWWOD GNNOYS-OL-LAveoUlY 991049 NOILVOINNWWOD Lidy909-VULNI



Abbreviations vii Aircraft Accident Report

HBAW flight standards handbook bulletin for airworthiness
IFR instrument flight rules

IPC Illustrated Parts Catalog

MAC mean aerodynamic chord

MEL minimum equipment list

MHR Sacramento Mather Airport

MM maintenance manual

MPPM maintenance policies and procedures manual
msl mean sea level

NASIP National Aviation Safety Inspection Program
OHM overhaul manual

P/N part number

PMI principal maintenance inspector

POI principal operations inspector

PTC pitch trim compensator

RASIP Regional Aviation Safety Inspection Program
RNO Reno/Tahoe International Airport

S/N serial number

SB service bulletin

SDR service difficulty reports

STC supplemental type certificate

TED trailing edge down

TEU trailing edge up

TRACON terminal radar approach control
TTS Tennessee Technical Services

ULD unit loading device



89 Aircraft Accident Report

5. Appendixes

Appendix A
Investigation and Hearing

Investigation

The National Transportation Safety Board was initially notified of this accident on
the evening of February 16, 2000. Investigators from the Safety Board’s Southwest
Regional Office went immediately to the scene of the accident. A full go-team was
assembled and departed Washington, D.C., early on the morning of February 17, arriving
at the accident site by late morning Pacific standard time. The go-team was accompanied
by then-Safety Board Member George Black and representatives from the Safety Board’s
Office of Government, Public, and Family Affairs.

The following investigative groups were formed during the course of this
investigation: Airworthiness (Structures/Systems), Maintenance Records, Maintenance
Inspection, Powerplants, Air Traffic Control, Operations/Human Performance, Aircraft
Performance, Flight Data Recorder, Cockpit Voice Recorder (CVR), CVR Sound
Spectrum, and Hazardous Materials.

Parties to the investigation were the Federal Aviation Administration (FAA); the
Boeing Company; Emery Worldwide Airlines, Inc. (Emery); the Air Line Pilots
Association (ALPA); Miami Aircraft Support (now known as Worldwide F light Services);
Tennessee Technical Services (TTS); and General Electric Aircraft Engines.

Public Hearing

A public hearing was conducted for this accident on May 9 and 10, 2002, in
Washington, D.C. Member John Goglia presided over the hearing. Parties to the public
hearing were the FAA, Boeing, Emery, TTS, and ALPA.



Factual Information 33 Aircraft Accident Report

1.11.2.3 Other Examples of Inaccurate FDR Elevator Data

During its investigation of this accident, the Safety Board discovered FDR elevator
position conversion problems with the FDR data from other Emery DC-8s. For example,
the Board noted that the FDR data from the Emery DC-8 used during the elevator flight
control tests (described in section 1.16.1) produced elevator position values that were not
consistent with the elevator travel that was physically measured on the test airplane during
the ground tests.” The Board’s initial parameter conversions were performed using
documentation provided by Emery that had full TEU and TED engineering values that
were the same as those obtained for the accident airplane (12.8° and 26.6°, respectively).

Further investigation revealed that in Emery’s DC-8 fleet, a full FDR correlation
was only completed on one airplane (as permitted by the Federal Aviation Regulations
[FARs]).”* In this case, Emery’s only full correlation was completed on the accident
airplane. After that initial full correlation, the correlation for the accident airplane was
applied to the rest of Emery’s DC-8 fleet as their FDRs were upgraded; the actual control
surface positions on those airplanes were not measured.”

After the ground tests, the FDR on the test airplane was replaced and the airplane
was returned to service. Several weeks later, the test airplane was involved in a landing
incident that the Board investigated.°° Evaluation of the elevator position data recorded by
the replacement FDR (converted using conversion data provided by Emery) revealed that,
as with the data recorded by the previously installed FDR, the recorded elevator travel
data did not match the elevator travel measured during the ground tests.

The Safety Board then examined the FDR data from another Emery DC-8 that was
involved in another incident.*! The Board’s evaluation of this recorded elevator Position
data revealed that the recorded elevator values did not fall entirely within the elevator’s
normal operating range.

*’ Because the test airplane’s neutral, maximum TEU, and maximum TED elevator positions were
measured during the ground tests, these measured elevator position values were used as the basis for the test
airplane’s elevator conversion and the Safety Board’s subsequent examination of that airplane’s FDR data.

“8 According to 14 CFR 121.343(j), operators are permitted to establish a single correlation for any
group of airplanes if “1) the airplanes are the same type, 2)...the flight recorder system and its installation
are the same, and 3)...there is no difference in the type design with respect to the installation of those
sensors associated with the flight data recorder system. Documentation sufficient to convert recorded data
into the engineering units and discrete values specified in the applicable appendix must be maintained by the
certificate holder.”

The Safety Board also noted that when the original conversions for the test airplane were used,
recorded control column positions were not consistent with the control column. input that was physically
measured on the test airplane during the ground test; however, the ranges of the recorded and measured
control column ranges were almost the same. As with the elevator, the control column values measured
during the ground tests were used as the basis for the control column conversion and subsequent
examination of the data.

°° The description of this incident, MIAQIIA129, can be found on the Safety Board’s Web site at
<http:www.ntsb.gov>.

51 The description of this incident, SEA01IA039, can be found on the Safety Board’s Web site at
<http:www.ntsb.gov>.



Aircraft Accident Report

96

Appendix B

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Factual Information 36 Aircraft Accident Report

Safety Recommendation A-97-30 asked the FAA to do the following:

Complete the planned flight data recorder (FDR) advisory circular (AC) to define
FDR certification requirements and FDR maintenance requirements, and
incorporate the FDR documentation standards contained in Notice N8110.65. The
AC should be released no later than January 16, 1998.

Ina July 14, 1997, letter, the FAA stated that it agreed with the intent of this safety
recommendation and promised to complete an AC for FDR certification and maintenance
requirements by January 1998. In its July 10, 1998, safety recommendation letter
regarding the Fine Air accident, the Safety Board classified Safety
Recommendation A-97-30 “Open—Unacceptable Response,” pending completion of the
proposed AC.

In its July 10, 1998, safety recommendation letter, the Safety Board also issued
Safety Recommendations A-98-53 through -56. Safety Recommendation A-98-53, which
superseded Safety Recommendation A-97-29, asked the FAA to do the following:

Require an immediate readout of all 11-parameter retrofitted...flight data
recorders (FDR) 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 14CFR Part 121,
Appendix B; and require that the readout be retained with each airplane’s records.

In response to Safety Recommendation A-98-53, the FAA indicated that it would
complete a survey of all FDR-equipped airplanes (not just those with 11-parameter
retrofitted FDRs) by February 2001. However, as of June 2003, the FAA had not initiated
this survey, and the gradual implementation of new FDR system upgrade rules in the
interim has increased the scope of the survey significantly.’ Because the FAA’s response
did not satisfy the intent of the recommendation (which, in part, was to ensure that FDRs
were being properly retrofitted and that the retrofitted equipment was recording
parameters properly), the Safety Board classified Safety Recommendation A-98-53
“Open—Unacceptable Response” on March 12, 2001. The Safety Board has received no
correspondence from the FAA regarding Safety Recommendation A-98-53 since its
March 12, 2001, classification.

*7 Implementation of the 1997 rule for Section 121.344 required upgraded parameters for all aircraft by
August 18, 2001.