American International Airways 808

On August 18, 1993, at 1656 eastern daylight time (EDT), a Douglas DC-8-61 freighter, N814CK, registered to American International Airways (AIA), Inc., d/b/a Connie Kalitta Services, Inc., and operating as AIA flight 808, collided with level terrain approximately 1/4 mile from the approach end of runway 10, after the captain lost control of the airplane while approaching the Leeward Point Airfield at the U.S. Naval Air Station (NAS), Guantanamo Bay, Cuba. The airplane was destroyed by impact forces and a post accident fire, and the three flight crewmembers sustained serious injuries. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed. The flight was conducted under 14 Code of Federal Regulations (CFR), Part 121, Supplemental Air Carriers, as an international, nonscheduled, military contract flight.

The captain and first officer had originated their 4-day sequence of flights in Atlanta, Georgia (ATL), at 2300 (start of duty day) on August 16. Flight 860, a DC-8-61, N814CK, had departed Atlanta at 0006, on August 17, destined for Ypsilanti, Michigan (YIP), after an intermediate stop in Charlotte, North Carolina (CLT). The flight arrived in Ypsilanti at 0408, whereby the flight engineer concluded his sequence and was replaced by the flight engineer involved in the accident.

The flight sequence continued with a change of airplane and the departure of flight 841, a DC-8-54, N802CK, from Ypsilanti to St. Louis, Missouri (STL), at 0746, and terminated at Dallas-Ft. Worth International Airport (DFW), Texas, whereby the flightcrew ended their duty day at 1200. The captain and first officer had been on duty for 13 hours, of which 5.6 hours was flight time; and the flight engineer had been on duty for 7 hours, of which 3 hours was flight time. The company provided a hotel room at the DFW Airport and the crew was relieved of flight duty for a rest period of 11 hours.

The flightcrew met in the hotel lobby in the evening hours of August 17, and arrived at the airport to begin their duty day at 2300. The scheduled flight sequence began with the departure of flight 840 from DFW at 2400, and proceeded to YIP, with an intermediate stop in STL. Flight 840 arrived at YIP at 0325 on August 18. The flightcrew changed airplanes to N814CK, and, after the "freight sort" had been completed, flight 861 departed YIP at 0620 for ATL. Upon arrival in Atlanta at 0752, the flightcrew was relieved of flight duty until their next scheduled sequence was to begin at 2300.

Shortly after 0800, the captain, domiciled in Atlanta, departed for his residence, while the first officer remained at the airport to visit with his family. The company provided the flight engineer with hotel accommodations for his scheduled rest period. The captain stated that he had telephoned his wife at their: home when he stopped en route at an automotive store and was told that the "company" needed him back at the airport immediately to fly an unexpected trip. The first officer and flight engineer were also notified by the company and rejoined the captain at the Atlanta airport.

According to the chief crew scheduler for AIA, the original airplane and flightcrew, N808CK, which was to operate as flight 808, from Miami, Florida, to the Naval Air Station, Norfolk, Virginia, and onto Guantanamo Bay, had been canceled due to mechanical problems. The accident crew was reassigned to fly N814CK to Norfolk, load freight, deliver the freight to Guantanamo, and then ferry the empty airplane back. to Atlanta. According to the crew scheduler, during his testimony at the Safety Board's public hearing on this accident, the revised flight assignment would have resulted in an accumulated flight time of 12 hours, and would have been accomplished within the company's "24-hour crew duty day policy."

N814CK departed Atlanta at 1010 that same day and arrived at Norfolk at 1140. Upon arrival, the captain exchanged greetings with the freight handler and then proceeded to the station office to obtain a revised flight plan from the company flight follower.

Upon completion of the freight loading and the incidental duties associated with the dispatch of the airplane, the captain assumed the duties of the flying pilot while the first officer performed the radio communications. Flight 808 taxied from the cargo ramp at 1405 and departed Norfolk at 1413. The captain stated that the airplane had performed satisfactorily during the en route portion of the flight and that the arrival into the terminal area at Guantanamo Bay was uneventful.

According to information derived from the recorded air traffic control communications and the cockpit voice recorder {CVR), the first officer established radio contact with the Guantanamo radar controller at 1634:49, while the flight was descending out of 32,000 feet (flight level (FL) 320). Several radio transmissions were exchanged between the first officer and the controller during a 3-minute period. The controller radioed, "Connie 808 heavy, Guantanamo radar, maintain VFR [visual flight rules] one two miles off the Cuban coast; no reported traffic in the area; report East Point; Leeward Field landing runway one zero; wind, one eight zero at eight; altimeter is two niner niner seven." The first officer acknowledged the transmission and stated, " ... we'd like to land [runway] two eight." The controller responded and issued further landing instructions, which included a report of crossing the East Point fix. However, the flightcrew was confused about the identification and location of the East Point fix, and the first officer requested clarification. Flight 808 crossed the East Point fix at approximately 1638, while at FL220.

At 1641:53, the CVR recorded the captain stating to the other crewmembers, "otta make that one zero approach just for the heck of it to see how it is; why don't we do that let's tell 'em we'll take [runway} one zero; if we miss we1l just come back around and land on two eight." This was followed by the first officer contacting the Guantanamo radar controller and requesting the approach to runway one zero. At 1642:48, the controller acknowledged the request and asked, " ... you want uh, left entry or right entry." The first officer responded, "make a right entry .... " The captain and first officer engaged in a discussion concerning the authorized entry pattern for the approach to runway one zero. The captain said, "it does say right traffic in the, in that uh, training clip that's all it says." The first officer followed with the comment, "right, I know for sure uh, 'cause I just went through recurrent. -- besides there's a big hill over there; it might give you some - depth perception problems."

At 1645:51, the control of flight 808 was transferred from the radar controller to the Guantanamo tower controller. The first officer made initial contact with the tower several seconds later, and, at 1646:07, the controller stated, " ... runway one zero, wind two zero zero at seven, altimeter two niner niner seven, report Point Alpha." The first officer acknowledged the transmission and requested "clarification" of the location of Point Alpha. The controller provided the crew with the information and followed this transmission several seconds later with, "eight zero eight, would you like runway two eight." The first officer responded, "we're gonna try ten first. .."

At 1646:41, the captain began the approach sequence, calling for the flaps to be set at 15 degrees and the approach checklist items to be performed. The flight continued toward Guantanamo Bay, and, at 1651:37, the first officer remarked to the captain, "you wanna get all dirty and slowed down and everything." The captain acknowledged the comment. At 1652:03, the tower controller transmitted, "Connie eight oh eight, Cuban airspace begins three quarters of a mile west of the runway. You are required to remain with this, within the airspace designated by a strobe light." The first officer responded, "roger, we'll look for the strobe light." Several seconds later, the first officer again remarked to the captain, I'd give myself plenty of time to get straight...maintain a little water off because you're gonna have to turn . . . I think you're gettin' in close before you start your turn." The captain responded, "yeah, I got it, I got it. .. going to have t. really honk it, let's get the gear down."

During the next several seconds, the CVR recorded the captain stating to the other crewmembers that he was having difficulty identifying the runway environment as they approached the airport and as the wing flaps were being lowered to the 50-degree down position. The captain then said, "now we gotta stay on uh one side of this road here, right." The first officer responded,, "yeah, we gotta stay on this side, on this side over here, you can see the strobe lights."

The airplane struck the level terrain approximately 1400 feet west of the approach end of runway 10; The accident occurred during the hours of daylight at 19 degrees 54 minutes North latitude; and 75 degrees 13 minutes West Longitude.

A crew of four U.S. Navy pilots, who were located in the cockpit of a Lockheed C-130 that was on the airport ramp, observed the approach and subsequent crash of flight 808. One of the pilots stated: "... I saw the DC-8 on a wide right base for runway 10. It appeared to be at approximately 1,000 feet agl [above ground level]. I was interested in watching such a large airplane shoot the approach ... It looked to me as if he was turning to final rather late so it surprised me to see him at 30 to 40 degrees AOB [angle of bank] trying to make final. At 400 feet agl, he increased angle of bank to at least 60 degrees in an effort to make the runway and was still overshooting. At this time the aircraft's nose turned right and it appeared he was trying to use bottom rudder to make the runway. At this point, he appeared to be 200 to 300 feet agl. He was still overshooting and my copilot remarked he was going to land on the ramp. His wings started to rock towards wings level and the nose pitched up. At this point the right wing appeared to stall, the aircraft rolled to 90 degrees AOB and the nose pitched down..."

Source: AAR-94/04, § 1.1

An evaluation •of the flightcrew fatigue factors and their relationship to the operation of flight 808 was conducted at the request of the Safety Board by members of the NASA-Ames Research Center Fatigue Countermeasures Program.

The crew had been on duty for about 18 hours at the time of the accident, having flown all night before accepting the new flight segment to Guantanamo. The captain stated that he felt tired on the morning when he accepted the trip to Guantanamo, after having flown all night 0n his scheduled trip, but said that he was not so tired that he considered it unsafe for him to fly.

One of the NASA researchers performing the fatigue study of the crew of flight 808, stated in his testimony at the Safety Board's public hearing: So with sleep loss, people would have problems making decisions. People who otherwise would make fine decisions deciding among three alternatives, could go with the worst one. They don't process critical information very well. Reaction time can be degraded. Again, it's not an extreme case when you're asleep .... People get tunnel vision. They can literally focus on one piece of information to the exclusion of other kinds of information ... The second is the fixation on the strobe light. I counted seven comments in the [CVR} transcript about the strobe... I think what's really critical about that is that ... in sleep loss situations, you get people with tunnel vision. They get fixated on a piece of information to the exclusion of other things.... The other thing, is right in the middle of that, he [the captain] disregards a critical piece of information ... the first officer or flight engineer -- someone saying, "I don't know if we're going to make this" ... So besides just fixating, you've got disregard for a critical piece of information.

Source: Source: AAR-94/04, § 1.17.10

The proximity of the runway 10 threshold to the boundary fence between U.S. and Cuban territory (and airspace), and the associated restrictions for U.S. aircraft overflying Cuban territory, places a burden upon pilots of aircraft landing on runway 10. [. . .] The approach must be conducted so that the airplane remains within the 3/4 mile distance from the runway threshold (as measured along the extended runway centerline) during the turn from base leg to final runway alignment. For pilots of large aircraft, the approach presents challenges that are not normally encountered during routine air carrier line operations. In nearly all other approaches, whether conducted in instrument or visual conditions, the air carrier pilot will ensure that the aircraft is aligned with the runway centerline a minimum of 2 miles from the threshold, and at a height of greater than 500 feet above the threshold. [ . . . ] In contrast, the approach to runway 10 at Guantanamo Bay requires the pilot to accomplish a tight radius turn from base leg to final approach using a steeper: than normal angle of bank and rolling out on runway heading over or nearly over the runway threshold. The roll out to a wings level attitude is completed at low altitude with minimum distance to correct for runway misalignment.

The Safety Board determined that the: approach to runway 10 was within the theoretical performance limits of the accident airplane using a maximum bank angle of 30 degrees. [ . . .] The Safety Board believes that it is unlikely that the pilot of a heavy transport airplane, having a relatively high approach speed, would be capable of adhering to all of the U.S. airspace restrictions associated with the approach to runway 10 at Leeward Point. Airfield, Guantanamo Bay without exceeding safe maneuvering bank angles at low altitude.

The load factor, airspeed, and heading data from the FDR were used to calculate the actual turning maneuver, stall margins and roll angles. The roll angles were determined to be less than 30 degrees at the initiation of the turn from base to final, but increased during the last 7 seconds of flight to beyond 50 degrees right wing down. The increasing bank angles effectively reduced the turn radius but increased the required load factor in order to maintain the turn and a constant rate of descent. The increasing load factor resulted in an additional loss of airspeed. Both the decreasing airspeed and greater load factors required the airplane to be operated at greater angles-of-attack, to the point that the airplane eventually stalled. The Safety Board found no indications that engine thrust was increased nor that the bank angle was reduced during this maneuver. Based on the position of flight 808 when the turn from base leg to final was initiated, the probability of successfully completing the approach was nil. However, the accident was not inevitable until the captain steepened the bank and permitted the airplane to stall. When the captain realized that an abnormally steep bank angle was required to align the airplane with the runway, he should have acted immediately to discontinue the approach by reducing the bank angle, increasing the engine thrust, and performing a go-around.

According to Douglas Aircraft Company (DAC), the loss of roll authority is "minimal" on the DC-8 at the onset of wing stall because the aerodynamic effectiveness of the ailerons is preserved during the flight in the stall regime. Based on the FDR and CVR data, and the performance characteristics of the DC-8, upon activation of the stall warning stick shaker, the captain would have had about 5 seconds to initiate corrective action and eliminate the stall hazard. The data also suggests that conventional stall recovery techniques (maximum thrust and wings level) and the execution of a go-around could have prevented ground impact.

Source: AAR-94/04, §2.1

The Safety Board's examination of the flight and duty time revealed the captain had been awake for 23.5 hours at the time of the accident, the first officer for 19 hours, and the flight engineer for 21 hours.

Therefore, the evidence in this accident shows that the flight crewmembers met all three of the scientific criteria for susceptibility to the debilitating affects of fatigue.

The Chief Executive Officer (CEO) of AIA was interviewed to determine the nature of the company policies and procedures with regard to crew scheduling. He stated that, to remain competitive, the company must often assign long duty times and "work everything right to the edge" of what was allowed by FARs. He also indicated that this was a common practice in the industry.

Source: AAR-94/04, §2.4

The National Transportation Safety Board determines that the probable causes of this accident were the impaired judgment, decision-making, and flying abilities of the captain and flightcrew due to the effects of fatigue; the captain's failure to properly assess the conditions for landing and maintaining vigilant situational awareness of the airplane while maneuvering onto final approach; his failure to prevent the loss of airspeed and avoid a stall while in the steep bank turn; and his failure to execute immediate action to recover from a stall.

Additional factors contributing to the cause were the inadequacy of the flight and duty time regulations applied to 14 CFR Part 12l, Supplemental Air Carrier, international operations, and the circumstances that resulted in the extended flight/duty hours and fatigue of the flightcrew members. Also contributing were the inadequate crew resource management training and the inadequate training and guidance by American International Airways, Inc., to the flightcrew for operations at special airports, such as Guantanamo Bay; and the Navy's failure to provide a system that would assure that the local tower controller was aware of the inoperative strobe light so as to provide the flightcrew with such information.

Source: AAR-94/04, §3.2

As the result of recent aircraft incidents and accidents that have occurred at Guantanamo Bay, on January 5, 1994, the Air Mobility Command issued the following memorandum to all civilian air carriers:

Until further notice, any civil air mission operating under the AMC international airlift contract is prohibited from using runway 10 at Guantanamo Bay. This restriction is placed on our contract operations solely due to safety.

Source: AAR-94/04, §2.9