Taken in isolation, this accident is simply the case of a crew's poor checklist discipline and, perhaps, stick and rudder skills. But there is much more to it than that.
This was another incident in a series of 13, 11 of which pointed to a problem with the Crew Resource Management culture at Pan American World Airways at the time. They were able to reverse this culture and became one of the safest airlines in the world.
There is no doubt there were a number of distractions in the cockpit and they had timing concerns that consumed much of their thinking. But all three pilots became consumed with what should have been primarily the captain's responsibility. I think the first and second officer were not in the "fly the airplane" loop, they were there to support the captain and easily distracted from their primary duty of ensuring the aircraft was airworthy.
Everything here is from the references shown below, with a few comments in an alternate color.
When flying oceanic, especially back then, departure timing was critical and these kinds of discussions in the cockpits were common. How late can we go and still have enough fuel? How low can we fly? At what point do we turn around for more fuel? When a captain manages the cockpit, somebody worries about these details but somebody also has to worry about flying the airplane. As a copilot (first officer) I would do my best to keep the big picture in mind and help the captain with these decisions where I could. But I always remained "plugged in" to the airplane, keeping the aircraft airworthy was always my top concern. You may argue that this had to be true with the first and second officers on this airplane too. It could be. But we see lots of evidence in other Pan American Boeing 707 accidents of the time that at least some of their non-captain pilots became passengers in the cockpit. The price for angering the captain was just too high, so you could be forgiving for "unplugging" from some of your aircraft duties.
[NTSB AAR-69-06], ¶1.1]
V1 148 knots, VR 154 knots, V2 168 knots, Engine pressure ratio (EPR) readings were 1.78 static and 1.82 rolling takeoff
[NTSB AAR-69-06], ¶1.12]
[NTSB AAR-69-06], ¶1.12]
As soon as I read this I pulled out my current airplane's checklist to confirm setting the flaps for takeoff only occurs once for us too, during the taxi check. You would be right to point out that modern aircraft are better at telling pilots things are left undone prior to takeoff. The accident report noted that some airlines of the time had mechanical checklists with slides that reminded them when things got skipped. All that is true. But it is still a fundamental duty on the flight deck to follow these critical checklists with some degree of precision. The Boeing 707 I flew had similar weaknesses when it came to failing to warn pilots about things undone. But we became paranoid about them as a result.
[NTSB AAR-69-06], ¶2.1]
I would add another cause to this list: a company-wide culture of poor cockpit discipline and a climate where challenging the captain was received poorly. I've read in a few Pan American pilot biographies where some captains would tell their new first officers to put away their checklists. "Forget that damn checklist, son," the captain would say. "You're not flying for Pan American today. You're flying for me." (Gandt, p. 118)
[NTSB AAR-69-06], ¶2.2(b)] The Board determines that the probable cause of this accident was an attempted takeoff with the flaps in a retracted position. This resulted from a combination of factors: (a) inadequate cockpit checklist and procedures; (b) a warning system inadequacy associated with cold weather operations; (c) ineffective control practices regarding manufacturer's Service Bulletins; and (d) stresses imposed upon the crew by their attempts to meet an air traffic control deadline.
Gandt, Robert, Skygods: The Fall of Pan Am, 2012, Wm. Morrow Company, Inc., New York
NTSB Aircraft Accident Report, AAR-69-08, Pan American World Airways, Inc., Boeing 707-321C, N799PA, Elmendorf Air Force Base Anchorage, Alaska, December 26, 1968
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