休斯顿西部航空706班机.pdf

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1、SA-426 File No. 1-0005 AIRCRAFT ACCIDENT REPORT HUGHES A I R WEST DC-9, N9345 AND U.S. MARINE CORPS F-4B, 151458 NEAR DUARTE, CALIFORNIA JUNE 6, 1971 ADOPTED: AUGUST 30, 1972 NATIONAL TRANSPORTATION SAFETY BOARD Washington, D. C. 20591 REPORT NUMBER: WTSB-AAR-72-26 I TECHNICAL REPORT STANDARD TITLE

2、PAGE . ReDOrt No. 1 2.Government Accession No. I ?.Recipients Catalog NO. I . T i t l e and Subtitle iughes Air West DC-9, N9345, and U . S. Marine Corps September 22, 1972 LkB, 151458, near Duarte, California, June 6, 1971 6.Performing Organization Code 1 . Author(s) 8.Performing Organization Repor

3、t No. NTSB-AAR-72-26 5.Report Date Bureau of Aviation Safety Il.Contract or Grant No. National Transportation Safety Board Washington, D. C. 20591 13.Type of Report and Period Covered 12.Sponsoring Agency Name and Address Aircraft Accident Report June 6, 1971 NATIONAL TRANSPORTATION SAFETY BOARD Was

4、hington, 0. C. 20591 H 1 .Sponsoring Agency Code I 15.Supplementary Notes This report contains new Aviation Safety Recomnendations A-72-200 thru 204. 16.Abstract A Hughes Air West E-9, N9345, and a U . S. Marine Corps F-4B, 151458, collided i n flight near Duarte, California, at approximately 1811 P

5、.d.t., June 6, 1971. A l l 49 occupants aboard the E-9 and the pilot of the F-4B were fatally injured. The radar intercept officer, the only other occupant of the F-4B, ejected safely after the collision. The E-9 was climbing to Flight Level 330 under radar control of the Los Angeles A i r Route Tra

6、ffic Control Center, and the F-4B was en route to M C A S E l Toro at approximately 15,500 feet, i n accordance with Visual Flight Rules. The the time of the accident, was good, and there were no clouds between the two aircraft. collision occurred at approximately 15,150 feet. The visibility in the

7、area, at this accident was the failure of both crews to see and avoid each other but recognizes that they had only marginal capability to detect, assess, and avoid the collision. Other factors involved included, a very high closure rate, comingling of I F R and VFR traffic in an area where the limit

8、ation of ATC system precludes effective separation and particularly considering the fact that they had an inoperable transponder. of such traffic, and failure of the crew of m0458 to request radar advisory service The National Transportation Safety Board determines that the probable cause of There a

9、re four new recommendations. 17.Key Words Midair collision, Scheduled air carrier (IFR) Military aircraft (VFR), Bylight 19.Securlty Classification 2O.Security Classification (of this report) (of this page) UNCLASSIFIED UNCLASSIFIED NTSB Form 1765.2 (11/70) ii I Released t o public Unlimited distrib

10、ution r - I I 1. 1.1 1.2 1.3 1.4 1.5 1.6 1.8 1.7 1.9 1.10 1.11 1.12 1.14 1.13 1.15 1.16 2. 2.1 2.2 3 . TABLE OF CONTENTS Synopsis . . . - . . - . - . - . . 1 Investigation . - . . . - . - - . 3 History of the Flight . . . . . - I . 3 Injuries to Persons - . . . - . . . 6 Other Damage Damage to Aircr

11、aft 6 . . . - - . - - . - . 6 Aircraft Information - . - . . . . 6 Crew Information - . . . . . . . . 6 Meteorological Information . . - . . 6 Aids to Navigation . . - . - - . - . 7 Aerodrome and Ground Facilities . . . ) 8 Communications . . . . . - . . . . . 8 Flight Recorders - - . . . . . . . 8

12、Wreckage Fire I . . . * . . - - - . 10 I . . . . - . 9 Survival Aspects . - . . . - - . 10 Other Tests and Research . - - . . - - . 11 -.-. .-. 14 Analysis and Conclusions . . . - . 14 Analysis Conclusions .*-.)- . 14 (a) Findings - . . . . . . - . . 25 .-.-.-. 25 Recommendations . . . - . . . - . .

13、 . 27 (b) Probable Cause - - . - . - 27 Footnotes .-. 32 Appendices Appendix A * . . . ) _ I . . . . . ) 34 Appendix B Appendix C .*.-*-. 35 . - . . . . - - a m . 37 Attachment 1 - Collision Area Attachment 2 - Computed Ranges, Bearings Attachment 3 - Visibility Chart DC-9 Attachment 4 - Visibility

14、Chart P-UB Attachments and Closure Rates SA-426 File No. 1-0005 NATIONAL TRANSPORTATION SAFETY BOARL WASHINGTON. D . C. 20591 AIRCRAFT ACCIDENT SEWRT SYNOPSIS A Hughes A i r west DC-9, N9395, and a U. S . Marine Corps F-4B, Bureau No. 151458. collided i n flight near Duarte, California, a t approxim

15、ately 1811 P.d.t. June 6. 1971. A l l DC-9, and the pilot of the F-4E were fatally injured. The 49 occupants, 44 passengers and five crewmembers, aboard the radar intercept officer, the only other occupant i n the F- 4B, ejected fzom the aircraft after the collision and parachuted to the ground. He

16、was not injured. Both aircraft were destroyed by the collision. ground impact, and fire. Los Angeles A i r Route Traffic Control Center. climbing to The Hughes A i r west DC-9 was under radar control of the Fliqht Level 330. The F-4B was being flown at approximately route to the Marine Corps A i r S

17、tation, E l Toro, California. 15.500 feet. i n accordance with Visual Elight Rules, en The collision occurred at an altitude of approximately 15,150 feet. The visibility i n the area. a t the time of the accident, was good and there were no clouds between the two aircraft during the final minutes of

18、 flight. - 2 - the probable cause of this accident bas the failure of both The National Transportation safety Board determines that crews t o see and avoid each other but recognizes that they had only marginal capability to detect. assess, and avoid the collision, Other causal factors include a very

19、 hiqh closure rate, comingling of IFR and VFR traffic i n an area where t h e , limitation of the ATC system precludes effective BuNo458 to request radar advisory service. particularly separation of such traffic, and failure of the crew of transponder. considering the fact that they had an inoperabl

20、e that the Federal Aviation Administration: (1) install video A s a result of this accident t h e Safety Board recommends tape on a l l radar displays and areall microphones i n air traffic control facilities; (2) provide positive control airspace from takeoff to landing for all IFR traffic; and (3)

21、 insure that a l l radar facilities are capable of the handling of such traffic. receiving Code 7700, and establish definitive procedures for Aviation Administration and the Department of Defense The Safety Board also recommended that the Federal cooperatively develop a program to inform all airspac

22、e users of the heaviest traffic areas. In addition, it was recommended that the Department of Defense: (1) restrict hiqh-speed, low-level operations t o designated areas and routes; (2) delineate explicit circumstances where the 10,000 feet/250 knots limitation may be exceeded; (3) consider usinq ai

23、r intercept radar for collision avoidance Radar Advisory Service and consider making the use of this purposes; and (4) publicize the availability of the FAA service mandatory. - 3 - t h Y d h a e f Y e 3 3 1 I ! i I 1. INVESTIGATION 1.1 Historv of the Flisht Hughes A i r west Flight 706 (RW706) was

24、a regularly Washington, with intermediate stops a t Salt Lake City, Utah, scheduled flight from Los Angeles, California, to Seattle, Boise and Lewiston, Idaho, and Pasco and Yakima, Washington. The flight departed Los Angeles International Airport a t Departure Control, contacted the Los Angeles A i

25、 r Route 1802 I/ and. following radar vectors from Los Angeles Traffic Control Center (ARTCC) a t 1806. In accordance with a request, the flight reported leaving 12,000 feet at 1809, and the controller advised, Air West seven zero six red, turn left heading zero four zero until receiving Daggett pro

26、ceed direct.ll RW706 acknowledged. O K , zero four zero direct to Daggett. This was the last recorded transmission from the flight. departed the Marine Corps A i r Station (MCAS) E l Toro, California, on June 4 . 1971, as part of a flight of two aircraft. The flight was scheduled for an overnight cr

27、oss- return, McClellan AFB, California, was t o be used for country to McChord A i r Force Base (AFB), Washington, and refueling northbound, and Mountain Home AFB. Idaho, was to be used southbound. Although the transponders on both aircraft apparently failed shortly after departure from MCAS E l Tor

28、o, the f l i q h t of two w a s permitted t o proceed to June 5. the flight continued to Mountain Home AFB, but the McChord AFB under control of the ATC System t y radar. On radio i n BuNo458 failed during the landing approach. A f t e r landing, the crews discussed the operational status of the two

29、 aircraft, and the flight leader decided t h a t he would proceed to MCAS E l Toro. The wingman and his Radar Intercept Officer (RIO) were instructed to await repairs to EuNo458 and then return t o MCAS E l Toro. The mechanical difficulties with the aircraft at t h i s time included: The U . S . Mar

30、ine Corps F-4B. Bureau NO. 151458 (BuN0458) 1. Inoperative transponder 2. Inoperative radio 3 . Oxygen system leak 4 . Degraded radar system - 4 - Maintenance personnel a t Mountain nome APB reGIaced a fuse check the transponder. They confirmed the oxygen leak, but to fix the radio, but they did not

31、 have the personnel t o could not repair it. N o attempt was made t o restore the radar t o peak performance a t that time. The crew of BuNo458 filed a Visual Flight Hules (VFR) Nevada, below the Area Positive Control (APC), 2/ because of flight plan to Naval Auxiliary A i r Station (NAAS) Fallon. t

32、he inoperative transponder and fuel requirements. On this was turned off shortly after takeoff from Mountain H o m e AFB. leg of the flight the oxygen leak increased, and the oxygen The maintenance personnel on duty a t NAAS Fallon were unable to provide the appropriate repairs, so the pilot contact

33、ed his squadron duty officer for instructions. Be was advised t o proceed t o MCAS E l Toro a t low altitude. After refueling, the crew again filed a VFR flight plan below APC. The takeoff was delayed from 1400 to 1716 because MCAS E l Tor0 was closed for an airshow between 1400 and 1630. The intend

34、ed route of flight was direct Fresno, 5-65 Bakersfield, J-5 Los Angeles, direct M C A S E l Toro. The fliqht departed a t 1716. climbed initially t o 1,500 feet, and then climbed to 15.500 feet to clear mountains and some clouds approximately 50 miles from NAAS Fallon. After crossing the mountains,

35、they descended to 5,500 feet and remained at that altitude until they reached Bakersfield. Approximately 15 miles north of the Bakersfield Flight Service Station a position report was made, and the MCAS E l Tor0 weather was checked. The crew also decided to deviate from the original plan a t this po

36、int. They flew east of the heavy traffic over Los Angeles. planned course, over Palmdale, to avoid the anticipated The fliqht continued i n a low profile, minimum altitude northwest of Palmdale. Due t o deteriorating visibility, 1,000 feet above the ground, until approximately 15 miles they again cl

37、imbed t o 15,500 feet. The RIO stated that the climb was made, using maximum engine power, without afterburner, and took less than 2 minutes. Shortly after level-off, the Distance Measuring Equipment (LIME) feature of the VORTAC J/ indicated 50 miles to MCAS E l Torc. The pilot executed a 3600 ailer

38、on roll a t t h i s time, which took approximately 3 seconds to complete. The RIO estimated that knots, and that the collision occurred appzoximately 1 the true airspeed in the climb and after level-off was 420 minute and 20 seconds after the roll. During most of t h i s - 5 - 1se to ,ut :he R 1 of

39、en is E . le ed ed n , an 16 DO 3 , n e t, n e x Id 1 . I t 2 1 :e le !d le !S * l e ,t r f t k t 0 1 S period, he was operating the radar i n the mapping mode, but, due to the extremely degraded air-to-air detection capability, no airborne targets were seen. Since the radarscope was i n the stowed

40、position, the R I O was leaning forward, and his line of sight was directed downward a t Approximately 3 t o 10 seconds prior t o collision. the RIO approximately a 450 angle while using t h e radarscope. raised his head, observed the DC-9 i n h i s peripheral vision approximately 500 to the right a

41、nd slightly beneath his aircraft. H e shouted t o t h e pilot, but t h e pilot had initiated an evasive r o l l before the RIO finished the warninq. H e did not see RW706 take any evasive action. After takeoff from Los Angeles, RW706 was qiven two radar traffic advisories hy departure control, and c

42、ontrol Angeles ARTCC. The data and radar positions of this sector was subsequently transferred to the R-18 sector of Los were manned by developmental controllers 2/, each of whom was heinq supervised by a journeyman controller. Consequently, four individuals were observing t h e radarscope a t the R

43、-18 position prior t o t h e collision. They all agreed that no primary tarqets were observed in proximity to RW706 a t any time. Five traffic advisories were given t o other aircraft in the R-18 sector i n the 6-minute timespan prior t o t h e collision. about the lateral axis. The RIO waited about

44、 5 seconds, After the collision, BuNo458 began to tumble violently and, after seeing numerous warning liqhts i n the cockpit, he ejected from the aircraft. The ejection was successful, and he parachuted to the ground without injury. Witnesses i n the area of the accident gave widely varyinq accounts

45、 of the collision. Thirty-four witnesses persons observed the two aircraft on converging courses. saw or heard jet aircraft prior t o t h e collision, and 24 I Fifteen persons saw a fighter aircraft in a rolling or evasive maneuver prior t o collision. Three persons on the ground and two pilots, a t

46、 varying distances from the proceeding along the route of flight described by the RIO. immediate collision area, observed a fighter aircraft (See Attachment 1.) Several witnesses in the area of the collision reported seeing a fighter aircraft doing rolls and circling i n the area. I 1.2 Injuries to

47、Persons Injuries C r e w Fassenqers Others Fatal CC-9 5 F-4B 1 Nonfatal DC-9 0 F-4B 0 None DC-9 0 F-4B 1 44 0 0 0 0 0 0 0 0 0 1.3 Damaqe to aircraft Both aircraft were destroyed by the collision, ground impact, and subsequent fire. 1.4 Other Damaqe a l l ground damage was restricted t o underbrush w

48、hich was Both aircraft crashed i n a remote mountaincus area, and burned in the ground fire. 1.5 Crew Information respective flights. (See ApFendix E for details.) 1.6 Aircraft Information The crews of both aircraft were qualified for the The Dc-9 was Froperly certificated and both aircraft had been

49、 maintained i n accordance with existing regulations. The weight and center of gravity of each were within prescribed limits. The DC-9 was serviced with Jet A fuel and the I-4B with JP-5 fuel. (See Appendix C for details.) 1.7 Meteoroloqical Informatkn The weather i n the vicinity of the accident si

50、te was characterized by low-level haze and smoke, scattered l o w was no frontal weather i n the area. clouds and high, thin, broken or scattered clouds. There issued by the National Weather Service a t LQS Angeles was i n The pertinent portion of the aviation area forecast part, as follows: Scatter