Douglas DC-8-63 accident at Swanton, Ohio, 15 Feb 1992

Accident narrative

On February 15, 1992, at 0326 eastern standard time, Air Transport International flight 805, a Douglas DC-8-63 freighter, crashed about 3 miles northwest of Toledo Express Airport in Swanton, Ohio. The crash occurred after the crew executed a second missed approach to runway 7 in night instrument flight conditions. The airplane was destroyed, and the flightcrew of three and one passenger were killed.

### The Flight

Flight 805 was a scheduled domestic air freight flight. It originated in Portland, Oregon, at 2145, stopped in Seattle, Washington, and departed Seattle at 2320 for Toledo. The crew had been released from duty on February 6 and returned to duty on February 13. They flew to Portland, were released at 1145 on February 15, and returned to duty at 1945 to fly flight 805.

The captain, 59, had 16,382 total flying hours, with 2,382 hours in the DC-8. He had failed his initial DC-8 type rating in 1986 but subsequently passed and was regarded by peers as a very good pilot. The first officer, 37, had 5,082 total flying hours, including 1,143 hours in the DC-8 as first officer and 1,992 hours as a flight engineer. The flight engineer, 57, had 21,697 total flying hours, with 7,697 hours in the DC-8. The passenger was a nonrevenue crewmember from another airline.

### The Approaches

The first officer was the flying pilot for the arrival into the Toledo area. The flight was vectored for an instrument landing system (ILS) approach to runway 7. The captain noted to air traffic control that they had been in instrument meteorological conditions for about 30 miles.

During the first approach, the cockpit voice recorder (CVR) captured the captain coaching and critiquing the first officer's flying technique, stating, "If you're gonna fly that slow you gotta have more flaps," and "You're not even on the localizer at all." At 0313, the captain announced they would have to go around because they were not near the localizer. He told the approach controller they had lost the localizer close in.

The controller vectored the airplane for a second attempt. The tower reported surface winds at 100 degrees at 10 knots, but the flightcrew noted winds at their altitude were 180 degrees at about 35 knots. The captain advised the first officer about the drift, stating they had a direct crosswind giving 12 to 13 degrees of drift.

As the first officer attempted to stabilize the second approach, the ground proximity warning system (GPWS) sounded three glideslope warnings and three sink rate warnings. The captain told the first officer to "push the power and get back up to the glidepath," and then, "Okay, now take it back off... stay with it." At 0324:17, the captain stated, "Oh [expletive] I got it," taking control of the airplane to perform a second missed approach. The flaps and landing gear were retracted.

### The Loss of Control

The flight was directed to climb and maintain 3,000 feet. At 0325:33, the tower controller directed a left turn to a heading of 300 degrees.

Flight data recorder (FDR) and radar data showed the airplane leveled at about 3,200 feet and initiated the left turn. The bank angle then steepened, and the airplane began a rapid loss of altitude and increase in airspeed.

At 0325:38, about 22 seconds before impact, the captain asked, "what's the matter?" and five seconds later, "What the [expletive] the matter here?"

At 0325:48, the captain asked, "You got it?" and the first officer replied, "I got it."

The CVR then recorded an altitude alert warning and GPWS sink rate and pull up warnings. The flight engineer twice called out, "Pull up." The captain said, "Up, up, up, up," and an unidentified voice responded, "I can't." The sound of impact was recorded at 0326:00.

### What the Investigation Found

The airplane crashed in a 15-degree left-wing-down attitude, descending at an angle of about 17 degrees. The crash occurred at an airspeed in excess of 300 knots. The debris field measured over 2,000 feet.

Investigators found no evidence of in-flight fire, in-flight separation of airframe components, or preimpact defects in the flight control cables. The Board considered several scenarios: * **Cargo shift:** The FDR recorded accelerations in excess of +2 g prior to impact, indicating the elevator and rudder controls were not rendered ineffective by damaged cables. * **Asymmetric flaps:** Flap retraction takes 6 to 10 seconds. The Board noted any asymmetric problem would have been evident to the captain within seconds and prompted a comment. * **First officer seat failure:** The seat had been written up previously as difficult to lock, but there was no reference to seat problems on the CVR, and the control difficulties began while the captain was flying. * **Open cargo door:** Seven of the main cargo door latches were found, with six in the locked position. No airflow noise was recorded on the CVR. * **Asymmetric engine thrust:** A sound spectrum analysis revealed an 8.2 percent thrust differential between two engines, but the Board concluded this would not be enough to cause the loss of control.

Weather data and observations from other flightcrews indicated low ceilings, visibilities, and a strong crosswind that resulted in greater than normal descent rates. However, the Board believed existing conditions did not preclude a successful approach and concluded weather was not causal, though the adverse crosswind precipitated the missed approaches.

Other flights in the area reported momentary glideslope excursions, and one flight executed a missed approach due to rapid fluctuations. However, ground and airborne checks by the FAA following the accident revealed no anomalies, and the Board did not consider the ILS to be a factor.

The Board noted that the first officer failed to properly capture the ILS localizer and/or glideslope during both approaches. The captain's interaction with the first officer was described as more representative of an instructor and student than a teamwork situation. The Board acknowledged that the crew's disrupted work/rest cycle could have resulted in fatigue, but stated the available evidence was not sufficient to conclude that fatigue adversely affected pilot performance.

The investigation examined the possibility of spatial disorientation. The captain had transitioned from a climb, reduced power, and was attempting to level off while in a steady left turn at night with no visible horizon. The Board noted that deceleration while turning can produce the sensation of turning in the opposite direction. The Board believed these events and circumstances strongly pointed to a conclusion that the captain experienced spatial disorientation.

The Board also considered a malfunction of the captain's attitude director indicator (ADI). A search of the Safety Board's database revealed 19 accidents involving attitude indicator failures, and FAA records showed 126 Service Difficulty Reports for ADI or vertical gyro failures. Only one ADI roll case and display ball were recovered from the wreckage. The ball had witness marks at 15 degrees and 42 degrees nose down. Because the Board could not determine which mark occurred at initial ground impact, it could not positively determine whether the captain's ADI malfunctioned, nor could it rule out the possibility.

A standby artificial horizon was recovered displaying an attitude corresponding to that of the impact. The Board believed the first officer's ADI was operating properly based on his recovery efforts. When the first officer took control, the bank angle had increased to about 65 degrees and the flightpath angle was about 15 degrees down. The bank angle reached 80 degrees before the first officer rolled the wings toward level and began pulling the nose up, recovering to a 15-degree bank by impact. The Board noted that airline pilots are not periodically trained to recover from unusual attitudes, but added that if the first officer had challenged the captain's overbank in the 10 seconds before control was transferred, the accident might have been prevented.

### Probable Cause

The National Transportation Safety Board determined that the probable cause of this accident was "the failure of the flightcrew to properly recognize or recover in a timely manner from the unusual aircraft attitude that resulted from the captain's apparent spatial disorientation, resulting from physiological factors and/or a failed attitude director indicator."