Douglas DC-3 accident at Bristol, Tennessee, 8 Jan 1959 (N-1891)

Accident narrative

On January 8, 1959, at about 2032 e.s.t., Southeast Airlines Flight 308, a Douglas DC-3 registered N 1891, struck a mountainside during an ILS approach to the Tri-City Airport in Bristol, Tennessee. The aircraft was demolished by impact and subsequent fire. All seven passengers and three crew members received fatal injuries.

**The flight**

Southeast Airlines was an intrastate carrier. Flight 308 was a regular trip from Memphis to Tri-City, with scheduled stops in Nashville and Knoxville. The crew for the Memphis to Nashville segment consisted of Captain Thomas A. Bond, First Officer Robert M. Irwin, and Stewardess Wanda C. Nalley. Captain Robert L. Gollmier deadheaded on this segment and was scheduled to command the remainder of the trip.

During the approach to Nashville, First Officer Irwin was unable to pick up the compass locator at the outer marker on the Automatic Direction Finding (ADF) receiver. Captain Bond stated that he and the first officer attempted several times to tune the radio but received neither an aural signal nor a visual indication. Captain Bond stated that upon landing he informed Captain Gollmier of the malfunction, but he did not make an entry in the aircraft log.

Captain Gollmier took command at Nashville. The flight proceeded uneventfully to Knoxville, where the crew received a special Tri-City weather observation reporting a 600-foot overcast ceiling, three miles visibility, light snow, and fog.

Flight 308 departed Knoxville at 1946, 27 minutes late, on an instrument flight rules clearance via Green Airway 5. At 2010, the flight reported over Bulls Gap. Tri-City approach control cleared the flight for an approach to runway 27 and transmitted the latest weather, which included a measured ceiling of 900 feet broken, 1700 feet overcast, three miles visibility, light snow, and fog.

Flight 308 reported to approach control that it was over the Gray intersection leaving 5,000 feet and making an outer marker approach. The controller advised the flight to report leaving the outer marker inbound.

At 2032, the controller called Flight 308 to ask its position. The captain asked if the glide slope was operating. The controller advised that it was and asked if the flight was inbound to the outer marker. The captain stated that his ADF was "acting up," that he did not pick up the outer marker aurally or visually, and that they were making a procedure turn. The controller acknowledged and asked the flight's altitude. No further word was received.

A Piedmont Airlines DC-3 holding at the Bristol intersection at 5,000 feet heard the 2032 transmissions. The Piedmont captain testified that he noted the time of the final call because he knew Flight 308 should not still be eastbound eight minutes after passing the Gray intersection.

**What the investigation found**

The wreckage was located the following day on the northwest side of the Holston mountain range, 18.75 nautical miles east of the Tri-City Airport and 1.25 nautical miles north of the ILS localizer path. The aircraft had struck trees on a 35-degree slope at an elevation of 3,140 feet. Initial impact marks showed the DC-3 was in level flight with a right bank of less than 10 degrees. The aircraft continued through the trees, lost its outer right wing panel, and came to rest inverted.

Investigators found no evidence of structural or mechanical failure or malfunction prior to impact. Both engines and propellers were capable of normal operation.

Examination of the radio equipment indicated the crew was not utilizing all available facilities. VOR No. 1 was tuned to the Tri-City ILS localizer. VOR No. 2 was tuned to 111.3 megacycles, a frequency not used by any navigational facility in the Tri-City area. The low frequency receiver appeared to be set between 325 and 349 kcs, which was unrelated to any local facility that could be utilized by the receiver. The ADF was tuned to 221 kcs, the Tri-City low frequency radio range, rather than the compass locators associated with the middle or outer markers. The marker beacon receiver was recovered with its tubes missing, presumed taken by a souvenir hunter, but it operated normally when the tubes were replaced.

Ground checks confirmed that the Tri-City ILS components and compass locators were functioning properly on the night of the accident.

The Board calculated that Flight 308 could not have been over the Gray intersection as reported. To reach the crash site eight minutes later would have required a groundspeed of 191 knots, which the Board noted was much too high for a DC-3 maneuvering prior to an ILS approach. Based on position reports and winds aloft, the Board believed the flight navigated from Knoxville in instrument weather conditions without using the low frequency radio aids defining Green Airway 5. The Board concluded that the flight was east of its intended course and reported being over Gray when it was actually several miles east of the intersection.

The Board further concluded that the crew, without realizing their actual position, followed the usual procedure for intercepting the localizer and passed to the south and east of the outer marker. The flight flew for 5 minutes and 45 seconds from its erroneous Gray report before starting a procedure turn, well beyond the normal 3 minutes and 30 seconds.

Because the aircraft intercepted the localizer east of the outer marker, the glide slope indicator would have shown a full fly-up deflection. The Board noted that the crew may have been confused by receiving an indication opposite to what they expected, or they may have concluded the equipment was inoperative. In either case, the Board believed the crew had a clear duty to discontinue the procedure immediately and execute a missed approach.

Company regulations required an operable ADF for flights dispatched under instrument flight rules. The Board believed the ADF was completely inoperative and that this condition was known to the crew at Nashville. Furthermore, FAA operations specifications prohibited an ILS approach if more than one component of the system was inoperative or its signals could not be received. Because the flight could not receive the compass locators and did not receive the outer marker, the Board concluded the approach should have been abandoned.

**Probable cause**

The Board determined the probable cause of this accident was "the failure of the pilot to identify Gray intersection properly and his decision to continue an ILS approach contrary to company and regulatory procedures."