Douglas DC-8-21 accident at New York International Airport, New York, 19 Jan 1961

Accident narrative

On January 19, 1961, at approximately 2017 Eastern Standard Time, an Aeronaves de Mexico Douglas DC-8-21 crashed and burned following a balked takeoff from runway 7R at New York International Airport. Four of the nine crew members were killed, and 28 of the 97 passengers were injured. The Civil Aeronautics Board investigated the accident and determined it was primarily caused by a check pilot, who was not seated in either pilot seat, unnecessarily aborting the takeoff.

### The Flight

Aeronaves de Mexico Flight 401 was scheduled to depart New York nonstop to Mexico City at 1830. The flight was delayed about an hour and a half due to weather conditions. Captain Ricardo Gonzales Orduna commanded the flight from the left seat. First Officer Antonio Ruiz Bravo and Second Officer Xavier Alvarez Bacha completed the operating crew, alongside five cabin attendants.

Eastern Air Lines Captain William B. Poe occupied the jump seat directly behind the captain in the capacity of check pilot. Under a cooperative agreement, Eastern Air Lines provided ground school, simulator training, and check pilots to assist Aeronaves in the early stages of its jet operations. The Eastern Air Lines Flight Manual, utilized by Aeronaves, authorized a check pilot to take over the controls during flight, including takeoff or landing, if it appeared the aircraft might be subjected to damage.

The aircraft, Mexican Registration XA-XAX, had arrived from Mexico City that afternoon and accumulated snow while parked. It was de-iced with Glycol. Captain Poe walked out on the taxiway to check the snow conditions, reporting a depth of about one inch of "very fine and very dry" snow. The aircraft's gross weight was 272,171 pounds, well under the permissible limit, and included an additional 2,000 pounds of fuel for anticipated headwinds.

### Weather and Runway Conditions

Between 1900 and 2100, the airport experienced a precipitation ceiling of 500 feet or less, with visibility dropping to one-quarter mile in snow and fog. Surface winds averaged 15 to 22 knots with gusts up to 27 knots. A snow committee check of runway 7R between 1945 and 2000 reported conditions ranging from patches of compacted snow on the first quarter to scattered finger drifts four to six inches deep on the last quarter.

While holding short of the taxiway, the flight received its IFR clearance at 2010. The tower transmitted the latest weather: precipitation ceiling 300 feet, sky obscured, visibility one-quarter mile in light snow and fog, wind east-northeast 18 knots with gusts to 24, and runway 7R visual range less than 2,000 feet.

### The Takeoff

At 2014:38, the flight reported rolling. Control tower personnel observed the first 6,200 feet of the takeoff roll visually until the aircraft was obscured by snow, noting that it had not yet rotated. Another controller tracked the aircraft on surface-detection radar to the eastern end of the runway, where it disappeared from view, followed seconds later by a bright orange flash northeast of the airport.

Captain Poe, the only survivor from the flight deck, stated that the checklist was accomplished normally. He reported that the takeoff roll appeared routine through the 100-knot check, when the first officer called out "cien" (Spanish for 100). Upon reaching approximately 130 knots, the first officer called out V1 and VR in rapid succession. The aircraft was then rotated quickly and somewhat excessively.

Poe stated he did not see the airspeed go over 130 knots, and as rotation started, he saw the airspeed drop rapidly to about 110 knots. At this time, Captain Gonzales pointed to or called out the airspeed indicator. Poe felt the aircraft could not become airborne and that the remaining runway was insufficient to put the nose back down and accelerate. He unfastened his safety belt, stood up, shoved the throttles forward briefly—noting normal engine pressure ratio (EPR) readings—and then pulled the throttles full back. Captain Gonzales immediately applied reverse thrust and wheel brakes, and Poe extended the spoilers. Poe believed the aircraft did not take off. Later tests showed Poe's actions would have taken about three seconds.

The aircraft continued the full length of the 10,000-foot runway and beyond it, crashing through a steel blast fence. It caught fire, broke through the airport boundary fence, and crossed Rockaway Boulevard, striking an automobile and injuring its driver. The aircraft shed many parts before coming to rest in flames 830 feet beyond the end of the runway.

### What the Investigation Found

The aircraft was extensively destroyed by impact and a prolonged ground fire. The four crew members on the flight deck and in the forward lounge died from multiple burns. Captain Poe was thrown clear of the wreckage.

Investigators found no evidence of pre-impact failure, malfunctioning, or fire in any of the aircraft's systems, structures, or flight controls. The engines were found to have been producing power as selected. The wing flaps were in the 15-degree takeoff position, the spoilers were extended, and the horizontal stabilizer was set 1.25 degrees nose-up. Intermittent anti-skid tire marks were found beginning 7,535 feet down the runway. The flight recorder was recovered, but examination revealed it had malfunctioned prior to the accident and was inoperative during the flight.

Despite Poe's belief that the aircraft never left the ground, witness accounts and physical evidence indicated otherwise. A passenger, who was an aircraft manufacturer employee, timed the roll. He testified that after 50 seconds, he thought the roll was too long and braced himself. One or two seconds later, he felt the aircraft lift off with a "thump" (which he attributed to the landing gear struts extending), stay airborne for a count of three, and touch down smoothly before reverse thrust was applied. A ground witness saw the aircraft's lights rise coincident with a reduction of engine power at about the 6,400-foot point on the runway. The Board concluded the aircraft did become airborne.

The Board analyzed the aircraft's performance data. On a dry runway, the DC-8 should have rotated at 143 knots after a 3,994-foot roll. Because of the snow, acceleration was slower, and the aircraft did not reach rotation speed until it was more than 6,200 feet down the runway. However, the Board noted that the aircraft could not have rotated abruptly at 110 knots, as elevator effect is too slow at that speed.

Furthermore, the Board calculated that decelerating from 130 knots to 110 knots in five seconds would require a drag force of 70,500 pounds. Because the engines at idle still produce some forward thrust, this rapid deceleration was physically impossible.

The Board concluded that the captain's airspeed indicator was giving an erroneous low reading. The first officer, observing his own indicator, correctly called VR at 143 knots. When Captain Gonzales pointed to his indicator, Poe read 130 knots and pulled the power.

The switch controlling the pitot and stall-warning anti-ice heaters was found seized in the "off" position. The pitot heater ammeter was seized at 1.1 amperes, which disassembly revealed was caused by heat expansion of the hairspring moving the hand from zero. The switch bore no impact marks, and its internal design made it unlikely to have been moved by the crash. The Board noted that failure to apply pitot heat during snow conditions may have played a part in the erroneous airspeed indication.

Flight simulator tests conducted by the Board indicated that a qualified DC-8 captain could complete a takeoff with a reasonable degree of safety under these conditions, and that captains normally cross-check the first officer's airspeed when an anomaly occurs. The DC-8-21 is capable of being rotated to its physical limits and continuing to accelerate until becoming airborne.

### Probable Cause

The Board determined that "the probable cause of this accident was the unnecessary discontinuing of the takeoff by the check pilot, who was not in either pilot seat."

The Board concluded that "contributing factors in this accident were the marginally poor weather, snow on the runway, and the possibility of the pitot head heat not having been on."