Lockheed L-049 accident at Richmond, Virginia, 8 Nov 1961

Accident narrative

On November 8, 1961, at 2124 e.s.t., an Imperial Airlines Lockheed L-049 Constellation crashed and burned during an attempted landing at Byrd Field in Richmond, Virginia. The flight crew had diverted to Richmond after two engines failed. During a poorly executed go-around on the remaining two engines, a third engine failed, and the aircraft crashed one mile from the runway threshold. Seventy-four passengers and three flight crew members died of carbon monoxide poisoning. Two flight crew members escaped the burning wreckage. The aircraft was totally destroyed.

### The flight

Imperial Airlines Flight 201/8 was a scheduled common carriage flight transporting newly inducted U.S. Army members to Columbia, South Carolina. The aircraft was serviced with 3,180 gallons of fuel. Captain James A. Greenlee had instructed that the outboard tanks (Nos. 1 and 4) be fueled to 800 gallons each.

The crew consisted of Captain Ronald H. Conway, Captain Greenlee, Flight Engineer William F. Poythress, Student Flight Engineer Peter E. Clark, and Stewardess Linda Johns. Captain Conway testified that although Greenlee was the senior captain, they agreed Conway would command the flight and Greenlee would act as copilot.

The flight departed Columbia on a VFR flight plan. As the aircraft took off, Poythress noticed a drop on the No. 3 fuel pressure gauge. He testified that Clark opened the Nos. 3 and 4 crossfeed valves to assure positive pressure, and the drop did not recur. Poythress stated the crossfeeds were closed when the aircraft reached its cruise altitude of 9,500 feet.

The flight landed at Newark at 1737. According to the surviving crew, 2,300 gallons of fuel remained. The flight departed for Wilkes Barre at 1822. Poythress stated he opened the Nos. 3 and 4 crossfeed valves prior to takeoff to prevent another fuel pressure drop. At Wilkes Barre, 31 additional passengers boarded. The flight departed for Baltimore at 1912, with Poythress again opening the crossfeeds for takeoff.

At Baltimore, 16 additional passengers boarded. The calculated takeoff weight was 62,176 pounds, well below the maximum allowable 98,000 pounds. The flight departed at 2030, with Poythress again opening the crossfeeds. At 2035, Greenlee filed a flight plan direct to Columbia at 4,500 feet, estimating two hours and 10 minutes en route with five hours and 30 minutes of fuel on board.

### The emergency

Conway flew the entire flight from the left seat. He recalled passing the Brooke Omni and asking Greenlee to note the time for a groundspeed check. Sometime later, the airplane yawed to the right, and the fuel pressure warning lights for engines Nos. 3 and 4 came on. Poythress took over the flight engineer's station from Clark and found the No. 3 engine had stopped rotating and the No. 4 engine was surging between 1,500 and 2,000 r.p.m. Both Conway and Poythress stated the fuel gauges indicated fuel, but they could not recall the exact amount.

Conway ordered Poythress to feather the No. 3 engine and concentrate on No. 4. When Poythress was unable to restart No. 4, he attempted to restart No. 3. Poythress ordered Clark to go to the passenger cabin and open the midship fuel crossfeed valve. Clark returned to the cockpit for a screwdriver, at which point Greenlee said, "don't open that valve. You have good pressure on 1 and 2; leave it there." The valve was not opened. Conway testified he knew nothing of this until after the accident.

Unable to restart either engine, Poythress advised getting the airplane on the ground. Conway agreed, turned toward Richmond, and ensured both the No. 3 and No. 4 propellers were feathered. The stewardess relayed the decision to land to the passengers over the public address system. Because the crew did not anticipate a crash landing, they did not instruct the stewardess to give emergency evacuation instructions.

### The approach and crash

At 2110, the flight contacted the Richmond tower. The controller advised that all runways were available and the wind was north-northwest at 15 knots with gusts to 22 knots. Conway advised they would use runway 33 and asked Greenlee to fly the airplane so he could check the flight engineer's station.

As the flight approached, Greenlee suddenly remarked, "let's land on this runway." Still flying the aircraft, he turned left to runway 02 and lowered the landing gear handle. Conway saw a lighted runway but thought they were too high and fast. He then noticed the landing gear lights indicated the gear was not down. Conway reached down and recycled the landing gear up.

Realizing the landing attempt had to be abandoned, both pilots called for full power on engines Nos. 1 and 2. A transmission was received in the tower: "Tower get everybody off. We're losing another one here and we can't get our gear down."

Conway took the controls and started a right turn toward runway 33, then handed control back to Greenlee, who had a better view of the runway from the right seat. Poythress announced a continuing decrease in power on the No. 1 engine. The landing gear handle was placed down again, and Clark assisted by pumping the gear with the hydraulic hand pump. Conway recalled seeing two green lights indicating two of the three landing gears were down on final approach.

Slightly left of the extended runway centerline, the airspeed began to decay rapidly. Conway pulled back on the control column. The aircraft stalled into the trees at an indicated airspeed between 90 and 95 knots, crashing one-half mile left of the final approach path and one mile from the runway threshold.

The aircraft struck the trees in a 10-degree right bank, 50 feet above the ground, and came to rest in a level attitude. Conway and Poythress escaped through the cockpit windows and doors. Conway stated that as he left, Greenlee and Poythress were at the crew exit door preparing to jump. The aircraft was immediately engulfed in flames.

### What the investigation found

The entire fuselage forward of the tail section and the major part of the left wing were destroyed by fire. The nose gear was retracted, and the main landing gears were down, though fire destruction prevented determining if the locks were engaged. The wing flaps were up. No evidence indicated a failure of the primary or secondary flight controls.

The passenger cabin was completely destroyed by fire. The grouping of bodies indicated many passengers had left their seats and attempted to evacuate. The main cabin door was either jammed by ground impact or blocked by debris. There was no evidence that the emergency over-wing exits were used. The cause of death for all victims was suffocation from carbon monoxide poisoning. The Board noted that the distribution of carbon monoxide levels described a normal biologic curve, and estimated the elapsed time from impact to loss of mobility was between 30 seconds and two minutes.

Examination of the engines revealed that the No. 1 engine suffered a complete internal failure prior to the crash due to a master rod and bearing failure. The Board concluded this was caused by overboosting during the emergency go-around. Engines Nos. 2, 3, and 4 showed no evidence of in-service failures or malfunctions.

The Board thoroughly explored the possibility of fuel contamination. A refueling truck used in Columbia was found to have gross contamination, including rust deposits and improperly seated filter elements. However, the Board felt the amount of contamination was not sufficient to cause a complete loss of fuel pressure, noting that other aircraft serviced from the same truck reported no operating difficulties.

Instead, the Board concluded that fuel exhaustion brought about by improper fuel management caused the stoppage of engines 3 and 4. The No. 2 fuel boost pump was found to be fitted with an improper brush, which Poythress testified he had manufactured from a brush obtained from the company's Chief Flight Engineer. The Board believed the No. 3 boost pump either had no repair or a temporary repair. The fluctuation on the No. 3 engine out of Columbia was symptomatic of a boost pump failure. When the crew opened the Nos. 3 and 4 crossfeeds, both engines operated exclusively on fuel from the No. 4 tank, supplied by the No. 4 boost pump. The Board believed the crossfeeds were left open for the majority of the flight, exhausting the 800 gallons in the No. 4 tank at the approximate time the power loss occurred.

The Board noted the engines could have been restarted if the crew had turned off the No. 4 boost pump to allow the No. 3 engine-driven pump to prime, or if the midship crossfeed valve had been opened. The procedures followed by Poythress indicated a lack of knowledge and inability to diagnose the situation.

The investigation also found that the aircraft was equipped with a hydraulic crossover valve, which would have allowed the primary hydraulic system to extend the landing gear after engines 3 and 4 failed. The valve was found in the fully closed position. The Board concluded the crew did not open it and were unaware the aircraft was equipped with it. Had it been opened, the gear would have extended in 20 to 25 seconds.

The Board reviewed Imperial Airlines' operations and maintenance practices. The investigation revealed company manuals were not kept current, inspection periods were exceeded, and inflight discrepancies were not reported. The FAA had conducted extensive inspections prior to the accident and found numerous improper procedures. The Board believed these sub-standard maintenance practices were condoned by management, who only corrected items specifically pressed by the FAA.

Regarding the flight crew, the Board concluded that confusion prevailed in the cockpit due to a lack of crew coordination and the issuing of conflicting orders. Greenlee's sudden turn to runway 02 and actuation of the landing gear were described as rash and a clear indication of a division of command. The Board concluded the flight crew was not capable of performing the function or assuming the responsibility for the job they presumed to do.

### Probable cause

The Board determines the probable cause of this accident was "the lack of command coordination and decision, lack of judgment, and lack of knowledge of the equipment resulting in loss of power in three engines creating an emergency situation which the crew could not handle."