File No.

1-0018

AIRCRAFT ACCIDENT REPORT

WORLD AIRWAYS, INC.
OC-8-63F, N802WA
KING COVE, ALASKA
SEPTEMBER 8, 1973

Adopted: May 8, 1974

NATIONAL TRANSPORTATION SAFETY BOARD

Washington, D.C. 20591
Report Number: NTSB-AAR-74-6
 TECHNICAL REPORT STANDARD TITLE PAGE
. Report No.

i
2.Government Accession No. 3.Recipientls Catalog No.
NTSB-AAR-74-6
I. Titie and Subtitle Aircraft Accident Report- 5.Report Date
World Airways, Inc., DC-8-63F, N802WA May 8, 1974
King Cove, Alaska, September 8, 1973 6.Performing Organization
Code
'. Author(s) 8.Performing Organization
Report No.
SY
I. Performing Organization Name and Address i0.Work Unit No. 1. In
1281 1.1 Hi
National Transportation Safety Board 1 1 .Contract or Grant No. 1.2 In
Bureau of Aviation Safety 1.3 Da
Washington, D. C. 20591 13.Type of Report and 1.4 Ot
Period Covered 1.5 CI
2.Sponsoring Agency Name and Address 1.6 Ai
Aircraft Accident Reoort
September 8, 1973 1.7 MC
NATIONAL TRANSPORTATION SAFETY BOARD 1.8 A!
Washington, D. C. 20591 1.9 CI
14.Sponsoring Agency Code AI
1.10
1.11 F'
15.Suppiementary Notes ,.1.12 A:
1.13 M
This report contains Safety Recornendation A-74-53. 1.14 F
1.15 S
16.Abstract 1.16 T
1.17 0
About 0542 Alaska daylight time on September 8 , 1973, World Airways, Inc., A
Flight 802, a DC-8-63F, crashed into Mt. Dutton, near King Cove, Alaska. The six 2.
2.1 A
occupants--three crewmembers and three nonrevenue company employees--were killed.
The aircraft was destroyed by impact and fire. 2.2 C

Flight 802 was a Military Airlift Comnand contract cargo flight from Travis AFB,, I
3. I
California, to Clark AFB, Philippine Republic, with intermediate stops at Cold Bay,
Alaska, and Yokota AFB, Japan. It was cleared for an approach 125 miles east of
the Cold Bay Airport. The flight reported that it was leaving 31,000 feet: this
1 1
was Flight 8 0 2 ' s last recorded transmission. The aircraft crashed at the
3,500-foot level of Mt. Dutton, approximately 15.5 miles east of the airport. ~

The National Transportation Safety Board determines that the probable cause of
the accident was the captain's deviation from approved instrument approach proce- ~

dures. As a result of the deviation, the flight descended into an area of unrelia- ~

ble navigation signals and obstructing terrain.

17.Key Words i8.Distribution Statement i

Aircraft accident, non-precision approach, back course This report is available to i
approach, non-compliance with approved instrument the'public through the l
approach prooedures, minimum sector altitudes, National Technical Informa-
operation in area of signal unreliability. tion Service, Springfield,
Virginia 22151
i9.Security Classification 20.Security Classification 21.No. of Pages 22.Price ~

(of this report) ( o f this page) 30

UNCLASSIFIED UNCLASSIFIED
WSB F o m 1765.2 (11/70)
ii
.PP
40 .
.
.on TABLE OF CONTENTS
.on

.
.
Synopsis..................... 1

.
1
1.1
. . . . .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
Investigation
History of the Flight
1
1

.
1.2 .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
Injuries to Persons
Damage to Aircraft
3
3
1.3
1.4 ...................
Other Damage 4
1.5 .................
Crew Information 4
1.6 Aircraft Information ............... 4
1.7 Meteorological Information ............ 4
1.8 Aids to Navigation................ 5
L
F 1.9 ..................
Conrmunications 6
1.10 Aerodrome and Ground Facilities .......... 6
. 1.11 .................
Flight Recorders 6
.a. 12 .................
Aircraft Wreckage 6
1.13 Medical and Pathologjcal Examination ....... 8
1.14 Fire ........................ 8
. 1.15 .................
Survival Aspects 8
1.16 .................
Test and Research
.................
Other Information
8
8
*
1.17
2
2.1
. Analysis and Conclusions
Analysis
.............
.....................
8
8
2.2 ....................
Conclusions 11
...................
(a) Findings 11
FB @) Probable Cause................ 11
Y, 3 . ..................
Recomendations 12

Appendices
Appendix A Invastigation and Hearing .... 13
Appendix B Crew Information . . . . . . . . . 14
Appendix C Aircraft Information . . . . . . . 15
Appendix D Flight Track ........... 17
Appendix E Transcript of Cockpit Voice
1-
Recording ...........
Appendix F Approach Plate for Cold Bay
19

Airport ............ 26
. Appendix ( Reconmendation .......... 27

.
iii

1
I
 File No. 1-0018

NATIONAL TRANSPORTATION SAFETY BOARD

WASHINGTON, D. C. 20591

AIRCRAFT ACCIDENT REPORT

Adopted: May 8, 1974

WORLD AIRWAYS, INC.

DC-8-63F, N802WA
KING COVE, ALASKA
SEPTEMBER 8, 1973

SYNOPSIS
About 0542 Alaska daylight time on September 8, 1973, World Airways,
Inc., Flight 802, a DC-8-63F, (N802WA), crashed into Mt. Dutton, near
King Cove, Alaska. The six occupants--three crewmembers and three non-
revenue company employees-were killed. The aircraft was destroyed by
impact and fire.

Flight 802 was a Military Airlift C o m n d contract cargo flight from

Travis AFB, California, to Clark AFB, Philippine Republic, with inter-
mediate stops at Cold Bay, Alaska, and Yokota AFB, Japan. It was cleared
for approach 125 miles east of the Cold Bay Airport. -The'last recorded
transmission from the flight to the Cold Bay flight service station was
that it was leaving 31,000 feet. The aircraft crashed at the 3,500-foot
level of Mt. Dutton, about 15.5 miles east of the airport.

The National Transportation Safety Board determines that the probable

cause of the accident was the captain's deviation from approved instrument
approach procedures. As a result of the deviation, the flight descended
into an area of unreliable navigation signals and obstructing terrain.
As a result of this accident, the Safety Board has made recommendations to
the Federal Aviation Administration.
1, INVESTIGATION

1.1 History of the Flight

World Airways, Inc., Flight 802, a DC-8-63F, (N802WA) was a Military

Airlift Command contract cargo flight from Travis AirForceBase (AFB),
California, to Clark AFB, Philippine Republic, with intermediate stops
at Cold Bay, Alaska, and Yokota AFB, Japan. .The crew reported to the
World Airways dispatch office at Oakland International Airport, Oakland,
California, at 2200 I-/. From there, they went by car to Travis AFB where
they were briefed by U. S . Air Force weather personnel. The crew filed
the following instrument flight rules (IFR) flight plan:

-1/ All times listed are Alaska daylight time, based on the 24-hour
clock.
 - 2 -

"william 1 Standard Instrument Department (SID), d i r e c t Ukiah, A t 05:

C a l i f o r n i a , c o n t r o l 1486 to gateway Redwood, d i r e c t 43'N-130%, VORTAC ?/
48°N-130%, d i r e c t 53'N-150%, d i r e c t 55'N-160%, d i r e c t Cold o f f i c e r , '1
Bay, a t f l i g h t l e v e l (FL) 310, true airspeed 480 knots, and I n respons
estimated time en route 4 hours 38 minutes." s a i d , "I g
first offi
The proposed a l t e r n a t e a i r p o r t , Anchorage, was l a t e r changed t o King t u r n , the
Salmon, Alaska. The f l i g h t was cleared a s f i l e d , except f o r achangeinSID. next minut
impossible
F l i g h t 802 departed Travis AFB a t 0111 and proceeded t o t h e v i c i n i t y for a circ
of i t s l a s t en r o u t e f i x , 55' N , 160' W, without i n c i d e n t . A t t h a t f i x , proach he
the crew was unable t o contact t h e Anchorage Air Route T r a f f i c Control r a i n they
Center (ARTCC) and f i n a l l y gave t h e i r p o s i t i o n r e p o r t t o t h e Cold Bay A t 0539, j
F l i g h t Service S t a t i o n ( F S S ) a t 0525. The d i s t a n c e from Cold Bay was l i t t l e hi$
reported t o be 125 d i s t a n c e measuring equipment @ME) miles, with an f o r t y DME:
estimated time of a r r i v a l of 0542. The Cold Bay FSS advised that the'
weather was ". . . measured c e i l i n g f i v e hundred overcast, v i s i b i l i t y A t 01
seven, with some very l i g h t d r i z z l e ... winds a r e t h r e e z e r o zero degrees no reason
a t two four with peak g u s t s a t three one ... the c e i l i n g s a r e ragged 4,000 fee!
and i t ' s been holding p r e t t y much t h a t way a l l evening .... I,
f i r s t off:
changed t'
A t 0527 F l i g h t 802 was cleared f o r an approach t o t h e Cold Bay A i r - seconds.
p o r t . Both transmissions were acknowledged. A t 0529, t h e f l i g h t re- heading w
ported i t was leaving 31,000 f e e t (FL 310). This was t h e l a s t recorded
transmission from F l i g h t 802. According t o f l i g h t data recorder (FDR) Af t e
information, t h e f l i g h t descended continuously and leveled off a t 3,500 radio a l t
f e e t 21. (See Appendix D.) "Twenty m
One forty
Although F l i g h t 802 was not cleared f o r a s p e c i f i c approach t o Cold hey John,
Bay, the only approved approach procedure, i n view of the weather and creased,
operating l i m i t a t i o n s , was t o use t h e l o c a l i z e r back course DME approach Six secor
t o runway 32. Two t r a n s i t i o n s a r e published f o r t h i s approach: (1) Pro- f e e t , on
ceed outbound on t h e l o c a l i z e r back course a t 7,000 f e e t t o t h e 19.5-mile
DME f i x , descend i n a procedure t u r n t o 3,500 f e e t on the west s i d e of the
l o c a l i z e r , and r e t u r n t o the 19.5-mile DME f i x . (2) I n t e r c e p t t h e 40-
1.2 x
mile DME f i x on t h e back course of t h e l o c a l i z e r and descend t o 3,500
f e e t inbound on t h e l o c a l i z e r before t h e a i r c r a f t reaches t h e 19.5-mile
DME f i x . (See Appendix F.) FJ
Nl
According t o the cockpit voice recorder (CVR) t r a n s c r i p t , a few NI
minutes a f t e r the f l i g h t s t a r t e d t o descend and during a discussion
about the a n t i c i p a t e d wind and approach speed, t h e c a p t a i n s a i d , " t h i r t y -
f i v e hundred f e e t m.s.1.". (See Appendix E.) The crew subsequently com-
1.3 x
pleted t h e in-range c h e c k l i s t , discussed t h e minimum descent a l t i t u d e The
(MA), and began tuning t h e navigation r e c e i v e r s . There was no mention i

of t h e s p e c i f i c instrument approach intended.

I -3; COl
f re
-21 A l l a l t i t u d e s and elevations a r e mean sea l e v e l .
 - 3 -

A t 0536, when t h e f l i g h t was about 35 n m i east of t h e Cold Bay

VORTAC 3 / and near t h e 3,500-foot level, t h e c a p t a i n asked t h e f i r s t
officer, 'Where's your DME?" The f i r s t o f f i c e r r e p l i e d , "Not Good.''
In response t o the c a p t a i n ' s remark, "No DME, huh?" the f i r s t o f f i c e r
said, "I got t h i r t y seven, we were f o r t y out the l a s t I saw." When t h e
f i r s t o f f i c e r asked t h e c a p t a i n whether he was going t o make a procedure
. .
turn, t h e c a p t a i n r e p l i e d , "No I . I wasn't going to." During t h e
next minute, t h e c a p t a i n s t a t e d four times t h a t without DME i t would be
impossible t o make the approach; he added t h a t t h e weather was too o lw
for a c i r c l i n g approach. 'The c a p t a i n d i d not explain w h a t type of ap-
proach he intended t o execute. When he was asked about t h e kind of ter-
r a i n they were f l y i n g over, t h e c a p t a i n s a i d , ''Mountains everywhere."
A t 0539, i n response t o the f i r s t o f f i c e r ' s question "we should be a
l i t t l e higher than t h a t out here, shouldn't we?" t h e c a p t a i n s a i d , "no,
f o r t y Dm, you're a l l r i g h t . "

A t 0540, t h e c a p t a i n s a i d , "I'll go up a l i t t l e b i t higher here

no reason t o s t a y down t h a t low so long." However, a f t e r climbing t o
...
4,000 f e e t momentarily, he again descended. A few seconds a f t e r t h e
f i r s t o f f i c e r reported, "I got twenty-four,'' t h e a i r c r a f t ' s heading was
changed t o 215O. This southwesterly heading was maintained f o r 30
seconds. During t h e remaining 70 seconds of t h e f l i g h t , t h e a i r c r a f t ' s
heading was changed from 215O t o 275O.

After h i s 24 DME c a l l o u t , t h e first o f f i c e r reported twice t h a t t h e

radio a l t i m e t e r was " alive" . About 22 seconds before impact, he reported
"Twenty miles," and t h e c a p t a i n responded, "Okay, what's t h e inbound?
One forty-one.'' The f i r s t o f f i c e r then s t a t e d , "Radio a l t i m e t e r s...
hey John, we're off course . . . ." Four seconds l a t e r , power was in-
creased, and t h e f i r s t o f f i c e r s a i d , "Four hundred f e e t from something."
Six seconds l a t e r a t 0542, t h e a i r c r a f t struck rising t e r r a i n , a t 3,500
f e e t , on t h e 087"radial, and 18 mi e a s t of t h e Cold Bay VORTAC.

1.2 I n j u r i e s t o Persons

Injuries -
Crew Passengers 0t h e r s

Fatal 3 0 3
Nonfatal 0 0 0
None 0 0

1.3 Damage t o A i r c r a f t

The a i r c r a f t was destroyed.

-3; Collocated very high frequency omnirange s t a t i o n and ultra- high

frequency t a c t i c a l a i r navigation a i d .
1.4 Other Damage

None
1.8 Aids t l
1.5 C r e w Information
The Co
The f l i g h t crewmembers were q u a l i f i e d f o r t h e f l i g h t . (See Appendix BJ west of the
northwest o

Company records i n d i c a t e t h a t t h e c a p t a i n flew i n t o Cold Bay 20

way 14/32
ground-and
-
times during t h e previous 9 years. No evidence was found t h a t he had
ever flown t h e l o c a l i z e r back course approach t o runway 32. Follow
the localiz
1.6 A i r c r a f t Information f e e t i s not
f i x , as f o l
The a i r c r a f t was properly c e r t i f i c a t e d and maintained according t o
current regulations. (See Appendix C.) -
Minim

1.7 Meteorological I n f o r m t i o n

The weather i n t h e Cold Bay a r e a consisted of o

lw overcast clouds
and strong, gusty, surface winds. The surface weather observations pre- After
ceding and following t h e accident were a s follows: i s authori:
published I
0455 -
- Measured ceiling- 500 f e e t , overcast, v i s i b i l i t y - 7 miles, very
l i g h t d r i z z l e , temperature-46' F . , dew point-45O F . , wind-300' The 1'
a t 24 knots, g u s t s t o 31 knots, a l t i m e t e r setting- 29.53 inches, only f o r a
10/10 of s t r a t u s clouds, c e i l i n g ragged. ILS. The
was approv
0555 - Measured ceiling- 500 f e e t , overcast, v i s i b i l i t y - 7 miles, tem-
- perature-45' F., dew point-45' F . , wind-300' a t 25 knots, The U
g u s t s 33 knots, a l t i m e t e r setting- 29.56 inches, 10/10 of f i e s the C
s t r a t u s clouds, c e i l i n g ragged, d r i z z l e ended a t 0530.

The a v i a t i o n terminal f o r e c a s t , which was issued by t h e National Weather

Service a t 1955 on September 7, was included i n t h e weather b r i e f i n g
given t o the crew a t Travis AFB.

P a r t of t h e Cold Bay 0315 winds a l o f t observation follows:

Heightsqeet) Direction ( t r u e ) Velocity (Knots)
1,000 320° 30 The i
3,000 330 32 runway 32
6,000 335 30
9,000 340 34
12,000 345 33
16,000 360 24
20,000 335 18
25,000 345 23
30,000 340 41
 - 5 -

1.8 Aids to Navigation

The Cold Bay airport is served by a VORTAC, about 4.5 miles north-
west of the airport; a low frequency radio range station, about 3 miles
northwest of the airport; and an instrument landing system (ILS) for run-
way 14/32. After the accident, navigational facilities at Cold Bay were
ground-and flight-checked; they operated satisfactorily.

Following completion of either of the two published transitions for

the localizer back course DME approach to runway 32, descent below 3,500
feet is not authorized until the aircraft has passed the 19.5-mile D m
fix, as follows:

Minimum altitude authorized (feet) DME fix (miles)

1,900 9.5
1,160 7.5
After the 7.5-mile DME fix is passed, descent to the MDA of 400 feet
is authorized. The 4.6-mile DME fix is the missed approach point. The
published minima for the DC-8-63F are 400 feet and 1 mile visibility.

The localizer back course DME approach to runway 32 is authorized

only for aircraft equipped for simultaneous reception of VOR, DME, and
ILS. The localizer and DME are not collocated. This approach procedure
was approved on March 11, 1971.

The U. S. Flight Information Publication, Alaskan Supplement, classi-

fies the Cold Bay VORTAC as unusable beyond 40 miles in the following areas:

Sector Belm altitude (feet)

040' - 060° 10,000

060°
0900
-- 01100
90' 9,000
8,000
110'
160'
-- 160"
1800
5,500
14,000
"800 - 290° 4,000
The approach chart for the localizer back course DME approach to
runway 32 listed the following minimum sector altitudes (MSA):
Sector -
Feet
360'
0900
-- 20970'0' 6,000
6,800
270' - 360° 2,800
 - 6 -

sions i n t l
MSA i s t h e miniam a l t i t u d e which provides a t l e a s t 1,000 f e e t of ob- and alined
s t a c l e clearance f o r emergency use w i t h i n 2 5 nmi of t h e f a c i l i t y , clock- a n a r e a ab(
wise between t h e s t a t e d magnetic bearings. The bearings t h a t d e f i n e sections 0:
s e c t o r s a r e outbound. t h e wreckat
1.9 Comnications The b
tensive.
The crew could not e s t a b l i s h radio connnunication with t h e Anchorage were conw
ARTCC. There were no other connnunication d i f f i c u l t i e s .
The 1
1.10 Aerodroae and Ground F a c i l i t i e s mately 30'
The Cold Bay Airport i s located on t h e western shore of Cold Bay a t The 5
an e l e v a t i o n of 98 f e e t . There a r e four l a r g e mountains within 30 miles. i z e r freql
Frosty Peak, 5,784 f e e t , i s about 8 miles south-southwest. Aghileen Pin- VOR (112 s f
nacles, 4,800 f e e t , and Pavlof Volcano, 8,215 f e e t , a r e about 23 and 31 cators W
miles, r e s p e c t i v e l y , northeast. M t . Dutton, 4,961 f e e t , &/ i s about 16 t h e capta:
miles east. Other mountainous t e r r a i n and i s l a n d s with elevations above RMI need11
2,000 f e e t e n c i r c l e most of Cold Bay. Low marshland and open sea l i e t o spectivel:
t h e north and west. internal 1
following
Runway 14/32, t h e instrument runway, i s 10,128 f e e t long and 150
f e e t w i d e , with an a s p h a l t surface. The west end of runway 8/26 i n t e r -
s e c t s t h e south end of runway 14/32. Runway 8/26 i s 5,126 f e e t long and
150 f e e t wide. Both runways have high i n t e n s i t y runway l i g h t s . Runway Cap t
32 has runway end i d e n t i f i e r l i g h t s and a v i s u a l approach slope- indicator Firs
l i g h t system.
The
1.11 F l i g h t Recorders measuring
t h e respc
The a i r c r a f t was equipped with a F a i r c h i l d Model F-5424, s e r i a l No.
5532, F l i g h t Data Recorder (FDR). The recorder was i n t a c t , with only
minor damage t o t h e o u t e r case. The f o i l recording medium was not
damaged, but the magnetic heading t r a c e was recorded a t 180° out of phase; Capi
t h i s condition had existed a t l e a s t s i n c e the a i r c r a f t ' s l a s t takeoff. Fir:
cap.
The a i r c r a f t was a l s o equipped with a F a i r c h i l d Model A-100, s e r i a l Fir!
No. 3028, Cockpit Voice Recorder (CVR). Although the recorder was damaged
mechanically, t h e tape was not damaged. A t r a n s c r i p t of the p e r t i n e n t por- The
t i o n s of the l a s t 18 minutes 23 seconds i s contained i n Appendix E. A measurem
c o r r e l a t i o n of t h e FDR and CVR records i s contained i n Appendix D. represen
frequenc
1.12 Wreckagg t i o n rec
The a i r c r a f t crashed i n t o a snowfield on the e a s t slope of M t . Dutton, bearing
a t t h e 3,500-foot l e v e l . The i n i t i a l impact l e f t f i v e d i s t i n c t impres-
The
positior
-4 / This i s the e l e v a t i o n shown on aeronautical c h a r t s . Other c h a r t s selectec
show an e l e v a t i o n of 4,834 f e e t . (See Appendix D.)
 - 7 -

sions i n t h e snow, which were shaped by t h e fuselage and t h e four engines

and alined on a heading of about 275O. The wreckage was s c a t t e r e d over
an area about 1,300 f e e t long and 300 f e e t wide. P a r t s of a l l major
sections of a i r c r a f t s t r u c t u r e and f l i g h t c o n t r o l surfaces were found i n
the wreckage a r e a .

The breakup of t h e a i r c r a f t ' s w i n g s , fuselage, and engines was ex-

tensive. Portions of t h e c e n t e r and a f t fuselage and w i n g r o o t areas
were consumed by ground f i r e .

The landing gear was r e t r a c t e d , and t h e f l a p s were extended approxi-

rcately 30'.

The No. 1 navigation receiver (VOR) was tuned t o the Cold Bay l o c a l -
i z e r frequency (110.3 MHz), and t h e No. 2 VOR was tuned t o t h e Cold Bay
VOR (112.60 MHz). Both needles on t h e Nos. 1 and 2 radio magnetic ind'i-
cators (RMI) were selected t o display VOR information. The needles on
the captain's RMI r o t a t e d f r e e l y ; the f i r s t o f f i c e r ' s No. 1 and No. 2
RMI needles were locked i n p o s i t i o n s of approximately 120° and loo, re-
spectively, clockwise from t h e top of t h e instrument. Examination of t h e
i n t e r n a l mechanism of t h e RMI's indicated t h a t they were displaying t h e
following information:

Heading No. 1 Needle No. 2 Needle

Captain's RMI 273' 20' 303O 20' 2870 20'

First O f f i c e r ' s RMI 275' 10' 44O 25' 285' 40'

The p i c t o r i a l d e v i a t i o n i n d i c a t o r s (F'DI) and t h e independent d i s t a n c e

measuring equipment @ME) i n d i c a t o r s were examined a t the f a c i l i t i e s of
the respective manufacturers. The following was found:

Heading Distance (Miles)

Captain's PDI 2 70° 934

F i r s t O f f i c e r ' s PDI 277' 22-33
Captain's DME Not Applicable 29.5
F i r s t O f f i c e r ' s DME Not Applicable 155

The c a p t a i n ' s navigation receiver was damaged mechanically, but

measurements w i t h i n t h e mechanism indicated a bearing of 25'. This would
represent t h e "parked position" associated with s e l e c t i o n of a l o c a l i z e r
frequency when the compass heading i s 295'. The f i r s t o f f i c e r ' s naviga-
t i o n r e c e i v e r w a s a l s o damaged; however, measurements indicated a 293.5'
bearing t o the VOR s t a t i o n s e l e c t e d .

The c a p t a i n ' s Doppler c o n t r o l box function switch was i n the manual

position, and t h e o f f s e t indicated was 5 miles, l e f t . Course A was
selected and set a t 259'. The "miles-to-go" i n d i c a t i o n was 17.5 miles.

c
 - 8 -

1.13 Medical and Pathological Information The f l l

called the (
The p a t h o l o g i s t determined t h a t the deaths of t h e s i x persons were Anchorage AI
caused by impact. Thermal i n j u r i e s occurred post mortem. thereafter,
f o r an apprg
1.14 -
Fire reference t l
between t h e
A severe ground f i r e penetrated t h e fuselage i n the wing r o o t a r e a pating a ba'
and consumed l a r g e portions of t h e s t r u c t u r e . Smaller i s o l a t e d ground t i o n , i t wa
f i r e s damaged t h e a f t fuselage, the separated w i n g s e c t i o n s , and the en-
gines. The crash s i t e was not a c c e s s i b l e t o f i r e f i g h t i n g equipment.
approach
fore the f i
.
have been t
1.15 Survival Aspects the t r a n s i t
a t 7,000 f e
This accident was not survivable. conclusion
asked him w
1.16 Tests and Research s a i d , "No,

Not applicable. The c i

mile DME f i
1.17 Other Information 3,500 f e e t
t i o n , have1
Recently, the Safety Board received d e t a i l s of an incident which in- cedure. Ht
volved a DC-8-63F a i r c r a f t during an approach t o t h e Cold Bay Airport on a i r c r a f t wi
October 3, 1973. According t o t h e crewmember who reported t h i s i n c i d e n t , indicating
the f l i g h t was making a "back door" approach t o runway 32. None of t h e significant
crewmembers were experienced with t h i s approach. A t 25 D m , while t h a t back courm
a i r c r a f t was approaching t h e Cold Bay VOR from t h e e a s t , and a t an a l t i - o f f i c e r re]
tude of about 4,000 f e e t , t h e "DME began searching and became e r r a t i c . " c a p t a i n prl
This crewmember c a l l e d t h e e r r a t i c behavior of t h e DME t o t h e a t t e n t i o n course of
of t h e c a p t a i n . As the f l i g h t broke out of the overcast, t h e crew I f he had
noticed mountains innnediately t o the l e f t and r i g h t of t h e f l i g h t p a t h ; 2 minutes
t h e a l t i t u d e was 3,500 f e e t , and t h e DME showed "around 22 a s i t came i n aircraft w
strong a t t h e time." The f l i g h t completed a v i s u a l approach t o t h e run- avoided a
way. During a discussion a f t e r t h e i n c i d e n t , t h e crew concluded t h a t westerly h
t h e i r examination of t h e approach c h a r t before t h e approach had produced westerly h
that led h
a "mental p i c t u r e " t h a t t h e approach t o t h e 20-mile DME point would be
over water. The reporting crewmember s t a t e d , "Close s c r u t i n y of the o f f - -
a-t S 2 ! 9
. ..
r o u t e s e c t o r a l t i t u d e s shaved us t h a t our approach should have been mini-
mum s e c t o r a l t i t u d e u n t i l established o n , t h e approach leg and 40 DME." As a
I operated f
! 2. ANALYSIS AND CONCLUSION r a i n woulc
retically,
2.1 Analysis Signal S t 1
ever, t h e
The flightcrew was q u a l i f i e d , and t h e a i r c r a f t was maintained accord- though tht
i
n g t o FAA and company procedures. There were no malfunctions of t h e a i r - unusable,
c r a f t systems o r powerplants. A l l ground navigational f a c i l i t i e s operated t o keep t i
w i t h i n tolerances.
 - 9 -

The f l i g h t proceeded r o u t i n e l y u n t i l about 0525, when t h e crew

called t h e Cold Bay FSS and reported that they were unable t o contact
Anchorage ARTCC. They were 125 miles from Cold Bay a t FL 310. Shortly
thereafter, they were given the current Cold Bay weather and were cleared
for an approach t o t h e Cold Bay a i r p o r t . Although t h e r e was no s p e c i f i c
reference t o t h e type of approach the crew intended t o make, conversation
between t h e c a p t a i n and t h e f i r s t o f f i c e r indicated t h a t both were a n t i c i -
pating a back course approach t o runway 32. Because of t h e wind condi-
tion, i t was necessary t o use runway 32; t h e c e i l i n g precluded a c i r c l i n g
approach. However, because t h e a i r c r a f t descended through 5,000 f e e t be-
fore t h e f i r s t o f f i c e r reported t h a t h i s DME was "not good", i t mst not
have been t h e i n t e n t of t h e captain, who was f l y i n g t h e a i r c r a f t , t o use
the t r a n s i t i o n t h a t required f l y i n g outbound on t h e l o c a l i z e r back course
a t 7,000 f e e t t o prepare f o r t h e back course approach t o runway 32. This
conclusion i s supported by t h e c a p t a i n ' s response when t h e first o f f i c e r
asked him whether he was going t o make-a procedure turn,. and t h e c a p t a i n
said, "No, I wasn't going to."

The c a p t a i n ' s only authorized a l t e r n a t i v e was to i n t e r c e p t t h e 40-

mile DME f i x on t h e back course of t h e l o c a l i z e r and descend, inbound, t o
3,500 f e e t before he reached t h e 19.5-mile DME f i x . There i s no indica-
tion, however, that t h e c a p t a i n planned t o adhere p r e c i s e l y t o t h i s pro-
cedure. H e maintained a westerly heading toward the VORTAC u n t i l t h e
a i r c r a f t was about 25 DMF,-miles from t h e VORTAC, d e s p i t e h i s remarks
indicating t h a t he r e a l i z e d he was w i t h i n t h e 40-mile range. The f i r s t
s i g n i f i c a n t heading change, which indicated an attempt t o i n t e r c e p t t h e
back course of t h e l o c a l i z e r , was not made u n t i l s h o r t l y a f t e r the f i r s t
o f f i c e r reported a 24-mile DME r e a d i n g s o r the sake of expediency, t h e
captain probably intended t o p o s i t i o n t h e a i r c r a f t inbound on t h e back
course of t h e l o c a l i z e r , between t h e 40-mile and t h e 19.5-mile DME f i x e s .
I f he had maintained t h e southwesterly heading, which he i n i t i a t e d about
2 minutes before impact, u n t i l he received r e l i a b l e i n d i c a t i o n s t h a t t h e
a i r c r a f t was about 30° from t h e l o c a l i z e r c e n t e r l i n e , he would have
avoided a c o l l i s i o n with the mountain. Actua'lly, he maintained the'south-

q- &@ .-__--
- s o u l of i t . -
westerly heading f o r only 30 seconds before he made a r i g h t t u r n t o a
westerly heading. Therefore, t h e c a p t a i n must have received i n d i c a t i o n s
that led him t o b e l i e v e t h a t he was- of t h e V m C instead of
4

As a r e s u l t of t h e en r o u t e descent t o 3,500 f e e t , the f l i g h t

operated f o r about 6 minutes before t h e crash i n an area where high ter-
rain would have a f f e c t e d t h e r e l i a b i l i t y of t h e VORTAC signals. Theo-
r e t i c a l l y , descent below t h e l i n e of s i g h t t o t h e VORTAC should reduce
signal s t r e n g t h t o a point a t which warning f l a g s should appear. H m -
ever, t h e CVR does not i n d i c a t e t h a t the warning f l a g s appeared. A l -
though t h e a i r c r a f t had descended i n t o the a r e a where t h e VORTAC was
unusable, the r e f l e c t e d s i g n a l s t r e n g t h , apparently, was s u f f i c i e n t
t o keep t h e VOR warning f l a g s biased from view. According t o CVR
 - 10 -
d a t a , t h e only i n d i c a t i o n t h a t t h e crew noticed an i r r e g u l a r i t y was t h e one". This
first o f f i c e r ' s remark t h a t h i s DME was "not good". That remark coincided t h a t t h e cap
with the a i r c r a f t ' s descent through 4,500 f e e t and may have been prompted t h e 19.5-mil
by i n t e r m i t t e n t operation of t h e f i r s t o f f i c e r ' s DME such a s t h a t des- s a i d , "Radio
cribed by t h e crew involved i n t h e approach i n c i d e n t near Cold Bay. The sound of inc
crew of F l i g h t 802 were apparently unaware of the t e r r a i n - r e l a t e d re- remark: "Fc
s t r i c t i o n s of t h e navigation s i g n a l s and made no attempt t o climb higher trace showed
f o r b e t t e r s i g n a l reception. Despite h i s monologue about the problems pact.
associated with l o s s of t h e DME, t h e c a p t a i n apparently kept relying on
the readings he received. Actually, the DME c a l l o u t s by t h e f i r s t o f f i c e r I n sum
of 37, 35, 29, 24 and 20 miles were a l l accurate. c r a f t not 01
t h e publish1
The p r o b a b i l i t y t h a t t h e f l i g h t ' s r i g h t t u r n t o a westerly heading, MvigatiOM'
about 20 seconds before impact, was based on erroneous azimuth informa- Lnterpretat:
t i o n i s supported by t h e reading obtained from t h e f i r s t o f f i c e r ' s vi- t h a t t h e c~
g a t i o n r e c e i v e r , which was tuned t o t h e Cold Bay VORTAC. The bearing mile range
mechanism of t h e recovered r e c e i v e r , indicated a 293.5O magnetic bearing
t o t h e VORTAC. The bearing from the crash s i t e t o t h e VORTAC, however,
cedures .
was 267". A t impact, the f i r s t o f f i c e r ' s navigation receiver controlled Since
t h e i n d i c a t i o n s of t h e No. 2 needles of both RMI instruments. The in- r a i n , he ob
t e r n a l mechanism of t h e c a p t a i n ' s RMI showed a 287O bearing t o t h e t i o n displa
VORTAC; t h e f i r s t o f f i c e r ' s , a 285" bearing. I f t h e e f f e c t s of impact of security
a r e considered, t h e r e a d i s on these instruments apparently corres- a l t i t u d e as
ponded c l o s e r t o the 2 9 3 . 9 input from t h e first o f f i c e r ' s navigation localizer.
r e c e i v e r than t o t h e 267' bearing of t h e c r a s h location. Therefore, t h e t o make, tl
Safety Board concludes t h a t the a i r c r a f t ' s o lw a l t i t u d e , i n conjunction ject t h e PI
with t h e intervening mountainous t e r r a i n , r e s u l t e d i n t h e d i s p l a y of er- soundness (
roneous azimuth information. which l e d t h e c a u t a i n t o b e l i e v e t h a t he was
southeast of the VORTAC and approaching the ILS back course. 2.2
Although t h e c a p t a i n had flown i n t o Cold Bay 20 times over a period a: 2
of 9 y e a r s , t h i s was only h i s second recent t r i p , and t h e f i r s t time he
had attempted t o f l y t h e back course approach. Nevertheless, h i s o v e r a l l 1
f a m i l i a r i t y with t h e t e r r a i n i n t h e Cold Bay a r e a was apparent from h i s
words, "mountains everywhere," i n response t o one of t h e f i r s t o f f i c e r ' s
questions. The reason f o r h i s ignoring t h e information shown on t h e ap-
proach c h a r t , t h a t indicated prominent peak e l e v a t i o n s and minimum s e c t o r
a l t i t u d e s , could not be found.

About 2 minutes before impact, t h e f i r s t o f f i c e r s a i d , 'We should

be a l i t t l e higher than t h a t out here, shouldn't we?" The c a p t a i n ' s
answer, "No, f o r t y DME you're a l r i g h t , " implies t h a t he believed t h a t t h e
minimum authorized a l t i t u d e of 3,500 f e e t a t t h e 40-mile DME f i x a l s o ap-
p l i e d t o ' t h e a r e a from which he was approaching t h e l o c a l i z e r . To sub-
sequent c a l l o u t s from the f i r s t o f f i c e r t h a t t h e radio a l t i m e t e r was
" alive" t h e c a p t a i n responded, "Okay", without i n d i c a t i o n of alarm.

Twenty-two seconds before impact, t h e f i r s t o f f i c e r reported, "Twenty

miles", and t h e c a p t a i n responded, "Okay, what's the inbound? One f o r t y -
 - 11 -
one". This response and t h e r i g h t t u r n i n i t i a t e d simultaneously suggest
that the c a p t a i n intended t o i n t e r c e p t the back course near, o r i n s i d e ,
the 19.5-mile D M f i x . Twelve seconds before impact, t h e f i r s t o f f i c e r
.
said, "Radio a l t i m e t e r s . . hey John, we're off course". The subsequent
sound of increased engine power coincided with t h e f i r s t o f f i c e r ' s f i n a l
remark: "Four hundred f e e t from something". The a i r c r a f t ' s a l t i t u d e
trace showed t h a t a pullup maneuver was s t a r t e d a few seconds before im-
pact.

I n surmnary, t h e i n t e n t i o n a l descent t o 3,500 f e e t placed t h e air-

c r a f t not only i n an a r e a of u n r e l i a b l e VORTAC s i g n a l s , but a l s o below
the published minimum s e c t o r a l t i t u d e . Although t h e readings of t h e
navigational instruments i n t h e a r e a of VORTAC u n r e l i a b i l i t y , and t h e i r
i n t e r p r e t a t i o n by t h e crew, a r e subject t o conjecture, evidence shows
that the c a p t a i n intended t o i n t e r c e p t t h e ILS back course w i t h i n t h e 40-
mile range from t h e VORTAC, which was contrary t o approved approach pro-
cedures.

Since t h e c a p t a i n would not knowingly r i s k c o l l i d i n g with high ter-

rain, he obviously d i d not f a m i l i a r i z e himself with t h e e s s e n t i a l informa-
tion displayed on t h e approach c h a r t . He may have acquired a f a l s e sense
of security by focusing h i s i n t e n t i o n on t h e 3,500-foot minimm authorized
a l t i t u d e associated with t h e 40-mile DME f i x on t h e back course of t h e
localizer. Had t h e c a p t a i n indicated what type of approach he intended
t o make, t h e f i r s t o f f i c e r would have been i n a b e t t e r p o s i t i o n t o pro-
ject the planned approach path on t h e approach c h a r t and question t h e
soundness of the c a p t a i n ' s plan.

2.2 Conclusions

a: Findings

1. The a i r c r a f t was properly c e r t i f i c a t e d , and t h e r e was no

known malfunction of t h e a i r c r a f t or i t s components.

2. The crewmembers were properly c e r t i f i c a t e d and q u a l i f i e d .

3. Air t r a f f i c c o n t r o l handling was r o u t i n e .

4. The weather f o r e c a s t was accurate.

5. A l l a i d s t o navigation a t Cold Bay were operating properly.

6. The only approach procedure t h a t was authorized under t h e

weather conditions was t h e l o c a l i z e r back course DME
approach t o runway 32.
7. The c a p t a i n d i d not comply with the approved instrument ap-
proach procedures.
 - 12 -
8. The captain was apparently not aware of the m i n i m Sector
altitudes, the published restrictions on the use of the Cold
Bay VORTAC, or the specific location of Mt. Dutton.

b. Probable Cause
The National Transportation Safety Board determines that the probable
cause of the accident was the captain's deviation from approved instrument
1. -
Invest

approach procedures. As a result of the deviation, the flight descended The S;

into an area of unreliable navigation signals and obstructing terrain. 1973, by tl
sent to thq
3 . RECOMMENDATIONS operations
records, s
AS a result of this accident, the Safety Board on May 24, 1974, sub- flight dat'
mitted recomnendation A-74-53 to the Administrator of the FAA. A COPY of Administra
the recomnendation letter is included in Appendix G. Teamsters,
was conple

BY THE NATIONAL TRANSPORTATION SAFETY BOARD 2. -

Heari

/s/ JOHN H. REED There

Chairman

/s/ FRANCIS H. McADAMS

Member
/s/ LOUIS M. THAYER
Member

/s/ ISABEL A. BURGESS

Member

/s/ WILLIAM R . HALEY

Member
 APPENDIX A

INVESTIGATION AND HEARING .

. 1

1. Investigation

The Safety Board was notified of the accident at 0750 on September 8 ,

1973, by the Federal Aviation Administration. An investigation team was
sent to the scene of the accident. Working groups were established for
operations, air traffic control, weather, human factors, maintenance
records, structures, systems, powerplants, cockpit voice recorder, and
flight data recorder. Interested parties included the Federal Aviation
Administration, World Airways, Inc., International Brotherhood of
Teamsters, and McDonnell Douglas Corporation. The on-scene investigation
was completed on September 17, 1973.

2. Hearing

There was no public hearing.

 - 14 -

APPENJXX B

CRhV INFORMATION

N80,
Captain John A. Weininger by World
hours be
Captain John A. Weininger, 52, held A i r l i n e Transport P i l o t Certifi- service
c a t e No. 462310, w i t h r a t i n g s f o r a i r p l a n e multiengine land, Lockheed & Whitnq
C o n s t e l l a t i o n , DC-6, E - 7 , DC-8, B-707/720, and commercial p r i v i l e g e s
f o r a i r p l a n e single- engine land and multiengine sea. He had accumulated
about 22,913 flight- hours, including 1,969 hours i n t h e E - 8 . H i s l a s t -
Po s
proficiency check was completed on J u l y 1, 1973, and h i s FAA f i r s t - c l a s s
medical c e r t i f i c a t e was issued April 11, 1973, with no l i m i t a t i o n s .

F i r s t O f f i c e r Gregg W. Evans

F i r s t Officer Gregg W. Evans, 2 7 , held A i r l i n e Transport P i l o t The

C e r t i f i c a t e No. 1730363, with r a t i n g s f o r a i r p l a n e multiengine land, of g r a v i
E-3, and commercial p r i v i l e g e s f o r a i r p l a n e single- engine land. H e had limits.
accumulated about 4,984 f l i g h t - h o u r s , including 457 hours i n the E - 8 . t h e crasl
H i s l a s t proficiency check was completed on February 8, 1973, and h i s FAA
f i r s t - c l a s s medical c e r t i f i c a t e was issued September 4 , 1973, with no All
limitations. from Augr
appropri;
F l i g h t Engineer Robert W. Brocklesby resupply
required
F l i g h t Engineer Robert W . Brocklesby, 46, held F l i g h t Engineer
C e r t i f i c a t e No. 1370804, with both t u r b o j e t and reciprocating powered
r a t i n g s . He had accumulated 9,830 f l i g h t - h o u r s , including 542 hours in
t h e DC-8. H e completed h i s t r a i n i n g i n t h e DC-8 on February 1 9 , 1973,
and h i s FAA second-class medical c e r t i f i c a t e was issued on J u l y 10, 1973,
with no l i m i t a t i o n s .

The c a p t a i n had been o f f duty f o r 53 hours before reporting f o r this

f l i g h t . The f i r s t o f f i c e r and f l i g h t engineer had been off duty for a
week. A l l t h r e e crewmembers had 7 hours 42 minutes of duty time and 4
hours 31 minutes of f l i g h t time f o r t h e 24-hour period preceding the
accident.
 - 15 -

APPENDIX C

AIRCRAFT INFORMATION

N802WA. a McDonnell Douglas DC-8-63F, serial No. 46146, was purchased

by World Airways, I n c . , on March 12, 1971. I t had been flown 10,077
hours before t h e accident f l i g h t . The last major inspection, phase
service check 3, was accomplished on September 5 and 6, 1973. Four P r a t t
& Whitney JT3D-7 engines were i n s t a l l e d as follows:

Position S e r i a l No. Time Since Overhaul Total T i m e

1
2
P671273
P67 1437 ---
4,790.57
---
6,884.58
8,594.57
3
4
P671337
P678974 --- 11,019.04
8,199.22

The computed takeoff gross weight was 332,992 pounds, and t h e center
of gravity was about 26.4 percent MAC. Both were within t h e allowable
limits. The estimated gross weight and center of g r a v i t y a t t h e time of
the crash were 262,992 pounds and 25 percent MAC, respectively.

A l l discrepancies listed on t h e a i r c r a f t maintenance log sheets

from August 1, 1973, through September 7 , 1973, were cleared through
appropriate maintenance action. The only deferred item concerned t h e
resupply of Doppler log sheets. The only open Airworthiness Directives
required r e p e t i t i v e inspections of t h e landing gear and c o n t r o l column.
G

---
a 0
SCALE
s IO
nautical miles
 WSVlV ‘3A03 9NIW
BO/ESL lH9114 ‘VMZ08N ‘43E9-8 30
‘3NI ‘SAVMMlV OWOM
 - 19 -
Appendix E

TRANSCRIPTION OF COCKPIT VOICE ReCORDEX DATA FAIRCHILD A- 100,

S I N 7028. WORLD ATRWAYS DOUGLAS MONL K-8-63CF, N8CeWA,

LEGEND

Cockpit a r e a microphone

Radio transmissions from World Airways Flight BO2

Voice i d e n t i f i e d a s Captain

Voice i d e n t i f i e d a s F i r s t Officer

Voice i d e n t i f i e d a s Second Officer

Nonrevenue company personnel

Voice u n i d e n t i f i e d

Cold Bay F l i g h t Service S t a t i o n

U n i n t e l l i g i b l e word

Nonpertinent word

Breaks i n c o n t i n u i t y

Questionable t e x t

Editorial insertion

Pause

Note: Times expressed i n elapsed time.

 - 20 -
TIME & SOURCE c o r n

0O:ll.O
RW-2 Ah, Cold Bay World e i g h t zero two, good
morning one twenty-six seven

00:21.0
CB World e i g h t zero two, World e i g h t zero two
Cold Bay

00:48.0
RW -2 Okay, we're unable t o reach Anchorage on
one eighteen f i v e , we're now one hundred,
one hundred and twenty-five DME out

01:Ol.O
CB World e i g h t zero two Cold Bay roger, under-
stand hundred and twenty-five DME out and,
ah, requesting, ah, a approach clearance?

01:49.0
REO-2 And World e i g h t zero two overhead Cold
Bay a t four two

01:59.5
CB World e i g h t zero two, Cold Bay roger,
'n what's your a l t i t u d e ?

02:03.0
RW-2 And we're l e v e l t h r e e one zero sir

02:08.0
CB World e i g h t zero two Cold Bay roger, and our
current weather, we're p r e s e n t l y f i v e hundred
measured c e i l i n g f i v e hundred, our measured
c e i l i n g f i v e hundred overcast, v i s i b i l i t y
seven with some very l i g h t d r i z z l e . Tempera-
t u r e i s four six, dew point four f i v e , winds
a r e t h r e e zero zero degrees a t , a t two four
with peak gusts a t t h r e e one, a l t i m e t e r ' s two
n i n e r f i v e three, t h e c e i l i n g s a r e ragged
and i t ' s been holding p r e t t y much, ah, t h a t
way a l l evening, over

0;?:36.0
RDO-2 Eight zero two roger

02:37.5
CAM-1 Same thing I copied a long time ago

03:21.0
CB A n : c l e a r s World e i g h t zero two f o r an
approach t o t h e Cold Bay Airport
 - 21 -

TIME & SOURCE CONTEXT

03:27.0
RBI2 Okay World e i g h t zero two, cleared f o r
t h e approach

CAM-2 That's t h e f i r s t time I ' v e ever been

c l e a r e d for an approach l i k e t h i s ?
who00 :
04:20.0
CAM Sound of Cold Bay low frequency range
"A" quadrant

05:OT.O
RD0-2 World e i g h t zero two descending out of
t h r e e one zero

05:22.0
CAM Sound of a l t i t u d e a l e r t

07:43.5
CAM-1 Thirty-five hundred f e e t m.s.1.

08:lb.O Want t o wake everybody up and g e t

CAM-1 'em up here, please?

08:30.0
CAM-1 In range check. What was t h a t a l t i m e t e r ?

CAM-2 Two nine f i v e t h r e e

CAM2 We're out of eighteen ( ( c a l l out on

in-range c h e c k l i s t ) )

@:20.5
CAM2 Do you want t h e ILS now John?

CAM-1 Yeah, soon as I g e t i n here about

f i f t y miles, 1'11 put it on

@:57.5
CAM2 MDA i s four hundred i s n ' t it?

CAM4 Yeah

10:07.0
CAM-3 In-range complete
 - 22 -

TIME & SOURCE CONTENT

CAM2 MM four Yorty

CAM-1 Four hundred and f o r t y ----

which i s about a hundred foot and
be, ah, f i v e f o r t y indicated

CAM-1 Ahh, we're a l i t t l e high, t h i n k 1'11

diddle around here, got a l i t t l e slow
g e t t i n g down, kinda help t o wake up t h e
passengers

11:16.0
CAM-1 Do you want t o p u t t h e heat on ----
scoops on, and a, a l l o f them, a l l t h e
way across

11:43.5
CAM-2 Okay, you're out of t e n

11:45.5
CAM-1 Okay, I can put t h e ILS on mine. Ten
three

11:50.5
CAM Sound of Cold Bay 1;s i d e n t i f i e r begins

m-(2) And t h r e e twenty-two i n t h e window

CAM-2 Okay, your ILS i d e n t i f i e s , d'ya hear it?

12:51.5
CAM-2 (Forty) five

CM-1 Where I s your CME?

CAM-2 Not good

CAM-1 #, no huh?

13:15.5
CAM-2 I got thirty- seven, we were f o r t y
out t h e l a s t I saw
 IC-
- 23 -

TIME & SOURCE CONTENT

13:16.0
CAM Sound o f a l t i t u d e a l e r t ( ( a t same time
word " t h i r t y " above ) )

13:19.0
CAM-2 Okay t h i r t y - f i v e

CAM-1 That doesn't help me much ----

right
when I need it goes t o ----"pitow"
---- how's your VOR, i s it working?

CAM-1 Gctta h a f t a , h a f t a go i n t o t h e f i e l d now

CAM-2 Into the station?

What, ah, a r e you going do a procedure

turn, John?

CAM-1 No I ---- no I wasn't going t o

CAN- 1 #, you c a n ' t even make a back course without,

without m yimpossible!

CAM- 1 Can't be done!

CAM-1 The whole t h i n g is predicated on o f f of

t h e , ah, VCRTAC, ----
without t h a t i t ' s
impossible approach. You might ----
there
i t ' s starting t o roll

CAM-1 Yeah, without DME: you c a n ' t make it!

CAM-1 I t ' s too low f o r a c i r c l i n g

14:31.5
CAM-2 Do you know what the t e r r a i n i s l i k e out
here ---- where's t h a t mountain t h a t you
were t a l k i n g about
CAM-1 Mountains every where

CAM Sound of engine power increase

I
 - 24 -

TIME & SOURCE CONTENT

CAM-1 Try t h e VOR on mine

CAM-2 J u s t a second

l4:55.5
CAM-2 I ' v e got twenty-nine miles (now)

CAM- l Okay back t o t h e ILS

CAM-2 We should be a l i t t l e higher than t h a t

out here shouldn't we?

CAM-1 No, f o r t y DME you're a l l r i g h t

CAM2 You're a l l r i g h t

CAM-1 You got a for----

CAM-2 You're all r i g h t

CAM- 1 You got, ah, f o r t y reading, but then

you l o s t t h e bloody t h i n g

CAM Sound o f power increase

15:kO.O
CAM Sound of a l t i t u d e a l e r t

CAM-1 I ' l l go up a l i t t l e b i t higher here ----

no reason t o s t a y down t h a t low so long

CAM Sound of power decrease

16:14.0
CAM-2 I got twenty-four

CAM-1 Okay

l6:41.5
CAM-2 The r a d i o a l t i m e t e r i s a l i v e

16:42.5
CAM Sound of a l t i t u d e a l e r t

CAM- l Okay, good

 - 25 -

TIME & SOURCE CONTENT

16:50.5
CAM Sound of a l t i t u d e a l e r t

17:20.5
CAM-1 Flaps twelve

CAM Sound of heavy c l i c k

17:32.5
CAM-2 Radar a l t i m e t e r ' s a l i v e , again

CAM-1 Okay

CAM-1 Ehhh

CAM-2 Airspeed

CAM-1 Yeah

18:ol.o
CAM-2 Twenty miles

18:w.o
CAM-1 Okay, what's t h e inbound? One forty-one

18:n.o
CAM-2 Radio a l t i m e t e r s * hey John we're off
course, # $

18:15.0
CAM Sound of power increase

18:16.0
CAM-2 Four hundred f e e t from somethin'

18:17.0
CAM-( 3) ("Let's have it" o r "shove it" )
((appears simultaneously with
word "somethin'" above))

18:22.5
CAM-1 Get back

18:23.0
CAM Sound of impact
 - 26 - APHNDIX
F
Z%wesen Approach Ch.ld NOV 12.7 I
(112) 98' COLD BAY, ALASKA
CO L D O A V R 122.1 126.7 2861 3023.56
~ J ~ O +,. 61ev COLD BAY
5631 LociBACK CRS DME ~ ~ ~ 3 2
Var 17'E LOC 110.3 ICDB E::'
I I

(3410') 19.5 DHI

 - 27 -
NATIONAL TRANSPORTATION SAFETY BOARD
WASHINGTON, D.C.

APPENDIX G

ISSUED: May 24, 1974

___________________----------------------
Forwarded to:

Honorable Alexander P. B u t t e r f i e l d
Administrator SAFETY RECOMMENDATION(S)
Federal Aviation Administration
Washington, D. C. 20591

On September 8, 1973, a World Airways E-8 was involved i n an

accident near King Cove, Alaska. The National Transportation Safety
Board's investigation has focused a t t e n t i o n on t h e instrument approach
procedure (IAP)f o r t h e ILS back course (BC) DME approach t o runway 32
a t the Cold Bay Airport , i n Cold Bay, Alaska.

Depicted on t h e p e r t i n e n t IAP chart i s a 40-mile DME i n i t i a l

approach f i x (IAF)and a prescribed minimum a l t i t u d e (MA) of 3,500
feet f o r inbound f l i g h t s a f t e r they pass t h e IAF. The Safety Board
i s concerned that t h i s information could l e a d t o a hazardous approach
situation i f t h e flightcrew e i t h e r misinterprets these data, or lacks
specific knowledge of other information not found on an IAP c h a r t .
For example, knowledge of s p e c i f i c distances and a l t i t u d e s a t which
NAVAID signals from t h e Cold Bay VOR a r e reported a s "unusable" i s
essential f o r t h e p i l o t who e l e c t s t o begin an IAP t o runway 32 from
mer the 40-mile IIME IAF. Such i n f o m a t i o n i s a l s o important because
the en route MA i s lower than t h e minimum reception a l t i t u d e (MRA)
specific f o r the a r e a beyond t h e 40-mile IAF. The IAP c h a r t does not
provide that information.

I n t h e World Airways accident, t h e f l i g h t was inbound t o Cold Bay,

from over t h e P a c i f i c Ocean e a s t of Cold Bay. The crew reported t h e
f l i g h t ' s p o s i t i o n t o Cold Bay FSS a s "125 DME out a t FL 3lO." Clearance
was issued f o r "...an approach t o t h e Cold Bay Airport." The crew began
an immediate en r o u t e descent t o 3,500 f e e t .
-
-,

-28 -
Honorable Alexander P. B u t t e r f i e l d (2)

According t o t h e CVR t r a n s c r i p t , t h e crew discussed t h e requirements

and s p e c i f i e d minima for t h e ILS back course DME approach t o runway 32
of t h e Cold Bay Airport. Crew conversation revealed that t h e c a p t a i n
d i d n o t plan t o make a procedure turn. After c a l l i n g out a DE reading
of 29 miles, t h e c o p i l o t questioned t h e captain, "We should be a l i t t l e
I
higher than that out here shouldn't we?" The captain r e p l i e d , "No,
f o r t y DME you're a l l r i g h t . " About 3 minutes 18 seconds l a t e r the
a i r c r a f t s t r u c k M t . Gutton a t t h e 3,500-foot l e v e l . M t . Dutton i s
about 17 miles east of t h e Cold Bay Airport, 15 miles NE of t h e pre-
s c r i b e d final approach course of runway 32.

The s i g n i f i c a n t f a c t o r s i n t h e accident were t h e following:

1. The f l i g h t descended en r o u t e t o 3,500 f e e t m.s.1.

without reservation.

2. According t o t h e information published i n the Alaska

Supplement of t h e F l i g h t Information Publication (FIP),
when t h e f l i g h t descended below 9,000 f e e t , it entered
an a r e a i n which t h e Cold Bay VORTAC s i g n a l s a r e reported
as "unusable. "

3. The descent a l t i t u d e s e l e c t e d by t h e crew coincided with

t h e 3,500 f e e t MA specified f o r an inbound f l i g h t on t h e
f i n a l approach t r a c k between t h e 40-mile DIE UIF and t h e
19.5-mile intermediate f i x ( IF ).

The Safety Board does not question t h e accuracy of t h e data

presented on t h e e x i s t i n g LAP c h a r t , nor does it question t h e procedure
as depicted. The LAP is s a t i s f a c t o r y with r e s p e c t t o t h e c r i t e r i a upon
which it was established. However, we believe t h e r e i s s u f f i c i e n t
evidence t o show t h a t misunderstanding of t h e procedure i s possible.

Another i n c i d e n t involving an apparent misunderstanding of t h e

ILS back course DME approach t o runway 32 a t Cold Bay occurred on
October 3, 1971. The p i l o t of t h e x-8 t o l d t h e Safety Board that h i s
f l i g h t was inbound to Cold Bay from California on t h e same approximate
r o u t e flown by t h e World Airways x-8.

According t o t h e p i l o t ' s statement, t h e approach p l a t e was s t u d i e d

and discussed. Descent t o 3,500 f e e t was s t a r t e d . To t h e b e s t of h i s
recollection, " ... an i n t e r c e p t angle t o t h e back course was t o be
established ... my f i r s t concern during t h e approach was around rn 25
and a l t i t u d e of around 4,000 f e e t m.s.1. The I%C3 began searching and
became e r r a t i c . We had entered s c a t t e r e d t o broken clouds a t around
6,000 m.s.1. and a t t h a t time t h e r e was no v i s i b i l i t y . ...
I called
out t h e e r r a t i c behavior of t h e DME t o t h e captain. Almost immediately
 - 29 -
Honorable Alexander P. B u t t e r f i e l d (3)

we became contact and a mountain with l a r g e g l a c i e r s was s i g h t e d c l o s e

off our l e f t wing and extending i n t o t h e cloud formation." The f l i g h t
proceeded VFR t o Cold Bay and landed on runway 32.

The p i l o t s t a t e d f u r t h e r t h a t , "the thinking had been t h a t i f we

were not e s t a b l i s h e d on t h e ILS course by t h e 20 DME, a 20 DME c i r c l e
would be maintained u n t i l on course. Also, descent t o 3,500 f e e t m.s.l.,
would be accomplished by that time. Our mental p i c t u r e a t t h a t time was
that t h e approach t o t h a t point would be over water." Examination of
the approach c h a r t showed that "our approach should have been minimum
sector a l t i t u d e u n t i l e s t a b l i s h e d on t h e approach l e g and 40 DME."
I n view of t h e p i l o t ' s statement and our findings i n t h i s accident,
the Safety Board believes that p o s i t i v e s t e p s should be taken t o reduce
the p o s s i b i l i t y of hazardous approaches i n t o Cold Bay. To t h a t end,
the IAP c h a r t f o r t h e ILS back course DYE approach t o runway 32 a t
Cold Bay could be modified i n one of s e v e r a l ways:

1. Delete t h e 40-mile DME IAF from t h e IAP chart.

2. Flag t h e 40-mile DME IAF on t h e plan view of t h e IAP
c h a r t t o show a crossing a l t i t u d e of 7,000 f e e t and
add t h e following note:

"Descent below 7,000 f e e t t o MSA, NOT AUTHORIZED

unless e s t a b l i s h e d on t h e ILS l o c a l i z e r back course
( o r 141" r a d i a l ) inbound. High t e r r a i n e i t h e r s i d e
of f i n a l approach course within 40 miles."

3. Add a note of caution a t t h e bottom of t h e plan view s e c t i o n

of t h e IAP (near t h e 40 mile IAF) t o advise, "NAVAID s i g n a l s
beyond 40 miles of t h e VORTAC a r e unusable below c e r t a i n
a l t i t u d e s . See FLP f o r a d d i t i o n a l information."

4. Show p e r t i n e n t NAVAID r e s t r i c t i o n s on t h e IAP c h a r t . Add

note: "High t e r r a i n e i t h e r s i d e of f i n a l approach course
within 40 miles of t h e s t a t i o n . "

These a r e only f o u r ways i n which t h e s i t u a t i o n could be improved.

The Safety Board r e a l i z e s t h e r e a r e others, some of which might a l s o
improve IAP c h m t z for a i r p o r t s where s i t u a t i o n s e x i s t s i m i l a r t o those
i n Cold Bay. However, with regard t o t h e s i t u a t i o n i n Cold Bay t h e
. National Transportation Safety Board recommends s p e c i f i c a l l y t h a t t h e
Federal Aviation Administration:
 - 30 -
Honorable Alexander P. B u t t e r f i e l d (4)

Modify t h e IAP chart f o r the ILS back cause

approach t o runway 32 a t Cold Bay, Alaska, in a
manner t h a t w i l l highlight t h e a l t i t u d e r e s t r i c t i o n s
on t h e use of t h e VORTAC and t h e hazards associated
w i t h deviations from prescribed approach procedures.

REED, Chairman, McADAMS T HAYER, BURGESS, and KALFY, Members

concurred i n t h e above recommendations.

B
y:
[ John H. Reed
Chairman

NTSB World Airways, Inc.

AAR nr! R 6-..
74-6
c.1