o

US. Department
of Transportation
Federal Aviation
Administration
CONFIDENTIAL MEMO

INFORMATION: Report on Arrow Air Date: DEC j 2 !9F9

Flight MF1285R, Gander, Newfoundland
Reply to
Assistant Manager, Accident Investigation Attn of:
Division, AAI-101

Director of Accident Investigation, AAI-100

Thru: Manager, Accident Investigation Division, AAI-100
On December 12, 1985, at approximately 6:45 a.m., Arrow Air
Flight MF1285R, a Douglas model DC-8-63, U.S. Registration
number N950JW on an international charter flight from Cairo,
Egypt, to Fort Campbell, Kentucky, with enroute stops at
Cologne, Germany, and Gander, Newfoundland, crashed shortly
after takeoff at Gander International Airport, Newfoundland,
Canada. All 248 passengers and 8 crewmembers sustained fatal
injuries. The flight was chartered by the United Nations
Multinational Force and Observers to transport members of the
U.S. Army 101st Airborne Division who were returning home from
peacekeeping duties in the Sinai Desert. (Additional factual
information on History of Flight is contained in Section 1.1 of
the CASB aviation occurrence report. Attachment #1)
The FAA Communications Control Center was notified at 0700 by
Gander ARTCC of the accident. Preliminary information was
obtained, and shortly thereafter, distributed to the FAA
Administrator, Secretary of Transportation, Office of Aviation
Safety (ASF-100), NTSB, White House, Department of State, and
many other Government agencies and offices. Robert D. Cook was
assigned as the FAA coordinator and George Siedlein from the
NTSB, the accredited U.S. Representative. Communications were
established with the CASB and they were informed of Mr. Cook's
and Siedlein's travel plans. Transportation was arranged by
FAA at Hanger #6 in the FAA Cessna citation N2. Mr. Cook and
Mr. Siedlein departed Washington National Airport at 11:30 a.m.
and arrived at Gander International at 1900, (a fuel stop was
made at Portland, Maine). Upon arrival, Mr. Cook and
Mr. Siedlein met with Mr. Peter Boag, the CASB Investigator-in-
charge and other investigative personnel. An organizational
meeting was held and the following working groups were
established: Operations, Structures, Systems Powerplants, Site
Survey, Airports/weather, Human Factors, and Flight Recorders.
Other U.S. personnel participating in the investigation were
representatives of Arrow Air, McDonnel Douglas Aircraft, Pratt
and Whitney, and the United States Army. (See attached list of
participants. Attachment #2)
 2
At some point in the early stages of the investigation,
Robert Cook requested support from the FAA Southern Region for
participation on the Operations group and Airworthiness group.
Mr. Harry Tabor from the Atlanta FSDO, an FAA DC-8 Operations
Specialist, and Mr. Paul Franklin, the Assistant Principal
Maintenance Inspector assigned to the Arrow Air Certificate,
Miami, Florida, were dispatched to Newfoundland. The main
activities in the early stages of the investigation were
centered around body recovery, recovery and readout of the
Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR),
weight and balance calculations, structures, systems and
powerplants documentation, and interviewing any eye witnesses.
During the on-scene portion of the investigation, FAA was
allowed to participate on the operations group and airworthi-
ness group, but because of Canadian law, was not allowed to
participate in the interview of eye witnesses.
Early in the investigation, Mr. Cook discovered that Arrow Air
was using 170 pound average weights for the passenger load.
This appeared to be contrary to standard FAA weight and balance
operation specifications which state "actual passenger weight
should be used when large groups of passengers are carried
whose average weight does not conform to the normal standard
weight. For example, a group of large athletes or a plane load
of men would exceed the average . . . ." In Mr. Cook's
opinion, this group of soldiers did not meet the requirements
of average weight. Mr. Cook communicated this information to
FAA headquarters and the FAA Southern Region Flight Standards
Division and Miami Flight Standards District Office, with the
recommendation that corrective action be taken. (See attached
recommendation.) (Attachment #3)
Arrow Air maintenance and flight operations records were
impounded by the Miami FSDO for review by NTSB, FAA, and CASB
investigators at a later date. Numerous requests for FAA
surveillance records and National Air Transportation inspec-
tions were processed throughout the investigation. Every
request was completed in a very timely manner. At various
times during the investigation, personnel from the Transport
Airplane Directorate, Long Beach Aircraft Certification Office,
and New England Region Engine Directorate participated in
various phases of the investigation. The on-scene portion of
the investigation continued for many months with NTSB personnel
participating with the CASB in further examination of the
wreckage. The operations group conducted a trip to Cairo,
Egypt, Cologne, Germany, and to Multinational Force
Headquarters in Italy to interview various personnel. The FAA
was not allowed to participate in this portion of the investi-
gation, only the NTSB. Additionally, there were several other
interviews of various personnel in the United States that CASB
 3

and NTSB conducted in which the FAA was excluded. (i.e., next
of kin, flightcrew, and other Arrow Air personnel.) Mr. Cook
and Mr. Siedlein departed the initial on-scene portion of the
investigation on December 20, 1985.
On February 3, 1986, Robert Cook and Mr. Vincent Lepera went to
CASB Headquarters to review aircraft maintenance records. The
review disclosed a trend of replenishing hydraulic fluid in the
main hydraulic system reservoir. This was brought to the
attention of the CASB systems group chairman who would research
this trend in more depth. This subject was discussed in detail
at the CASB public hearing and in the official accident report.
Four Accident Investigation Briefs were prepared by ASF-100
during the on-scene investigative phase (see attached document
#4). On March 24, 1986, Mr. Robert D. Cook and Mr. James
Dillman attended a prehearing conference conducted in Gander,
Newfoundland, to prepare for a formal public hearing to be held
in Ottawa, Canada, in mid April 1986. (See attached
document #5.)
A CASB public hearing was held in Ottawa, Canada, on April 19,
1986. The 7-day hearing was scheduled to hear testimony from
approximately 34 witnesses including four FAA witnesses:
Mr. Anthony Kijek, the principal operations inspector,
Mr. Gerald Nash, the 1984 National Air Transportation
Inspection Team Leader and Mr. Vincent Lepra, the 1986 Special
Inspection Team Leader and Mr. Frank Giannolla, the FAA
principal maintenance inspector. The scope of the witnesses
testimony is contained in the attached document #5. Mr. James
Dillman was the principal FAA spokes-person, Mr. Robert Cook,
acted as FAA Technical Consultant. On October 7-8, 1986, the
CASB conducted DC-8-63 simulator tests at Sterling Training
Center, Copenhagen, Denmark. The objective was to fly the
simulator with a clean wing surface performing various take-off
scenarios, and then introduce wing surface contamination and
fly the same profiles. Results of simulator test are contained
in a memo dated October 14, 1986, drafted by Captain John T.
Coe of Arrow Air (memo attachment #6). Additional testing was
also conducted at various locations in the U.S. and Canada,
some with FAA participation, some without (reports contained in
CASB docket). Mr. Robert Cook participated in the simulator
flight testing in Copenhagen, Denmark.
A draft CASB accident report was circulated to all participants
for comment. This report was circulated extensively within the
FAA for review and comment. In January 1988 a final response
was coordinated with all FAA elements and sent to the
Administrator for his signature on January 29, 1988, and
returned to the Chairman of the CASB. (See attached
documentation #7.)
 4

Sometime in the month of June 1987, Robert D. Cook was informed

by Mr. William Hendricks, ASF-1, Director of Aviation Safety,
that he was to testify on behalf of the Multinational Force and
observers in litigation concerning the recovery of monies
expended on the families of the soldiers that were killed in
the Arrow Air accident. Mr. Donald W. Madole of the law firm
of Speiser, Krause, and Madole was representing the Multi-
national Force. Depositions were held in Miami, Florida, on
June 16, 1987. The case was successfully settled in favor of
the Multinational Forces before trial (deposition
attachment #8).
The final CASB Aviation Occurrence Report was issued on
October 28, 1988. Due to considerable controversy over the
issuance of the report within the CASB, Transport Minister
Benoit Bouchard, on March 23, 1989, commissioned retired
Canadian Supreme Court Justice Willard Estey to review the
entire record of the Gander Accident Investigation to determine
if further investigation or inquiry was warranted.
Justice Estey's review concluded that further investigation of
the accident was not warranted and recommended that no further
inquiry by the Board or any other person or agency under the
Inquiries Act of Canada be conducted. (Attachment #9)

Robert D. Cook
9 Attachments
Q
U.S Department
Memorandum
of Transportation
Federal Aviation
Administration

INFORMATION; Report on Arrow Air Date: j ^ g jggg

Flight MF1285R, Gander, Newfoundland
Reply to
Assistant Manager, Accident Investigation Attn, of: Cook:x78190
Division, AAI-101

Director of Accident Investigation, AAI-1

Thru: Manager, Accident Investigation Division, AAI-100 JP^
This is in response to your memorandum of December 13, 1989,
requesting additional information on CASB Working Groups that
were formed during the investigation of the Arrow Air accident
in Gander, Newfoundland.
To answer the majority of your questions with accurate and
factual data, a request has been transmitted to the CASB
requesting information in regard to specific areas of the
investigation. On January 4, the CASB Chief, Investigations
Operations, indicted that the assembled responses to your
request should arrive the week of January 9th (Attachment #10).
In regards to FAA participation in the Arrow Air accident, the
FAA's Southern, New England, and Northwest Mountain Regions
were requested to provide information to this office on their
participation and involvement on any aspect of the Arrow Air
Investigation (Attachment #11, 12, & 13). Additionally, the
Miami Flight Standards District Office was asked to provide, as
background material, a list of all FAA principal inspectors
assigned to the Arrow Air Operating Certificate, and members of
the National Inspection Team that were directed by the
Secretary of Transportation to conduct an in-depth inspection
on the Arrow Air accident (Attachment #11).
Beginning specifically with your request as to United States
involvement and participation with regard to any explosive or
incendiary device aboard the aircraft and activities which the
CASB undertook to resolve this issue, the following is offered.
To the best of my recollection after George Siedlein and myself
arrived at Gander Airport Terminal, a representative of the
Federal Bureau of Investigation (FBI) introduced himself and
indicated that his group (number unknown) would be working with
the Royal Canadian Mounted Police (RCMP) on the criminal
aspects of the investigation. Mr. Siedlein explained that he
 2

was assigned as the U.S. accredited representative and would

appreciate being kept informed of the progress of their
investigation. That was the only contact I had with the FBI.
The on-scene portion of the investigation included identifying
metal fractures or penetration that were suspicious in origin
and turning those parts over to the RCMP for analysis and
testing. Results of their analysis is contained on page #78 of
the CASB accident report. Very little information about the
analysis of those parts was released by the investigator-in-
charge during the on-scene phase of the investigation. The FAA
agrees with the portion of the CASB report that disucsses
explosion or fire. If further contact with the FBI was
established with other elements of the FAA, I have no knowledge
of this contact.
Examination of the #4 engine, on scene, raised some suspicions
that the reverser may have been in a position other than the
stowed position at impact. The engines were documented on site
and then shipped to the National Research Laboratory in Ottawa,
Canada, for further detailed examination. Physical evidence of
hardware did not support the theory that the #4 engine thrust
reverser had deployed prior to ground impact. The FAA was
allowed, with the NTSB, to participate in the examination of
the engines at Ottawa as observers (attachment #12). Results
of that examination are contained on page #29 of the CASB
accident report. The FAA has no reason to dispute the facts
presented by the CASB.
Airframe ice is discussed in the Arrow Air memorandum dated
December 12, 1989. Simulator flight testing was conducted at
the Sterling Training Center, Copenhagen, Denmark. The
objective was to fly the simulator with a clean-wing surface
performing various take-off scenarios and then introduce wing
surface contamination and fly the same profiles. The results
of this simulator testing is contained in attachment #6
memorandum dated October 14, 1986. The simulator tests were
recorded by the CASB and are on video tape. Simulator tests
with wing surface contamination introduced were flown by
Captain John T. Coe of Arrow Air, flight instructors from the
Sterling Training Center, and a McDonnell Douglas DC-8 test
pilot. The results of these simulator tests, as documented by
Captain John T. Coe, are as follows:
"On the second simulator session, the simulator was
reprogrammed to simulate wing surface contamination of
1.44mm thickness of wing surface contamination. Data for
these changes was provided by the University of Dayton,
through lift/drag curves, which were constructed for
various conditions of smooth and rough wing surfaces.
Additional drag coefficient curves provided by McDonnell
Douglas were used to develop the program changes.
 3

The contaminated aircraft tests were performed under the

same conditions as listed previously, with the exception
of the addition of wing surface contamination. The vari-
ous tests performed were the same as the clean airplane
test. The initial take-off was made by a DC-8 rated pilot
from Sterling. He was not told about the wing surface
contamination. On his initial T.O. with the lower V
speeds after rotation and lift off, as the airplane accel-
erated to 177 kts, he increased the pitch about 10-11° and
the aircraft stalled. The result was a rapid break in
pitch attitude to a nose down 20°. There was no stick
shaker or aircraft buffeting prior to the stall. At the
higher V speed take-off the aircraft stalled at 170 kts
when the pitch was increased above 10° to establish
V2 + 10 climb pitch attitude.
There were some adjustments made to the drag coefficient,
before I flew because it was felt that what was originally
programmed was excessive. Even with less drag, above a
certain pitch attitude (12-15°) , the airplane would
stall."
Additional simulator flight testing was also conducted at Los
Angeles, California, on August 31, 1987, with Mr. Jim Ashley
from ANM-160L participating for FAA (Attachment #13). Results
of that flight testing will be forthcoming from CASB. In a
memorandum from the Manager, Flight Standards Division,
ASO-200, dated January 20, 1988 (Attachment #9), there are
comments on the presence of ice on the leading edge of the wing
when the aircraft landed at Gander. The request for additional
aerodynamic analysis and engineering/performance data was not
included in the Administrator's comments on the FAA's review of
the draft Aviation Occurrence Report 85-H50902 (T26HP). The
consensus of opinion by FAA Flight Test Engineers (ANM-160L)
was that appropriate simulator testing had been conducted and
was verified by non-biased simulation in numerous simulator
tests. This was also the conclusion of the FAA Transport
Airplane Directorate and McDonnell Douglas personnel at Long
Beach. Additionally, further discussions with the FAA Southern
Region Flight Standards Division, ASO-200, and the Miami Flight
Standards District Office, who originated the comments, were
held to discuss the benefits of performing additional simulator
testing and analysis. It was determined that appropriate
simulator testing had been conducted and that there was no need
to request additional simulator tests.

fed/
R o b e r t D. Cook
Attachments
Peter S. Boag
Canadian Aviation Safety Board
Chief Investigation Operations
As part of the Federal Aviation Administration's (FAA)
involvement and participation with the Canadian Aviation Safety
Board (CASB) in the investigation of the Arrow Air accident at
Gander, Newfoundland on December 12, 1985, the FAA needs
additional information in regard to specific areas of the CASB
investigation.
Specifically the FAA requires:
1. A list of all investigation groups that were formed and the
United States advisors, observers, or participants, if any, that
were assigned to a particular group.
2. A list of primary causal issues that were pursued and
resolved during the investigation and any United States advisors,
observers, or participants that were involved in that activity.
3. Information covering the investigation as to the presence of
any explosive or incendiary device aboard the airplane. A
description of the investigative activities conducted by the CASB
to explore and resolve this issue and the extent of any
involvement of United States personnel.
4. The CASB Group Report of the investigation of the aircraft
engines. What theories were purported i.e., #4 engine in
reverse. How that issue was resolved, who the United States
advisors, observers, or participants were, and the extent of
their involvement.
5. Airframe Icing Issues. The CASB Group Report on all flight
simulator testing conducted with various participants. Indicate
the scope and depth of all testing and performance analysis that
was conducted and any involvement of United States personnel and
the extent of their involvement.
I trust the above information request is understandable and can
be furnished in an expeditious manner. My thanks in advance for
providing this information.
 ©
U.S. Department
Memorandum
ot Transportation
Federal Aviation Flight Standards District Office-19
Administration P.O. Box 592015
Miami, Florida 33159

Subject: INFORMATION: Date:

Arrow Air Lines
Accident Investigation

Reply to
From: Manager, Miami FSD0-19 Attn of: Centanni:x2568

To:
Accident Investigation Division, AAI-101

The following are the Principal Inspectors assigned to Arrow Air Lines
since its inception:

INSPECTOR BEGINNING DATE ENDING DATE

C. Duff May 1981 April 1984

J. Hobcroft April 1984 September 1984
R. Barbieri September 1984 May 1985
A. Kijek June 1985 February 1987
L. Centanni February 1987 August 1987
C. Siceloff August 1987 December 1987
R. Gavin December 1987 March 1988
H. Turner March 1988 Present

Principal Avionics Inspectors;

M. Peacock May 1981 July 1981

L. Dillinger July 1981 March 1988
T. Dean March 1988 April 1989
R. Araujo April 1989 Present

Principal Maintenance Inspectors:

J. Doskow May 1981 July 1984

T. Carroll August 1984 April 1985
F. Giannola April 1985 October 1989
P. Franklin October 1989 Present

The following were attendees at the Public Inquiry in Canada from

April 7 thorugh 18, 1986:

R. Wiltuck
J. Walsh
A. Kijek: Testified April 15, 1986
F. Giannola: Testified April 16, 1986
FAA Attorney at the Public Inquiry in Canada:

J. Dillman AGC

Inspector P. Franklin provided technical support for the accident

investigation in Gander Newfoundland from December 12 through 20, 1986.

The National Inspection Team (NIP) commenced inspection of Arrow Air, Inc.
on January 21, 1986 at Miami International Airport. This inspection was
directed by the Secretary of Transportation to the Federal Aviation
Administration (FAA) to conduct an in-depth inspection of airlines
operating under military charter.

The Inspection Team members were:

Team Leader

Vincent J. Lepera AEA

Operations Team Leader

Joseph Dillon ASO

Operation Team Members

Richard Millstrip AGL

Joseph McDonnell ASW
Carolyn Johnson (Cabin Safety Specialist) ACE

Airworthiness Team Leader

Larry Vaughan ASO

Airworthiness Team Members

George Chopay AEA

Paul Erickson ASO
Robert Mulvaney ACE

Records Examination Assistance Program (REAP) Members

Roger Phaneuf
Kelly Goode
Lisa Markle
 Q
US. Department
Memorandum
ot Transportation
Federal Aviation
Administration

SubjectNFORMATION: Arrow A i r DC-8 A c c i d e n t a t Ganderjste; r -, -, ,ggg

J
Newfoundland, Canada
\%
Reply to
* Fr
oiyr.anager, Engine Certification Office, ANE-14Qutn of:

"•"Assistant Division Manager, AAI-101

(Attn: Robert D. Cook)
This is in response to your recent request for information
concerning Federal Aviation Administration (FAA), Engine
Certification Office (ECO), involvement in the subject accident
investigation.
The investigation was formally directed by the Canada Aviation
Safety Board (CASB). No FAA-ECO personnel participated on-site.
An FAA-ECO engineer (M. Bouthillier) did participate as an
observer (under United States National Transportation Safety
Board direction (Mr. G. Dail)) during the engine teardown at
CASB, Ottawa, Canada, during January 7-9, 1986. The FAA-ECO
representative did not participate in the composition of, or
approval of any official document concerning the engine teardown
findings. Two representatives from Pratt & Whitney Aircraft
(PWA) also participated as observers during the subject teardown.

FAA-ECO has contacted PWA, and have been informed that no formal
factual account report was published by PWA. However, PWA did
formally concur with the CASB factual record of teardown
findings. Specifically, we are told the report only addresses
the Number 4 engine as potentially having been at a lower thrust
setting than engines 1 through 3 at impact, but that the physical
evidence cannot confirm this. No mention of the Number 4 thrust
reverser is made, it being determined that the physical evidence
substantiated that the Number 4 thrust reverser was stowed at
impact. We are not aware of any other significant teardown
findings.
 2.
If additional specific information concerning engine teardown
findings is required, such data is available through PWA. If you
%have_any-further questions, please contact this office.

Jay J. Pardee
 TO: AAI-100, Bob Cook
CC: AIR-2
FROM: ANM-100

Per your request we have gathered the information on contacts the Directorate has had regarding the Arrow
3 Air Accident. Please confirm receipt of this information and advise if we can be of further assistance.

Arrow Air DC-8 Accident at

Gander. Newfoundland

DATE FAA OTHERS HOW SUBJECT

12/12/85 M. O'Neil D. Cavenaugh Simulator Accident Briefing

ANM-120L MOT

12/13/85 ANM-100L ASF-100 Fax Accident Briefing Update

12/17/85 M. O'Neil D. Cavenaugh Telecon Accident Briefing Update

ANM-120L MOT

12/19/85 M. O'Neil R. Cook Telecon ASF-100 Request for SB

ANM-120L ASF-100 27-189

01/14/86 M. O'Neil D. Cavenaugh Telecon Update of #4 Engine Thrust ANM-

120L MOT Reverser

02/11/86 ANM-100L ASF-100 Fax 3 Letters from P. Boag

(CASB) to G. Seidlein
(NTSB)

03/17/86 ANM-100L ANM-100 Staff FAA Invited to Review

Telecon Data From Flight Data Recorder

03/17-18/86 J. Ashley D. Glynn, DAC Meeting Develop Possible

ANM-160L F. Weigms, DAC at Scenarios in Which
S. Lund, DAC DAC Calculated Performance
M.Garrett, DAC Could Match FDR Airspeed,
R. Brumby, DAC Load Factor & Heading
R. Cook, ASC-100
B. Donner, NTSB
D. McNair, CASB
P. Boag, CASB
08/31/87 J. Ashley D. McNair, CASB Simulator Simulator Evaluation
ANM-160L P. Boag, CASB at Flying Tigers
R. Taylor, Flying Tigers
A. Sweeney, P&W
J. Agar, DAC
J. Coe, DAC

09/06/89 R. Vakili S. Didrikson Telecon Concerns Raised by ALPA

ANM-140L MOT Pilot About SB 78-95
R. Follensbee
ANM-140L

09/18/89 R. Vakili S. Didrikson Fax Explanation of SB 78-95,

ANM-140L MOT Rev. 2

11/09/87 D. Hsu D. McNair Telecon Request for Copies of ANM-

120L CASB STC's SA2497NM & SA3086NM

11/10/87 ANM-100L CASB Fax Copies of STC's SA2497NM &

SA3086NM
12/24/87 ANM-100L ASF-100 Mail Received Draft Copy of
CASB "Aviation Occurrence
Report No. 85-H50902 (T26HP)"

01/12/88 ANM-100 ASF-100 Mail Letter with No Comments to

CASB Reports

03/21/89 ANM-100L AAI-101 Mail Received Final CASB Aviation

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