GRIFFIN, GA, USA
N83FA
Douglas C54A-DC
During the airplane's takeoff roll, about 3/4 down the 3,700 foot runway, a witness reported that the color of the #1 exhaust flame changed from blue to yellow, accompanied by an audible change in the engine power level. The nose of the airplane yawed left and the left wing dipped. Directional control was regained and the takeoff continued. Skid marks were found about 650 feet before the departure end of the runway that continued about 1360 feet to an abandoned grocery store impacted by the plane. About 315 feet before the building, the left wing contacted a privacy fence, and a utility pole, resulting in a fire at the disrupted left wing main fuel tank. A pilot/mechanic who helped dispatch the airplane observed that the elevator was free as it taxied. Fire damage to all engines precluded a detailed post crash examination of essential fuel and ignition systems. The toxicological report regarding the second pilot indicated that 1.110 mcg/ml (ug/ml, ug/g) of Diphenhydramine, was detected in the blood. According to NTSB medical personnel, Diphenhydramine is a sedating antihistamine often found in over-the-counter allergy medications. A single oral dose of medication containing Diphenhydramine, at twice the recommended maximum of over-the-counter dosage, resulted in maximal blood levels of between 0.08 and 0.16 mcg/ml. The level of Diphenhydramine found during the toxicology examination of the second pilot approximated ten times the levels found following a dosage at twice the recommended strength. Diphenhydramine was also found in the urine. Additional prescription and nonprescription medications were also found during the toxicological examination of the second pilot.
HISTORY OF FLIGHT On April 4, 1997, about 0016 eastern standard time, a Douglas C54A-DC, N83FA, collided with a commercial building during takeoff from the Griffin-Spalding County Airport, in Griffin, Georgia. The airplane was operated by Custom Air Service under the provisions of Title 14 CFR Part 91. Visual meteorological conditions prevailed. An instrument flight rules (IFR) flight plan was filed for the positioning flight. The airline transport pilot-in-command, and the commercial second pilot, were fatally injured, and the airplane was destroyed by ground fire. The flight was originating at the time of the accident, en-route to Americus, Georgia, to pick up a load of automobile parts for transfer to Rockford, Illinois. A pilot/mechanic associated with the operation of the airplane observed its start, taxi, run up, and takeoff. He stated that he always looked at the elevator to see if the controls were locked, and noted that the elevator was "down" as the airplane taxied. He reported that the engine run up was accomplished on all four engines with no discernible problem. During the airplane's takeoff roll on runway 14, the main landing gear strut was observed to partially extend as the airplane "became light on the landing gear." Then the witness noted that the color of the #1 exhaust flame changed from blue to yellow, accompanied by an audible change in the engine power level. The nose of the airplane yawed left and the left wing dipped. This occurred when the airplane was about 3/4 down the 3,700 foot runway. When the airplane passed his position adjacent to the runway near the departure end, he heard the tires "blow." He observed that the tail of the airplane was extremely high throughout the continued takeoff roll. The witness did not recall hearing any further decrease in engine power. An explosion and fire was reported to have occurred when the airplane impacted the building. Another witness reported that he observed fire on the left side of the airplane and at the rudder about the time the airplane was at the parking lot for the building. PERSONNEL INFORMATION The captain was issued an airline transport certificate on May 25, 1995. His ratings included airplane multiengine land, DC-3, and DC-4. He held commercial privileges with an airplane single engine land rating. Additionally, the captain held a mechanic's certificate with airframe and powerplant ratings. He was issued a first class medical certificate on November 25, 1996, with the limitation that the holder shall possess correcting glasses for near vision while exercising the privileges of his airman certificate. It could not be determined if the captain was wearing glasses at the time of the accident. Airman records obtained from the Federal Aviation Administration (FAA) indicated that the captain received a DC-4 rating on March 11, 1995. According to records provided by the operator, the captain successfully completed a proficiency flight check in the DC-4 aircraft on October 28, 1996. A report of the accident on NTSB Form 6120.1/2, Pilot/Operator Aircraft Accident Report, and a copy of the crew member records required by Title 14 CFR Part 125.401 were requested from the operator. The records indicated that the captain had in excess of 12,000 total flight hours with more than 1,000 hours in the same make and model airplane. The records indicated that the captain had a total of 45.4 flight hours within the 90 days prior to the accident, with 27.7 hours in the same make and model airplane. According to the operator's report of the accident, the captain had in excess of 32 flight hours at night, and more than 10 hours of actual instrument flight hours, within the 90 days prior to the accident. Based on the records provided by the operator, it could not be determined if the captain met the proficiency requirements of Title 14 CFR Part 125.401, specifically, the instrument flight hours and the number of instrument approaches within the previous six months. Instrument flight hours and completed instrument approaches are recorded by the operator's pilots on the "flight log." It was observed in the operator's records that this information was not recorded, consistently. The second pilot held a commercial pilot certificate with airplane single and multiengine land, and airplane instrument ratings. He also held a flight engineer certificate, with reciprocating engine powered rating. Additionally, the second pilot held a mechanic certificate with airframe and powerplant ratings. He was issued a second class medical certificate on July 23, 1996, with the limitation that the holder shall wear glasses which correct for near and distant vision while exercising the privileges of this airman certificate. A waiver was issued to the pilot on July 16, 1993, for defective distant vision 20/200, corrected to 20/20 bilaterally. It could not be determined if the second pilot was wearing glasses at the time of the accident. Records provided by the operator indicated that the second pilot received a proficiency check as second in command in the DC-4 on July 19, 1996. The operator's report of the accident listed the second pilot's total flight hours as greater than 5,000, with more than 1,500 hours in the same make and model airplane. According to his request for a medical certificate dated July 23, 1996, he had 3,550 total flight hours with 50 flight hours within the six months prior to the examination. The operator's report of the accident indicated that the second pilot had no pilot in command experience in the DC-4. According to records provided by the operator, the second pilot had 78.2 total flight hours within the 90 days prior to the accident, all in the same make and model airplane. The second pilot's instrument flight proficiency, required by Title 14 CFR Part 125.401, could not be determined from the records provided by the operator. In the report of the accident completed by the operator, the second pilot's night and instrument flight hours within the previous 90 days were listed as more than 45 and 15 hours respectively. The second pilot's medical certification file was obtained from the FAA and examined. In his request for a medical certificate dated July 23, 1996, the second pilot indicated that he was not currently using any medication, that a hospital admission had been previously reported, and that there were no changes. Additionally, he indicated that he had not seen a health professional within the three years prior to the examination. His medical certificate request dated June 21, 1994, indicated that he had hernia surgery in June, 1992. AIRCRAFT INFORMATION According to FAA records, N83FA was registered to Robert D. McSwiggan, and certificated in the Transport category, as a Douglas C54A-DC. The records indicated that on November 13, 1962, the airplane conformed with Type Certificate Data Sheet No. A-762. The airplane, serial number 10365, had been modified in 1962 by Aviation Traders (Engineering) Ltd., United Kingdom, and designated by the Civil Aviation Authority as an ATL.98 Carvair. (Three view drawing attached). It was operated under the provisions of Title 14 CFR Part 125, and Part 91. According to the operator, it was operated on the accident flight under the provisions of Title 14 CFR Part 91, as a positioning flight. In the operator's report of the accident, the airplane was listed as having 50,558 total flight hours, with 91 hours since the last inspection, performed on January 27, 1997. According to the operations specifications, issued to the operator by the FAA, the airplane was to be maintained in accordance with Custom Air Service's Manual and the Manufacturer's Manual. The approval for inspections in accordance with Title 14 CFR Part 125.31(b)(3) was issued by the FAA on August 1, 1996. The airplane was inspected using eight numbered inspections at intervals not to exceed 150 hours. A review of the operator's completed inspection forms for the airplane indicated this requirement had been met. The altimeter and pitot static system, and the transponder were last inspected on August 28, 1995, according to the operator's records. There were no uncorrected discrepancies found in the operator's inspection records for the airplane. In addition to the initial review of the airplane records reported above, the records were again examined on October 20, 1998. Pink copies of the three page log form used to record flight hours and in-flight airplane discrepancies were examined. The pink copy of the form included a record of corrective actions for in-flight discrepancies that were recorded by flight crewmembers. The log pages are preprinted with sequential numbers and contain a block for entering the date and flight hours flown for each flight. The log pages examined began on 2/5/96 with preprinted number 1430408 and ran continuously through log page number 1430438 dated 7/9/96. A second set of log page numbers began with log page number 83001 dated 7/30/96 and ran continuously through log page number 83055 dated 4/2/97; except for log page number 83044, 83045, and 83047. The flight hours recorded were continuous also, except for the missing pages that accounted for a total of 17 hours. Log page 83055, dated 4/2/97, the last flight prior to the accident flight consisted only of the 1st page of the form, a half page that recorded the flight hours and the names of the flight crewmembers. The copilot on the April 2nd flight, was also the copilot on the accident flight who was fatally injured. The captain for the flight on 4/2/97 was interviewed via telephone on October 13, 1998. The captain stated that as far as he could recall there were no discrepancies with the airplane during the flight. They flew from Griffin to Americus, Georgia, then to St. Louis and returned. He stated that he and the copilot commented to each other how well the airplane, particularly the engines, were operating. Regarding the flight control lock pin, it was normally removed in sequence according to the checklist. He related one event when he pulled onto the runway and discovered that he control lock pin had not been taken out. So, they slowed down and reviewed the checklist very carefully. The captain stated that he and the copilot had discussed that the most dangerous aspect of most trips was the departure at Griffin. They had decided that with the normal takeoff weight of about 59,000 pounds from Griffin, if the airplane had a problem after 50 or 60 knots, the best course of action was to continue the takeoff rather than try to stop. If an attempt was made to stop, it would just result in smoking the tires and blowing them out. According to the captain, an accelerate-stop chart was not in the airplane manual , but the distance was the same as accelerating and clearing a 50 foot obstacle. During a normal takeoff at Griffin, the airplane would lift off about the point that the accident flight started smoking the tires where the skid marks are on the runway, about 800 to 1,000 feet from the departure end. The airplane was powered by four Pratt and Whitney R2000-7M2 radial engines. According to the operator's report of the accident, the engine hours since overhaul were as follows: #1=688.1; #2=936.3; #3=399.1; #4=1,448.6. The engine time between overhaul is 1,600 hours. From the flight log pink forms found in the airplane records, the airplane total time was listed as 50,558.31 hours. Component cards, Serviceable Component Tags (Yellow Tags), and log book entries were examined for the engine and propellers reflecting the following information: Number 1 engine: Component card-Pratt & Whitney (P&W) R2000-7M2 Serial Number (SN) BP700946 installed 1/16/96 at aircraft time 49,885.02 with a time between overhaul (TBO) of 1,600 hours. The yellow tag indicated the same information and indicated an overhaul had been completed on 4/26/82 on work order (WO) 399 by Genair Corp. The log book indicated the engine was repaired by Genair at 11 hours since overhaul on 11/17/87, WO 975. The engine was installed, per the log book, on N83FA on 10/9/94, with 11 hours since overhaul. The log book reflected the engine was removed for repairs at different times and reinstalled. Number 2 engine: Component card-P&W R2000-7M2 SN BP702224 installed 8/23/95 on N83FA at aircraft time 49,615.58 hours with TBO of 1,600 hours. The yellow tag indicated the engine was overhauled on 2/13/95, WO 30628, by Precision Airmotive Corp. The log book indicated the engine was installed on N83FA on 2/13/95, at zero time since overhaul, at airplane time of 49,615.58. Number 3 engine: Component card-P&W R2000-7M2 SN P105712 installed 1/16/96 on N83FA at airplane total time 50,170.15 with a TBO of 1,600 hours. The yellow tag reflected the same information plus overhauled by Garside's Aircraft & Engine Parts and Service, Inc, WO 5205. The log book indicated the engine was installed on N83FA on 3/16/96 at zero time since overhaul at airplane time 50,170.15. Number 4 engine: Component card-P&W R2000-7M2 SN 702373 installed on N83FA 10/21/94 at airplane time 49,109.23 with TBO of 1,600 hours. The yellow tag reflected the same information with overhaul by Precision Airmotive Corp, on 9/9/94, WO 29202. The log book reflected the same information with the engine installed on N83FA on 10/21/94 with zero time since overhaul. Number 1 propeller: Component card-Hamilton Standard (HS) Model 23E50 SN FA4435 installed on N83FA on 5/18/94 at 48,773.12 airplane hours, with a TBO of on condition, and Airworthiness Directive due at 3/1/99. The log book reflected the same information, indicating the propeller was overhauled by Aviation Propellers, Inc. on WO 4748 on 3/31/94. AD 81-13-06R2, requiring a propeller overhaul each 3,000 hours or 60 months, was indicated as having been complied with. The yellow tag also reflected a major overhaul on 3/31/94 by Aviation Propellers, Inc, WO 4748-B. Number 2 propeller: Component card-HS 23E50 SN RRB6586 installed on N83FA on 6/19/94 at airplane time 48,8816.46 hours at zero time since overhaul, with TBO of on condition. AD due 3/30/99. The log book reflected the same designation information and indicated the propeller was overhauled by Aviation Propellers, Inc., on WO 4739-B. The yellow tag indicated the propeller was overhauled on 3/30/94. Number 3 propeller: Component card-HS 23E50 SN NKS1845 installed on N83FA on 9/14/94 at 49009.18 airplane hours, with zero time since overhaul. TBO 3,600 hours at 52,609.18 airplane hours. AD due at 9/19/99. The logbook contained the same descriptive information and indicated the propeller was overhauled on 8/30/94 by Aviation Propellers, Inc. on WO 4873-B. The yellow tag indicated the propeller was overhauled on 8/30/94. It was noted that the Propeller AD Compliance Record, a separate page in the airplane records, recorded the #3 propeller SN as G6371. The yellow tag reflected the same SN as in the log book. Number 4 propeller: Component card-HS23E50 SN RA959 installed on N83FA, on 9/14/95 at 49,659.13 airplane hours total time, with zero hours since overhaul. The TBO was on condition, and the AD was due at 1/2000. The log book reflected the same descriptive information and listed an overhaul by Aviation Propellers, Inc. on 1/5/95 on WO 4817-B. The propeller was installed on N89FA, on 3/28/95 and was not flown. The propeller was installed on N83FA at zero time since overhaul on 9/14/95. The yellow tag indicated the overhaul was on 1/6/95 and that AD 81-13-06R2 had been complied with. According to the operator, because the accident flight was conducted under the provisions of Part 91, a Weight-Balance Manifest Flight Release/Following Form was not required. (See Tests and Research for excerpts of Title 14 CFR Part 91.103). Additionally, the flight log page for the accident flight was not located. The operator believed it was aboard the airplane at the time of the accident. A weight and balance form for the flight was subsequently provided by the operator indicating that the airplane's weight at takeoff was 56,345 lb., with a center of gravity (CG) at 14% mean aerodynamic chord (MAC). The Carvair flight manual provided by the operator indicated that the maximum takeoff weight for the airplane was 73,800 lb., with a CG limit of 12% MAC forward, and 29% MAC rear.
The flightcrew's inadequate procedures, during a rejected takeoff following a possible engine malfunction at a critical time in the takeoff, and the second pilot's physical impairment.
Source: NTSB Aviation Accident Database
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