1 ~ASAAOtWMHZ PA rpz O-APZ _DADOw <4MI>yH ZO TO i : PB 219 370 AMERICAN AIRLINES, INC. McDONNELL BOUGLAS 00-10-10, NIO3AA NEAR WINDSOR, ONTARIO, CANADA JUNE 12, 1972FILE No. 1-0004 AIRCRAFT ACCIDENT REPORT AMERICAN AIRLINES, INC, McDONNELL SOUGLAS DC-10-10, NID3AA WEAR WINDSOR, ONTARIO, CANADA JUNE 12, 1972 ADOPTED: FEBRUARY 26, 1973 NATIONAL, TRANSPORTATU Washington, D.C. 2 REPORT MURGLX: NTSH:TECHNICAL REPORT STANDARD THT [To kepart Way] etaverimant RecassTon Wo. | 3-RecipTent's Catalog Wo. | NESB=nAR~73. Ti, Title and SubeTtle Alzorafi Accident” Report.——~~—1-5 Report Bate = Avertean Airlines, Tne. , NeDounell Douglas DC-10-20, February 28, 1973 NIOBAA, near Windaor, Ontario, Canada, June 12, 1978. |"B:Performing OrganlzatTon | ifchor s] eaaeeeaeemree! if OrganTeatTon | Report No. } Tower Uate We [a7 Perforatng Urgent zatlon Wane and Rldross National Transportation Safety Noard ee Bureau of aviation Safety TGontract oF Grant Wo: Haehiagton, D.C, 20591 a riod Covered ‘[icapoarar lng gency Wate and Rides Atroragt AcoLdent Report NATIONAL TRANSPORTATION SAFETY BOARD posed Washington, 0. ¢. 20597 TH SpansarTng Reaney Cote [ 15. SupeTamentary Wei ‘this report contains no nay atzorafe Safaty Recomondations. [We-Abstrace ‘Acertcan AirHinos, Ine., NeDonnell Douglas 00-10-10, wae danaged aubstantiatly wuhon tha aft bulk cargo comparteant door separated from the atreraft in flight at spproxinately 11,750 feat wean sea Level, The separation caused rapid decomprocsion, Which, in turn, caused £atlure of the cabin floor over the bulk cargo compartmant. ‘The aoparated door caused minor damage to the fuselage above the door and oub- erantial dasaga to the loading edge and upper surface of the Left: horLzoutal stabiliser, vec were 56 passengers and a crew of LL aboard the aircraft, ‘lwo stewardeuses and nine facsengers recofved minor injuries ‘Tno National tranaportarion Safety Bowrd deteratnae chat thts acetdene var the taproper engagonent of the latching nechantan fo~ urge compartnent door during the proparation of the afrplana for Flight, ‘the dooign| Sharactertntien of the door latching sechanisn permitted tha door to be apparently closed whion, in fact, the Latches were not fully engajed, and the Latch lockyAre ern tot in place, V7. ey Wore aa ~[VEDUISerThatTon Statement —| Adveratt Acokdent, Rapid Docomprasnton, Tuy light Retoane to publics Separation, Dosign Dottctency. dLetekbutien unlined (of this report) (oF this page) a UNCLASSIFIED UNGLASSZFIED isn Porm 1765.7 Wi, - Twgeaurl ey ClasaTfTeat Ton] B-SecurTty Classi icatlon [RV-NG. oF Fi =| irTABLE OF CONTENTS Synopsis Probable Cause. Investigation History of che Plight... Injuries to Persons « Damage to Aircraft... Other Damage Grew Information Aircraft Information Meteorological Informati Aids to Navigation 5... Communications : Acrudrome and Ground Facilities... Flight Recorder ... Aircraft Wreckage . Fin Survival Aspects oo... Tests and Research : Analysis and Conclusions... Analysis veseee sees Conelusiens n ta) u ) : nee 1 Appendices ‘Appendix A Tvestgation and Hearing . 18 Appendix Grew e 16 Appeaidix Aircraft information . 18 Appentix ‘Gockpit Voice Recorder Transevipt 194 Appendix C00 Cab lone Piacente eee eee 38 ‘Appendix ¥ Cargu Door 36 Appenilx G NESW Safety Recommuendations A-72-97 and 98 to the Federal Aviation Administator and Response . 3740NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D. AIRCRAFT ACCIDENT REPORT Adopted: February 28, 1973 20591 AMERICAN AIRLINES, INC. McDONNELL DOUGLAS DC-10-10, N103AA NEAR WINDSOR, ONTARIO, CANADA, JUNE 12, 1972 SYNOPSIS ‘An American Airlines, ine..MeDonaell Douglas DC-16-10, was damaged substantially when the afc Gull cargo compartment door separated from the ancsavt in flight at approximately 11,750 feet maw sea kvel. The separation caused rapid decompre om, which, in turn, caused failure of the cabin ~over the bulk cargo compartment. ‘the flow ally collapsed into the cargo com. Pattinent, soning various contral cables which were routed tisough the floor bears to there enyine and to the empennage contiol systems ‘The separated door caused minor damage to the fuselage above the door opening and sub- 1 damage to the leading edge and upper surface of the left horizontal stabilizer. ‘There were 56 passengers and a crew of UL aboard the aircraft, Two stewardesses and nine nor injuries, c Transportation Safety Board de- termines that the probable cause of this acces was the improper engagement of the latching mechanism for the aft bulk cargo compartment door daving the preparation of the airplane for flight. “The design characteristies of the door am permitied rhe duor to be apparently closed, when, latches were not fully engaged 1 Hoping were notin pce, AAs aresil of the investigation ofthis accident, the Safery Board made two recommendations to the Federal Aviation Administretor. 1. INVESTIGATION 1 History of the Plight American Aielines, Inc, Flight 96, a DC-1010, NIO3AA, was a scheduled passenger flight from Los Angeles, California, to LaGuardia Airpor, New York, with intermediate stops a¢ Detroit, Buffalo, New York. Flight 96 de- parted Los Angeles International Airport at 1436 e.s.! on une 12, 1972, 46 minutes after its scheduled departure. ‘The delay was a result of passenger handling and sir traffic control Flight 96 arrived at Detroit a: 1836. This seg. ‘ment of the Flight was without incident. uel, cargo, and passengers were loaded aboard the airplane at Detroizand is takeoff gross weight ‘was computed to be 300,888 pounds, well under the maximum allowable. ‘The last compartment to be secured prior co dispatch of the fight was the afe hulk eargo compartment The samp service agent who serviced he aft cargo compartment had difficulty closing. che door, He stated that he closed the door elec- trically, He listened for the miotor to stop rane ata then attempced to close the door handle This handle is designed to clese the small went oor which is located on the cargo door, to position a lockpin behind a cam on each of the se he 24 huefous lavches and to open the cireuit to the cock pit warning lights. The agent could wot elose the handle with normal foree, 50 he applied additional force with his knee. This caused tie handle to stow properly, but the veut door was el.sed in a slightly cocked position, ‘The agent brought this to the artention of a mechanic who gave his ap proval for release of the aircraft, ‘The flight deparced the camp at 1971 with the door inthis condition, According co the flight engineer, the cargo door ig ligh on hia panel never illuminated during the taxiour. or at any time during che flight. “This light was designed co illuminate when any cargo door is not properly secured for Hight. Following receipt of clearance to Runway 03 Righe, the Aight took off at 1920, ‘The first offices was Alying the airplane. Flight 96 was cleared to maintain runway heading and to con- tact the departure controller who cleared it to limb co 6,000 feet and veetored it t9 i V-554, Upor Flight was dlesred to to Flight Level 210% and % contact the ‘Traflie Gonerol Center (AR ‘About 1925, while rhe an rately 11,750 fect altitude and climbing at 260 ced (KUAS), the flighterew heard anu! Felt a definite “thud.” Simultaneously, luge and ditt lew ap into their faces, the ruskler pedals moved tw the full left-cudder position, all three thrust levers mvoved back to neat the flight ile position, and cie airplane yawed to the right. The ce prain reported that he lost is vision momentarily: he chowzht chat a midair collision had occurred! and tha: the windshield has’ been ‘The captaia immedistely disengaged the suto- pilor mul tock control of cic airplane, He re con the controls for the rest of the Might es responded to power appli: the Ne. 2 sugine thrust le could not be moved. ‘The airspeed was stabilized at 250 knots, and at this speed the allecon re we was normal, elevator response was Ox sluggish, and directional contro! required: as Heft aileron input. Rudder control | right yaw. The captain declared a and Air Route Traffic Conteol cleared the flight back to Detroit via radar vectors. ‘At the time of the occurrence, most of the flight attendants heard s loud noise, observed “fog” in the cabin, and felt motion of the eabin ait. They recognized the rapid decompression of the cabin air, and one of the first setéons of most of the flight attendants was to see whether the passenger oxygen masky had deployed. |The decompression of the cabin air through the aft cargo compartment done caused the eabin floor dn the aft lounge area to fail down aed and par tially drop into the cargo compartinent. No passengers were in this urca of the cabin: how fever, two flight attendants, who were in their seats at the aft exits, were thrown to the floor and received minor injuries, Thoir injuries did not prevent ther, from perforning their duties. During the retum flight to Decroit, the pas: sengers were briefed on 3 possible crash landing and were giver: instructions for the emergency ‘evacuation of the ai “The aieplant: was radar vectored to the localizer course for an Instrument Landing System (1S) approach tw Runway 03 Left at the Detroit Metropolitan Wayne County Aieport. At the captain's request for a long final approach, the controller plamed (or a 20-mile localizer course inieroept. A slow descent was initiated and, ac- cconding to the captain, because of limited elevator contol, the No. 2 engine was secured. He ap: pied power on the Nos. 1 and 3 engines to assist in pitchup conttol. The captain decided not to dump fuel because ot th age in the empennage area, part of the final approach the airspeed was 150 knots and the sink rate was appro , feet per minute. Extension of the landing, and 38° flaps inereased the sink rate t0 1,500 fect por svinute, Addition dhrust increased the airspeed! (0 160 t» 195 knots and stabilized the sink rate at approximately 800 fect per minute. ‘The temainder of the appwcach we hisprofile. ‘The captain stated that the i deck angle was extremely flat compar raft's to that of acura appeuach and tata wuelowy he had scrious doubts if the landing gear was ex tended. He further stated that he used no stabilizer trim and that he and the first officer beh td to apply back presse to the sotrle totlaetheaieplane, Thestiplanelnded at ‘The airplane touched down 1,900 feet de the runway and mediately starved tower to the right. “Te captain applied rovers thas to engines No, 1 and No. 3 and applied full lft aileron. As the aircraft veered further right, che fist officer appled full reverse thrust to the let engine and brovght the ig cegine out ofr verse. This action provided dretional contcl and the airplane paralleled the right side of runway for 2,800 feet before it han gad loft turn hack to the runway. The airplane came to rest approximately 8,800 fect from tle tu way threshold. ‘The nose and lefe main landing sear were on the runvay surface, and the right train landing gear was off the ronway suriace, “he capan ordre che emergency evatathn slur activated ace the arylane came to test ‘The evacuation slides were deployed and all passengers and crew used he ies 1.2 Injuries to Perso Inj Crew Pastengers Ody Fatal ° o o Nontatal = 9 0 None 9 7 2d Damage to Aircraft “The cabin floor in the aft lounge area sustained major damage. ‘The fies: nine transverse floor beams inthe lounge area were fra tured approxi: imately 6 inches fro I struts neat the left side of the compartment. ‘These beams aso failed in bending near the right side of the ar phe, and allowed the floor to settle parti into the cargo compartwent. seats attached ¢0 this floor sect the vert ns however, a circular bar installed near the aft end of the lounge tore Loose. ‘his bar came to rest in the lefe comer of the lounge, where the cabin floor deflection was the greatest, ‘The deflection of the floor datnaged and jammed number of the engine and flight control systems cables. One cable to the left rudder and a pair of elevator cabks weie severed, In the cackpit area, the ‘manual stabilizer trim handles were inoperative, nd the rudder pedal torque tube and left rudder cable horn were separated, The aft cargo com- partment door separated from the aigplane aud ‘caused minor damage to the fusel door and substantial damage to the leading edge and upper surface ofthe eft horizontal stabilizer ‘The cargo door was recovered from a field sev eral miles from the aiepore, 1.5 Crew Information ‘The flighterew and cabin attendants were qualified and certificated for the operation of this Might. (Por detailed Appendix bh) 1.6 Airerafi tnformati he airplane was a MeDonnell Douglas DC 10-10, registration No. NIOSAA, serial No, 46503. tt had accumulated 2542: 15 cotal fying hours and 8:47 hours since che last Tine mainte nnajor airplane sna spection was performed on April 26, 1,825 hours’ etal can certificated dance with com pany and Federal Aviation Administration (PAA) reqalitements, ‘The only recorded discrepancy to the cargo doot closing mechanism vecusced on March 3, 1972. ‘The log entyy noted that the door would snot close electrically, and that it had to be manually latched. Corrective action consistedF an adjustment to the door-cfosing switch 10 permit elecerie operation of the latches. No Airworthiness Directive pertaining to 1-10 cargo doors was in effect me che time of the accident, However, McDonnell Dougl Service Bulletin $2.27, DC:10 SC 612, which pe tained to the electrical wiring to the latch actua- tor, had been issued on May 30, 1972. The modification recommended replacement of the cargo door latch actuator wiring with heavier gage wire. American Airlines had not complied with this bulletin at the time of the accident nor was compliance mandatory. ‘The reason for the issuance of this bulletin was stated in the bulletin as: "Reason: Three operators have reported failure of the clectrieal latch actuators to lateh/unlacch the cargo doors. Latch actuator failure is at- tributed to an excessive vlege drop seucing the output torque to the actuator. dition may prevent electrical lat ing of the hooks. Failure to provide adequate torque nevessicates manual latching/unlate‘hing of the doorsresulting in fight delays, tnersas- ing the wite goge between the circuit breakers ani the actuators will reduce the voltage drop and provide adequate torque to operate the tatch hooks under all anticipated conditions.” 1.7 Meteorological ta The surface weather obsevations at Detroit Mecropolian Wayne County Aigpart, Detroit, Michigan, for a period prior to snd following the accident were, in part, as Follows 1906.-Special estimated 4,500 tect broken, 7,000 feet overeast, visi c4 restric tion to visibility smoke ant fog, wind 090° at 7 knots, temperature 56° F.. dew point 70° F alkimcter setting 29.85. 1955 -Eestinnted 4,500 oveccast, 1-1/2 aniles visibility, restriction to visibility smoke and fog. wind 140" at 6 knots, cempe alow point 58°F, re 61 F altimeter setting 29.85 Bese eG 1.8 Aids to Navigation se were no reported malfunctions of the navigational aids during. che emespency. Ron: way O3L, is equipped wich a full Instrument Landing System, which was uilized by the erew "approach. ford All communications with Flight 96 were in accordance with established pro: There were no reported difficulties. cedures 1.10 Acrodrome Ground Facilities Detroit Metropolitan Wayne County Airport is located approximately V7 statute miles south west of Detroit, Michigan. “The geographic loca- tions 42°13.1" north Istitude and 83°20.9" west Fongitude, at a field elevation of 639 feet mean sea level. ‘The aitport is operated concinuously Ywonway 03 left is 10,500 fect in length, and 200 fect in width, of concrete construction, with alloweather markings. It is equipped with high: intensity tunway lights with centerline lights and high-intensity approach lights. he approach lights are equipped with sequence flashing lights “The rimway is also equipped with touchdown cone lights Fivcfighting and resee equipm were as follows 2.-Yankee Walters, 2,500 gallon tankers. 1 Yankee Walters, 3,000 gallos tanker. 1 Drdge Light Reseie Tatck, 1,000 porns sky ehemical 1-750 gallon pumper. 1 Dodige Resewe Van nt available ‘Yen firefighting, personnel were available on hour shifts 14 Hight Recorder he airplane was equipped with a Sundstrand Dats Control Model 573 Flight Data Recordes.te i a digital reeocder with an associated dota acquisition system of the expanded parameier type. "The recording mediam ts one-quarter inch magnetic tape, on which aircraft performance information is recorded socially i digital form for four sequental tacks covering 28 hours of aiteraft operation ‘The data reeorder was oper to the time the doo formation obs tained from it confirmed the crew's testimony that che incident oceutred at an altitude of 11,750 feet, However, the data recorded after the incident was lagely abeeraat, and fitele a ful information was obtained." The aberrant recording was the result of inadequacies of the nstallation in chs particular data recordee which cenised acceleration loads to affect the perfor ance of che recorder. tn additicn t0 the flight dary recorder, aireraft_was equipped with a Fairchild Mode! 100 cockpit woice recorder (CR). The CA tape was recovered intact, and a transcript of the ppertinene communications is included in Appen dix, ing normally up 1.12 Aireraft Wreckage ‘Aw examination of the airplane and of the aft ‘eargo door which had separated in flight was conducted. The cargo door hinges door fiame, and the four rollers on the door sill, which engage door latches apon closing were basically usdamaged. The rollers were free to rotate and, exeept for wo sitall gouge marks on the second roller from the front, they were undamaged. ‘The door actuator gear box was in pace: how: ever, the motor had separated frown the door and was hanging by its electric wires, The actuator dl separated and was not recovered, The door itself separated from the fuselage fn Hight, leaving approximately 80 yercent of its exterior skin in place on the door hinge he door was found with the four latches nearly closed, with the lockpins mot engaged, with the vent door overtraeled beycund the open position and with che dooe handle in the towed portion. The Hatches, which were filled with ‘earth, were approximately 0.1875 of an inch from their fally closed. positions, and the latch nechanisms were 0.35 of an inch from their over- center stop positions, Hecliminary examination of the screw-type actuator which operates these latches indicated ‘hac the length of the actuator meassred between the eonterlines of its attach bolts was less than its normal extended position. ‘The actuator was removed and taken to the manufaetarer for examination and disassembly. le was determined that the clectrial extend limit switch was closed. ‘The gear train was operated ‘manually until the extend linit switch opened, The fully extended actuator measured 11.777 inches and the retracted measurement was 9.950 inches. ‘The actuator, a8 recovered, measured 11,040 inches, ‘The unit was given an electrical load test_ which consisted of loads of 1,500 potnds, 2,000 pounds, and 2,600 pounds. Volt age readings varied from 28 V DC to 13 V DC. When a load of 1,500 pounds was applied, the unis crepe slowly with a voltage of 13 V IX! and current draw of 11 ampere. When 2,000 pounds were applied the un age of 13 V DC and a eurrene of 13.5 ampere. With a load of 2,600 pounds applicd, the unit crept with 18 VDC and 17 ampere. The elt setting was 2,900 pounds. All esting was per formed with a new electrical motor installed. ‘The original motor had separated from the ac. iator end was never rccovered. erept with a volt Examination showed that a highcompression force 0s transmitted frosn the latches through the ineversible latch lin structure. This was evi setuator to the door it fron che Brivelling of the upper sie uf che bushing on the actuator attach lg and from the damage observed on the actuator support bracket. ‘This support bracket was in place on its attach structure; however, the two bolts which connected the bracket to the siruicture wore sheared. A part of one hole was sill inthe door skin whic was attached to the anplave. ‘The holes in the bracket and che atch structire were aboot 0.375 of am inch ont of aligninent at the outbo: late motion between these sive chafemarks in the paint parts was the ste‘of the support bracket shore it fitted against the mount stracture, These marks indicated maximum relative motion between these parts ‘of 1,05 inches ‘the small vent door on she aft cargo door, the door handle, and the latch lockpins are inter- connected. ‘The system is designed to. prevent the door from clasing and ehe handle from stow. ing if the lockpins are not in place behind the closed latches. ‘The link from the door handle eo tal torque tube which controls the vent door aud the lockpins had failed in tension near its lower end. ‘The fractured ends were separated by. several together “The horizontal torque tube was bent slightly. and it was opt of fis braving on the forward end, ‘The wnt door, which is attached to the torque tube, had overtraveled its normal open position and was jammed ia place, “the vent door guard had failed in she downward direction. ‘The linkage from the torque tube to she lock: pin amechanisny was intact, except that the pivot point was broken on the heslerank wick con: push-rod sorion (from the handle) to horizontal lockxebe motion, ‘The forward end of the Tock tobe wae bent outboard. Ti door frame was yartilly fractured in of this bond. The hr-kpins beyond theie nora? snlscked positions. horizon: thes and could not be pulled The cargo setuation aud warning. system hydeaulic power system, the main wheel brakes, ee nose stovring system, the cmpennage couteol, and the No. 2 engine contra systeny nine he argo door warning Hight system was Tour operable ftom the cockpit aft to the comne:tor plug on the cargo door frame, None of the citeui breakers whieh contra power to the cargo doors and warning, systems was fous tripped. ‘The wiring to the door, the tock vraening swite, the elosed fie switch and che cfsed limit waruing switch were separated from their attachments on the doe structure ad nthe hydraulic gel brakes or steer No diserepancies were f power systems, oF in the wl ing system. Although the left euder pedal was jammed, the left brake pedal operated normally. Operation of the v ols in the cock pit revealed the following: 1. ‘The nose steering system was positioned approximately 13 left because of the left rudder peda’ input signe, The system was operated from the contrat weet with the torque link disconnected; this operated the nose stecting system normally 2, The elevator system was operable through ‘out itsrange: however, che input loads were higher than normal 43. ‘The stabilizer ecim switches on the control wheel operated normally however, che ator was inoperative, idee tim control was operable vo Js; lkewever, the trim would not posicion the rudder eo the let. ‘The collapse of the cabin floor damaged a and flight control system wuced through the Poor \ The foitowing damage was calle boams observed: 1 Blewater Control System The right hand elevator eables (No. 5 and No, 6) were preloaded dorvnward by the collapsed cabin floor structure. ‘The erable: however, hight nora contol frees were requted ttoth lefechand elevator cables were sepa rated, The No. 4 cable pulled oat of the left tension regulator, and the No. 3 eable pled our of as seaged fitting to the ele vator crank, 2, Rudder Control System ‘the No. 2 (right) rudder cable was stretched tant by the collapsed floor struc tate aud could not be me pedal mechanism had or ‘ward position and was jaramed Toft stop and the lower e The nox.con the rudder torque tube had both failed ‘The rudder itselt was deflected, trailing edge right ‘The rudder trim eables were also pre foaded by the collapsed Moor steuctures hhoweves, there was limited response to rudder trim inthe ea wailing edge righ trim we From souteal to 3, Harisontal Stabilizer Trim The horizontal stabilizer could be o> crated up and down by the switche cither cumtrob wheel, ‘There was ns sponse from the alternate electrical tun switches on the pedestal, Both lend mana im suitcase handle cables hed failed, and both right cl cables sone prefoaded. In order to the stabslizer manually with these les, bots andles must be function “The horizontal stabilizer position indica tor drive erank shearpins weie sheared, and the stabilizer position inclieator cables (No. 135 and No, 136) had failed. AL No. 2 Engine Control ‘The No. 2 engine throttle, fuel shutoff, and fiowall shueoff cables had all fled The hycleaulic, fire, ane Fuel fixewall het off valves were in thei: mid positions Lbs Pine ‘There was me fire Aspects “The accent was sora All erewmeuabers and passen airplane dhevagh sis of is wight emergency exits All cxcape slides for thse exits Funetioned vor rs exited the nine passengers and the two cabin ants who local hospital for po le frsctnres a injuries. “The injuries consisted of comusions and lacerations “of extremitios and sprained ankles. One passenger suffered a dislocated Finger and another passenger facial injury from ing struck by a floor hate during che decom pression, All other injuries were frietion burns sustained whew the passengersslid down or exited the bottom of the evacuation slides, “the events from the tine of decompression snail emergency evacuation areas follows: ‘The Decompression he decompression taanifested itself 10 the passengers and flighe attendants as a mulled explosive sound and a whitegray fo, which formed throughout the cabin, ‘The door to the cockpit and the door of the galley lift ‘opened, and several ceiling panels in the conter cof the cabin fell dowo. 8 floor hatch in the aisle next to seat 4H flew ap and struck a passenger in the face The chief flighe attendant, who was stand ie attendants Win the forward serview ste from this area. The owo fli seated at the two aft exits were thrown to the Aoor, which had partially collapsed into the baggage compartment telow, The cirealar stand bar on thiseollapsed flooe seetion was torn loose front the floor, Of she eight flight attendants, five reported thae thei First houghe was to each foroxygen wsks, The antomatie release for the oxygen system is preset to operate ar 14,000 feet, nul since the airplane was below that altitude, tlhe system dit not actuate, One fight atcend: ant at Exit 21 obtained a wall around oxygen hte and call il ehe cockpit on the Satersom system vo tell se erew thac the damage was in the rem of the aigplane. The chief ight acendans and che fight attendant stationed at Buit 1K, went to the cockpit for insteue Passenger Preparation The chief fight ate on instr tions from the captain, told the other Might | ) | | |avtendanes to prenoee che cabin for an emer geuicy landing, She obtained an estimate of available preparation rime (8 to 10 minutes) and proceeded, with the aid of the emergency checkbat, to brie! the passengers by nieans of the puble address system. ‘The other fight attendants demonstrated the brace position to the passengers, pointed out exit locations, gave testructions for use of ehe emergency escape slide and collected personal belongings and shoes. A number of passengers reported that the emergency instruction acd was very tueful in determining thew nearct exit locs tio Passengers seated adjacent to the collapsed flooe scetion were zelocated, as were several ‘of the pestengess seated in she vicinity of the fallen ceiling panel. ‘The two flight attendants ansigned to Exits 1, and 48 were relocated so the jampscats inthe forward service area Feacwation Devin the landing rollout af che sitplane, several other ceiling panels fell down, When the airplane cams toa stop. the cal wont out. the emergency lighting. system iuminoted, and the emergency evscuation signal was activated by the cockpit crew. ‘There vas 00 delay in cpeting of the six exit dors (three on cach side of the fuselage). The two rear ents, HL and 4R, were not used because of the collapsed floor section in that atea, The evacuation slides deployed pot matically although two skde packs fell ins the cabit. and had co be Kicked out. Most pat sengs7s reportedly needed mo encouragement to leave the aitplauc and were waiting near the doors for slife deploymeat. ‘The evact tion preceeded smoothly except that wo elderly female passengers had to be helped through exits by a Migh: attendant, and one passenger's path was obstructed by a fallen ceiling panes, “The evacuation was estiwated by the Might antendants tc: have been completed in 30 seconds. 1.15 Tests and Research The maunfacturer conducted a ses to deter: mine i the aizplare could be pressurized with the vent ducr open and the nylon bagyage cur in acting a8 a seal enveloping the vent door cage. Another vest was conducted to determine the force necessary to stow the aft baggage door ocking handle by forcing the handle linkage ‘overcenter to an apparent doorlocked position without the lockpin engaged. ‘The fires cout revealed that the curtain asa 9 could maintain appecximacely 5 p-si differential pressure, Above 5 pati the curtain was miched into the vent door cage and pressurt:ation was fost. The second test revealed that the force re- quired to stow che haadle was approximately 120 pounds. When the door linkage was forced ‘overcenter, the locking pins did not engage. Mt was noted further that the sliding lock tube was deflected, and the cap end made contact with the cockpit door warning indicator actaat indicator switel ean be actuaced ing atm. 2, ANALYSIS AND CONCLUSIONS LI Analysis “The initiating Factor of this accident yas the snflight opening and ssparacion of the alt cango door. Structural damage to the door verified that the latches were not overcenter when the sloor ‘opened in flight. ‘The two fasteners whieh at tached the doce Latch acwuasor to the door had uth failed in shear. Part of ove of the bolts ‘was found in the piece of door skin which 2°- mained on the airplane-an indication shat this failure oceurred in the ait, ond not when the maim portion of the door impacced the ground. Forces transmitted bach through ihe linkages fom the door latches are eee means by which the actuator sal supporting bracket could bee loaded in flight. These latch toads are trans rwitted back dhrough the actuator cally if theactuator linkages ace not overcenter. evidenc “thas, the cates that the latch actuator did not extend far enougis to drive the latehes beyond the overcenter position, and that pressurization forcesion the door were transmitted back through the latch inkage to the actuator support bracket According to the manufacturer, the dimension sv the latch crautk and the avereenter stop jould have been 0.47 inch for this particular sctuator extension, With a 0.47 inch displace- ent, a 4.5 pasi. pressurication differential across the door would have been sufficient to fail the two fasteners which had an ultimate shear strengths of 6,600 pounds. The manufacturer noted that the 4.5 pas figure was an approx mation, since redundancy of the system, toler. ances, deflections, and variances in rigging can all affect the load transmitted through the ‘mechanism, When the door laiches are fully closed, actus: tion of the door handle moves a lockpin in place bbehind a cam on each latch, These pins then prevent the latches from opening for any reason. The lockpins could not have been engaged in this case since the latches did not attain their fully closed positions, and the door handle should not have stowed. The agent who operated the door said that the door handle did noe close normally. He had to force the handl with his knee, and the vent doce, which is also ‘operated by ‘the handle, did not then close properly. ‘A subsequent test of the door m-chanism demonstrated thst the door handle could accu ally be stowed without the lockpins in place it « force of 120 pounds was applied to the han Deflection of the mechanism permitted this to happen. ‘The same deflection might have per mitted che pilot indicator switch to make con tact, whcin, in this system, prevents illumination of the cockpit waming light, ‘Thus, the crew had no warning that the door mechanism was ‘aot functioning properly. Such a switch contact was also observed in the test conducted at the menufacturer’s facility. ‘The iv casing pressure differential between the pressurized bulk cargo compartment and the ‘outside atmosphere ‘luring the climbout loaded the latches, which erentually caused filwe of the fasteners which secured the actuator support bracket to the door structure. ‘The latches were then spreng open, which permitted the door to blow open. The combination of airloads and impact of the donr with the aiteraft fuselage caused the door structure to fail, and most of the door separated from the siplane The loss of the aft cargo compartment door a rapid loss of pressurization ia that mpartment. ‘This particclar cargo compat tment as not equipped with pressure rclief vents to the passenger cabin above it, as were other cargo compartments on the airplane. ‘Thus, the loss of the door caused the ful differential pres sure between the pressurized pastenger cabin and the atmosphere to be exerted on the eabin floor over the compartment. This loading failed the floor support structure, and the cabin floot collapied downward into the cargo compartment. The collapse of the floor resulted in the loxs of much of the control of the empennage control Ithough the airplane was designed with considerable redundancy in its flight control sys- tems, the control cables from the cockpit to the empennage control actuators aze routed oot beams over this cargo compartment. The eabin floor displacement and floor beam deformation sither severed or severely impaired the operation of these cables. ‘The Board believes that the lack cf pressure vents in this cargo compartment represents significant hazard; sudden luss of pressuriza- tion i this compartment should not jeopardize the safety of the Aight. If complete venting is not feasible, even partial pressure relief might reduce the ‘cabin floor displacement and the attendant interference with critical flight ols. surfac 1m this case, the crew reported, and the inves tigation confirmed, that the captain’ left rudder pedal deflected to and jammed beyond its nor- ‘mal maximum forwacd pesition, affording no adder control from the cockpit. ‘The crew also reported that the airplane yawed to the right. ‘The left rudder cable was found broken ber ritting slack in the right rudder cable. The weight aad force of the cabin floor deflectedthe intact right rudder eable downward, pusting a right signal into che. rudder control valve sy3- tem. There was no impaitment of aileron eontrol and the crew proximately 45° left aileron covconnteract the right yaw. ‘The exew reported thar extremely heavy com trol forces were necessary for pitch contol Two elevator control cables were separated and two remained intact: however, the downward Foading of the floor om the cables made cof increased Forces necessary to mae the ec yoke. ‘The crew reported that the stabilizer trim control was lost. Fxamination of the system did not confirm this statement, The stabilizer trim indicator was inoperative because of a ‘broken cable. The manval stabilizer trim on che pedestal (suitease handles) was inoperative be- cause the cables to the left handle were sepa rated, To operate the sabilizer trim manually with the suizcase handles, both handles must be functioning. One handle positions che control valve and the other constols the direction of operation (up or down). It was not confirmed which valve was inoperative because of cable separation. The normal operation of the sta biliore trim is by the crim switches on the captain's and the first officer's control yoke. These switches functioned normally when checked. TThe crew reported that they secured the No. 2 ine during thedescemt into Detroit. Examina- tion revealed that the cable to the fire shutoff valve was separated, The cables to the No. 2 engine thrust lever and fuel shutoff valve were also separated. Therefore, the Board believes that the engine was shut down when the cables separated and that no control of the engine existed from the cockpit subsequent to cable separation, "The deszent and approach to the Detroit Metropolitan Wayne County Airport were suc- cessfully made under these conditions, ‘The problems which manifested them the landing and rollout as des were high approach speed (160 to 16 knots) to counteract high sink rate, no rudder control, 43° left aileron to counteract right yaw, no left 10 brake, bitiy ‘The erew stated that when the landing gear and 35° flaps were extended! at 150 KIAS air. speed, the sink rate increased to 1500 10 1800 fect por minute and, in onler to stabilize at a normal sink rate, an irspeed of 160 40 165 KIAS was necessary. At this airspeed, che airplane had an abnormally shallow derk angle and at touch- down, application of control forces by both the captain and first officer was required to Hare the airplane. Subsequent vo touchdown, the airplane yawed to the tight and directional control was main- tained only by asymmetrical reverse thrust. Since the captain was applying lefe aileron, the first officer applied the asymmetiical reverse thrust. ‘x the airplane deceleraced and the right ruéder isplacement became less effective, the airplane began a gradual left curn toward the runway. ‘This turn was due te the full left deflection of the rudder pedal which activated the nosewhecl steering 10° to 12° to the left. Rudder trim, although limited, was available, Thetrim cables reposition che neutral setting of the rudder control valves. The rudder actua- tor had a right displacement sigaal from the cable system; this was in the same direction as the trim signal. ‘The trim wheel functioned nor- mally wo che right; however, it was necessary for the pilot to use both hands co move the rin wheel to neutral because the floor was binding the cables, ‘The three hydraulic systems remained intact. ‘There was no leakage of Haid or loss of pressure. Wher the auxiliary pumps were tuened on, pres- sure was built up in both brake systems, When the two pedals were depresced, both brake gages registered pressure. The report of no Heft brake was in all probability caused by the pilot's in- ability to actuate the pedal, as the rudder pedal was overextended to the left, which necessitated along awkward reach. The manner in which the flight attendants handled the emergeney was indicative of exccllert training and a highly professional attitude, “This was evident in their immediate recognition of the possible need for supplemental oxygen, the id uncertain nosewheel steering capileadership exhibited by the chief flight artendane in directing the other flight attendants and in staying abreast of the airplane's progress, in pre- paring the passengers for an emergency landing n the prompt and elaborace briefing given the passcngers. Several individual, iaipromptu decisions had to be made by the flight attendants beeat se of the various unknown faccts of the situation For instauce, the proximity of the passengets to the collapsed floor section prompted flight attendants to move all occupants from that ares. Several passangers were moved from the vicinity cof fallen ceiling panels, A flight attendane briefed ‘one of the male passengers near her door in the ‘operation of this exit, just in case she would not be able wooperateialter landing. Another Flight attendant instructod two foreign passengers on the bracing position and the locstion and use of their exit becsuse she noticed a lack of compre- henson on the port of these persons when emer. gency instructions were given, Prior to the landing, ail flightattendants were seated, and che ‘chief flight attendant had reported to the captain thac che emergency checklist had been com- pleted and that the cabin was prepared for emer. gency land ‘The evacuation ‘vs initiated when the emer- eney evacuation signal was activated from the cockpit. The evacuation alarin produced a favorable influence on passenger behavioe. All attendants reporied that they were wot quite ready at their statious when the first possengers appeared, ad many of them had to be hel back to give the slides rime to deploy. This was especially true in the ease of the slides from the overwing exits which require 17 seconds to in flat fully. ‘Two slide packs fell onto the cabin floor and had to be kicked out of the door. This is not unusual, however, since the motion of the door, in traveling to its fll open position, constantly aleers the fouition of the package in relation co the door sll, A slight delay or premature release of the package may cause it co fall on the door sill instead of oucside. Injuries were sustained by nine passengers. Most of the passengers were unable to maintain uw ea ea ee ER ST eS en 4 “feet first” position while sliding down the center of the dow'le occupancy sur not able to stabilize themselves because 1 could ot reach he raised sides, As a re some passengers were injured at the end of the slide, 2.2 Conclusions (0) Fined A, The cewmembers were properly certificated for the operation, 2. The airplane was operated in ac- cordance with FAA and company regulations and procedures. 3. The airplane was within the gross weight ane! center of gravity li 4. The aft bulk cargo compartment door opened inflight and separated fiom the aiplane. 5. Relief vents were not installed be- tween the passenger cabin and tke aft bulk cargo comparement te minimize the pressure loading an the cabin floer in the event of a tepressurization of the ‘cargo compartment, 6. ‘The los of pressure in the cargo compartment created a pressure differential of sufficient magnitude to cause the cabin floor and its supporting structure to fail 7. ‘The cabin flooe displacement and floor beam deformation imo the cago compartmens severed some of the cables and severely impaived the operation of otiers to the No, 2 engine and empennage flight con- tools. Stabilizer trim was available, ab though the stabilizer indicator was inoperative, 16 erew was not awate of that, and they did not use {tim for the approach and landing. 9. ‘There were no malfunctions of the three hydraulic systems, the air- plane's brake system, and the nose- wheel steering system,10, n. 2, 13. M4, 5. The width o ‘The cargo door latche. were not latched overcenter; this condition was attribated to low wlare to the latch motor. ‘4 sarvice bulletin to corect this condition was in effect at the time ‘of the accident, but the recom- mended modification had sot been incorporated, ‘The ramp service agent forced the door handle closed without the Tockpins in place. Althoc gh the docw was not then properly closed, deflection of its locking mechanism permitted the pilot indicator switch to make contact which turned the cockpit warning light off. “The preparation of the passengers for an emergency landing and the subsequent evacuation were well executed. ‘The Board commends the Might- crew for the manner in which they auccesrfully coped with the unusual inflight emergency. Additionally, the Board commends the flight attendants for their actions which axe indicative of excellent training and a high professional attitu ‘The emergency evacuation alarm syste effective. double occupancy emergency slides made it sifficule for the evacuees to stabilize their sitting positions during the descent, when they reached the bottom of the slide. (b) Probable Cause The National Transportation Safety Board determines that the probable cause of chisaccident was the improper engagement of the latching mecha nism for the aft bulk cargo compart- rwent door during the preparation of the airplane for flight. The desgo characteristics of the door latching tmechan‘im permiteed the door to be apparently closed, when, in fact, che latches were not fully engaged and the latch lockpins were not in place, 3. RECOMMENDATIONS AND CORRECTIVE ACTION ‘Asa result of the investigation ofthis accident, the Sefety Board on July 6, 1972, issued two recommendations (Nos. A-72-97 and 98) directed to the Administrator of the Federal Aviation Administration. Copies of the recommendation letter aad the Administrator's response thereto are inclysted in Appendix P.Sn ne ee ee er an, ER ee BY THE NATIONAL TRANSPORTATION SAFETY HOARD ist JouNeH. Thain Si ERANCIS H. Meat Nene st LOUtS Member Is) ISABEL Member fs) WILLIAM R. HALEY Member Pebinary 24,1974APPENDIX A INVESTIGATION Aus) HEARING 1. Investigation ‘The Board's Chicago field office received notification of the accident at approximately c-li.,on June 12, 1972, from Aunerican Airlines Flighe Dispatch Office at Chicago's O'Hate Field. An investigator from the Chicago. Field Office war on the seene at approxiznatcly 0330 eal. on June 13,1972. investigators from Washington and the New York Field Office arrived con the scene on the morning of June 13, 1972. Woking groups ware established for Opers tions, Human Factors, Structares, Systems, Maintenance Records, and Flight Recorders Parties to the Investigation included: America Aitlines, Inc., the Federal Aviation Adminis tration, Allied Pilots Association, and McDonnell Douglas Aircraft Corporation. 2. Hearing ‘There was no public hearing. 3. Preliminary Report ‘A orcliminary report on this accident was issued by the Safety Board on August 22, 1972. i i ; Preceding page blank i | 15 ;APPENDIX 8 CREW INFORMATION Captain Bryce MeCormick, aged 52, was employes! by an airlines om May 26, 1944, He holds Airline Transport Pilot Certificate No, 10506, with ratings in the Doughs DC-6/7, 1C-10, Boeiag 727 and 707, and the Convair 990-ype aircraft, iad passed his most recent examination for an FAA first-class medical certificate on ct 24, 1971, without any physical waivers and his company physical examination on Octaber 29, 1971. He had accumulated 24,048 hours of fying tine as uf June 12, 1972, of vihich $:51 hours were flowa on chis fight, Ke had acquired 56 otal hours in the Souglas Hen aireraf He had completed grote schoul and ight raining in the Dengan 1X10 and had passed is flight proficiency rating check on March 30, 1972, fis most recent line check had been performed on April 24, 1972 First Officer Peter Whitney, aged 34, was employed by American Airlincs om 1965. He holds Airline Transport Certificate No, 1621264, Hee had pused his most recent examiuition for an FAA first-class inedieil certificate on January 21, 1972, without any physical waivers and his company physieal examination on May 26, 1972. He had accumulated 7,947 hours of fying time as of June 12, 1972, of which 5:51 hours were flown on this fight. He had acquied 75 tocal hours in the Douglas DC-10 aircrafc. His most recent proficieuey check in the Douglas DC-10 had been on March 30, 1972, Flight Engineer Clayton Burke, aged $0, was re-emplced by American Airines on March 15, 1954. He holds Flight Bugincer Certificate No. 1298279. He had passed his most recent examination (or an PAA tnedical cetficate on Docember 15, 1971, without any physical waivers, and his company physical examination on Decembet 14, YH, Me had accumulated 13,898 "outs of flying time «s of June 12, 1972, of which 5:51 hours were fawn on this flight. He had acquired 45 cotal hours in the Douglas DC10 aircraft His most recent proficiency eheck in the Douglas 1XC-10 had been on March 30, 1972 CChiof Flight Attendant Cyla Smith as employs by American Airlines on May 28, 1968. She completed her DC-10 training in May 1971 and her most recent emergency procedure ing on May 11, 1972. cewardess Beatrice Copland was employed by American Airlines on Jal, 30,1970. She completed her DC-10 training in March 1972 and her most recent evaergency procedure tin ing on June 14, 1971, Stewardess Jamies Hickingbottom was employed by American Ax ‘She completed het DC-10 training in October 1971 and her most re ining on May 23,1972. Stewardess Colicen Maley was employed! by American Airlines on May 20, 1971. S pleted her DC-10 training, in january 1972 and her most recent emergency procedure ‘on May 16, 1972 ‘Stewardess Sandra McConnell was employed by American Airlines on March 23, 1969. She completed her DC-10 traning in October 1971 and was scheduled for emergency procedure training on June 13, 1972. ‘Stewardess Charlotte McGee was employed by American Airlines on May 27, 1971. completed: her DC40 training in November 1971 and her most recent emergency procedur training on Nay 22, 1972. Stewardess Carol Stepheus was employed by American Airlines on May 16, 1972, and graduated from American Airlines Stewardess School on May 16, 1972. eptember 8, fines on Apeil 24, 1969. ‘emergency procedure 16