C I V I L A E R O N A U T I C S B O A R D

AIRCRAFT ACCIDEW RFPORT

AERONAVES DE MEXICO, XA-XAX, LiOUGIAI; E-8,

NhW YOHK INTIBNATIONAL AIRFOIiT ,
VI% YORX, P E N YORK, JANUARY 19, 1961
J

SYNUPSTS
_L

An Aeronaves d e &kX:LCO X-8-21, Mexican R e g i s t r a t i o n XA-XAX, crashed

and. burned following G ba.llreci t a k e o f f from runway 7R: Kew York lnternstional

Airport, New York, New York, Jallrrary 19, 1961, about 2C1.7. Four of the

nine crew members were k i l k e d ; all 97 passengers survived but some were

inj u r e d .

This acciderit was apFarently caused primarily by unnecessary b a l k i n g

of t h e t a k e o f f b y the check pilot, who wae not I n e i t h e r pilot seat. Con-

t r i b u t i n g f a c t o r s were marginal weather, snow on t h e riinwa.y, and an a n t i -

i c i n g heater p o s s i b l y not used,

 - 2 -

Investigation
-.__

The F l i g h t

Aeronaves de Mexico F l i g h t No. 401 of January 19 was scheduled t o d e p a r t

New York I n t e r n a t i o n a l A i r p o r t , New York, N. Y . , a t 1830 -

1/, nonstop t o Mexico

City, Mexico. There were 97 passengers and a crew of 9 aboard, i n c l u d i n g 5

cabin a t t e n d a n t s . Captain Ricardo Gonzales Orduna was i n command of t h e f l i g h t .

i n the l e f t seat. Eastern A i r Lines! Captain W i l l i a m B. Poe occupied. t h e jump

seat i n t h e c a p a c i t y of check p i l o t , d i r e c t l y behind him. Other crew members

were F i r s t O f f i c e r Antonio Ruiz Bravo, Second O f f i c e r Xavier Alvarez Bacha,

Purser G l o r i a Sanchez Herrejon, Steward Albert0 Reyes Campos, Stewardess

Margarita Badillo, Stewardesses Laura X a r t i n de Jorge, and Maria Autoniata

Ponce de Leon.

Departure was delayed about one and one-half hours by t h e l a t e a r r i v a l of

t h e crew and about 40 of t h e passengers due t o weather c o n d i t i o n s .

-. The a i r c r a f t had ar-rived from Mexico C i t y a t 1519, t h a t day, and snow had

accumulated on i t . Glycol was used t o remove t h e snDw from t h e a i r c r a f t in-

cluding t h e p i t o t heads, and t h e process was cor-tinued u n t i l time t o start t h e

engines f o r t a x i i n g o u t . The Second O f f i c e r and Captain Poe conducted a walk-

around i n s p e c t i o n of t h e a i r c r a f t . They had supervised t h e later p o r t i o n of t h e

r e f u e l i n g o p e r a t i o n s , i n c r e a s i n g t h e f u e l l o a d by 2,000 pounds, because of

a n t i c i p a t e d headwinds. Captain Foe walked o u t on t h e taxiway t o check t h e snow

c o n d i t i o n s l o c a l l y and r e p o r t e d a depth of about one i n c h . H e described t h e

snowfall as " f a i r l y hard," and t h e snDw as "very f i n e and very d r y . "

-1/ A l l times h e r e i n a r e e a s t e r n standard based on t h e 24-hour. clock.

 - 3 -
The crew boarded t h e aircraft at 1935, Final clearance a_nd dispatch papers
were received from Bstern Air Lines Operations after the de-icing had been

finished. The engines were then started and the flight was cleared to runway

, 7R at 2004, Its gross weight a t t h i s time was 272,171 pounds, well under the
permissible limit, and the location of the center of gravity was also well

within permissible limits. While holding short of the taxiway, the flight

received its IFR clearance at 2010 Two minutes later it was cleared to taxi

to the westerly end of runway TR, where it stopped and was then cleared for

takeoff. The latest airport weather was given to the flight as: precipitation

ceiling 300 feet; sky obscured; visibility one-quarter mile; light snow; fog;
- wind east-northeast 18; gusts to 24; altimeter 29 64- While the aircraft was
being taxied to takeoff position it was given “runway 4R 2/ visual range less

. than 2,000 feet,” At 2014:38 the flight reported: “Aeronaves 401 rolling.‘I
. (The weather minimms for this flight were: ceiling 200 feet; visibility one-half

mile. )
The first approximate 6,200 feet of takeoff roll was observed by control

, tower personnel, visually, until the aircraft was lost to view by obscuring

snow, approximately 3,800 feet from the control tower. They stated that EL

that time the aircraft had not tsken off 020. rotated. Another tower controller

observed the aircraft by airport surface-detection ground radar from the start

. of its roll to the eastern end of runway 7R, where it disappeared from view. A
. few seconds later he observed a bright orange flash in the sky northeast of

the airport. He could not tell if the aircraft left the runway. Ebergency
:. procedures were started immediately by the controllers and an unsuccessful
 - 4-

Captain Poe w a s t h e Only s u r-v-i v o r of t h e four cockpit occupants, He s t a t e d

I _

a6 fo$&ws: The c h e c k l i s t w a s accomplished normally, The runway c o n d i t i o n was

good and everything a p p a r e n t l y occurred i n a r o u t i n e manner through t h e lOOcknot

'.
t i m e check when t h e f i r s t o f f i c e r c a l l e d o u t "cien" (Spanish f o r loo), Upon

reaching approximately 130 k n o t s ( t h e V i speed) t h e f i r s t o f f i c e r c a l l e d o u t

*
v1 and VR i n ra?id successions The a i r c r a f t was t h e n r o t a t e d q u i c k l y and some-

what excessivelyk Poe d i d not see t h e a i r s p e e d go over 130 knot6 and as rotation

s t a r t e d h e saw t h e a i r s p e e d start t o drop back q u i t e r a p i d l y t o about 110 k n o t s r

'
A t t h i s time t h e Aeronaves c a p t a i n c a l l e d o r pointed t o t h e a i r s p e e d i n d i c a t o r , ,
! Poe f e l t t h a t t h e a i r c r a f t could not become a i r b o r n e under t h e s e c o n d i t i o n s and
. t h a t t h e runway remaining was not long enough t o put t h e nose back down t o start

t h e takeoff again from t h a t speed, H i s only choice, so he stated, w a s t o t r y

L

t o g e t t h e a i r c r a f t stopped on t h e runway. Poe unfastened h i s s a f e t y b e l t ,

' stood t o gauge p r o g r e s s down t h e runway, moved forward, shoved t h e t h r o t t l e s

forward b r i e f l y , noted a normal and uniform response from t h e engine instruments

( t h e EPR gauges were reading normally from 2,52 t o 2.541, and t h e n p u l l e d t h e

t h r o t t l e s f u l l back, Captain Gonzales "immediately" p u l l e d t h e r e v e r s e t h r o t t l e s

' back i n t o reverse t h r u s t and used wheel brakes, Poe extended t h e spoilers and
,
t h e n sat down on t h e jump s e a t without r e f a s t e n i n g his s e a t b e l t , He b e l i e v e s

' t h a t t h e a i r c r a f t d i d not t a k e off. Whether it d i d o r not w i l l be discussed l a t e r

. i n t h i s report, Pee's a c t i o n s would have t a k e n about t h r e e seconds, as shown by

. later test,

The a i r c r a f t continued ahead t h e f u l l l e n g t h of t h e 10,000-foot runway,

beyond it, through a b l a s t fence 3/> c a t c h i n g on f i r e , through t h e a i r p o r t

-This
I fence i s o f 10-foot s e c t i o n s of s t e e l : e a c h 10 feet h i g h , desjgncd to
w i t h s t a > d a n d deflect t h e hLc':Dt of J e t ~ n g i i i ~ b The + sec.T;ions are bols;ed
s u f f i c i e n t l y f r e n g i b i e t o fail I x i d l l y if s t r u c h by a - n r aircraft, i 2 e < >
l n n d id
from t h e o p p o s i t e d i r e c t i o n .
 - 5 -
..
boundary fence, smd a c r o s e Rockaway Boulevard where it s t r u c k an automobile,

i n j u r i n g t h e d r i v e r and sole oceupan-t, After going through t h e blast fence,

many p a r t s were shed b e f o r e t h e a i r c r a f t came t o r e s t i n F l ~ ~ e830

s f e e t be-

yond t h e end of t h e runway. Emergency v e h i c l e s from t h e a i r p o r t and of t h e

New York Fire Department were quickly s t a r t e d f o r the scene. Although impedes

somewhat by westher conditions, t.hey reached it w i t h i n abouQ s i x minutes and

extinguished t h e f i r e . , Evacuation and rescue of t h e occupants had already been

e f f e c t e d i n a t.ot.al t i m e of about f i v e minutes, although most persons were o u t

of t h e wreckage and a m y from t h e f i r e s l t e in h a l f t h i s time,. Many of t h e

s u r v i v o r s were t a k e n t o hospitals i n privately-owned v e h i c l e s . Destruction

of t h e a i r c r a f % was extenrsive,

Ve at he r

During t h e period from 1900 t o 2100 t h e r e was a p r e c i p i t a t i o n c e i l i n g of

500 f e e t o r less due to mow P r e v a i l i n g v i s i b i l i t y rerminzd a t l e s s thenn one

mile and gradually dropped t o o n e - q u a r t e r . m f l e i n snow and fog. Runway visual

range decreased un.tI.1 it was reported 16 less than 2,000 f e e t at t h e t i m e of

the a c c i d e n t .
The snow c o n s i s t e d of small dry f l a k e s and w a s blown and d r i f t e d by sur-

f a c e winds which averaged 1 5 t o 22 knots with g u s t s up t o 27 k n o t s .

A check of snow on runway 7 R between 1900 and 2000 was r e p o r t e d as follows

by a r e p r e s e n t a t i v e of t h e snow committee. -4/

Fi rst Quarte r - Mostly c l e a r with some patches of coqpacted snow.
( o f runway)

-&/The snow c o m l t t e e , composed of persons from various a i r l i n e s u s i n g N . Y , In-

t e r n a t l o r i a l A i r p o r t , undertakes t h e nkasurernent and r e p o r t i n g of snow conditions
on runwctyn for e,-1 opc :'.LL~,o~s .
 -6 -,

Second Quurter 0 Scatter& patches of snow one t o two- Inches deep,

Third Q u a r t e r 0 Snow patches t w o t o t h r e e inchee deep.

Last Quarter - Scattered snow finger d r i f t s four t o six inches deep.

Runway 7R remained open and a v a i l a b l e f o r use until closed by t h e a i r p o r t manage-

ment immediately a f t e r t h e a c c i d e n t and because t h e r e o f .

As has been s t a t e d , t h e weather information t r a n s m i t t e d by t h e tower t o

F l i g h t 401 a6 it taxied onto runway ?R a t about 2012 was: p r e c i p i t a t i o n c e i l i n g

300 f e e t ; sky obscured; v i s i b i l i t y one-quarter m i l e ; l i g h t snow end fog; vlnd

east-northeast 18; g u s t s t o 2L; a l t i m e t e r 29,64; runway 4R visual range l e s s

!
than 2,030 f e e t .

About one minute a f t e r t h e a c c i d e n t t h e Weather Bureau observed and

r e p o r t e d : p r e c i p i t a t i o n c e i l i n g 300 f e e t ; sky obscured; v i s i b i l i t y one-quarter

&le; snow, fog, blowing snow; temperature 20°F, dewpoint 160~;

wind east-

n o r t h e a s t 19; g u s t s t o 24; a l t i m e t e r 29.65; runway 4R v i s u a l range less t h a n

2,000 feet.
A f e w minutes a f t e r t h e a c c i d e n t t h e p i l o t of another Dc-8, which was pre-

paring t o take off a f t e r F l i g h t 401, was c l e a r e d t o t a x i up runway 7R about 3,300

f e e t i n o r d e r t o r e t u r n t o h i s t e r m i n a l (runway 7 R was then c l o s e d ) , He r e p o r t e d

v i s i b i l i t y was approximately 1/2 t o 3/4 of a m i l e and t h a t he observed snow

patches about one inch deep covering l/3 of t h e runway, He d i d not see F l i g h t 401

take o f f .

Two tower c o n t r o l l e r s and some eyewitnesses saw F l i g h t 401 during i t s take-

off r o l l a t d i s t a n c e s from 1/2 t o 2 / 3 of a m i l e i n blowing maw.

The crew of t h e last f l i g h t (also 51 g e t ) t a k i n g off from runway 7R before
t h e a c c i d e n t , r e p o r t e d t h o t a t the time of t h e i r t a k e o f f , 1947, v i s i b i l i t y WAB
 - 7 -

'
1 / 2 t o 3/4 o f a m i l e w i t h c e i l i n g s of 300-400 f e e t , with an improving trend,
-
: . a n d t h a t snow w a s not s t i c k i n g t o t h e i r a i r c r a f t .

Eastern A i r Lines F l i g h t Xanual p r e s c r i b e s s i x inches o f snow depth as

, maximum f o r DC-8 t a k e o f f . There i s nothing i n t h e r e c o r d t o i n d i c a t e a depth

of more t h a n s i x inches anywhere on runway 7R, although i t was probably c l o s e

t o t h a t figure a t t h e upwind end of the runway. A t LaGuardia A i r p o r t , o n l y a

few miles away and where weather c o n d i t i o n s should not have differed a p p r e c i a b l y ,

the U* S. Weather Bureau measures and r e p o r t s snow conditions. O f f i c i a l ob-

s e r v a t i o n s t h e r e bear o u t a probable snow depth of up t o six inches ( d i s c o u n t i n g

d r i f t i n g and plowing) a t New York International a t t h e t i m e of' t h e accident.

V i r t u a l l y continuous l i g h t d r y snow had f a l l e n and t h e temperature had re-

. mained a t about 20°F during t h e s e v e r a l hours t h e a i r c r a f t w a s parked on t h e

. a i r p o r t between f l i g n t , s l

Witnesses

The t a k e o f f r o l l was timed by one passenger, a h i g h l y q u a l i f i e d employee o f

an a i r c r a f t manufacturer, H i s experience caused him t o e s t i m a t e t h a t r o t a t i o n

should s t a r t i n 35 t c 40 seconds,' When 50 seconds passed and the aircraft w a s

s t i l l on t h e runway he thought t h e roll was t o o long, t i g h t e n e d h i s seat b e l t ,

and leaned forward f o r p r o t e c t i o n . Not over one o r two seconds l a t e r , he t e s t i f i e d ,

t h p a i r c r a f t l i f t e d o f f t h e runway w i t h a ''ttiump,," stayed a i r b o r n e no longer t h a n

a count o f t h r e e , and was back on t h e runway w i t h brakes and r e v e r s e t h r u s t being

applied. The "thump" was caused, fie b e l i e v e s , by t h e normal r a p i d extension o f

t h e l a n d i n g gear s t r u t s as t h e a i r c r a f t l e f t t h e runway- He b e l i e v e s t h e r o t a t i o n

maneuver s t a r t e d w i t h a fast p u l l u p j u s t a f t e r 52 o r 53 seconds o f t a k e o f f roll,

and, r i g h t after r o t a t i o n and becoming a i r b o r n e very b r i e f l y , t h e power was r e t a r d e d ~

 - 8 .-
d smoothly on all t h r e e gears and immediately went
and t h e a i r ~ r a f t ~ t o u c h edown
.
into r e v e r s e t h r u s t . He sensed pronounced braking a c t i o n f r o m wheel brakes,

About t h i s time t h e a i r c r a f t s t r u c k something, ran o f f t h e runway i n t o rough

t e r r a i n , & r i n g which he heard t h e rending of metal and f e l t a "tremendous" s e r i e s

of bounces up and down and sideways. This witness was i n seat 2B i n t h e f i r s t -

class s e c t i o n .

Most of t h e passengers thought t h a t t h e a i r c r a f t d i d l e a v e t h e ground b r i e f l y .

This opinion, based o n ' t h e apparent f a l l i n g away of runway l i g h t s , was shared by

two Aeronaves DC-8piI.3ts who were r i d i n g as passengers and one stewardess who

was s e a t e d aft i n t h e cabin. Some persons on t h e ground who watched t h e takeoff

ts of it, thought t h e a i r c r a f t d i d l e a v e t h e runway r a t h e r a b r u p t l y ,

One w e l l - q u a l i f i e d groun I t n e s s s a w t h e a i r c r a f t ' s l i g h t s r i s e f o r a s h o r t time

c o i n c i d e n t w i t h reduction of engine power a t about t h e 6,400-foot p o i n t on t h e

runway, Others could not s e e c l e a r l y enough, or not a t a l l , t o s a y i f t h e air-

c r a f t l e f t t h e runway. (This runway i s nearly t w o miles long and ground v i s i b i l i t y

was r e s t r i c t e d due t o blowing snow,)

Blowing and d r i f t i n g snow o b l i t e r a t e d t i r e t r a c k s made d u r i n g the takeoff

r o l l b e f o r e measurements could be made. This precluded any p o s s i b i l i t y of

l e a r n i n g d e f i n i t e l y t h e p r e c i s e p o i n t a t which t h e a i r c r a f t may have l e f t the

runway.

Systems

I n v e s t i g a t i o n of s e v e r a l systems of t h e a i r c r a f t w a s G r e a t l y hampered by

cavering snow and c o l d weather, F i r e destroyed most of the s t r u c t k e , including

a m a j o r i t y of t h e systems components. An unknown amount of a d d i t i o n a l damage n s

caused by t h e f i r e f i g h t i n g and rescue operations. There was no evidence of f i r e

i n my syGtem prior t o the accident. Bo evidence c o u l d be Found t o incticate any

I'

I
 - 9 -
system had been malfunctioning. A s far as can be determined no_ circuit brcakers
--

were opened during the time the aircraft was on the ground at New York. The switch
controlling the pitot and stall-warning anti-ice heaters was found in the “ o f f ”

position. There was no evidence of impact to t h i a switch or t o the surrounding

structure.
The flight recorder foil survived the crash and severe ground fire,altholGk

EL heavy accumulation of mud, kerosene,and carbonized residue was found on the

exposed portion of the f o i l which normally would have contained the pertiner,t

Intelligence. A mixture of hydrochloric and hydrofluoric acids cleaned the

carbonaceous deposits off the f o i l but caused sone etching of the traces,

Examination of the record f o r a period of at least four trips pl-i.orto t h e

accident revealed that the recorder had malfunctioned on two occasions. This

malfunction resulted in no later61 foil movement; however, the s t y l i i far the

four parameter traces were still tracing. Therefore, only a vertical stylii trace

was made when the foil fafled Po advance. The last failure of the recorder oc-

curred prior to the accident of the 19th of January and the recorder was in-

operative at t h e time of the accident Thus, the foil yielded no fntelligence

whatever relative to this balked takeoff?

Powerplants

A l l damage resulting from rotational Interference is attributable to loads

and distortions imposed by impsct forces. In general, the rotor blades and vanes

of engines Nos, 2 and 3 showed somewhat more severe r o t a t i o n a l damage. Oil systems
of all engines were normally clean and t h e r e were no s i g n s found of inadeqmie
lubrication A l l main bearings except Bo, 6 of No. 1 engine were inspected and

found free of any indication of operational distress. Because impact forces had

s o l i d l y ::::;.xed the XCI 1 cn,lr:c in th!z S o : 6 bci.rin;< 3rc8, : ~ n d t h w e ~ z r es o OLL:~

 - 10 -
indications that would cast doubt on the pm-crash condition Qf this bearing,
.
it was considered impractical to uncover it. The hot slections of a l l engines
: yielded no overtemperature indications.
There were no signs of fuel contamination,inany of the five samples taken

; from fuel in use by each engine and from the refueling truck. A l l were laboratory.
analyzed as "catlsfactory:,,!' The fuel pumps and fuel controls of engines Nos. 2,

3, and 4 were still operable (those of No. 1 were not) and were test-run with
satisfactory results. However, there was no rewon to suspect any difficulty
with the No. 1 fuel pump and fuel control.

In short, the investigation of these four powerplants yielded no indication

- . .. of any powerplant distress and indicated that they had been producing power
.. : aa selected.

- ..
, Structur.es

..
'
The general cluster of wreckage came t o rest about 100 feet beyond Rockaway

Boulevard in marshy, frozen, and snow-covered terrain on a heading of about lo5

.
degrees magnetic and slightly to the right of the extended centerline of runway 7R
Tire marks of the normal intermittent anti-skid type were found beginning

-.. 7,535 feet down the 10,000-foot runway. They extended 2,235 feet farther down
-
t h e runway and ended approximately 230 feet from t h e runway end.

A l l four engines separated from the aircraft. Nos. 1, 3, and 4 came t o

. rest east of Rockaway Boulevard close t o the main wreckage, The No. 2 engine

. came to rest on Rockaway Boulevard. The left main landing gear also separated

from the aircraft and came to rest on RockawrLy Boulevard addacent to the No, 2

.. engine, Several other airplane component pe.rts and many fuselage and wing
-
fragments were strewn over the accident path from the blast fence to the main

, wrecicagc: site.
 -u-
Fire broke o u t early during t h e sequence of events a f t e r - t h e a i r p l a n e
- --
struck t h e blast fence. A t a p p r o x l m t e l y 150 f e e t east of this fence and

extending about 300 f e e t i n an easterly d i r e c t i o n t h e ground was scorched.

A scorched fragment of t h e wing leading edge was found approximately 400 f e e t

east of t h e blast fence The m a j o r i t y of t h e d e s t r u c t i o n of t h e wings and

t h e fuselage was t h e r e s u l t of t h e i n t e n s e and prolonged f i r e which p e r s i s t s 6

after t h e a c c i d e n t ,

The f u s e l a g e was almost completely d e s t r o y e a by t h e prolonged f i r e

following t h e a c c i d e n t . Only portions of t h e f l i g h t Beck upper s t r u c t u r e ,

t h e b e l l y and lower s i d e p a n e l s , and t h e extreme a f t a r e a were unmelted.

The f u s e l a g e had remained reasonably i n t a c t throughout t h e a c c i d e n t sequence

except for a partial s e p a r a t i o n of t h e f l i g h t deck s e c t i o n . The heat

d e s t r u c t i o n f o l l o w i n g impact precluded any establishment as t o the e x t e n t

of t h i s damage
. The wing c e n t e r sect'ion and t h e wings, except f o r t h e i r bottom skins,

were substantially consumed by f i r e b u t t h e o u t l i n e was i n i t s o r i g i n a l con-

figuration The l e f t , wing from leading edge wing station 785 and rear spar

wing station 693 t o t h e t i p j and t h e r i g h t wing from l e a d i n g edge s t a t i o n 81Cs

and rear spar s t a t i o n 763 t o t h e t i p , were unburned

The wing flays were destroyed by f i r e except f o r t h e No. 2 engine exhaust

gate, which w a s t o r n off The wing s p o i l e r s , which were extended, were con-

sumed by f i r e as was approximately 50 percent of t h e t a i l assembly.

The a c t u a t o r s from t h e burned wing flaps were i n t h e 15-degree takeoff f l a p

position. The remaining r i g h t outboard wing s l o t door w a s open, t h e remaining

r i g h t wing spoiler linkage was s e i z e d 'in t h e 60-degree extended p o s i t i o n , t h e

 - 12 -
c o n t r o l gust lock mechanism was i n the. "off1' p o s i t i o n and t h e horizontal
-
s t a b i l i z e r was set 1.25 degrees a i r c r a f t noseup.

The cockpit area, i n c l u d i n g t h e instruments, c o n t r o l s , and c i r c u i t breaker

p a n e l s , was'almost t o t a l l y consumed by f i r e , KDwever, t h e overhead panel, t h e

g l a r e shield panel, and a number of darnaged f l i g h t instruments were recovered.

The p i t a t heat s e l e c t o r w a s found s e i z e d i n t h e "off" position, both wing Jandiw

l i g h t switches were on, and the w i n d s h i e l d h e a t WQS on warmup, b u t other switches

were freely moveable because of f i r e damage. Both s t a t i c s e l e c t o r s and both

-
KIFIS 5/ t e s t switches were in the normal position.

The p i t o t h e a t e r amxeter was seized at the 1.1 ampere i n d i c a t i o n , m d d i s -

assembly r e v e a l e d t h a t h e a t expansion of t h e h a i r s p r i n g had moved the hand from

zero t o t h a t reading. No impact marks were found on t h e overhead panel, d i s -

assembly of t h e s e l e c t o r switch r e v e a l e d no marks of o v e r t r a v e l , and there were

no impact marks on t h e hard rubber p i t o t s e l e c t o r lever.

An e x t e n s i v e s e a r c h , o f t h e wreckage a r e a f a i l e d t o l o c a t e t h e copper air-

speed p i t o t heads, t h e p i t o t Sumps, o r any part of t h e a i r s p e e d system o t h e r t h a n

t h e i n d i c a t i n g inskruments, t h e one s t a t i c port, and a f e w s h o r t sections of

a i r s p e e d aluminum t u b i n g .

Only a s t a t i c p o r t from t h e air data 6yStemwas found. It w a s not con-

taminated other t h a n with mud similar t o t h a t p r e s e n t at t h e a c c i d e n t acene, a d

no contamination i n t h e s h o r t aluminum a i r s p e e d l i n e s e c t i o n s was found,

The airspeed i n d i c a t o r s were recovered w i t h t h e c a p t a i n ' s s e i z e d at 60 knots
( a t t h e s t o p ) and t h e f i r s t O f f i c e r ' s a t 63 knots. A foam d e p g s i t was found w i t h i n

t h e c a p t a i n ' s instrument emanating from a n opening I n a t o r n o f f l i n e . The NOS. 1,

2, 3 and 11. engine pressure r a t i o instruments (EPRs) i n d i c a t e d 2.25, 2.55, 2.6 and
-5/ Kol-lzzan i G , c p a t c d
--uI -I

~ ~ i InzwuLy,ciit
~ n t ~yctez.
2.5, reapcctfvely. T h e i r E e t t l n g b o p vere found a t 2.55, 2.55; 2,5 and 2.2,
respsct4velya The 1U~s 1 2,3 and 1: ?xhaust temperature gaxges i n d i c a t e d
o
3kOoC, ~OO'C, 3OOGC, acid 300 C , r e s p e c t i v e l y , Tne Nos. 1, 2, 3 and 4 tachomzters

i n d i c a t e d io, 85, 1 and 15 percenx, r e s p c t i v e l y .

The empcnnzge f l i g h t c o n t r c l s y s t e n forward of t h e leading edge of the

h o r i z o n t d Etabilirer was debtroyed The empennage c o n t r o l systems were propeI1y

connected arid bU.bstantially i n t a c t MosZ of t h e f u e l system, h y d r a u l i c system,

and e1ectrlc:il eystern were destroyea

I n summaryj, t h e r e was foQncl DO evldeazcz of f a l l u r e , malfunctioning o r f i r e

p r i o r t o Impact i u any of t h e V&P$OL?S p r c b snd compoaents mentiovled above.

This &ircrai"t,was serjz,i ~ i m b e r45432 and its t o t a l airfrwne t i m e was 529

hours and 24 rnintdtes a t t h e t i m e of the a c c i d e n t . Four hcuss and 19 minutes was

accumulated t h e d-ey ~ f 't h e a c a l d m t on t h e t r i p PTOD Mexico t o bkw Y w k -

The a i r c r a f t was d e l i v e r e d t o Aerona.\res de Mexico at Long Beach, C a l i f o r n i a ,

October 28, 1960, aad flown t o t h e % s t e r n M r Lines maintenance f a c i l i t y at

Miami, F l o r i d a , t h e same day Aeronaves de Mexlca snd FBstesn Air Lines had
previously worked o a t an agr.cmrnt on t h e maintenance t o be performed on XA=XAX..

I n general, Aeronaves de Mzxico p c r f o m z d all t r i p checks and c a l l items on Lie

Mexican end of' tiLc r o u t e , u s i a g t h e procedures a d program 8s t h e r'ederal

Aviation Agency q p r o v e d Emtern Pilr L I n s s s y s t a n . &stern performed a l l r o u t i n e

maintenance ar,d d l inajor and tdxrmround j n s p e c t i o n s in t h e United S t a t e s and

complied with 2,li ctf th? Pedesai Aviation Agency Alawcrthiness D i r e c t i v e s , EaslC?t.fi

i n t e g r a t e d XA-AAX i n t o i t s own E-8 maintenance program,

The time s l r l c o Izst phase check ( N Q . 2 ) was 120 hours and 11 minu.tes and

was cmple-tcd or1 J % ~ u e r v 3 3962, by E a S t e r n A i r Lines a t Mimi, F l o r i d a , The

t i m e s i n c e t h e l a s t i n t e r p h a s e check was 1 2 hours and 54 minute; and w e s con-

pleted Jancary 17, 1961, i n Mexico, The last t r i p check w a s completed at

I d l e w i l d I n t e r n a t i o n a l A i r p o r t , New York, on t h e day of t h e accident;..

A l l writeups on t h e a i r c r a f t , except f o r a hard landing on November 11,

1960, were malfunctions of v a r i o u s p i e c e s Of equipment as might normally be

expected i n r o u t i n e day-to-day o p e r a t i o n . The a p p r o p r i a t e hard landing i n -

s p e c t i o n vas complied with by Eastern A i r Lines personnel.

The maintenance h i s t o r y of t h i s a i r c r a f t appeared t o be without any item

which could be s i g n i f i c a n t l y r e l a t e d t o t h i s a c c i d e n t .

Human F a c t o r s
Medical examinations were made on t h e bodies of t h e f o u r deceased crew

members. Three had been on t h e f l i g h t deck and one had been i n t h e lounge i m -

mediately aft of t h e f l i g h t deck, All four deaths were caused by m u l t i p l e burns

o r g e n e r a l i z e d t h i r d and f o u r t h degree burns. Tests f o r t o x i c i t y produced

n e g a t i v e r e s u l t s on a l l four, and t h e r e was no s i g n i f i c a n t l e v e l of carbon

monoxide i n any of t h e f o u r .

Aa has been mentioned, EAL Captain Poe w a s t h e o n l y f l i g h t deck s u r v i v o r ,

H e was thrown s e v e r s 1 f e e t c l e a r of t h e wreckage, as w a s h i s seat, No o t h e r

flight deck seats were found.

Twenty-eight of t h e cabin occupants, both passengers and a t t e n d a n t s , were

i n j u r e d i n d i v e r s e manners and varying degrees. As f a r as can be determined,

t h e s e persons, as w e l l as a l l o t h e r cabin occupants, d i d have t h e i r seat b e l t s

fastened, as d i r e c t e d . '
 - 15 -
. Operating and Trzini.ng Agreement Between Aeronavel and Eastern AFr Lines

A j o i n t t r a i n i n g agreement between Aeronaves de Mexico, EasCern A i r Lines,

and t h e Uuglas A i r c r a f t Company, provided t h a t Aeronaves f l i g h t crews receive

E-8 t r a i n i n g , u s i n g Eastern A i r Lines ground and simulator f a c i l i t i e s and

Douglas Company flight i n s t r u c t o r s f o r check-out i n t h e DC-8 a i r c r a f t , Eastern

A i r Lines provi&ed DC-8 ground school c l a s s e s between October 3, 1960, and

November 4, 19601 f o r f i v e Aeronaves DC-8 c a p t a i n s and e i g h t Aeronaves p i l o t s ,

~
i n c l u d i n g t h e crew o f F l i g h t 401/19, Ground school t r a i n i n g included t h e
. following:: g e n e r a l information, d i s p a t c h , performance, h i g h - a l t i t u d e weather,

radio and radar: a u t o p i l o t , a n t i - i c i n g and de-icing, e l e c t r i c a l , powerplant I

f i r e p r o t e c t i o n , f u e l , h y d r a u l i c s , flight controls, oxyQen system, p r e s s u r i z a t i o n

and a i r conditioning, i n s t r ~ u n e n t s , and emergency procedures, All t h r e e f l i g h t

'

crew members of F l i g h t 401/19 graduated from t h e DC-8 ground school w i t h high

grades

A l l t h r e e f l i g h t crew members received f l i g h t simulator t r a i n i n g from

,
1 Easltern Air Lines and completed t h e i r courses s a t i s f a c t o r i l y .

.I All t h r e e f l i g h t crew members were f l i g h t - t r a i n e d i n t h e X-8 at M i a m i ,

.1. I
Florida, by Douglas A i r c r a f t Company f l i g h t i n s t r u c t o r s , Captain Gonzales w a s

-. checked o u t as "captain" and both F i r s t Officers Bravo and Bacha were checked

out as both " f i r s t and second o f f i c e r s : " and q u a l i f i e d at t h e systems panel,

The cabin a t t e n d a n t s received 25 t o 30 hours of X-8 t r a i n i n g a t New York,

which included: a i r c r a f t f a m i l i a r i z a t i o n , D C - ~systems: jet-age terms, emergency

equipment l o c a t i o n and use- a v i a t i o n physiology, emergency f i r s t - a i f i ; emergency

L .
evacuation, demonstration and i n d i v i d u a l p a r t i c i p a t i o n and use of emergency e x i t

doors, windows, evacuation chute o r s l i d e , and a review of t h e t r a i n i n g program.

T h i s was f o l l o v e d by a v r i t t e n c x m i n a t j o n which all a t t e n d a n t s passed w i t h

h i c h Gradec,
 I A cooperative s e r v i c e agreement between Aeronaves de Mexico and Eastern

. A i r Lines was arranged so t h a t Eastern would provide c e r t a i n ETervices f o r Aeronayez

: a t t h e New York I n t e r n a t i o n a l Airport Eastern f a c i l i t y , and Aeronaves de Mexico

would f u r n i s h Eastern c e r t a i n s e r v i c e s at t h e Aeronaves f a c i l i t y i n Mexico City.

.This agreement provided f o r ground s e r v i c e s at I d l e w i l d (New York International.)

A i r p o r t and included such items as t h e handling of Aeronaves a i r c r a f t at t h e

Eastern Terminal, p r o v i s i o n f o r Aeronaves t i c k e t counter space, turnaround s e r v i c e ,

i n c l u d i n g i n t e r i o r and e x t e r i o r cleaning of t h e a i r c r a f t and a i r c r a f t s e r v i c i n g ,

cargo handling, p r e p a r a t i o n of weight and balance, f l i g h t plans, d i s p a t c h r e l e a s e s ,

- f l i g h t t r a f f i c ; and miscellaneous ramp s e r v i c e s , S i m i l a r s e r v i c e s were t o be

- provided by Aeronaves f o r Eastern a i r c r a f t at Aeronaves f a c i l i t y i n Mexico City,

Eastern provided t r i p checks and d e p a r t u r e checks and included such adjustments,

1'.
r e p a i r : o r replacements as necessary t o c o r r e c t u n s a t i s f a c t o r y items r e p o r t e d i n
.-' the a i r p l a n e powerplant performance report In conneetion with F l i g h t 401/19,
-- Eastern provided t h e r e q u i r e d ramp s e r v i c e s , including t h e de-icing, cargo and

passengerz baggage handling, f l i g h t planning and dispatching, weather b r i e f i n g

.' and turnaround s e r v i c e and i n s p e c t i o n , There were no uncorrected items i n t h e

.. a i r c r a f t f l i g h t log according t o t h e Mexican c a p t a i n who commanded t h e a i r c r a f t

-.. on i t s l a s t p r i o r f l i g h t and a l s o according t o t h e s u r v i v i n g EAL Captain Poe,

Eastern loaned Aeronaves q u a l i f i e d check p i l o t s t o assist i n t h e e a r l y s t a g e s

. of Aeronaves j e t o p e r a t i o n between Mexico and New York, This a s s i s t a n c e w a s f o r

approximately two months so t h a t EAL check p i l o t s could accompany each Aeronaves

'
X-8 c a p t a i n f o r at least t h r e e round t r i p s and each Aeronaves f i r s t o f f i c e r f o r @

maximum of twelve round t r i p s over t h e New York-Meaco C i t y r o u t e , I n accordance

with agreement t o assist Aeronaves i n any proper and p r a c t i c a l manner, EAL arranged
 - 17 -
t o a s s i g n t o Aeronaves f o u r of i t s s e n i o r check p i l o t s q u a l i f i e d on t h e E-8,

The6e check p i l o t s on t h i s assignment would s p e c i f i c a l l y p e r f o r a t h e following

functions :

1. Observe and monitor t h e performance o f Aeronaves f l i g h t personnel.

2. Coach and f a m i l i a r i z e Aeronaves f l i g h t personnel w i t h s t a n d a r d

procedures f o r t h e DC-8, and p a r t i c u l a r l y t o familiarize Aeronaves
f l i g h t crews with A i r t r a f f i c c o n t r o l procedures i n t h e New York a r e a .

3. To assist Aeronaves f l i g h t crews i n any o t h e r p o s s i b l e way which,, i n

t h e knowledge and experience of o u r check p i l o t s , would c o n t r i b u t e
t o t h e safe, e f f i c i e n t conduct of t h e Aeronaves o p e r a t i o n ,

EAL Captain W . B. Poe WES aboard Aeronaves F l i g h t 401/19, i n accordance

r .

with t h e above.
The Eastern A i r Lines F l i g h t Manual, u t i l i z e d by Aeronaves de Mexico,

c o n t a i n s t h e following:

* . ."The Check P i l o t o r I n s t r u c t o r shall t a k e over t h e c o n t r o l s a t

any time during t h e f l i g h t when i n h i s opinion t h e Captain o r P i l o t
w i l l not be a b l e t o maintain c o n t r o l o r recover w i t h i n s a f e l i m i t s
from any maneuver. This ' t a k i n g over' of c o n t r o l s s h a l l i n c l u d e
any t a k e - o f f o r landing when it appears t h e a i r c r a f t may be s u b j e c t e d
-to damage.. + "
Takeoff Perf ormanc e

The Douglas A i r c r a f t Co. Inc,, manufacturers o f t h e s u b j e c t a i r c r a f t , h a s

f u r n i s h e d t h e Board with c e r t a i n t a k e o f f d a t a , All of It i s p r e d i c a t e d on t h e

following conditions, which & r e t h o s e p r e v a i l i n g , o r assumed, a t t h e time and

place of t h e accident.

A i r c r a f t nose 300 f e e t from southwest end of runway 7R a t start of

takeoff r o l l

Takeoff gross weight 270,671

Flaps s e t 15 degrees
Engine a n t i - i c e On
EPR -
6/ (Brakes r e l e a s e d a f t e r t a k e o f f power 2.52 -
96% t h r u s t 4 engines
i s s e t and blowaway j e t s o f f f i v e
seconds a f t e r brake r e l e a s e )
_I_.-
Z7
- Aecoxiitig to t e s t i n n n y of Criptnin ~ c e
 Wind 18 k n o t s east- n o r t h e a s t
* Terppersture 20 degrees F,
Runway 7R I d l e w i l d
MAC 26 percent
Runway g r a d i e n t Zero

Because t h e r e a r e no known data a p p l i c a b l e Lo snow-covered runways, t h e

following i s based on a dry, concrete runway.

Normal Takeoff P r o f i l e
[;;;;;;ed D i stance Time Thrust Attitude A1titud.e
'W (Sec.,) '(EPR)- 1-( (Feet)
100 K Ck 100 0
I 2000 2 1 A3 2.52 -1 0
V1 130~8 3270 29.6 2.52 -1 0
Mi 143 $0 3994 33.6 2*52 -1 0
Liftoff 154.6 4801 37.0 2.52 119 to /11 0
v2 160 56 5950 4Z18 2-52 119 to ill 35
35 Ft a l t 160~56 5950 42,18 2,52 /9 t o /11 35
(Distance i n f e e t i s i n r e l a t i o n t o western end of runway 7 R )

(B) P r o f i l e f o r a n Abort (Balk) a t V 1

100 K Ck 100,o 2000 21.3 2.52 -1 0
v1 130 +8 3270 29.6 2.52 -1 0
Erakes 130.8,1 3.520 33.26 Forward
Idle
.. 1. Accelerate Stop Distance (Brake6 Only)
6350 Forward -1 0
Idle
2, Accelerate Stop Dictance (Brakes p l u s #2 and #3 engines i n r e v e r s e
t h r u s t t a k e o f f power and if1 and #4 engines
i n forward i d l e t h r u s t )
5965 2.52 -1 0
#2 md #3
3 . Accelerate Stop Distance (Brakes p l u s all f o u r engines i n r e v e r s e
t h r u s t t a k e o f f power)
5660 2.52 -1 0

(C) Abort (Balk) a t VR (No r o t a t i o n s t a r t e d )

100 K Ck 100 0 > 2005 21.3 2,52 -1 0
V1 130.8 3270 29.6 2.52 -1 0
VR 143 - 0 3994 33.6 2.52 -1 0
Brakes 143 ,O/ Forward -1 0
Idle
1, Accelerate Stop Distance (&ekes Only)
8185 Forward -1 0
Idle
 Airaaeed Uistanrle Time Thrust kttitude A 1t i t U &
EGt<T- DZg- (';cC_> -(-Ezg- --) ~(Feetj-
2. Accel-crate F a y 3 Dit-tance (Brakes 21u.s $2 a?id $3 exgiiiec in :everse
t h r u s t takeoff power and ill and #h engines
i n forward idle thrust)
7710 2.52 -1 0
+#2 84 #3
3. A c c e l e r a t e Stop Distance (Brckes plus all four engines in reverse
t h r u s t t a k e o f f pover)
7445 -12.52 0
(n) -
A c c e l e r a t e t o Tine of 50 Seconds and 52 Beconds without Rotation
w

100 K Ck LOO 0 2000 21.3 2.52 -1 0

vz 23s * 8 3270 29 6 2.52 -1 0
VR 3-4; 0 3994 33.4 2.52 -1 0
50 scc 200.01 7470 50 0 2-52 -1 0
52 Scc Run 20s Ol'(0 52 0 2.52 -3 0
7-
l,o-te:
- ;_stirrated d i s t a n c e t o s t o p aircrclt a f t e r reacMng 208 and 81170
f e e t on iwnmy i s 5,300 f e e t a?iti$ioiial if brakes are used and
all four engines a r e i n r e v e r s e t h r u s t a t tnkeoff power

(E) Vm ( t h e minimrn q c e d a t ~ ~ h l eth3-a

h ajrcraft, cou3d have I P f t , the
runwcy) vas 137,8 knots

V i t h r e s p e c t t o t h e .runway l i g h t i n g , invectigation has discllosed that t h e

runway l i g h t i n g had been changed and that there had been one or m r e cotices t o

sirmen ( N O W 4 S ) on t h e s u b j e c t . These chenges i:i l i g h t i n g were 0x1 %lirel a s t haLf

of t h e r u n - a y . A t t h e time Foe pulled t h e t h r o t t l e s the a i r c m f t w88 atill on

t h a t p o r t i o n 02 t h e runm.y which WELG lig'r-iecl, ~ 1 8o r i g i n a l l y preecribed, and he

does not a s c r i b e any irregularity In I.ighting on the far end as a factor i n dis-

continuing t h e t a k e o f f ,

Anlalvs i s

be d e s i r e d . As now provided t h e y a r e not p r o p e r l y r e p r e s e n t a t i v e of pertinent;

runway c o n d i t i o n s The trxnsmissometcr cannot mewure runway visual range

 t h e %ime o f t h e a c c i d e n t IELS observed a t a p o i n t w e l l removed h o r i z o n t a l l y and

v e r t i c a l l y from runway 7Ra The procedures used f o r mzesuring snow depth are

not precise 3s t o t h e p e r m i s s i b l e l e n g t h of' t i n e i n advance of a takeoff t h a t '

runway m2asuremmts of E ~ O Wdepth can be mado, t h e p o i n t s along t h e runway a t

which measurements choi!-d be made,eend t h e means f o r e s t a b l i s h i n g density. How-

ever, t h e weather a n d runway c o n d i t i o n s , though marginzl, a r e n o t considered t o

have been p r o h i b i t i v e OP critical.

Much of t h e aircraft w a s destroyed b y In9r-c-k and f i r e 2nd ccuaid not be

examined. However, t h e Zsc-ts d i s c l o s e d by t h o s e parts which vere exsrcj nakle,

plus the c i r c l m s t a n e e s , m,ke extremcly c n l i l c e l y khe possibility of failure o r

mechanical malfunctioning of: any p a r t of t h e aircraft o r of 2:re p r i o r to i m p a c t .

Vhen Ca9tain Goiizde:j called o r p o l n t e d t o tile airspeed i s d . ~cator, Captain

Poe f e l t t h a t t h e 130 k i o t s which t h e i n d i c a t o r w a s t h e n showing vas insufficient

for t a k e o f f and, a f t e r gauging p r o g r e s s , q u i c k l y p u l l e d t h e power. But what re-

=ins un!mown is Captain Gonzales' motive i n p o i n t i n g tovard o~ c..;j,,Pling attention

t o t h e airspeed i n d i c a t o r . He may have been c a l l i n g t o Fae'a s t t p n t i o n a n i n d i -

cation which was t o o l o v ( a s Foe e,pp,rently believed), o r he m,y hsve been con-

veying t h e i d e a that t h e airs_need i n d i c a t o r was not t o be t r u s t e d and shauld be

ignored. Whether t h e l a t t e r i s t h ? case o r not, a f t e r Poe g u l l e d the t h r o t t l e s

t h e a i r c r a f t was committed t o 8 balked t a k e o f f , i r r e s p c t i v e of ~rhat;was i n s t o r e

a t t h e end OB thc runhTay.

There i s no way of p o s i t i v e l y e s t a b l i s h i n g the d e p e n d c b i l i t y of t h i s a i r -

speed I n d i c a t o r . The rnaiiiteiiance records i n d i c a t e t h a t it should h a w been

functioning p r o p e r l y , As has been mentioned, t h o s w i t c h c o n t r o l l i n g t h e h e a t to

t h e y l t o t Lubr 3 i13s rourld "off " \'~I(A j < gilt, :I ~ 3 , ''<I:T C;UT~,); ~,,~i:t?oi'','
[-:Y ~ 7 . i ~ ~
 - 21 -
knocked t o " o f f " a t inipzc'c cannot !E e s t a b l i s h s d , although the l a t t e r i s g n l i k a l y

as h a s been sxplaincd. If it wits n o t IronfTduring t a k e o f f , an :?rraneous airspead.

i n d i c a t i o n rray hz.:fJe r s e u l t e d . ?i?LS subject w ! l l bs discussed later j.3 t h i s anzlyeis.

dxandnation of the e n g i m s subs tantla-ied t h 3 t t h y w r e capable o f developing

f u l l power and t h a t they had n o t been dx-ilaged p r i o r t o impact. As h z s h e n pointed

c u t , one of P o e t s o b s z r v a t i c n s d c r i n g %he b r h f pnricd when he was we5ghing a b a l k

was t h a t o f t h e f o u r d t R gaugzs, a!?d ??,? LtEted t h a t t h y wer3 reacing normally,

are e l e c t r i c a l l y hnated a n d can 'ne h r n s d off ccly 'cy mans cf ?be c i r c u i t breakars

(which %as n o t d o r x a~ fczr 9.2 C?.G ba z s c z r t a i n e d d u r i ? g fhe period t h a t 'che a i r -

craft WGS on t h e grccnd b ~ t i , ~ e aflights

i a t k w York I n t e r n a t i o n a l A i r p o r t ) * '?:?US,

dicating 13cJ kno LS, a k c a c c c r d b g t o Poi?, an5 sixrtly tk-ereaftzr quickly rzducad

.t,o 110 k n o t s 6.urjr1:< r.c.t.zLicn clrt, which tkne "J::*i;ain Gonzales pcinted tc c r nenti.cz;ea

hi.s airsp3ed. All three o f t,hr;sz c c n d i t i m s were c b v i c u s l y abnormal.

Poe also fel-?;',!lab t h e a i r c r e f t d i d n o t become airbcrne 2nd was n e t a c c z l 2 r z t i n g

properly a f t e r r ' o t a t j c n , alti:oc.=;h ho," f e l t t h a t t.he r c t z t i o n was a b r u p t and BX-

cessive. ile t h e r a f c r z ? x i x e d e n g i n e po:-;er xi thout crc.ss-checking w i t h t;ho f i r s t

c?ffi.cer' s a i r s p e e d , 'W: s t,2:~1rdsssi n the a f t cabin c m l d n o t have nc-biced t h o

runway l i g h t s b x o r j t:i: f'mk?zr a n y u n l e s s t h e a i r c r a f t YZS airborne, as r e t a t i o n

o n l y would have lcwered f,i;i2 tsil. a n d caused t h e l i g h t s t o beccms closzr. !ilso,

 - 22 -
. t h e a i r c r a f t ' s lights were fieen t o r i s e f o r a. s h o r t time coinclden't v i t h ' r e d u c -

. t i o n of' engine power at about t h e 6,400-foot point on th6 runway,* The l a n d i n g

. l i g h t s a r e l o c a t e d i n t h e t r a i l i n g edges of t h e wings and t h e navigation l i g h t s

are a t t h e tips, b o t h of which would lower s l i g h t l y d u r i n g r o t a t i o n since t h e y

a r e somewhzit a f t of t h e main l a n d i n g gear and would n o t r i s e except a f t e r t h e

a i r c r a f t became a i r b o r n e . The two DC-8 p i l o t s and t h e w e l l - q u a l i f i e d passenger,

a l l of whom were s e a t e d well forward, b e l i e v e d t h e a i r c r a f t t o have,been a i r b o r n e ,

as do two l a y groundwitnesses. A d d i t i o n a l l y , t h e l i f t i n , - e c n s a t i o n d e s c r i b e d by

p a s s e n g e r s i n t h e a f t p a r t of t h e cabin (which should have lowered If r o t a t i o n

o n l y had o c c u r r e d ) , t h e s t o p p i n e of runway roughness, t h e smooth f e e l i n g of

f l i g h t , the thuap normally c o i n c i d e n t with e x t e n s i o n of t h e l a n d i n g gear oleo

s t r u t s on becoming airborne q u i c k l y , a touchdown burq, and t h e preponderance of

o t h e r w i t n e s s ' evidence, e s t a b l i s h t h e aircraft being a i r b o r n e f o r o few seconds.

According t o t h e Douglas A i r c r a f t Company performance d a t a t h e a i r c r a f t ,

under e x i s t i n g c o n d i t i o n s b u t on a snow-free runway, would normally have been

r o t a t e d a f t e r a 3,994-foot roll i n 33.6 seconds at 143 knot8 and become a i r b o r n e

a t 4,801 f e e t i n 37 seconds a t 154.6 knots. But t h e evidence of f i k persons on

the ground i n d j c a t e s t h a t t h e a i r c r a f t was n o t a i r b o r n e by t h e t i m e it had r o l l e d

6,200 f e e t down t h e runway'

According t o Lhe sRme perforniance data t h e a i r c r a f t , i n 50 secondc, should

have t r a v e l e d 7,OlcO f e e t along t h e r u n m y end reached a speed of 200 knots. But

i t d i d n o t t r a v e l 7,Oli.O f e e t i n t h a t t i m e . A t $0 seconds ( b y c a l c u l a t i o n ,

Table D), with uniform acceleration, I t rhouXd 'nave passed t h e 6,2QO-foot p o i n t

a t a n a i r s p e e d of 163.8 k n o t s . It became a i r b o r n e two o r t h r e e seconds l a t e r ,

touched down, and causcd i n t e r m i t t e n t skid. marks beyond t h e 7,040-foot p o i n t

( a t 7,535 f e e t ) . A C L I ~ L t~h ~c J t ~
akeoff r o l l s t a r t e d about 300 f e e t €~rcmt h e
threshold where a normal. turn fro& the taxiway wodd place the aircraft. It
18, therefore, obvious' %hat the aircraft was not acceieratihg properly.

'The aircrkft could not have become airborne at lei38 then 137.8 knots.
It met have been €Q@reC18bly greater t h a n thnt figure because an abrupt aitd

exctblsive! rotaBion, as apparently did occur, I s not possible at that minim@

takeoff speed due t o the r e l a t i v e l y elawer elevator effect at that speed.
&

The tested three-second average time required far B e t o unfasten h i e

$eat b e l t , stand up, astlmate progreas, move the throttles ahead $lightly,

then close them, when applied to a E - 8 simulator rotateiP at P63-lniot airspeed,

reeulted in a simulated l5O-foot climb.

Thls altitude could not have been pomlble ti0 the aircraft could n o t h a w

touched down agsin in a Irirsximum 1,335-foot disrtance, and IndlceLteIj that the ais-
epeed at becoming airborne mu& have been considerably leas than 163 $nota.
Thus, the takeoff speed could not be l e s e pllran 137.8 knots and not BO much

CLa 163 knots. A uniiarq acceleration to l3O knotrs, then a constant speed to the

end of the 50-6econd period, would require 16 seconda at 130 b o t s (which no

captain is l i k e l y to allow). Thls indicates that acceleration CCBEI pb8bly

norm1 to the 100-knot point, but not normal thereafter. The probebillty cxierts

that after t h e 100-knot polat the speed continued to Increase, but more slowly,
to the 143-knot ~ i r s p e e da t l i f t o f f , , since t b l a WM t h e airspeed that the f i r s t

officer ahould and probably did c a l l &ti VR. From th%eit i~

clear that elther
the captain's airspeed Indic&t%on xi36 erroneou8 or Foe was mistaken i n stftting
that It read 130 b o t s ,

On the basis 'of the follmlng evidencey It I s concluded that t h e captain's

airspeed indicator waa giving mwerroneous low reeLdLng at t h e timectakeoff w8s
aborted. The f i r s t ofli"$cer, ob::zrvj k3g b l a airr5,ncec'r indicator, had c ~ l l e do m
 '. VR (143 knots). Immediately thereafter, Captain Gonzales had pointed to

. his airspeed indicator and Captain Poe in checking the airspeed on the
captain's instrument had read 130 knots and advanced, then closed t h e throttles.
At the time of the accident the sustained wind velocity m s 19 knots with

: gusts to 24 knots. Such gusts might account for a slight change but not a

l3-knot increase (130 t o 143) or 20-knot decrease (130 t o 110) in the air-

speed indications. It is evident, therefore, that the captain's airspeed

must have been indicating erroneously for some other reason.

The possibJlity of Glycol entering the airspeed systems through the pitot

heads during anti-icing and de-icing of the aircraft was explored2 However,
... because both pitot smpe were drained after use of Glycol, the possibility

. of Glycol having a f f e c t e d the airspeed systems anears to be E O E ~ur?likely.

It cannot be definitely shown, due to impact and fire damage, that no

. '. mechanical malfunction of the captain's airspeed system occurred. However, a
:review of the aircraft's records revealed no uncorrected airspeed items and

indicated a satisfactory leak test of the airspeed systems on January 4, 1961,

' w i t h no malfunctioning noted thereafter. In addition, the l e f t airspeed indi-

cator was evidently slow by at least 13 knots up to the rotation point.

' Similar leaks simultaneously affecting both systems are extremely unlikely.

As has been stated, it cannot be definitely substantiated that the pitot

' . heat selector was not moved by impact to the "off" position, where it was
' . found. This is so because the copper pitot heads and the transducer heating
. elements were not found despite extensive effort by investigators and con-

siderable expense for earthmoving equipment.

 - 25 - L

The pitot heat selector furnishes current for the heating elements in

the captain's and first officer's pitot heads and for the stall-warning

transducer. Current is supplied to all three when the selector is in any

one of the four positions except "off". The ammeter indicates current

drawn by whichever one of these three elements is selected. The proper

ampepage is 1.75 to 2.75 for each airspeed pitot, and 1.25 to 2.75 for the
' stall-warning transducer. The ammeter indicated 1.1 amperes when found
. (probably moved to that figure from zero by fire, as has been mentioned).

Neither the knob of the pitot heat selector nor the assembly in the immediate

vicinity bore any marks of impact, although there was marked fire damage.

Moreover, there were no marks of overtravel within t h e selector switch, and

it is unlikely that impact would move the selector knob due.to the internal

spring followup design of the switch. This strongly indicates that the
selector was not moved by impact.

Thus, it appears that the left airspeed indicator was slow to the l3O-knot
: point and then suddenly changed. Since leaks are unlikely, the cause could
only have been of a type that w a s changeable with increased airspeed. The

probable cause for such an erroneous reading could not be determined. How-

ever, the possibility exists that failure to apply pitot heat during snow
~, conditions may have played a part in the erroneous indication.
 - 26 -
-
As has been shown: t h e r e waB no decay i n engine power and consequently t h e

slow a c c e l e r a t i o n must have been due t o snow on the runway. The amount of t h i s
1essening.of a c c e l e r a t i o n is not s u b j e c t t o p r e c i s e and s p e c i f i c q u a n t i t a t i v e

analyaio, If t h e r e had been no impairment of acceleration, t h e a i r c r a f t would

normally have been only 3,994 f e e t down t h e runway r a t h e r than 6,200 o r more

f e e t a t t i m e f o r rotation.

It has been e s t a b l i s h e d t h a t t h e a i r c r a f t was capable of continuing t h e tdse-

off i f power had not been reduced by Poe Eastern's Operations Manual, u t i l i z e d
by Aeronaves, authorizes t h e check p i l o t t o t a k e over c o n t r o l a t h i s d i s c r e t i o n ,

as has been mentioned under I n v e s t i g a t i o n . Whether or not Gonzales would have

continued t h e takeoff if Poe had not reduced power w i l l never be known.

I n an e f f o r t t o determine whether o r not continuation of such a takeoff a8

t h a t involved In t h e accident ( w i t h one 'or both a i r s p e e d indicators malfunctioning)

is s a f e r than d i s c o n t l n u i n g , t h e takeoff, arrangements were made w i t h two air car-

riers f o r t e s t s i n t h e i r DC-d f l i g h t simulators. These t e s t s i n d i c a t e d t h a t (1)

such a takeoff by a q u a l i f i e d Dc-8 captain could be completed w i t h a reasonable

degree of s a f e t y , and ( 2 ) captains normally do cross-check with t h e f i r s t o f f i c e r ' s

airspeed under such condition&.

Any small amount of mow which m y have remained on the a i r c r a f t a f t e r de-

enowing o r any small amount which may have accrued while t a x i i n g did not, palpably,

have any s i g n i f i c a n t e f f e c t on t h e a i r c r a f t ' s takeoff c a p a b i l i t y . Therefore, snow

on t h e s t r u c t u r e i s not considered t o be a f a c t o r i n t h i s a b n o r m l t a k e o f f ,
Aeronaves de Mexico u t i l i z e o - s t e r n ' s c h e c k l i s t s and, s i n c e t h e accident,
Eastern has changed i t s cockpit c h e c k l i s t t o eliminate t u r n i n g off t h e p i t o t heat
selector once it is turned on p r i o r t o engine stertinz. A t t h e time of thc acci-

dent the procedure vas to t u r n it "off"' and "ontt 2g:ain before t3keoff'.
 - 27 -
The DC-8-21 a i r c r a f t has, the c a p a b i l i t y of being r o t a t e d t o its physical

limits ( u n t i l t h e bottom of t h e eqennage almost touches t h e runway) and COB-

t i n u i n g t o a c c e l e r a t e until becoming airborne. Once it becones air'borne, even

. though r o t a t i o n has continued t o the maximum physical limits, airspeed continues

t o increase, assuming there a r e no malfunctions o r f a i l u r e s . It i s not possible

i n a E-8-21 t o "get on the back side of t h e power curve, '' i . e . , t o e n t e r t h e

region of operation wherein t h e power required i s g r e a t e r than t h e power a v a i l -

able, while t h e a i r c r a f t i s on the ground. I f t h e angle of a t t a c k i s not f u r t h e r

increased following l i f t o f f , t h e aircrtsft would continue t o a c c e l e r a t e . Flight

tests have proven t h a t maximum r o t a t i o n at t h e minimum speed w i l l result i n a

p o s i t i v e r a t e of climb and t h e s h o r t e s t runway distance t o l i f t o f f . Once air-

borne t h e takeoff performance c h a r a c t e r i s t i c s w i l l be much t h e s m e 8s if r o t a -

t i o n had been made a t t h e predetcmined f l i g h t manual V3> taking i n t o considera-

t i o n , of course, t h e differences i n elapsed time, dirrtance, and airspeed.

A question has been raised as t o the p o s s i b i l i t y of decreasing the speed

of t h e a i r c r a f t Prom 130 t o 110 knots very quickly - say within five seconds -
during o r immediately after rotation, a8 Poe believed, To achieve such a decrease
i n airspeed t h e deceleration would have t o be 8.44 f e e t / s e c e 2 (0.26g) which,

at t h e takeoff gross weight of Z!'j'O,OoO pounds, would require a drag f o r c e of

70,5()0 pounds. Thrust a v a i l a b l e from t h e four engines, a t between 110 and

130 h o t s , i s approximately 59,000 pounds. Assuming conservatively t h a t 59,000

pounds of thrust i s in balance w i t h t h e drag (no acceleration), an a d d i t i o n a l

11,000 pounds of drag would be needed upon r e t a r d i n g power t o i d l e t o produce

a 0.26-g deceleration, Actually, w i t h t h e t h r o t t l e s i n "idle," t h e engines are

s t i l l producing some forward thrust: To. determine t h e e f f e c t of t h e Increased

 __ - 28 -
drag on t h e a i r c r a f t , due t o t h e r o t a t e d a t t i t u d e , a series of c a l c u l a t i o n s
'
vere made. AS6Uing t h a t t h e a i r c r a f t ' s speed w a s stabilized a t about 130

knots ( t h r u s t = drag), and t h e n rotated, t h e t i m e necessary t o d e c e l e r a t e

" t o 110 knots is:

6.9' rotation :: 45.7 seconds

8' r o t a t i o n = 34 seconds
12' r o t a t i o n = 18 e;econds
These t i m e s are obviously t o o long t o be considered I n t h i e case. In

a d d i t i o n , t h e assumption t h a t t h e a i r c r a f t was s t a b i l i z e d at 130 knots is

false because t h e engines were apparently operating properly and p r d u c i a g

t h e proper amount of t h r u s t f o r continued a c c e l e r a t i o n . !€%us, it can be

seen t h a t it i s not possible for t h e a i r c r a f t t o have decelerated from 130

. .-' knot6 to 110 knots in f i v e seconds.

. .'-' Conclusion
The Board concludee that the a i r c r a f t did beccmne airborne. Investigation
of t h e accident has pointed o u t t h a t Captain Poe erroneously believed that if
' . t h e speed of r o t a t i o n were appreciably below t h e calculateCa V speed, a longer
R
takeoff run would result.
The Board concludes t h a t t h e takeoff was discontinued as a remit of

the a c t i o n of the check pilot, who was not seated i n a p i l o t seat, i n reaching

forward without warning and p u l l i n g t h e t h r o t t l e 8 back. This a c t i o n caused

. pr3wer t o be decreased on all f o u r engines.

: Probable Cause

The Board determines t h a t t h e probable cause of t h i s accident waa t h e

unnececsary d i s c m t i n u i n g of t h e takeclff by t h e Check pil.ot, trho vas n o t i n

e i t h e r p i l o t seat.
 - 29 -
Contributing Factors

The c o n t r i b u t i n g f a c t o r s i n this a c c i d e n t were t h e marginally poor

;reather, snow on t h e runway, and the p o s s i b i l i t y o f t h e p i t o t head h e a t

n o t having been on.

BY THE C I V I L AERONAUTICS B=)ARD:

/s/ ALAN s. BOYD

Chairman

/s/ ROBERT T. MURPHY

Vice Chairman

/s/ CMNGURNEY
Member
/s/ G. JOSEPH MIbJETTI
Member

/s/ wHI'INm GILLrnAND

Member '
 ..
Investigation
The Civil Aeronautics Board was notified of this accident immediately after

occurrence, and an investigation was immediately initiated in accordance with

t h e provisions of Title V I 1 of the Federal Aviation Act of 1958.

The Carrier
Aeronaves de Mexico operated under United States Civil Aeronautics Board

foreign air carrier permit issued pursuant to Order E-11730, dated August 16, 1957.
It specified that Aeronaves de Mexico shall conform to the airworthiness and
airman competency requirements of the Government of Mexico for Mexican interna-

t lonal service.
A concurrent foreign air carrier operations specification, No. 2032, was
issued by the United States Civil Aeronautics Administration, dated December 6 ,

1957. It eertified that Aeronaves de Mexico was properly and adequately equipped
and able to conduct a reasonable safe operation as a foreign air carrier, in the
scheduled air transpsrt of persons, property and mail, w i t h i n the United States.

Flight Personne1
Captain Ricardo Gonzalez Orduna, age 46, a Mexican Mationerl, held a currently

effective airline transport certificate No. 98 (Mexican). He was checked out

as a E-8 captain by the Buglas Aircraft Company on November 30, 1960, at Miaxli,

Florida. He was rated i n the being 247, C-39, DC-3, E - 4 , L-49, Britannia,
and the E-8. His total pilot time was 15,210:34 hours, of which 94 hours were

in Oc-8'~. His total night time in E - 8 slrcr8zftwas 46:47 hours, and his total
instrument time i n the last three years was 182 hours. The date of his last

Class "A" medical examination was J u l y 27, 1960.

- i -
 F i r s t Officer Antonio Ruiz Bravo, age 32, a Mexican National, held a cur- -
r e n t l y e f f e c t i v e a i r l i n e t r a n s p o r t c e r t i f i c a t e No. 390 (Mexican). He was checked

out as F i r s t Officer and Second Officer by b u g l a s A i r c r a f t Company on November 27,

1960, a t M i a m i , Florida. He was rated as Captain i n t h e E - 3 and F i r s t Officer

and Second O f f i c e r i n t h e E-8. His t o t a l p i l o t t i m e was 8,260:56 hours, of which

125:3?' were i n Dc-8'~. H i s t o t a l night time i n E-8 a i r c r a f t was 51+:06hours, end

his total i n s t r u m e n t time i n t h e l a s t t h r e e years was 16Q:W. The d a t e of h i s

last Class "A" medical examination was November 19, 1960.

Second O f f i c e r Xavier ALvarez b c h a , age 32, a Mexican National, h e l d a

c u r r e n t l y e f f e c t i v e a i r l i n e t r a n s p o r t c e r t i f i c a t e NO. 553 (Pilexican). ~e was

checked out a6 First Officer and Second Officer by Dsuglas Aircraft Company on

November 26, 1960, at Miami, Florida. H e was rated as Captain i n t h e E - 3 and

F i r s t Offices and Second Officer i n t h e E-8. His total 2 i l o t t i n e WRS 8,143305

hours, of which l23:34 were in DC-$'s. His total night time i n E-8 a i r c r a f t was
53:48 hours, and h i o t o t a l instrument time I n t h e last t h r e e years was 1?6:00. The

date of his last Class "A" medical examination was September 25, 1960.

Captain W i l l i a m B, Foe, age 53, a United States National, was a designated

Eastern Air Lines E-8 check p i l o t , and held a valid a i r l i n e translport p i l o t

certificate with ratings: M-202, 404, Constellation, L-188, E-3, E - 4 , g-6,

DC-7, and E-8 a i r c r a f t . He had a t o t a l of 19,495:OO f l y i n g hour&, of which
285:Oo were i n t h e E-8. H i s t o t a l n i g h t time was 4,800:a)hours, with ti total

i n s t r m e n t time of 2,124:OO. H i s last FAA f i r s t - c l a s s medical examination was

taken November 4, 1960 ( l i m i t a t i o n : reading glasses) e

- ii -