Analaysis of an aircraft accident – 1997 Florida Air Disaster

Analaysis of an aircraft accident – 1997 Florida Air Disaster

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1997 Florida Air Disaster On August 7, 1997, during midday at about 12.30, a Fine Air’s Cargo plane Douglas DC-8-61, N27UA, crashed in the busy commercial area of small warehouses shortly after takeoff near Miami International Airport, Miami, Florida. The cargo accident brought in the death of the three flight crew members, a security guard on board and a motorist on the ground with minor injuries to two people. Fire which is considered to be dangerous in any aircraft accident brought the death, supported by the huge impact. The Fine air flight 101 was destined for Santo Domingo, capital of the Dominican Republic in the Caribbean. In the investigation that followed, the necessary information was abstracted from Cockpit Voice Recorder (CVR), Flight Data recorder (FDR), surveillance camera, ground scars and wreckage scatter.

fine air

The investigation determined that the primary cause of the accident was “Cargo loading and stabilizer trim setting, the aft centre of gravity is produced by improper cargo loading and high pitch up rotation caused by stabilizer trim setting”. The relative position of the center of the gravity and the neutral point is very important from aerodynamic point of view, which lacked in the cargo plane resulting in the crash. Some witness on the ground reported that the pilot pulled up straight and kind of lost altitude and the plane went down after 30 seconds later, landing on the top of a car. The investigation showed that few minutes after the takeoff, the pilot pitch up the nose of the aircraft to balance the imbalanced cargo plane which increased the angle of attack of the plane. As we know the aerodynamic stall results if the angle of attack exceeds the critical angle of attack, the cargo plane was not able to produce the necessary lift due to stall. Fully recovery of the aircraft was unlikely due to low altitude and the imbalance nature of the aircraft, so that the plane recovered shortly and got stalled again, resulting into the impact because of the series of stalling.

human error in aviation

The history of the 101 cargo aircraft showed no significant accidents with minor corrosion, ruptured hoses and worn out struts including an aborted takeoff .With the investigation followed, the Federal Aviation Administration (FAA) inspectors stated that” there was no minimal guidance in FAA written directives for the surveillance of cargo operations, and that there were no guidelines on how to evaluate the condition of pallets, netting, and other cargo equipment”  .Seeing the accident scenario and Safety Board’s report on the Miami accident, human error seems to be the major cause. According to Safety board officials “the pilot did not report an emergency to the control tower”. Human errors like in the case of loading right amount of the loads by the loading personnel (they are generally unaware of the critical loading in an aircraft), evaluating and checking appropriate loading error by the supervisor, Fine air’s executive participation for the guidance and monitoring, verification and proper load distribution in aircraft, and large number of necessary checks before the takeoff of the cargo plane contributed the crash. The flight engineer was also hindered to ensure that all cargo pallet locks were locked because of the company operating procedures and practices in Miami International Airport  .

fine air crash

The Fine air’s cargo plane history and its resulted accident signify that there are loopholes in the inspection, surveillance and taking corrective actions by Miami Flight Standards District Office (FSDO). Miami FSDO lacked regular participatory actions on the results of the previous reporting. In spite of the aging problem of the plane, the cargo plane was not properly loaded which shows the negligence of the Fine air on the sensitivity analysis and the associated risk involved. National Transportation Safety board reported that “Although the principal maintenance inspector (PMI) noted a pattern of logging entries on return flights to Miami and expressed his concerns to Fine Air management, no further action was taken either by the PMI or Fine Air management to address this problem”. There was no significant hardware component failure before the accident but the inappropriate loading generated the imbalance which reduced the reliability of the cargo container and the overall aircraft and increased the risk. It was neither safe nor reliable. The loading personnel lacked effective knowledge on the management of the cargo in the aircraft. Also, the software might have shown its reliability in measuring the weight of the cargo and the overall aircraft but the role of pilot on the implementation of software indications and reliability is questionable.

As a result of the accident, several amendments and modifications were made by FAA based on the causes of the accident. The development and implementation of the Air Transportation Oversight System (ATOS) program by FAA keeping in mind the system safety issue to address the inspections and surveillance was noticeable. Immediate actions were enforced by FAA against the cargo carriers based on the standards created by Miami accident. Safety Recommendation A-95-111 were issued by the Safety board which necessitates FAA to determine whether the resources in inspection and surveillance are properly allocated and effective to maintain the oversight at an acceptable level. “As part of its revised procedures, Fine Air developed a loading supervisor certification form that loading supervisors must sign to indicate that the load was placed on the airplane according to plan and restrained properly”. With the advent of this, the loading process of cargo in the cargo aircraft was standardized with the division of loading process into several scientific procedures and steps, so that they can prevent the aircraft accident in the near future to a large extent.

The disastrous cargo accident taught us many lessons which can be learned seeing the consequences of the negligence involved from all departments. The primary lesson learnt is that effective participation at workers’ and management level is needed in determining whether the flight is safe or not depending upon its previous history, components efficiencies, amount of loading and load distribution etc. Prior checkup and maintenance is required if there is any noticeable previous defects on the aircraft. The productive training to loading personnel on handling the loads, effective training to pilots on handling misloading and mistrimmed stabilizers can significantly reduce such accidents including the emergency landing. It should be made sure that the cargo doesn’t shift from its position, changing the effective center of gravity drastically, during takeoff. The airlines should also have standards and schedules for calibrating scales used to weigh cargo. The computerized system of calculating the effective center of gravity and signaling danger on misloading helps to minimize such errors. Stall warning horns should be incorporated to make pilot aware of the stall speed being approached. Computerized auto recovery and alert system is a part of software interaction in the aircraft which could minimize the aircraft accident. Specially, cargo airlines should verify in the number of levels for the flight takeoff. The owning Airlines should be sensitive in its effective management since air industry is a critical and sensitive sector in which a small mistake can lead to large negative consequences. They should regularly do the risk assessment and document it to implement later.

Standardization of flight training and flight procedures could supplement the accident reduction method. Federal Aviation Administration should bring necessary amendments in its policies for the regular inspection and surveillance of the aircraft. They should also increase their budgets on the surveillance and inspection program. The necessary training, seminars and awareness on System Safety, role of hardware, role of software and role of human including their interactions should be provided regularly from the ground level to managerial level. Effective communication is also required among various departments of airlines governing bodies and the particular airlines. In general, responsible act is necessary from every individual associated with the airline industry for the prevention of such accident. Bibliography Navarro, Mireya. (1997, August 8). 3 Are Killed as Cargo Plane Crashes in Miami . New York Times.

Research Based Article Contributed by

subedi

Kshitiz Kumar Subedi
4th year student
IOE Central Campus,Pulchowk

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