Don't ever let an airplane take you someplace where your brain hasn't arrived at least a couple of minutes earlier.
20 September 1990
Pinal Airpark, Marana, Arizona (KMZJ)
Omega Air
Boeing 707-321B
N320MJ
1 Fatal, 2 Serious
The Boeing 707 airliner holds a place in history as one of the first commercially successful jet airliners, with the first flight of a production model flying as early as 1957. Both the production models, as well as the USAFs KC-135 version, share a common basis as offshoots of the original Boeing 367-80 prototype. The 707 series flew for nearly two and a half decades as frontline airliners in US passenger service, seeing service with some of the largest names in the business: PanAm, TWA, American, and Continental, to name but a few. Additionally, it saw longtime service then and even now with a number of foreign carriers, both passenger as well as cargo. As larger, newer and more efficient airliners began being produced, the 707 began to be retired from frontline service. Many 707s that didn't have a further lease on life began appearing at the various civil aircraft storage facilities that exist in the southwest USA such as Tucson Airport, AZ; Kingman, AZ; Pinal Airpark/Marana, AZ; Mojave, CA; Las Vegas-McCarran, NV, and Roswell, NM. The last revenue flight of a scheduled passenger 707 for a US airline was flown by TWA on 30 October 1983. With a low demand for these fairly inefficient (by then-modern standards) aircraft, the aforementioned storage facility airports began to fill with 707s facing an uncertain fate.
As compared to the fate of civil 707s, their cousins known as the USAFs KC-135s, were going strong in military service as the primary air-to-air refueling aircraft for both the US as well as some foreign nations. In the early 1980s, the USAF decided to undertake an ambitious and one-of-a-kind program to modify and upgrade the KC-135. Operating primarily the KC-135A-model at the time, this model tanker used the Pratt & Whitney J57-P-59W water-injected turbojet which produced approximately 10,000 lbs of thrust dry, and about 13,000 lbs wet thrust through the use of demineralized water in a 670 gallon center-body tank. The older J57 engines weren't exceptionally powerful and were fuel inefficient as well as noisy, being straight turbojets. The USAF wanted to upgrade A-model -135s flown by the USAF Reserve as well as the Air National Guard with Pratt & Whitney TF33-PW-102 turbofan engines, enabling 14% more fuel efficiency to be gained. This upgrade aircraft would be known as the KC-135E. In order to reduce costs for this program, the USAF decided to purchase a large number of former and retired civilian 707 airliners in the early 1980s, both US as well as foreign, in order to take not only the engines and pylons, but control surfaces and other parts for retrofit to the E-model -135s. Many retired 707s and 720s were found in both the US as well as abroad and ferried by aircraft brokers and other operators to the USAFs boneyard at Davis-Monthan AFB, AZ, for final disposition and parting out. Many of those retired airliners have since been scrapped, but a good few remain today, still parked out of sight on the "back 40" of the AMARC storage facility.
N320MJ was one of the many 707s purchased by the USAF for the KC-135 donor program. In its previous lives, N320MJ served with PanAm as well as BWIA airlines under three previous registrations. 320MJ had arrived in mid-1990 at the large storage facility at Pinal Airpark (ICAO: KMZJ) just north of Tucson, as a last stop prior to making the 35 mile flight to Davis-Monthan AFB (ICAO: KDMA). Here, she was stripped of various pieces of equipment in preparation for the final mission. On the morning of 20 September 1990, the 3-person Omega Air ferry crew arrived at Pinal Airpark to prepare for the 14 CFR 91 ferry flight to KDMA. Preflight, start and taxi operations were uneventful, and 320MJ announced its intentions to depart RW 12 at KMZJ for the VFR flight. There were a good few witnesses to the departure: both pilots as well as mechanics located on the Evergreen Aviation ramp, as well as helicopter pilots located at the Arizona Army National Guard's Silverbell Army Heliport on the north side of the field. Reports from these witnesses indicate that on 320MJs initial takeoff roll, the first 2000 feet appeared normal, but as the takeoff progressed, the 707 began to swerve left and right from the runway centerline. The crew of 320MJ successfully aborted the takeoff at approximately the 3000' point on the runway, just shy of halfway down the runway, and taxied clear. Taking a few minute delay at the end of the runway, 320MJ was then seen to begin a taxi back to RW 12 for another takeoff attempt. Again taking about a 1 minute delay, 320MJ announced it was departing RW 12 southeast bound and taxied into position. Following engine runup, 320MJ again made a static takeoff and no directional control problems were noted by the eyewitnesses. Lifting off at the approximate midfield point, 320MJ began what was described as a "moderate rate, constant right roll" very soon after the main landing gear broke ground. The right roll continued until the right wingtip contacted the dirt ground just off the western side of the runway approximately 5 seconds after liftoff, and the aircraft cartwheeled into the ground, the fuselage rotating 270 degrees to the right, and coming to rest pointing east towards the ramp. The impact severed the forward fuselage and cockpit just forward of the wing leading edges, leaving it separated and oriented 90 degrees to the left of the fuselage and pointing north. A small post-crash fire ensued which was quickly extinguished by Army National Guard crash/rescue firefighters as well as Evergreen company fire personnel. The Captain sustained fatal injuries from blunt force trauma due to the impact, while the co-pilot and flight engineer were trapped in the wreckage and sustained serious injuries, both having to be extricated from the crushed and compromised cockpit section. The aircraft was destroyed. Initial postaccident investigation of the wreckage revealed no outstanding discrepencies with the airframe or powerplants. However the rudder trim was found in the cockpit to be set to about 79% right deflection.
Probable Cause
*Preflight Planning/Preparation - Inadequate - Pilot In Command
*Operation With Known Deficiencies In Equipment - Performed - Pilot In Command
*Checklist - Not Used - Pilot In Command
Secondary Factors
*Lack Of Recent Experience In Type Of Aircraft - Pilot In Command
*Lack Of Recent Experience In Type Operation - Pilot In Command
Tertiary Factors
*Inadequate Surveillance Of Operation - FAA (Organization)
*Insufficient Standards/Requirements - FAA (Organization)
*Terrain Condition - Ground
MikeD says
This accident was one of those investigations where as the proverbial onion was peeled back, more and more errors and deficiencies were discovered, focusing in three major areas, which will be reviewed in order:
1. How the operators were preparing the aircraft for last-flight ferry;
2. The preflight planning and crew performance of the flight crews performing the ferry operations; and
3. FAA oversight of the 707 donor program in general, and operator/operations in particular.
N320MJ Ferry Preparation
N320MJ was prepared for its final flight to KDMA in much the same way most of other 707s were: by being stripped to near bare-bones condition prior to the flight. While one might reasonably expect such equipment stripping to include such items as cabin seats, galley and lavatory facilities, and carpet/interior fixtures to include plastic wall linings as well as overhead carryon bins; the 707s in this program were stripped far beyond that. During the investigation, it was discovered that in addition to the aforementioned cabin items removed, the cockpits of these aircraft had numerous items removed by aircraft parts dealers contracted to effect the removal of these items for reuse/resale, including (but not limited to) numerous flight and navigation instruments, indicators, annunciator lights, and in many cases fuel quantity gauges and other fuel indicating instruments. This lack of instrumentation was noted by and documented by maintenance personnel at Davis-Monthan who received the aircraft following their final-leg flights from Pinal Airpark, where the stripping was performed. During the investigation, it was determined that many of the 707s arriving at KDMA had flown their final ferry legs over highly populated areas, while lacking essential cockpit instrumentation. And each 707 was configured differently, some missing some items of instrumentation, while others missing different items. In N320MJs specific case, over 50 items of instrumentation and annunciator indicators had been removed from the pilot's and co-pilot's instrument panel. For flight instrumentation, the pilot and co-pilot each had an airspeed indicator and an altimeter only; no primary attitude indicators. A small standby attitude indicator, or "peanut gauge", was located in the lower left portion of the center instrument panel, next to where the engine instrument cluster used to be. There was one VHF communications radio. There was no mag compass, and the only engine performance instruments were four Engine Pressure Ratio (EPR) gauges taped with masking tape atop the center portion of the dash/glareshield. No Cockpit voice Recorder or Flight Data Recorder was installed, these also having been removed. A small quick-checklist was noted in the wreckage, which listed start/taxi and shutdown procedures and directed before takeoff/landing procedures to be accomplished via a mechanical checklist (panel mounted checklist). The rudder trim setting confirmation was contained in the Before-Takeoff checklist, yet was missed by the flight crew, who couldn't remember if the checklist had been used for that phase of operation during post accident interviews.
With the mass amount of fixed equipment stripped from both the cabin and cockpit, as well as having no cargo aboard and a very light fuel load, the actual weight and balance of N320MJ was uncertain, since no records of a current W&B existed. It was estimated that N320MJ was approximately 35,000 lbs below the lowest minimum takeoff weight that the performance charts began at. As such, the flightcrew had no idea where their aircraft stood performance-wise. For investigation purposes, Boeing and NTSB personnel estimated the weight of the aircrafts takeoff weight configuration, as well as set the actual right rudder configuration, in an engineering B-707 simulator. 60 takeoff attempts were made with the parameters replicating N320MJ. Of these 60, many of the attempts resulted in the same right wing ground strike that occurred in the accident sequence. It was found that on the takeoff, maintenance of directional control wasn't too difficult; however with the severe lack of flight instrumentation available...especially horizon information due to the missing primary ADIs....that following liftoff, the estimated deck angle was such that visual sight of the horizon was lost as the ground/terrain disappeared underneath the nose of the aircraft. This resulted in a challenge to maintain wings level during the initial climb, and the standby attitude indicator was located in such a place that was inconvenient and not in the normal crosscheck habit. Additionally, no secondary forms of instruments to determine wings-level when the ground couldn't be seen existed in the cockpit, such as an HSI, RMI, turn-and-slip, or even compass. As such, the crew was truly flying a fairly modern jet airliner, seat of the pants; with less flight instrumentation than a Cessna 210.
N320MJ Crew Preflight Planning and Performance
As noted in the previous paragraphs, the crew of N320MJ were knowingly flying in a very minimally equipped airliner aircraft, utilizing minimal checklists and seemingly relying on memory for checklists during the takeoff and landing segments of flight. This would be the most reasonable explanation for the missed right-rudder trim condition on takeoff, as well as the failure of the Captain to insure his shoulder harnesses were strapped/secured. The lack of a shoulder harness, while it wouldn't have prevented injury due to the severe cockpit damage, could've meant the difference between fatal vs serious injuries for him. The 60 year old Captain held an ATP certificate with ASEL and AMEL category/class ratings and an Instrument - Airplane and had over 13,000 hours TT, with 12,000 ME and 4000 in the B-707, and 14 hours in the last 90 days. His last BFR was 15 months prior, performed in the B-707. However, it was discovered that the Captain didn't hold a vaild/current medical. It appears that with the experience of the flightcrew of N320MJ, that they were very comfortable with the aircraft being in the shape and configuration it was, especially since they had made a number of these same ferry flights for the company before. It would appear a certain amount of familiarity and/or complacency set in for the crew, especially with the memory checklist usage for critical phases of flight, where a standard flow became nonstandard due to the severe change of what would be "normally there" instruments-wise to check. Additionally, the lack of hard performance data was likely of little concern to the crew due to their familiarity of the aircraft in "normal" conditions, and their likely mental interpolations of TOLD data for this days flight. The question remains, however, of why the crew recognized enough of a problem during the first takeoff roll to abort the takeoff, yet took off on the second attempt with the same problem. It would be logically thought that the time spent post-abort at the departure end of the runway would've resulted in either the re-accomplishment of the Before-Takeoff checklist, or at a minimum, a more detailed and thorough flow that would've caught the mis-trim setting. At the very least, one would assume that the directional control problem during the first takeoff would've been attributed to either a nose-wheel-steering problem, or some sort of trim problem; and the double-checking of those items accomplished accordingly. Due to head trauma and the other serious injuries, the surviving co-pilot and FE couldn't remember specific details of either the first takeoff, or the accident itself; so the specific reason(s) this item was missed twice, will never be known.
FAA Operational Oversight
N320MJ was issued a Special Airworthiness Permit for the ferry flight, just as all other 707s involved in the program had been in order to undertake the same flight. During the investigation, it was discovered that the FAA Designated Airworthiness Representative (DAR) for the 707 donor program, although having over 20 years with the FAA in various positions, held no A&P license, and had no experience with either large aircraft, return to service of large aircraft following major maintenance, or even what the minimum amount of flight instrumentation necessary for safe flight for large aircraft. The DAR inspected and signed off N320MJ for its Special Airworthiness Certificate, even though there was no current weight and balance information. When questioned later, the DAR couldn't remember what actual instrumentation remained in N320MJ. Additionally, it was found that much of the work performed on N320MJ was done so by personnel who held no FAA A&P licenses or Repairman's licenses.
Review of applicable FAA regulations concerning the appointment of DARs was so broad that people who weren't necessarily experienced in maintenance and inspection functions, as related to airworthiness determiniations, were still allowed to become DARs. Even though DARs are technically supposed to come from the pool of FAA Maintenance Inspectors, as directed by the FAA regulations, this DAR was appointed for a position he was well underqualified for. Consequently, N320MJ was inspected and given a "stamp of approval" through issuance of a Special Airworthiness Permit, by an inspector with neither the requisite knowledge, training, or experience to recognize what type of minimum instrumentation and equipment was safe for flight. Although no specific guidance existed listing the minimum instrumentation required for issuance of a Special Airworthiness Certificate, the NTSB became concerned that DARs were neither trained nor qualified to certify as airworthy, large transport-category aircraft that they had zero experience with.
The NTSB made recommendations to the FAA to both determine the minimum flight instrumentation required for the issuance of Special Airworthiness Certificates, as well as make a top-to-bottom review of the qualification and selection criteria for Designated Airworthiness Representatives.
Final Thoughts
The accident of N320MJ was one of those accidents that really didn't have to happen. Weather wasn't a factor. The crew was extremely experienced. But through a combination of complacency due to having done these flights a few times, lack of recency, willingness to accept very substandard equipment, a low sense of caution especially considering the far-from-normal condition the B-707 was in, and failure to recognize and interperet what the airplane was trying to tell them with that first takeoff roll; this crew met its demise after only 6 seconds of flight. What should've been a vanilla VFR sortie to cover 35 air miles, turned into an accident that didn't even cover 3500 feet, and the loss of a very experienced Captain. Secondary and Tertiary factors aside, and even laying the aircraft and cockpit condition aside, the biggest hurdle this crew failed to recognize was the airplane attempting to communicate to them that it wasn't in the right condition for flight. Even without listening to the airplane, the following of a proper checklist to insure execution as well as completion of critical items for takeoff, could've avoided this tragedy. I personally remember seeing the remaining wreckage of this aircraft sitting where it ended up, just a few days after the accident, when I had traveled to Tucson from Prescott. A sad sight to see, and even worse to know later as I reviewed this accident, just how preventable it was.
Oftentimes, cutting corners can be a necessity in order to make takeoff times, make arrival times, get a necessary mission accomplished, or otherwise get things going. Just insure that you have the knowledge, skill, ability, and most importantly, the SA as well as the caution to know what corners can be cut and by how much. Failure to do so just may put you into a square corner you won't be able to get out of, much as the title to this accident synopsis suggests.
MikeD
The above is not intended to be an undue criticism of the person or persons involved in the incident described. Instead, the analysis presented is intended to further the cause of flight safety and help to reduce accidents and incidents by educating pilots through the sacrifices of others in our profession.
Photo: N320MJ, post-accident. (photo credits K. Burton)
20 September 1990
Pinal Airpark, Marana, Arizona (KMZJ)
Omega Air
Boeing 707-321B
N320MJ
1 Fatal, 2 Serious
The Boeing 707 airliner holds a place in history as one of the first commercially successful jet airliners, with the first flight of a production model flying as early as 1957. Both the production models, as well as the USAFs KC-135 version, share a common basis as offshoots of the original Boeing 367-80 prototype. The 707 series flew for nearly two and a half decades as frontline airliners in US passenger service, seeing service with some of the largest names in the business: PanAm, TWA, American, and Continental, to name but a few. Additionally, it saw longtime service then and even now with a number of foreign carriers, both passenger as well as cargo. As larger, newer and more efficient airliners began being produced, the 707 began to be retired from frontline service. Many 707s that didn't have a further lease on life began appearing at the various civil aircraft storage facilities that exist in the southwest USA such as Tucson Airport, AZ; Kingman, AZ; Pinal Airpark/Marana, AZ; Mojave, CA; Las Vegas-McCarran, NV, and Roswell, NM. The last revenue flight of a scheduled passenger 707 for a US airline was flown by TWA on 30 October 1983. With a low demand for these fairly inefficient (by then-modern standards) aircraft, the aforementioned storage facility airports began to fill with 707s facing an uncertain fate.
As compared to the fate of civil 707s, their cousins known as the USAFs KC-135s, were going strong in military service as the primary air-to-air refueling aircraft for both the US as well as some foreign nations. In the early 1980s, the USAF decided to undertake an ambitious and one-of-a-kind program to modify and upgrade the KC-135. Operating primarily the KC-135A-model at the time, this model tanker used the Pratt & Whitney J57-P-59W water-injected turbojet which produced approximately 10,000 lbs of thrust dry, and about 13,000 lbs wet thrust through the use of demineralized water in a 670 gallon center-body tank. The older J57 engines weren't exceptionally powerful and were fuel inefficient as well as noisy, being straight turbojets. The USAF wanted to upgrade A-model -135s flown by the USAF Reserve as well as the Air National Guard with Pratt & Whitney TF33-PW-102 turbofan engines, enabling 14% more fuel efficiency to be gained. This upgrade aircraft would be known as the KC-135E. In order to reduce costs for this program, the USAF decided to purchase a large number of former and retired civilian 707 airliners in the early 1980s, both US as well as foreign, in order to take not only the engines and pylons, but control surfaces and other parts for retrofit to the E-model -135s. Many retired 707s and 720s were found in both the US as well as abroad and ferried by aircraft brokers and other operators to the USAFs boneyard at Davis-Monthan AFB, AZ, for final disposition and parting out. Many of those retired airliners have since been scrapped, but a good few remain today, still parked out of sight on the "back 40" of the AMARC storage facility.
N320MJ was one of the many 707s purchased by the USAF for the KC-135 donor program. In its previous lives, N320MJ served with PanAm as well as BWIA airlines under three previous registrations. 320MJ had arrived in mid-1990 at the large storage facility at Pinal Airpark (ICAO: KMZJ) just north of Tucson, as a last stop prior to making the 35 mile flight to Davis-Monthan AFB (ICAO: KDMA). Here, she was stripped of various pieces of equipment in preparation for the final mission. On the morning of 20 September 1990, the 3-person Omega Air ferry crew arrived at Pinal Airpark to prepare for the 14 CFR 91 ferry flight to KDMA. Preflight, start and taxi operations were uneventful, and 320MJ announced its intentions to depart RW 12 at KMZJ for the VFR flight. There were a good few witnesses to the departure: both pilots as well as mechanics located on the Evergreen Aviation ramp, as well as helicopter pilots located at the Arizona Army National Guard's Silverbell Army Heliport on the north side of the field. Reports from these witnesses indicate that on 320MJs initial takeoff roll, the first 2000 feet appeared normal, but as the takeoff progressed, the 707 began to swerve left and right from the runway centerline. The crew of 320MJ successfully aborted the takeoff at approximately the 3000' point on the runway, just shy of halfway down the runway, and taxied clear. Taking a few minute delay at the end of the runway, 320MJ was then seen to begin a taxi back to RW 12 for another takeoff attempt. Again taking about a 1 minute delay, 320MJ announced it was departing RW 12 southeast bound and taxied into position. Following engine runup, 320MJ again made a static takeoff and no directional control problems were noted by the eyewitnesses. Lifting off at the approximate midfield point, 320MJ began what was described as a "moderate rate, constant right roll" very soon after the main landing gear broke ground. The right roll continued until the right wingtip contacted the dirt ground just off the western side of the runway approximately 5 seconds after liftoff, and the aircraft cartwheeled into the ground, the fuselage rotating 270 degrees to the right, and coming to rest pointing east towards the ramp. The impact severed the forward fuselage and cockpit just forward of the wing leading edges, leaving it separated and oriented 90 degrees to the left of the fuselage and pointing north. A small post-crash fire ensued which was quickly extinguished by Army National Guard crash/rescue firefighters as well as Evergreen company fire personnel. The Captain sustained fatal injuries from blunt force trauma due to the impact, while the co-pilot and flight engineer were trapped in the wreckage and sustained serious injuries, both having to be extricated from the crushed and compromised cockpit section. The aircraft was destroyed. Initial postaccident investigation of the wreckage revealed no outstanding discrepencies with the airframe or powerplants. However the rudder trim was found in the cockpit to be set to about 79% right deflection.
Probable Cause
*Preflight Planning/Preparation - Inadequate - Pilot In Command
*Operation With Known Deficiencies In Equipment - Performed - Pilot In Command
*Checklist - Not Used - Pilot In Command
Secondary Factors
*Lack Of Recent Experience In Type Of Aircraft - Pilot In Command
*Lack Of Recent Experience In Type Operation - Pilot In Command
Tertiary Factors
*Inadequate Surveillance Of Operation - FAA (Organization)
*Insufficient Standards/Requirements - FAA (Organization)
*Terrain Condition - Ground
MikeD says
This accident was one of those investigations where as the proverbial onion was peeled back, more and more errors and deficiencies were discovered, focusing in three major areas, which will be reviewed in order:
1. How the operators were preparing the aircraft for last-flight ferry;
2. The preflight planning and crew performance of the flight crews performing the ferry operations; and
3. FAA oversight of the 707 donor program in general, and operator/operations in particular.
N320MJ Ferry Preparation
N320MJ was prepared for its final flight to KDMA in much the same way most of other 707s were: by being stripped to near bare-bones condition prior to the flight. While one might reasonably expect such equipment stripping to include such items as cabin seats, galley and lavatory facilities, and carpet/interior fixtures to include plastic wall linings as well as overhead carryon bins; the 707s in this program were stripped far beyond that. During the investigation, it was discovered that in addition to the aforementioned cabin items removed, the cockpits of these aircraft had numerous items removed by aircraft parts dealers contracted to effect the removal of these items for reuse/resale, including (but not limited to) numerous flight and navigation instruments, indicators, annunciator lights, and in many cases fuel quantity gauges and other fuel indicating instruments. This lack of instrumentation was noted by and documented by maintenance personnel at Davis-Monthan who received the aircraft following their final-leg flights from Pinal Airpark, where the stripping was performed. During the investigation, it was determined that many of the 707s arriving at KDMA had flown their final ferry legs over highly populated areas, while lacking essential cockpit instrumentation. And each 707 was configured differently, some missing some items of instrumentation, while others missing different items. In N320MJs specific case, over 50 items of instrumentation and annunciator indicators had been removed from the pilot's and co-pilot's instrument panel. For flight instrumentation, the pilot and co-pilot each had an airspeed indicator and an altimeter only; no primary attitude indicators. A small standby attitude indicator, or "peanut gauge", was located in the lower left portion of the center instrument panel, next to where the engine instrument cluster used to be. There was one VHF communications radio. There was no mag compass, and the only engine performance instruments were four Engine Pressure Ratio (EPR) gauges taped with masking tape atop the center portion of the dash/glareshield. No Cockpit voice Recorder or Flight Data Recorder was installed, these also having been removed. A small quick-checklist was noted in the wreckage, which listed start/taxi and shutdown procedures and directed before takeoff/landing procedures to be accomplished via a mechanical checklist (panel mounted checklist). The rudder trim setting confirmation was contained in the Before-Takeoff checklist, yet was missed by the flight crew, who couldn't remember if the checklist had been used for that phase of operation during post accident interviews.
With the mass amount of fixed equipment stripped from both the cabin and cockpit, as well as having no cargo aboard and a very light fuel load, the actual weight and balance of N320MJ was uncertain, since no records of a current W&B existed. It was estimated that N320MJ was approximately 35,000 lbs below the lowest minimum takeoff weight that the performance charts began at. As such, the flightcrew had no idea where their aircraft stood performance-wise. For investigation purposes, Boeing and NTSB personnel estimated the weight of the aircrafts takeoff weight configuration, as well as set the actual right rudder configuration, in an engineering B-707 simulator. 60 takeoff attempts were made with the parameters replicating N320MJ. Of these 60, many of the attempts resulted in the same right wing ground strike that occurred in the accident sequence. It was found that on the takeoff, maintenance of directional control wasn't too difficult; however with the severe lack of flight instrumentation available...especially horizon information due to the missing primary ADIs....that following liftoff, the estimated deck angle was such that visual sight of the horizon was lost as the ground/terrain disappeared underneath the nose of the aircraft. This resulted in a challenge to maintain wings level during the initial climb, and the standby attitude indicator was located in such a place that was inconvenient and not in the normal crosscheck habit. Additionally, no secondary forms of instruments to determine wings-level when the ground couldn't be seen existed in the cockpit, such as an HSI, RMI, turn-and-slip, or even compass. As such, the crew was truly flying a fairly modern jet airliner, seat of the pants; with less flight instrumentation than a Cessna 210.
N320MJ Crew Preflight Planning and Performance
As noted in the previous paragraphs, the crew of N320MJ were knowingly flying in a very minimally equipped airliner aircraft, utilizing minimal checklists and seemingly relying on memory for checklists during the takeoff and landing segments of flight. This would be the most reasonable explanation for the missed right-rudder trim condition on takeoff, as well as the failure of the Captain to insure his shoulder harnesses were strapped/secured. The lack of a shoulder harness, while it wouldn't have prevented injury due to the severe cockpit damage, could've meant the difference between fatal vs serious injuries for him. The 60 year old Captain held an ATP certificate with ASEL and AMEL category/class ratings and an Instrument - Airplane and had over 13,000 hours TT, with 12,000 ME and 4000 in the B-707, and 14 hours in the last 90 days. His last BFR was 15 months prior, performed in the B-707. However, it was discovered that the Captain didn't hold a vaild/current medical. It appears that with the experience of the flightcrew of N320MJ, that they were very comfortable with the aircraft being in the shape and configuration it was, especially since they had made a number of these same ferry flights for the company before. It would appear a certain amount of familiarity and/or complacency set in for the crew, especially with the memory checklist usage for critical phases of flight, where a standard flow became nonstandard due to the severe change of what would be "normally there" instruments-wise to check. Additionally, the lack of hard performance data was likely of little concern to the crew due to their familiarity of the aircraft in "normal" conditions, and their likely mental interpolations of TOLD data for this days flight. The question remains, however, of why the crew recognized enough of a problem during the first takeoff roll to abort the takeoff, yet took off on the second attempt with the same problem. It would be logically thought that the time spent post-abort at the departure end of the runway would've resulted in either the re-accomplishment of the Before-Takeoff checklist, or at a minimum, a more detailed and thorough flow that would've caught the mis-trim setting. At the very least, one would assume that the directional control problem during the first takeoff would've been attributed to either a nose-wheel-steering problem, or some sort of trim problem; and the double-checking of those items accomplished accordingly. Due to head trauma and the other serious injuries, the surviving co-pilot and FE couldn't remember specific details of either the first takeoff, or the accident itself; so the specific reason(s) this item was missed twice, will never be known.
FAA Operational Oversight
N320MJ was issued a Special Airworthiness Permit for the ferry flight, just as all other 707s involved in the program had been in order to undertake the same flight. During the investigation, it was discovered that the FAA Designated Airworthiness Representative (DAR) for the 707 donor program, although having over 20 years with the FAA in various positions, held no A&P license, and had no experience with either large aircraft, return to service of large aircraft following major maintenance, or even what the minimum amount of flight instrumentation necessary for safe flight for large aircraft. The DAR inspected and signed off N320MJ for its Special Airworthiness Certificate, even though there was no current weight and balance information. When questioned later, the DAR couldn't remember what actual instrumentation remained in N320MJ. Additionally, it was found that much of the work performed on N320MJ was done so by personnel who held no FAA A&P licenses or Repairman's licenses.
Review of applicable FAA regulations concerning the appointment of DARs was so broad that people who weren't necessarily experienced in maintenance and inspection functions, as related to airworthiness determiniations, were still allowed to become DARs. Even though DARs are technically supposed to come from the pool of FAA Maintenance Inspectors, as directed by the FAA regulations, this DAR was appointed for a position he was well underqualified for. Consequently, N320MJ was inspected and given a "stamp of approval" through issuance of a Special Airworthiness Permit, by an inspector with neither the requisite knowledge, training, or experience to recognize what type of minimum instrumentation and equipment was safe for flight. Although no specific guidance existed listing the minimum instrumentation required for issuance of a Special Airworthiness Certificate, the NTSB became concerned that DARs were neither trained nor qualified to certify as airworthy, large transport-category aircraft that they had zero experience with.
The NTSB made recommendations to the FAA to both determine the minimum flight instrumentation required for the issuance of Special Airworthiness Certificates, as well as make a top-to-bottom review of the qualification and selection criteria for Designated Airworthiness Representatives.
Final Thoughts
The accident of N320MJ was one of those accidents that really didn't have to happen. Weather wasn't a factor. The crew was extremely experienced. But through a combination of complacency due to having done these flights a few times, lack of recency, willingness to accept very substandard equipment, a low sense of caution especially considering the far-from-normal condition the B-707 was in, and failure to recognize and interperet what the airplane was trying to tell them with that first takeoff roll; this crew met its demise after only 6 seconds of flight. What should've been a vanilla VFR sortie to cover 35 air miles, turned into an accident that didn't even cover 3500 feet, and the loss of a very experienced Captain. Secondary and Tertiary factors aside, and even laying the aircraft and cockpit condition aside, the biggest hurdle this crew failed to recognize was the airplane attempting to communicate to them that it wasn't in the right condition for flight. Even without listening to the airplane, the following of a proper checklist to insure execution as well as completion of critical items for takeoff, could've avoided this tragedy. I personally remember seeing the remaining wreckage of this aircraft sitting where it ended up, just a few days after the accident, when I had traveled to Tucson from Prescott. A sad sight to see, and even worse to know later as I reviewed this accident, just how preventable it was.
Oftentimes, cutting corners can be a necessity in order to make takeoff times, make arrival times, get a necessary mission accomplished, or otherwise get things going. Just insure that you have the knowledge, skill, ability, and most importantly, the SA as well as the caution to know what corners can be cut and by how much. Failure to do so just may put you into a square corner you won't be able to get out of, much as the title to this accident synopsis suggests.
MikeD
The above is not intended to be an undue criticism of the person or persons involved in the incident described. Instead, the analysis presented is intended to further the cause of flight safety and help to reduce accidents and incidents by educating pilots through the sacrifices of others in our profession.
Photo: N320MJ, post-accident. (photo credits K. Burton)
