Aircraft Accidents and Lessons Unlearned LI: Arrow Air Flight MF1285R

On December 11, 1985, Arrow Air flight MF1285R, a Douglas DC-8-63, registration number N950JW, crashed on departure out of Gander International Airport, Gander, Newfoundland. The aircraft had been taking off from runway 22; it did not achieve altitude before, according to witnesses, it banked right and pitched up, all while descending down the embankment at the end of the runway.

The Multinational Force and Observers chartered the flight to bring service men and women of Fort Campbell’s 101st Airborne Division back to the United States from Cairo. The aircraft had a scheduled stop in Gander as part of its flight plan, taking on fuel and catering services.

The Canadian Aviation Safety Board (CASB) conducted the investigation, the subsequent hearing and wrote the accident report. The report stated that wing icing was the accident’s major contributor. Not mentioned were other major contributors, e.g., poor judgment and a lack of conditional awareness; the flight crew did not correctly analyze the danger imposed by ice accretion on the flight surfaces.

A look into fatigue and its effects on the crew was made by examining the research of Doctor Stanley Mohler, Director of Aerospace Medicine at the Wright State University of Medicine. Doctor Mohler applied his fatigue-rating index to the flight crew’s schedule and found that the crew’s conditions, at the time of the accident, fell into the “category of ‘may dangerously deplete physiological reserves’.” Doctor Mohler determined that the accident crew was fatigued despite their taking the flight over from the arrival crew in Gander.

An examination of the aircraft and engines determined that the number four engine was not operating as efficiently as the other three engines. However, tests and flight simulations eliminated the aircraft and engines as contributors to the accident.

The accident flight’s weight and balance records were examined and found to be safely within the mean aerodynamic chord envelope; the center of gravity (CG) was well within limits. The cargo weights were identical to those of the previous leg and the passengers did not change seating. An argument could be made comparing actual weights versus average weights, but the CG would still have been safe. The CASB had calculated the weights and found a discrepancy, but the previous leg’s CG was not retrimmed in flight, therefore the accident aircraft’s CG was not in conflict.

The CASB gave credence, in the absence of other information, to witness statements about flight controls, hydraulics, the number four engine and thrust reversers, all of which could not be substantiated. Another, a yellow/orange glow under the aircraft belly was entertained, but could not be validated as anything more than, e.g., a red anti-collision beacon reflecting off the open landing gear slave doors.

It was unfortunate that CASB Board Hearing time was wasted on issues that had little to do with the accident; not to say examining all possible scenarios was wrong, just pursuing information irrelevant to the accident. For instance, the Director of Maintenance (DOM) was asked about an uncontained engine failure that had occurred four years earlier in Casablanca and the repairs to wings and flight controls as a result. A DOM does not concern himself/herself with non-emergency items or repairs, no matter the detail; the DOM would instead be a good source for company policy and fleet problems, not individual aircraft. Missing cargo panels and Engine Hi-temp gauges received unnecessary attention; they were not found to be contributors to the accident and diverted interest away from the causes.

It was determined that icing was the likely culprit of this accident. Ice would have answered questions relating to increased stall speeds, the roll to the right, inadequate lift, even a heavier than recorded aircraft weight. The ice could have been distributed unevenly across the wings upsetting lift on one side more than the other. The aircraft, having recently arrived from the previous leg, could have had supercooled wings, which, after being newly fueled, would have added to the icing problem. Little was added by some witnesses interviewed: ramp handlers, fuelers and servicers who did nothing to answer aircraft icing questions. Oddly, the report made no mention of the flight engineer’s preflight external inspection, for he could have seen wing ice and snow accumulation from behind the wings.

In 1982, an Air Florida B737, flight 90, crashed taking off out of National Airport. Cause: Icing. At the time of Arrow Air MF1285R, the airlines were required to have deicing plans approved by the Federal Aviation Administration (FAA) in their Operations Specifications. Deicing was not a new concept; at the time of this accident, airlines were already using anti-icing fluids with deicing fluids. So, why, after the disastrous Air Florida flight 90 accident, where the root cause was negligence on part of the flight crew, did this flight crew choose to fly the airplane, untreated by deicing, under a similar precipitation event?

It was interesting that the CASB did not raise a more obvious question: Was this accident due to simple negligence, military charter concerns or both? Military charters are frequent business ventures between the military and commercial aviation; my son returned from the Iraq conflict on a Continental B767 thirteen years ago. In addition, the military assures civilian lift support by engaging with air carriers in the Civil Reserve Air Fleet (CRAF), where the military supplements the air carrier to have access to their aircraft in time of need.

But CRAF does not work like a charter. In a charter, the airline does not work with the military, the military is the customer. And while the military and the commercial airlines are dedicated to safety, their paths to safety are far different because their missions are different. It is this disparity in safe practices that results in urgency miscommunications between the air carrier provider and the military customer.

Therefore, what is it about military charters that makes the most qualified airline personnel lose their capacity for common sense?

A load master for a B757 charter company wrote (what he considered to be) an amusing an article about how humorous a B757 captain was who, while flying a military charter, scoffed at a deicing delay and instead swept ice and snow from his wings with a broom instead of “having to wait” for the deice crew to show up in the morning. Aside from not being funny, the operational and maintenance violations were numerous beyond the captain ignoring the airline’s deicing program.

In April 2013, National Air Cargo flight 102, a B747 cargo jet crashed while taking off out of Bagram Airfield in Afghanistan. The accident was due to unrestrained cargo, which moved aft on rotation. This same freight exceeded the cargo floor’s structural weight limits, destroying the floor’s integrity when the B747 landed in Bagram. The floor’s failure left the floor cargo locks and netting restraints useless – the cargo moved because there was nothing to hold it in place. The accident B747’s cargo bay was marked with cargo weight limits per station that normally would have prevented the accident by drawing attention to the overweight loads, but National 102’s load crews and pilots ignored these warnings.

The planes, National Air Cargo 102 and Arrow Air MF1285R crashed, but not because safety protocols were not in place. As a rule, the Department of Defense (DOD) conducts regular audits on those the DOD contracts with and the air carriers with CRAF agreements. Similar to FAA audits, the DOD audits employ Operations and Airworthiness representatives who dig into the air carrier’s policies from a safety standpoint; in fact, DOD audit findings require the FAA air carrier certificate office respond to discovered safety items of concern with how the safety issue would be corrected and how quickly. If not corrected, the contract is canceled.

However, an air carrier audit did not cause the Arrow Air MF1285R crash. Arrow Air’s deice program existed; the flight crew was familiar with the meteorological conditions and fueling issues with which icing would become a problem. Did the second officer conduct a preflight walkaround? Did the flight crew opt out of deicing in favor of an on-time departure? An airline is run on a schedule; as part of the airline culture, there is an urgency to ‘fly the airplane’, to meet the schedule and the next one.

Did time constraints for departure eclipse common sense and experience? The aviation industry will never know because the right questions were not asked. However, when entering into a lease agreement, the most important factor to be considered is safety, even when it is inconvenient.