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Galaxy Airlines 201

Accident Case Study

The captain's reputation preceded him and the rest of the crew was ready to defer to his experience.


 

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Figure: Location of air start access door, from NTSB AAR-86/01.

Accident Report

  • Date: 21 January 1985
  • Time: 01:04
  • Type: Lockheed L-188A Electra
  • Operator: Galaxy Airlines
  • Registration: N5532L
  • Fatalities: 6 of 6 crew, 64 of 65 passengers
  • Aircraft Fate: Destroyed
  • Phase: Climb
  • Airport: (Departure) Reno/Tahoe International Airport, NV (RNO/KNRO), United States of America
  • Airport: (Destination) Minneapolis-St. Paul International Airport, MN (MSP/KMSP), United States of America

Narrative

[NTSB AAR-86/01, ¶1.1.]

  • During ground servicing, a fuel truck was backed into a point about 5 feet behind the trailing edge of the right wing. A total of 2,357 gallons of Jet A fuel was added. When the refueling was completed, the fueler unhooked the hose and stowed it on the fuel truck along with the electrical grounding cables. As he climbed on the truck, he saw the flight engineer securing the single point fueling panel.
  • The engine air start cart was then moved into a position about where the fuel truck had been parked. The fueling supervisor said that he had connected both the air start and ground power units. As the passengers were boarded, the ground handling supervisor and two other persons loaded 67 pieces of luggage into the aft baggage compartment. The flight engineer had instructed the ground handlers to load the luggage in this way since the forward bin contained crew bags and galley stores. The luggage was not weighed before it was loaded, on the airplane.. Sixty-five passengers were boarded in groups. During the latter part of the passenger loading, the ground handling supervisor removed the baggage belt loader from the aft cargo compartment and closed the door. He noticed the flight engineer finishing the engine servicing, apparently having already closed the forward cargo compartment. The forward cargo compartment was closed when the ground handling supervisor made his pre-departure check. He then took his position at the left front of the aircraft for the engine start. Although he ordinarily communicated with the flight crew by means of a headset connected to the aircraft, he was unable, after several attempts, to establish such communications with Galaxy 203. As a result, he used standard hand signals for this purpose. The flight crew then flashed the taxi lights on and off several times in apparent acknowledgment that hand signals were now being used.
  • At this time in the cockpit, the crew was preparing for the engine start. At 0055:51 the captain asked, "How does the clearance read?" The first officer responded, "We're cleared the Reno Seven Departure 41 as filed." The captain then asked the first officer several questions concerning departure. The cockpit voice recorder (CVR) indicated that the before start checklist was not completed properly. There was no verbal response by the captain to the flight engineer's check items. Ten checklist items were then skipped and six items were called for in incorrect order. Fourteen more items, required at intermediate stations, were not called out. No predeparture briefing, which was also required, was recorded on the CVR. A reason for this was later suggested by the president of Galaxy who testified that because the flight crew members ". . .were in a hurry when they got in, he (the captain) would have immediately got the clearance and probably did the departure briefing at that time." Galaxy's broker agent at Reno similarly . described the captain as in a hurry. He testified that the captain, whom he described as "very conscientious" and "very punctual," was angry because he believed that the flight was over three hours late.
  • Following ground servicing the ground handler supervisor signalled to the crew that they could commence engine starting. However, after engines one and four were started, he noticed that the other ground handler was unable to disconnect the air start hose. It was stretched taut from the power cart to the airplane's air start access panel, located on the underside of the right wing leading edge, close to the fillet area. He gave the flight crew an emergency stop signal. He then left his. position, disconnected the hose, and returned to his previous position. He testified that although he thought he did, he could not remember closing the air start access door. This door is about 8 l/2 by 11 inches in size. After the ground handling supervisor disconnected the hose, the other ground handler picked it up and folded it onto the air start cart. She said that she did not close the access door nor did she see it being closed; instead, after stowing the host, she drove the tractor and pulled the air start cart away from the airplane. The power cart was pulled away from the airplane by the fueling supervisor.
  • At 0101:32 the first officer requested takeoff clearance. Four seconds later Galaxy 203 was given clearance to take off from runway 16R.
  • At 0102:44 the sound of engine power increase could be heard on the CVR. At 0103:O1 a sound similar to a glare shield rattle or nosewheel shake was heard. Four seconds later, the captain said, "My yoke."
  • At 0103:19 the first officer called out "V-one." Almost simultaneously a sound characterized as a "thunk" was heard. Four seconds later, the first officer called "V-two." This call was followed by another "thunking" type sound.
  • At 0103:26 the captain called for gear up. The first officer acknowledged the order. At 0103:29 the captain asked the flight engineer, "What is it, Mark"? He responded, "1 don't know. I don't know, Al."
  • At 0103:37 the flight engineer said, "That's METO."
  • Maximum Except Take Off engine power

  • Three seconds later the captain ordered the flight engineer, "Okay pull 'em back from METO." At 0103:43 the captain directed the first officer. to request-permission from the tower to execute a turn to a left downwind to return to the field. Two seconds later the request was made to the Reno tower. At 0103:SO the flight engineer said: "RPMs look stable, horsepowers look good." At 0103:55 the captain told the first officer to "Tell 'em we have a heavy vibration." The first officer so informed the tower at 0103:58.
  • At 0104:OO the tower cleared Galaxy 203 to maintain VFR conditions and to enter a left downwind to runway 16 right. The controller also asked, "Do you need the equipment"? Two seconds later, after the captain told him, "Yeah," the first officer responded, "That's affirmative." The Reno tower controller then asked Galaxy for the number of people on board and fuel remaining. At 0104:13 the first officer replied, "Sixty-eight and we got full fuel." At 0104:14 the Ground Proximity Warning System (GPWS) sounded. At 0104:18 the first officer said, "A hundred knots." He repeated this three seconds later. At 0104:24 the captain called for maximum power. Six seconds later the sounds of impact were recorded. The cockpit voice recorder terminated at that time.

Analysis

[NTSB AAR-86/01, ¶1.5.1]

  • With his military experience, much of it in the P-3 aircraft, the military version of the Electra, the captain had accumulated over 5,000 hours in that airplane. He was an Electra check airman at the time of the accident, although he was not designated by the FAA to perform those duties for Galaxy. He had accrued about 14,500 total flight hours and was more than 20 years older than both the first officer and flight engineer.
  • The first officer was hired by Galaxy in June 1984. At the time of the accident, he had over 5,909 total-flight hours and 172 hours in the Electra, all of which were accrued at Galaxy. He received 40 hours of basic indoctrination and 80 hours of initial classroom training on the airplane from June 16, 1984 to July 17, 1984. In September 1984, he was observed in a flight in the Electra. The chief pilot, who observed the flight, commented that his "performance on all maneuvers was marginal,.. however, within prescribed limits.

[NTSB AAR-86/01, ¶1.16.2]

  • A former official of Lockheed Corporation described how an Electra would be affected aerodynamically if a wing mounted air start access door was left open. He testified that this ". . . could be the source of a heavy buffet resulting from major separation of (air) flow over the inboard wing and the resulting flow field striking the horizontal tail, driving the airplane and buffet heavily, very similarly to a stall buffet. At this particular location (there is) . . . a very high local flow field which increases the local angle of attack in that region, far above the normal angle of attack of the airplane or the fuselage reference line of the deck angle if you will. If that door is left open (this) could cause the door to come up and act like a very severe spoiler.
  • His comments were supported by reports received by the Safety Board following the accident. Several flight crew members who had flown the Electra described experiences they had encountered which resembled the vibrations reported by Galaxy 203. All occurred at low speeds, just after rotation and lift off. Further, all were found to have been caused when the air start access door was inadvertently left open and then pulled upward by the airstream.
  • In one incident a flight engineer said that the vibrations led the captain to believe that the aircraft was in a stall. The captain then added power, lowered the nose, and flew out of the vibrations. In another case, the first officer characterized the vibrations he experienced as "very severe." He and the captain both believed that the aircraft was about to stall. When they increased power, the vibrations seemed to decrease. Another flight engineer also experienced vibrations immediately after takeoff. When the captain lowered the nose and increased the airspeed to about 160 knots, the buffetting ended."
  • All of the evidence demonstrates that the controllability of N5532 was not compromised by the open air start access door. All systems, propellers, powerplants, and structural components were found without preexisting damage and were functioning at impact. Although the open air start access door would create vibrations, particularly at low air speeds, the airplane could have been controlled and flown safely had the flight crew responded appropriately to the perceived emergency while at a low altitude. The Board believes that the crews' inappropriate response of reducing power below MET0 and their failure to monitor airspeed and other performance parameters led directly to the accident.

[NTSB AAR-86/01, ¶2.2]

  • At 0103:29 the captain asked the flight engineer, "What is it Mark?" referring to the heavy vibration. His subsequent call for power reduction indicates that he suspected that the engines or propellers were the cause and he acted accordingly.
  • The Safety Board determined that the propellers and engines were operating at the time of impact.
  • The evidence supports the conclusion that the air start access door was the source of the vibration encountered by Galaxy 203.
  • There was no evidence of physiological factors adversely affecting the crew's performance. Likewise, there was no indication that the crewmembers were fatigued or otherwise incapacitated.
  • The crew actions do, however, suggest a carelessness with regard to their adherence to procedures. For example, at Reno the flight engineer instructed ground handlers to load all passengers' baggage in the aft bin of N5532 since the forward bin contained crew bags and galley stores. Further, according to the surviving passenger of Galaxy 203, passengers were seated throughout the airplane, and not in accordance with Galaxy Airline's weight and balance manual, which required that passengers be seated forward of row 18 when the passenger load was between 25 and 66 passengers. Both of these actions suggest that the flight crew did not compute an accurate CG during their flight planning. Had they done so, they most likely would have found that the CG was beyond the allowable aft limit.
  • Similarly, the "before start: check list was not completed. According to the CVR, there was no verbal response by the captain to the flight engineer's check items. Ten check list items were then skipped, three items were called for in reverse order, and three more items, in incorrect order, were called for. Fourteen more items, required at intermediate stations, were not called out. The captain's answer should have been specific, rather than the "Yea" which he gave in response to some items. In addition, there was no pre-takeoff briefing by the captain.
  • The Board believes that these actions demonstrate a lack of appreciation by the crew in general, and the captain in particular, of the need to adhere to standard operating procedures.
  • The Safety Board believes that the captain's initial assumption that the powerplants may have produced the vibration was not inappropriate since malfunctions in powerplants or propellers could have caused it. However, his reducing power on all four engines, at a low altitude and at a low airspeed, followed by his failure to take alternate action when the vibration continued, led directly to his failure to control the airplane.
  • A proper course of action in response to an engine or propeller vibration shortly after takeoff would have been to maintain MET0 power until the airplane reached a safe altitude and then reduce power in one engine at a time. Thus, if the vibration was reduced, the engine or propeller causing the problem would have been apparent. At the same time, sufficient power would have been generated by the other engines to maintain both airspeed and a safe altitude. Nevertheless, reducing power on all four engines simultaneously would not have caused the accident, provided the captain had immediately restored MET0 power when it was evident that the power reduction did not decrease the vibration. This was particularly critical since the airplane was so close to the ground. Although it was dark, and hence it would have been difficult to see the ground, the captain should still have been aware of their proximity to it since they had just taken off. Consequently, he should have been particularly sensitive to the need to maintain altitude and airspeed.
  • The Safety Board believes that the captain attempted, but was unable, to perform adequately the dual tasks of troubleshooting (that is, locating the source of vibration) and flying the airplane.
  • The captain was characterized as "always in command." In addition, a first officer described him as the type of captain who would often check first officers on their knowledge of equipment and procedures. This characteristic of "being in command" may have been heightened by the composition of the flightcrew on Galaxy 203. The first officer and flight engineer differed considerably from the captain in two important dimensions that affect the nature of the interpersonal relationships of flightcrew members in the cockpit: age and flight experience. The captain was more than 20 years older than the junior crewmembers, and he had been piloting aircraft in general and the Electra in particular for years, whereas the others had been operating the airplane for only a few months. Such diversity can contribute, under routine circumstances, to deference by the junior crewmembers to the senior member.
  • Despite their relative inexperience, the junior crewmembers were qualified in the Electra. They could have assisted the captain in monitoring the flight instruments and controlling the aircraft. Instead, they responded directly to the captain's commands; the first officer, by communicating with the Reno tower, and the flight engineer, by monitoring the engines. If the first officer had noted the airspeed sooner and forcefully informed the captain of the deteriorating airspeed, thus acting contrary to the captain's direction, it is possible that power could have been applied in sufficient time to have prevented the accident.
  • Moreover, the inappropriate actions of the first officer extended beyond his interaction with the captain to his interaction with the local air traffic controller as well. His failure to place more important aircraft monitoring duties at a higher priority than responding to the question of the controller, albeit in accordance with the captain's direction, demonstrated a failure to apply a critical tenet of flying: aircraft control takes precedence over all other flight related duties.

Findings

[NTSB AAR-86/01, ¶3.1]

  • The captain attempted both to determine the cause of the vibration and fly the airplane simultaneously, which he was unable to do.

Probable Cause

[NTSB AAR-86/01, ¶3.2] The National Transportation Safety Board determines that the probable cause of this accident was the captain's failure to control and the copilot's failure to monitor the flight path and airspeed of the aircraft. This breakdown in crew coordination followed the onset of unexpected vibration shortly after takeoff. Contributing to the accident was the failure of ground handlers to properly close an air start access door, which led to the vibration.

See Also

Crew Resource Management

Situational Awareness

References

NTSB Aircraft Accident Report, AAR-86/01, Galaxy Airlines, Inc., Lockheed Electra-L-I 88C, N5532, Reno, Nevada, January 21, 1985

Revision: 20150404
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