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Pan American World Airways 217

Accident Case Study

Taken in isolation, this accident is simply the case of a crew succumbing to spatial disorientation. But there is much more to it than that. A highly experienced pilot flew his aicraft into the ocean with two other pilots watching. But there is much more to it than that.

This was another incident in a series of 13, 11 of which pointed to a problem with the Crew Resource Management Culture at Pan American World Airways at the time. They were able to reverse this culture and became one of the safest airlines in the world.


Accident Report

  • Date: 12 December 1968
  • Time: 22:02
  • Type: Boeing 707-321B
  • Operator: Pan American World Airways
  • Registration: N494PA
  • Fatalities: 9 of 9 crew, 42 of 42 passengers
  • Aircraft fate: Damaged beyond repair
  • Phase: Approach
  • Airport (departure): New York-John F. Kennedy International Airport (KJFK), USA
  • Airport (arrival): Caracas-Simon Bolivar International Airport (SVMI), Venezuela

Narrative

[NTSB News Release]

  • Type of Accident: Undershot, Collision with ground/water, controlled
  • Pilot Data: ATP, age 50, 24,000 total hours, 6,737 in type

[Gero]

  • Designated as Flight 217 and en route from New York City, the jet airliner crashed in the Caribbean Sea and exploded while descending for a landing at Maiquetia Airport, serving Caracas, killing all 51 person aboard (42 passengers and a crew of nine).
  • The accident took place some 10 miles (15 km) from shore, during the final approach phase that was being conducted under visual flight rules (VFR) procedures. It was dark at the time, but the meteorological conditions were good, with a ceiling of 2,000 ft (c. 600 m) and unlimited visibility udner the clouds.
  • The bodies of more than half of the victims and significant portions of the aircraft, including the tail assembly, two engines and the flight data recorder (FDR), were subsequently recovered from the water, which was 360 ft (110 m) deep at the crash site. Some of the occupants may have been knocked unconscious on impact and drowned.
  • Although the cause of the accident could not be determined, it was considered possible that the pilots had been deceived by a sensory illusion produced by town lights on upsloping terrain in the vicinity of the airport, which, as studies have shown, can create the impression of being higher than is actually the case and thus result in an undershoot.

Analysis

I am still on the hunt for an official accident report for this; but there is enough information to hypothesize the pilots simply flew the aircraft into the ocean. Looking at the other Pan American World Airways Boeing 707 crashes from 1959 to 1974, you will see a culture of captains who had very little oversight and crews who kept quiet when the captain made a mistake. There isn't enough evidence to say that was definitively the case here, but this accident does become a data point in an overall picture. See: CRM Culture for more about this.

Cause

[NTSB News Release] Investigated and reported by Venezuelan Govt. Possible visual illusion caused by town lights on upslope.

See Also:

Crew Resource Management Culture

Controlled Flight Into Terrain

Spatial Disorientatin

References

Gero, David, Aviation Disasters: The World's Major Civil Airliner Crashes Since 1950, The History Press, 2012, Stroud, Gloucestershire

NTSB News Release, DCA69R002, https://www.ntsb.gov/news/press-releases/_layouts/ntsb.aviation/brief.aspx?ev_id=10023&key=0

Revision: 2018011420170915
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