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Pan American World Airways 6005

Accident Case Study

Taken in isolation, this accident appears to be a simple case of a pilot flying an instrument approach incorrectly. 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.


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Photo: Pan American World Airways Boeing 707-321C, N461PA, from www.logbookmag.com

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Accident Report

  • Date: 25 July 1971
  • Time: 13:21
  • Type: Boeing 707-321C
  • Operator: Pan American World Airways
  • Registration: N461PA
  • Fatalities: 4 of 4 crew
  • Aircraft fate: Damaged beyond repair
  • Phase: Approach
  • Airport (departure): Guam International Airport (PGUM), Guam
  • Airport (arrival): Manila International Airport (RPLL), Philippines

Narrative

I don't have anything official about this accident, though I know where such a report exists. It is in the "ICAO Accident Digest Circular 118-AN/88" which is also known as the "ICAO Accident Digest Circular No. 20" or something like that. I have ten such circulars, just not this one. I've been looking. If you have one, please let me know, hit the "contact" button.

What appears here is from the Aviation Safety Network, which is very good. But it isn't much.

[Aviation Safety Network] The Boeing, named "Clipper Rising Sun", was on a cargo flight from San Francisco via Honolulu, Guam and Manila to Saigon. While on a VOR/DME approach to Manila runway 24, the aircraft struck Mount Kamunay at an altitude of 2525 feet (770 m).

Analysis

The following narrative is from the excellent book, Sky Gods, by Robert Gandt. It may be one of the best books on Crew Resource Management ever written.

[Gandt, pp. 85-87]

Jim Wood was the first of his class to complete first officer training. For his initial line trip he was scheduled to fly with one of the ancients, a senior captain named Lou Cogliani. The trip was to Honolulu and back.

Wood showed up an hour and a half early. His shoes were spit-shined. The three gold stripes on each sleeve glowed like neon. He was prepared to learn about flying from the old master.

"Sir," he said, extending his hand, 'Tm Jim Wood, your first officer."

Captain Lou Cogliani, Master of Ocean Flying Boats, peered at the young man over the tops of his half-frames. It was the Look. He ignored Wood's hand. "How long you been flying, kid?"

"Ten years, including the Air Force and-"

"Never mind that shit. How long you been with Pan Am?"

"I'm new, sir. Just out of training."

Cogliani leaned over the operations counter. "Goddamnit, Evans," he barked at the clerk. "What's going on here? I told 'em I didn't want any new hires in my cockpit."

"I don't make the schedule, Lou. There's the phone. Call the chief pilot if you want."

Cogliani glowered at the phone. Then he shuffled through the paperwork for the flight to Honolulu. He ignored his new copilot.

They took off. Cogliani still had not spoken to Wood, except to order him to read the checklist.

Wood watched how the old master flew the 707. Captain Cogliani, he noticed, flew an airplane the way a bear handled a beach ball. He gripped the yoke with both hands. The veins stood out on his tensed forearms. He yanked, jerked, shoved, manhandled the protesting 707 all the way to 35,000 feet.

Wood glanced back at the flight engineer. The engineer nodded and rolled his eyes.

Wood was confused. Cogliani was a Skygod-a Master of Ocean Flying Boats. He was one of those legends that Wood most of all wanted to be like someday. He was supposed to be a hero. Something was wrong, thought Jim Wood. The Skygod was an asshole.

Approaching Honolulu, Cogliani commenced his descent from altitude too late, ignoring Wood's reminder about their rapidly diminishing distance from the airport. Too high for the approach, Cogliani had to fly a circle to lose altitude. Then he overshot the localizer, the final approach course. Honolulu Approach Control vectored them back onto an approach course straight into the runway.

At fifteen hundred feet above the field, the captain had still not called for the landing gear down. Wood kept his silence.

A thousand feet. Still no gear. Jim Wood bit his lip and said nothing.

At six hundred feet, Wood could stand no more. "Do you want the landing gear down, captain?"

Cogliani glowered at him. "Landing gear? Goddammit, I'll tell you when I want the gear down." Two and one-half seconds later, with a great deal of authority, he told him. "Gear down!"

No one, not even a new hire like Jim Wood, would dare suggest that the captain-a Master of Ocean Flying Boats-might actually have forgotten to lower his landing gear. Instead, Wood did something even more foolish. He laughed.

Three days later, in the chief pilot's office, Wood received his first lesson in Skygod protocol. The chief-the craggy-faced man who had welcomed Wood's class to Pan American-regarded the young man over the tops of his own half-frames.

"Do you want to keep your job, son?"

"Yes, sir."

"Then get this. You will sit there and raise and lower the captain's landing gear-on command-and keep your impertinent, newly hired mouth shut. Clear?"

"Yes, sir."

"Good. Get out of here."

[Gandt, p. 94]

The news filtered down to the crew lounge. Pilots stood in clusters talking about the crash.

"What was it?"

"A 707 freighter, on descent into Manila. Disappeared off radar. They think it hit the mountain range east of the airport."

"Who was the captain?"

"Lou Cogliani."

Cogliani. No comment, just a silent nod. It wasn't the right time to make judgments. But each pilot guessed in his heart what had happened out there in the Pacific. And he worried that it could happen again.

Cause

From what little we have here, it would seem the pilot flew below a minimum altitude on approach. I think it was more than a matter of poor instrument skills. I think the culture of the airline allowed the skills of their captains to atrophy because there was very little oversight. I think the crew didn't actively back up the captain because they were fully indoctrinated into a culture that discouraged any kind of negative feedback towards the captain. In that situation, crew often become passengers.

[Aviation Safety Network] Improper crew-coordination which caused a premature descent.

See Also:

Controlled Flight Into Terrain

Crew Resource Management Culture

References

Gandt, Robert, Skygods: The Fall of Pan Am, 2012, Wm. Morrow Company, Inc., New York

NTSB Aircraft Accident Summary,DCA72RZ001, Pan American World Airways 6005, N461PA, July 25, 1971

Revision: 20180201
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