Martin 404, N464M

Case Studies

"The Beav" sez:


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Photo: Martin 404, (Photo: Jon Proctor)
Click photo for a larger image

Sixty miles west of Denver, Colorado stands a 12,000 ft wall. This wall is the Continental Divide. Through the Continental Divide runs an engineering marvel, the Eisenhower Tunnel, the longest and highest mountain tunnel on the Interstate System. On average 35,000 cars a day pass through the Eisenhower Tunnel. But what most drivers do not know is that just 3 miles east of the tunnel’s entrance lies the wreckage of a Martin 404. The tragic story of how this aircraft, its crew, and its passengers came to rest there holds lessons for all of us who make our profession in aviation. And though it occurred fifty years ago its lessons still ring true today:

“. . . the numerous deficiencies, unsafe practices, and deviations from regulations, involved in this operation, are typical of operations where none of the participants acknowledge responsibility for the safe conduct of a flight.” — National Transportation Safety Board

Let’s take a look at the deficiencies, unsafe practices, and deviations of Wichita State University’s “Gold” flight.

Cover story:

2020-10-02

Last revision:

2020-10-02

Accident Report

  • Date: 2 October 1970
  • Time: 13:00 MDT
  • Type: Martin 404
  • Operator: Golden Eagle Aviation
  • Registration: N464M
  • Fatalities: 2 of 3 crew, 30 of 37 passengers
  • Aircraft Fate: Destroyed
  • Phase: En route
  • Airport: (Departure) Denver-Stapleton International Airport, CO (KDEN), USA
  • Airport: (Destination) Logan-Cache Airport, UT (KLGU), USA

Narrative

[NTSB AAR-71-4, Excerpts]

October 2, 1970: . . . The first officer was the president of Golden Eagle Aviation, Inc . . . he advised some of them that the flight would take the "scenic route" from Denver to Logan . . . there was no specific conversation with [the Captain] concerning the route, and there was no flight planning as to routing . . .The aircraft was 5,190 lb over the max. permissible takeoff weight . . . All who observed the aircraft along the last 10 miles of flight in Clear Creek Valley stated that the aircraft was below the mountaintops at all times. . . . the plane was well above the critical engine altitude, and it didn't appear to be much above the minimum control speed . . . Two witnesses estimated that the aircraft was only about 100' above the highway as it was coming toward them . . . The aircraft made a steep turn in front of them . . . Seconds later, the aircraft struck the trees . . . None of the participants in this flight, the owner of the aircraft, lessee, or the company providing the crew and other services acknowledged that they were the operator and accepted responsibility for the safety of such flight.

How was this possible?

[The Denver Magazine, "The Crash" 5280, Excerpts]

The Martin 404 aircraft was a 40-seater, and there were 36 people associated with Wichita State University’s football program on the plane on October 2. They were bound for Logan, Utah, and a Saturday football game against Utah State University.

When the nearly 20-year-old twin-engine plane took off from Kansas, it carried 14 Wichita State starters, the head coach, team staff, administrators, wives, and boosters. N464M was one of two chartered planes flying from Wichita to Utah. The planes were code-named “Black” and “Gold” for the university’s colors.

The trip was straightforward: The two planes would leave Wichita, refuel at Denver’s Stapleton International Airport, and arrive around 2 p.m. in Logan. The flight path would take the team on a route that looked a bit like an elongated zig-zag line, a north-by-northwest path to Laramie, Wyoming, then a turn west to Logan. It was hardly a straight shot, but circumnavigating the central Colorado Rockies was far and away the safest way to get to Logan. The route was favorable for Ron Skipper—the first officer in the Gold plane carrying the starters—who’d logged approximately 30 hours flying the Martin 404 and was unfamiliar with the terrain of the Rockies.

Though he only weighed 165 pounds, Skipper was full in the face, with slicked reddish-brown hair and thick glasses he was required to wear when he flew. The 34-year-old Oklahoman was also the CEO of the flight crew–leasing company, Golden Eagle Aviation, which contracted with the planes’ owner to carry the Wichita players.

Somewhere between the takeoff in Kansas and the refueling stop in Denver, Skipper told his passengers that he’d deviate from the flight plan and take the group through the mountains, maybe show them some ski resorts.

As the plane refueled on the Stapleton tarmac, it exceeded its maximum-certified gross takeoff weight. Even if the plane lost 200 gallons of fuel per hour, typical for a Martin 404, the plane would remain overweight throughout the flight. And there was perhaps an even bigger concern: Neither Skipper nor the 27-year-old captain, Dan Crocker, had an aeronautical sectional chart of the new route. Skipper excused himself, left the plane, and bought a map inside the airport terminal.

[PopFlock Wichita State University Crash, Excerpts]

While the aircraft were refueled and serviced in Denver, First Officer Skipper purchased aeronautical sectional charts for the contemplated scenic route. The National Transportation Safety Board (NTSB) investigation report stated the First Officer testified that he intended to use the charts to help point out landmarks and objects of interest to the passengers. The report concluded the crew did not allow enough time for the charts to be studied properly to avoid high terrain before takeoff commenced. After takeoff in clear weather, the two aircraft took divergent paths away from Denver.

The overloaded aircraft, nearing Loveland Pass as it flew up Clear Creek Valley, became trapped in a box canyon and was unable to climb above the mountain ridges surrounding it on three sides, nor complete a reversal turn away from the sharply rising terrain. At 1:14 p.m. MDT, the "Gold" aircraft struck trees on the east slope of Mount Trelease, 1,600 feet below its summit, and crashed. The NTSB report stated a belief that many on board survived the initial impact, based on the testimony of survivors and rescuers. The load of fuel on board did not explode immediately, allowing survivors to escape the wreckage, but the passenger cabin was eventually consumed by an explosion before those still alive and trapped inside could escape.

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Photo: Martin 404 N464M Wreckage, (Photo: Jon Proctor)
Click photo for a larger image

Of the total of 40 on board, the death count at the scene was 29, which included 27 passengers, captain, and flight attendant. Two of the initial 11 survivors later died of their injuries to bring the total dead to 31, 14 of whom were Wichita State football players. First to arrive at the crash scene were construction workers from the nearby Eisenhower Tunnel project and motorists on U.S. 6 (I-70). The first officer (company president) survived; he was flying the plane from the left seat.

[NTSB AAR-71-4, Excerpts]

The first officer for N464M, Mr. Ronald G. Skipper, was the president of Golden Eagle Aviation, Inc. The Captain for N464M, Danny E. Crocker, had been hired by Golden Eagle Aviation, Inc., as a mechanic, and was used only occasionally as a pilot on an "individual contractor" basis, according to Mr. Skipper.

With respect to the flightpath after departure from Stapleton, Mr. Skipper testified that there was no specific conversation with Capt. Crocker concerning the route, and that there was no flight planning as to routing other than the intention "to go to Logan direct, or as direct as possible.”

After intercepting Clear Creek Valley, the flight proceeded along US Hwy 6, slightly south of it, past Georgetown and Silver Plume, toward Loveland Pass. The elevation at Georgetown is 8,512 MSL and at Silver Plume is 9,118 MSL. Thereafter, the valley floor continues to rise, reaching an elevation of 11,900 feet MSL at Loveland Pass. In the area west of Georgetown, the mountains on either side of Clear Creek valley range from 12,477 MSL to over 13,000 MSL.

Across the end of the valley at the Loveland ski resort area, the ground rises rapidly from the valley floor at 10,600 MSL to 12,700 MSL at the Continental Divide, directly ahead on a westward flight path.

Pilots of an aircraft proceeding westward along Clear Creek Valley at an altitude of 11,000' or less would not have a view of the end of the valley until in the vicinity of Dry Gulch, since it would be cut off by Mt. Sniktau (elev. 13,234').

Mr. Skipper testified that in the vicinity of Dry Gulch, "We were in the valley. It began to look to me as if we were not going to climb so as to have clearance, sufficient clearance, over what I now know to be the Continental Divide ahead of us. I said something to the effect to Capt. Crocker that maybe we should reverse course and gain some altitude. I initiated a turn to the right. We were to the left side slightly of the valley." In continuing testimony, Mr. Skipper said: "I initiated a turn of appx 45 change in heading, a medium bank turn which in my mind is somewhere between 20 and 30 degrees, and as I was rolling out of this turn, Capt. Crocker said 'I've got the airplane.' He initiated a left turn, the aircraft began vibrating, he put the nose down, and shortly thereafter we crashed." He also testified that to his knowledge the aircraft was operating properly up until the moment the vibration occurred.

Eight of the surviving passengers were interviewed. All confirm that the aircraft was continuously below the mountaintops while flying up Clear Creek Valley. None recalled any indications that the engines were not running normally. Several recalled that the aircraft was banked sharply just before impact. The banks upset a stewardess who was serving refreshments to the passengers. Three described the aircraft as shaking or vibrating coincident with, or immediately following, the initiation of the rapid banks. One survivor, who had been standing in the doorway to the pilot's compartment and immediately behind the two pilots, stated that the vibration felt like "a boat slapping water." While he was standing in the doorway, he overheard the pilots discussing the elevation of the mountain peak ahead, and about that time the quick right turn and left turn were made. He did not recall any conversation between the two pilots other than this. The engines sounded normal to him and, until the right turn was initiated, it did not seem to him that the pilots were overly concerned about the flight.

[NTSB AAR-71-4, Excerpts]

It became apparent in the early stages of this investigation that there was a disagreement among the three interested parties concerning the designation of "operator." In the course of the public hearing, an FAA witness testified that the FAA considered Golden Eagle Aviation, Inc., to be the operator, and as such did not have the proper authority for the operation of Martin 404 aircraft. Both the Jack Richards Aircraft Company and Golden Eagle Aviation, Inc., contended that the Wichita State Univ. was the operator. It was the position of Wichita State Univ. officials that they had chartered the aircraft and Wichita State Univ. was not the operator.

Analysis

The vibration of the aircraft described by FO Skipper and the survivors occurred concurrent with the attempt to execute a 180 degree reversal of course. The severest vibration occurred during the left bank, described by surviving passengers as "very, very steep" and "awful sharp." One of them stated that the bank was reduced greatly just before the aircraft struck the trees. The swath cut through the trees indicated a bank angle of 31 degrees. Ground witnesses located on US Hwy 6, only a few hundred feet from where the aircraft crossed the road in front of them, stated that the entire top of both wings and aircraft fuselage was visible to them. At an altitude of 11,000' MSL, with a left turn initiated just before the aircraft starts to cross US Hwy 6, a bank in excess of 60 degrees will be required for terrain avoidance at an indicated airspeed of 140 kts. Accordingly, the Board believes that the vibration was the result of abrupt maneuvers and a steep bank which induced prestall buffet, and was not the result of malfunction of the aircraft, aircraft engines, or control systems.

In considering the operational factors in this accident, the lack of adequate flight planning for the alternate route segment from Denver to Logan is immediately apparent. Mr. Skipper testified that at the start of the trip, he had in his possession a flight plan prepared by the FO of the other crew. This flight plan called for a northbound departure from Denver, on established airways, via Laramie, Wyo. This route parallels the mountain ranges and offers ample time to climb to a safe altitude before turning westward over the mountains. The change in routing was purely for sightseeing purposes. Mr. Skipper several times testified that Capt. Crocker was the pilot-in-command of the trip and that it was Capt. Crocker who made the decisions relating to the flight. However, with respect to the route between Denver and Logan, Mr. Skipper also testified that after the flight departed from Wichita, it was he who made the decision to purchase charts at Denver to be used in pointing out landmarks and points of scenic interest to the passengers. Accordingly, while Capt. Crocker may have been distinguished as the PIC by virtue of the fact that he held a type rating on the aircraft and Mr. Skipper did not, it is the Board's opinion that Mr. Skipper, in his capacity as president of Golden Eagle, was in fact the person who decided the route to be traveled.

Mr. Skipper, by his own testimony, was aware of the "drift down" safety practice employed by airlines and most operators of large aircraft when operating over mountainous terrain. Notwithstanding, he flew the aircraft in the mountain valley below the mountaintops at an altitude higher than the aircraft was capable of maintaining in the event of an engine failure.

It must also be presumed that neither Mr. Skipper nor Capt. Crocker spent any time examining the charts for the route to be flown, since Mr. Skipper did not return to the aircraft after he purchased them until appx 15 minutes before takeoff and, at that time, engaged in conversation with the passengers. If the charts had been studied, the pilots could have known that the minimum altitude necessary to clear Loveland Pass at the end of Clear Creek Valley, was 12,000' MSL Mr. Skipper was flying the aircraft at reduced power at appx. 11,000' MSL when the flight reached Dry Gulch and the crew first discovered that Clear Creek Valley was ending in what has been described as a "box canyon."

With respect to the ability of the aircraft to climb over the mountains ahead, a review of the performance data shows that if max continuous power had been applied when the aircraft was at Dry Gulch, a climb gradient of 4.57 percent could have been achieved. This translates into a climb capability of 240 feet per mile traversed. Since the distance from Dry Gulch to Loveland Pass was only 2 miles, and the distance to the other lowest point on the Continental Divide ahead was appx 3 miles, it would have been impossible for the aircraft to clear the terrain ahead.

Concerning the aircraft's ability to execute a reversal turn, at 140 kts IAS a 60 deg bank will produce a turn radius of 1,490'. However, in a 60 deg bank, even at max continuous power, altitude would be lost at a rate of about 340 fpm.

At 130kts, the turn radius in a 60 deg bank would be 1,300'. However, this would require the aircraft to be operated constantly at only 2 kts above stall speed, and well into the stall buffet range. Entry into the stall buffet boundary would result in an increase in the rate of sink because of the drag induced by flow separation.

Even if the pilot had possessed sufficient skill to operate the aircraft within such extremely small tolerances, there would not have been sufficient space available to execute the turn. The Board concludes that once the aircraft had reached the Dry Gulch area, it was no longer possible to have executed a course reversal. If the crew had been concerned about the aircraft's ability to clear the terrain ahead less than 1 minute sooner, when the aircraft was still 1-1/2 to 2 miles east of Dry Gulch, a successful turnaround could have been executed with use of maximum continuous power and a bank angle of only 30 deg. However, at that point on the flightpath, the crew would have been unable to see that the valley ended at Loveland Pass, and thus they proceeded into an area from which an escape was not possible.

Any decision that was to be made, had to be made immediately. It is likely, therefore, that this is what induced Capt. Crocker to take over the controls. The steep left bank was then necessary to avoid the mountain. In the process, the aircraft was stalled, resulting in a loss of altitude, and contact with the trees.

Finally, with regard to the problem in this accident concerning the identification of the operator who had the responsibility for compliance with the regulations applicable to the flight, it is obvious that there was classic disagreement among the parties involved in the flight. As previously stated in this report, it was the position of the FAA that Golden Eagle Aviation, Inc., was the operator. Both Jack Richards Aircraft Company and Golden Eagle Aviation, Inc., contend that WSU was the operator. It is the position of WSU that they were not the operator but had been merely chartering air service. For present purposes, it is sufficient to conclude from the post accident denial of the parties that they were the operator with the responsibility for the safe conduct of this flight, that they did not acknowledge such responsibility at the time of the flight.

It is the view of the Board that the numerous deficiencies, unsafe practices, and deviations from regulations, involved in this operation, are typical of operations where none of the participants acknowledge responsibility for the safe conduct of a flight. As this Board stated in a prior accident report, "It is not unusual that such operations are characterized by safety problems such as those found to be present in this operation." (Ref- Aircraft Accident Report- Douglas DC-3, N142D New Orleans Louisiana, March 20, 1969) The Board believes that the management required for a safe operation appears to have been absent and was a significant factor in this accident.

[NTSB AAR-71-4, Excerpts]

The aircraft was 5,190 lb over the max. permissible takeoff weight at Denver, and 2,665 lb over the max. certificated takeoff weight at impact.

The original flight plan was altered to provide a "scenic route" for sightseeing purposes.

The aircraft was operated over Clear Creek Valley at an altitude always below the mountaintops.

After the flight reached the Dry Gulch area, it was no longer possible for the aircraft either to climb over the terrain ahead, or to execute a course reversal.

None of the participants in this flight, the owner of the aircraft, lessee, or the company providing the crew and other services acknowledged that they were the operator and accepted responsibility for the safety of such flight.

Cause

[NTSB AAR-71-4, Excerpts] The Board determines that the probable cause of this accident was the intentional operation of the aircraft over a mountain valley route at an altitude from which the aircraft could neither climb over the obstructing terrain ahead, nor execute a successful course reversal. Significant factors were the overloaded condition of the aircraft, the virtual absence of flight planning for the chosen route of flight from Denver to Logan, a lack of understanding on the part of the crew of the performance capabilities and limitations of the aircraft, and the lack of operational management to monitor and appropriately control the actions of the flightcrew.

Application

"The Beav" sez:

Clearly Golden Eagle Aviation President Ronald Skipper desired to offer his customers a unique and memorable flight. The tragedy is that this desire led him to cut corners and take foolish risks. His decisions placed the lives of each person aboard at risk and ultimately led to the deaths of 31.

His willingness to takeoff overweight is reflective of the way he must have ran his whole operation. What kind of safety culture can you have with this sort of example from the top?

Sadly, even following the accident, Mr. Skipper didn’t learn the lesson: “I feel I did everything that I could have done in the situation. I feel badly that it happened, of course. I feel badly that we were even flying the team that day. But I don’t feel badly about anything I did.” – Ronald Skipper

He may not have learned the lesson, be we certainly can.

So, how about your operation? What is the culture of your flight department? Ever takeoff exceeding the departure obstacle analysis maximum weight? Ever continue to operate despite mechanical issues or discrepancies that you know full well ground the aircraft? The list could continue, but the lesson is to face reality and recognize the warning flags within your operation. What areas have normalization of deviance crept in? Identify it, confront it, fix it. Be a professional. Be unwilling to compromise what you know is legal and right.

Eddie Sez:

I take away one more lesson from this accident: When boss in on board, there is really only one pilot in command. I witnessed this first in my Air Force Boeing 707 and 747 squadrons where the commander was typically an instructor pilot and would often fly as the "copilot" to a newly upgraded aircraft commander. They would play the game of allowing newly upgraded "captains" the freedom to make decisions, but if those decisions differed from theirs, well, it wasn't good. Now leading my third flight department, I realize this also holds true in the civilian world.

Whenever I play the role of copilot, I am mindful of two things. First, captains can't be effective captains if they are worried about their decisions being overruled by the copilot who signs their paychecks. So I try not to do that. Second, if I feel so strongly about an upcoming decision that I am willing to overrule the captain, I need to make sure I make my feelings as the "copilot" known before that happens. It is a balancing game. You want the young captain to gain the needed experience without risking a demoralizing confrontation. Sometimes there is more to be learned from a mistake that doesn't jeopardize safety, than there is from a public rebuke from the boss. You may not have intended that, but a politely phrased suggestion from the boss can be received as a stern tongue lashing. Be mindful of how your words are received.