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

Eddie Sez:

The captain's reputation preceded him and the rest of the crew was ready to defer to his experience. When they had a severe vibration during initial climb out caused by an unsecured door, the captain attempted to analyze the situation while flying the airplane. He gave his crew specific tasks and they were happy to accomplish these tasks while giving up the task of keeping the airplane flying and analyzing the situation to the captain. The captain was characterized by many as very good but the evidence indicates he wasn't much of standard operating procedures. Had he or the crew followed SOPs in any one of the following areas, the accident could have been avoided:

  • The captain directed a reduction in power very low to the ground but SOPs would have had him wait until a safe altitude and airspeed. That would have also given him and the crew more time to consider the problem.

  • The captain's direction to reduce power on all four engines would have been better carried out one engine at a time if the vibration was indeed caused by an engine or propeller problem.

  • The captain's rushed actions forced the rest of the cockpit crew into simply responding to his requests and made it easy for them to cede to him their responsibilities.

  • The first officer should have prioritized backing monitoring flight condition over talking on the radio.

What follows are quotes from the relevant regulatory documents, listed below, as well as my comments in blue.


Accident Report


Narrative

[NTSB AAR-86/01, ¶1.1.]


Analysis

[NTSB AAR-86/01, ¶1.5.1]

[NTSB AAR-86/01, ¶1.16.2]

[NTSB AAR-86/01, ¶2.2]


Findings

[NTSB AAR-86/01, ¶3.1]


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

Procedures & Techniques / Crew Resource Management

Procedures & Techniques / Situational Awareness


References

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