SA-426 Fi l e No.

1-0005
AIRCRAFT ACCIDENT REPORT
HUGHES AI R WEST DC-9, N9345
AND U.S. MARINE CORPS F-4B, 151458
NEAR DUARTE, CALIFORNIA
JUNE 6, 1971
ADOPTED: AUGUST 30, 1972
NATIONAL TRANSPORTATION SAFETY BOARD
Washi ngt on, D. C. 20591
REPORT NUMBER: WTSB-AAR-72-26 I
TECHNICAL REPORT STANDARD TI TLE PAGE
. ReDOrt No. 1 2.Government Accessi on No. I ? . Rec i p i en t ' s Cat al o g NO.
I
.. T i t l e and Su b t i t l e
iughes Air West DC-9, N9345, and U. S. Marine Corps
Sept ember 22, 1972
LkB, 151458, near Duarte, California, J une 6, 1971 6. Per f or mi ng Or g an i zat i o n
Code
1 . Aut hor (s ) 8. Per f or mi ng Or g an i zat i o n
Repor t No.
NTSB-AAR-72-26
5. Repor t Dat e
Bureau of Aviation Safety I l . Co n t r ac t o r Gr ant No.
National Transportation Safety Board
Washington, D. C. 20591 13.Type of Repor t and
Per i o d Cover ed
12.Sponsor i ng Agency Name and Address
Ai rcraft Accident Report
J une 6, 1971
NATIONAL TRANSPORTATION SAFETY BOARD
Washi ngt on, 0. C. 20591
H
1 .Sponsor i ng Agency Code
I
15.Suppl ement ar y Not es
Th i s r ep o r t c ont ai ns new Av i at i o n Saf et y Recomnendat i ons A-72-200 t h r u 204.
16. Abs t r ac t
A Hughes Air West E- 9, N9345, and a U. S. Marine Corps F-4B, 151458, collided
i n fl i ght near Duarte, California, at approximately 1811 P.d.t., J une 6, 1971. A l l
49 occupants aboard the E - 9 and the pi l ot of the F-4B were f atal l y injured. The
radar intercept offi cer, the only other occupant of the F-4B, ejected safel y af ter
the col l i si on. The E- 9 was climbing to Flight Level 330 under radar control of the
Los Angeles A i r Route Traffi c Control Center, and the F-4B was en route to MCAS
E l Toro at approximately 15,500 feet, i n accordance with Visual Flight Rules. The
the time of the accident, was good, and there were no clouds between the two ai rcraf t.
col l i si on occurred at approximately 15,150 feet. The vi si bi l i ty i n the
area,
at
thi s accident was the fai l ure of both crews to see and avoid each other but recognizes
that they had only marginal capabi l i ty to detect, assess, and avoid the col l i si on.
Other factors involved included, a very high closure rate, comingling of IFR and VFR
traf f i c i n an area where the l i mi tati on of ATC system precludes effecti ve separation
and parti cul arl y considering
the fact that they had an inoperable transponder.
of such traf f i c, and fai l ure of the crew of
m0458
to request radar advisory servi ce
The National Transportation Safety Board determines that the probable cause of
There are four new recommendations.
17.Key Words
Midair col l i si on, Scheduled air carri er (IFR)
Military ai rcraft (VFR), Byl i ght
19. Sec u r l t y Cl as s i f i c at i o n 2O. Sec ur i t y Cl a s s i f i c a t i o n
(of t h i s r ep o r t ) (of t h i s page)
UNCLASSIFIED UNCLASSIFIED
NTSB Form 1765.2 (11/70) ii
I
Released to public
Unlimited di stri buti on
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1.
1.1
1.2
1.3
1.4
1.5
1.6
1.8
1.7
1.9
1.10
1.11
1.12
1.14
1.13
1.15
1.16
2.
2.1
2.2
3.
TABLE OF CONTENTS
Synopsis . . . - . . - . - . - . . 1
I nvesti gati on . - . . . - . - - . 3
Hi story of the Fl i ght . . . . . - I . 3
I nj uri es to Persons - . . . - . . . 6
Other Damage
Damage to Ai rcraf t 6
. . . - - . - - . - . 6
Ai rcraf t I nformati on - . - . . . . 6
Crew I nformati on - . . . . . . . . 6
Meteorol ogi cal I nformati on . . - . . 6
Aids to Navigation . . - . - - . - . 7
Aerodrome and Ground Facilities . . .) 8
Communications . . . . . - . . . . . 8
Fl i ght Recorders - - . . . . . . . 8
Wreckage
Fire I . . . *. . - - - . 10
I . . . . - ..... 9
Survi val Aspects . - . . . - - . 10
Other
Tests and Research . - - . . - - . 11
-...-.. . . - . . 14
Anal ysi s and Conclusions . . . - . 14
Anal ysi s
Conclusions
. . *- . . )- .... 14
(a) Fi ndi ngs - . . . . . . - . . 25
. . . - . . - . - . . 25
Recommendations . . . - . . . - . . . 27
(b) Probable Cause - - . - . - 27
Footnotes . . - - . . . . . . . 32
Appendices
Appendix A * . . . ) _ I . . . . .) 34
Appendix B
Appendix C
. . . *. . - *- . . 35
. - . . . . - - a m . 37
Attachment 1 - Col l i si on Area
Attachment 2 - Computed Ranges, Bearings
Attachment 3 - Vi si bi l i ty Chart DC-9
Attachment 4 - Vi si bi l i ty Chart P-UB
Attachments
and Closure Rates
SA-426 Fi l e No. 1-0005
NATIONAL TRANSPORTATION SAFETY BOARL
WASHINGTON. D. C. 20591
AIRCRAFT ACCIDENT SEWRT
SYNOPSIS
A Hughes A i r west DC-9, N9395, and a U. S. Marine Corps
F-4B, Bureau No. 151458. collided i n f l i ght near Duarte,
Cal i forni a, at approximately 1811 P.d.t.. June 6. 1971. A l l
DC-9, and the
pi l ot of the
F-4E were f atal l y i nj ured. The
49 occupants,
44 passengers
and fi ve crewmembers, aboard the
radar i ntercept officer, the onl y other occupant i n the F-
4B, ej ected fzom the aircraft after the col l i si on and
parachuted to the ground. He was not i nj ured. Both
ai rcraf t were destroyed by the col l i si on. ground impact, and
fire.
Los Angeles A i r Route Traffic Control Center. cl i mbi ng to
The Hughes A i r west DC-9 was under radar control of the
Fl i qht Level 330. The F-4B was being fl own at approximately
route to the Marine Corps A i r Stati on, E l Toro, California.
15.500 feet. i n accordance wi th Vi sual El i ght Rules, en
The col l i si on occurred at an al ti tude of approximately
15,150 feet.
The vi si bi l i ty i n the area. at the time of the acci dent,
was good and there were no clouds between the two aircraft
duri ng the f i nal minutes of f l i ght.
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the probable cause of this acci dent bas the f ai l ure of both
The Nati onal Transportati on safety Board determi nes that
crews t o see and avoid each other but recogni zes that they
had onl y marginal capability to detect. assess, and avoi d
the col l i si on, Other causal f actors i ncl ude a very hiqh
cl osure rate, comingling of I FR and VFR traffi c i n an area
where t he, l i mi tati on of the ATC system precl udes ef f ecti ve
BuNo458 to request radar advi sory servi ce. parti cul arl y
separati on of such traffic, and f ai l ure of the crew of
transponder.
consi deri ng the f act that they had an i noperabl e
that the Federal Avi ati on Admi ni strati on: (1) i nstal l vi deo
A s a resul t of thi s acci dent the Safety Board recommends
tape on al l radar di spl ays and "areall microphones i n ai r
traffi c control facilities; (2) provi de posi ti ve control
ai rspace from takeoff to l andi ng f or al l IFR traf f i c; and
(3) i nsure that al l radar f aci l i ti es are capable of
the handling of such traf f i c.
recei vi ng Code 7700, and establ i sh def i ni ti ve procedures for
Avi ati on Admi ni strati on and the Department of Defense
The Safety Board al so recommended that the Federal
cooperati vel y develop a program to inform al l airspace users
of the heavi est traffi c areas. I n addi ti on, it was
recommended that the Department of Defense: (1) restrict
hiqh-speed, low-level operati ons t o desi gnated areas and
routes; (2) del i neate expl i ci t ci rcumstances where the
10,000 feet/250 knots l i mi tati on may be exceeded; (3)
consi der usi nq air i ntercept radar f or col l i si on avoidance
Radar Advisory Servi ce and consi der making the use of thi s
purposes; and (4) publ i ci ze the avai l abi l i ty of the FAA
servi ce mandatory.
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1. INVESTIGATION
1.1 Hi storv of the Fl i sht
Hughes A i r west Fl i ght 706 (RW706) was a regul arl y
Washington, with i ntermedi ate stops at Sal t Lake Ci ty, Utah,
scheduled f l i ght from Los Angeles, Cal i forni a, to Seattle,
Boise and Lewiston, Idaho, and Pasco and Yakima, Washington.
The f l i ght departed Los Angeles I nternati onal Ai rport at
Departure Control, contacted the Los Angeles A i r Route
1802 I/ and. following radar vectors from Los Angeles
Traffi c Control Center (ARTCC) at 1806. I n accordance with
a request, the f l i ght reported l eavi ng 12,000 f eet at 1809,
and the control l er advised, "Ai r West seven zero si x red,
turn l eft heading zero four zero unti l recei vi ng Daggett
proceed direct.ll RW706 acknowledged. 'OK, zero four zero
direct to Daggett." This was the l ast recorded transmi ssi on
from the fl i ght.
departed the Marine Corps A i r Stati on (MCAS) E l Toro,
Cal i forni a, on J une 4. 1971, as part of a f l i ght of two
aircraft. The f l i ght was scheduled for an overni ght cross-
return, McClellan AFB, Cal i forni a, was to be used f or
country
to McChord A i r Force Base (AFB), Washington, and
refuel i ng northbound, and Mountain Home AFB. I daho, was to
be used southbound. Although the transponders on both
ai rcraf t apparentl y fai l ed shortl y af ter departure from MCAS
E l Toro, the f l i qht of two was permitted to proceed to
J une 5. the
f l i ght
continued to Mountain Home AFB, but the
McChord AFB under control of the ATC System t y radar. On
radi o i n BuNo458 f ai l ed duri ng the l andi ng approach. A f t er
landing, the crews discussed the operati onal status of the
two aircraft, and the f l i ght leader decided that he would
proceed to MCAS E l Toro. The wingman and hi s Radar
I ntercept Officer (RI O) were i nstructed to awai t repai rs to
EuNo458 and then return to MCAS E l Toro. The mechanical
di f f i cul ti es wi th the aircraft at t hi s time included:
The U. S. Marine Corps F-4B. Bureau NO. 151458 (BuN0458)
1. I noperati ve transponder
2. I noperati ve radio
3. Oxygen system leak
4. Degraded radar system
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Maintenance personnel at Mountain nome APB reGIaced a fuse
check the transponder. They confirmed the oxygen leak, but
to f i x the radio, but they di d not have the personnel to
could not repair it. No attempt was made t o restore the
radar t o peak performance at that time.
The crew of BuNo458 fi l ed a Visual Fl i ght Hules (VFR)
Nevada, below the Area Posi ti ve Control (APC), 2/ because of
f l i ght pl an to Naval Auxi l i ary A i r Stati on (NAAS) Fallon.
the i noperati ve transponder and f uel requirements. On thi s
was turned off shortl y af ter takeoff from Mountain Home AFB.
l eg of the f l i ght the oxygen l eak increased, and the oxygen
The maintenance personnel on duty at NAAS Fal l on were unable
to provide the appropri ate repairs, so the pi l ot contacted
hi s squadron duty officer for i nstructi ons. Be was advised
to proceed to MCAS E l Toro at low al ti tude.
After refuel i ng, the crew agai n f i l ed a VFR f l i ght pl an
below APC. The takeoff was delayed from 1400 to 1716
because MCAS E l Tor0 was cl osed f or an airshow between 1400
and 1630. The intended route of f l i ght was direct Fresno,
5-65 Bakersfi el d, J-5 Los Angeles, direct MCAS E l Toro. The
f l i qht departed at 1716. climbed i ni ti al l y t o 1, 500 feet,
and then climbed to 15.500 feet to clear mountains and some
clouds approximately 50 miles from NAAS Fallon. After
crossi ng the mountains, they descended to 5,500 f eet and
remained at that al ti tude unti l they reached Bakersfield.
Approximately 15 miles north of the Bakersfi el d Fl i ght
Servi ce Stati on a posi ti on report was made, and the MCAS E l
Tor0 weather was checked. The crew also decided to devi ate
from the ori gi nal pl an at thi s point. They flew east of the
heavy traf f i c over Los Angeles.
planned course,
over Palmdale, to avoid the anticipated
The f l i qht continued i n a low profi l e, minimum al ti tude
northwest of Palmdale. Due to deteri orati ng vi si bi l i ty,
1,000 feet above the ground, until approximately 15 miles
they agai n climbed to 15,500 feet. The RI O stated that the
climb was made, using maximum engine power, without
afterburner, and took less than 2 minutes. Shortl y af ter
l evel -off, the Distance Measuring Equipment (LIME) f eature of
the VORTAC J/ i ndi cated 50 miles to MCAS E l Torc. The pi l ot
executed a 3600 ai l eron rol l at thi s time, which took
approximately 3 seconds to complete. The RI O esti mated that
knots, and that the col l i si on occurred appzoximately 1
the true ai rspeed i n the climb and after l evel -off was 420
minute and 20 seconds af ter the rol l . During most of thi s
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period, he was operati ng the radar i n the mapping mode, but,
due to the extremely degraded ai r-to-ai r detecti on
capabi l i ty, no ai rborne targets were seen. Si nce the
radarscope was i n the stowed posi ti on, the RI O was l eani ng
forward, and hi s l i ne of si ght was directed downward at
Approximately
3 t o 10 seconds pri or t o col l i si on. the RI O
approximately
a 450 angl e whi l e usi ng the radarscope.
raised hi s head, observed the DC-9 i n hi s peripheral vi si on
approximately 500 to the ri ght and sl i ghtl y beneath hi s
ai rcraf t. He shouted t o the pi l ot, but the pi l ot had
i ni ti ated an evasi ve rol l before the RI O fi ni shed the
warninq. H e di d not see RW706 take any evasi ve acti on.
After takeoff from Los Angeles, RW706 was qi ven two
radar traf f i c advi sori es hy departure control , and control
Angeles ARTCC. The data and radar posi ti ons of this sector
was subsequentl y transf erred to the R-18 sector of Los
were manned by developmental control l ers 2/, each of whom
was hei nq supervi sed by a journeyman control l er.
Consequently, four i ndi vi dual s were observi ng the radarscope
at the R-18 posi ti on pri or to the col l i si on. They al l
agreed that no primary tarqets were observed i n proximity to
RW706 at any time. Fi ve traf f i c advi sori es were gi ven t o
other ai rcraf t i n the R-18 sector i n the 6-minute timespan
pri or t o the col l i si on.
about the l ateral axi s. The RI O wai ted about 5
seconds,
After the col l i si on, BuNo458
began
to tumble
vi ol entl y
and, af ter seei ng numerous warning l i qhts i n the cockpit, he
ejected from the ai rcraf t. The ej ecti on was successful , and
he parachuted to the ground wi thout i nj ury.
Witnesses i n the area of the acci dent gave wi del y
varyinq accounts of the col l i si on. Thi rty-four wi tnesses
persons observed the two ai rcraf t on converging courses.
saw or heard jet ai rcraf t prior t o the col l i si on, and 24
I
Fi fteen persons saw a fi ghter aircraft i n a rol l i ng or
evasi ve maneuver pri or t o col l i si on. Three persons on the
ground and two pi l ots, at varyi ng distances from the
proceeding
al ong the route of f l i ght described by the RI O.
immediate col l i si on
area,
observed a f i ghter ai rcraf t
(See Attachment 1.) Several wi tnesses i n the area of the
col l i si on reported seei ng a f i ghter ai rcraf t doing rol l s and
ci rcl i ng i n the area.
I
1 . 2 I nj uri es to Persons
I nj uri es C r ew Fassenqers Others
Fatal CC-9 5
F-4B 1
Nonfatal DC-9 0
F-4B 0
None DC-9 0
F-4B 1
44 0
0 0
0 0
0 0
0
0
1.3 Damaqe to ai rcraf t
Both ai rcraf t were destroyed by the col l i si on, ground
impact, and subsequent f i re.
1.4 Other Damaqe
al l ground damage was restricted t o underbrush which was
Both aircraft crashed i n a remote mountaincus area, and
burned i n the ground f i re.
1.5 Crew I nformati on
respecti ve fl i ghts. (See ApFendix E for details.)
1.6 Ai rcraf t I nformation
The crews of both ai rcraf t were qual i f i ed f or the
The Dc-9 was Froperl y certi f i cated and both aircraft
had been maintained i n accordance wi th exi sti ng regul ati ons.
The wei ght and center of gravi ty of each were wi thi n
prescribed limits. The DC-9 was servi ced wi th J et A f uel
and the I - 4B wi th J P-5 fuel . (See Appendix C f or details.)
1.7 Meteorol oqi cal I nformatkn
The weather i n the vi ci ni ty of the acci dent site was
characteri zed by low-level haze and smoke, scattered l ow
was no f rontal weather i n the area.
cl ouds and high, thi n, broken or scattered clouds. There
i ssued by the Nati onal Weather Servi ce at LQS Angeles was i n
The perti nent porti on of the avi ati on area f orecast
part, as follows:
Scattered, vari abl e t o broken cl ouds at 23,000 f eet,
vi si bi l i ty 3 i o 6 miles, haze and smoke. coastal
I
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stratus i ncreasi ng and moving onto immediate coast 1900
to 2100 then spreadi ng i nl and about 20 miles by
midnight wi th hi gher coastal terrai n occasi onal l y
obscured.
shallow l ayer of rel ati vel y moist unstabl e ai r near the
The Vandenberg AFB 1700 radi osonde ascent showed a
surface to the base of an 80 C., i nversi on near 1,000 feet
wi th the top near 4,000 feet. The associ ated winds al oft
observati on was, i n part, as follows:
J j j Direction Ptrue) Vel oci tv tknotsl
Surf ace
1.000
3,000
6,000
12,000
9.000
15.000
265
340
260
020
110
060
020
5
5
5
7
16
9
19
Of f i ci al sunset at Los Angeles was at 2002.
1.8 A i ds to Naviqation
The Los Angeles ARTCC uses three ARSR-1E l adar systems
range of approximately 150 miles. and is disFlayed at the
f or the control of traffic. Each of these systems has a
with a 21-inch cathode ray tube. The antennae f or the ARSR-
control posi ti ons on an RBDE-5 hori zontal scan converter
1E systems rotate at 5 r-p.m. Addi ti onal l y, each sector has
a verti cal di spl ay which i s used as a backup system, and an
ai d i n recei vi ng radar handoffs. The verti cal di spl ay is
al so an RBDE-5 scan converter.
The R-18 sector control l er at the time of the acci dent
was monitoring the San Pedro ARSR-1E system on the
hori zontal di spl ay. Thi s is a j oi nt-use system wi th the
military. The antenna is located near l ong Beach.
Cal i forni a. The control s were adj usted to the 55-mile
range. wi th 5-mile range marks. The di sFl ay was off-
moving target i ndi cator (MTI) S/ was set at l evel 4, and the
centered approximately 40 miles to the southwest. The
staggered pul se repeti ti on frequency (PRF) ci rcui t was
operating.4/
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the RBDE-5 sector verti cal di spl ay. The ASR-4 antenna is
The R-18 control l er had the ASR-4 System sel ected on
l ocated at LOB Angeles I nternati onal A i r por t , and has a
range of approximately 50 miles. The rate of antenna
rotation is 12.75 r.p.m.
The R-36 sector control l er was monitoring the Boron
ARSR-1E radar system on the hori zontal scan converter at the
vi ci ni ty of Edwards AFB. Cal i forni a. The contrcller had the
time of the accident. The Boron antenna is l ocated i n the
had radar-i denti fi ed RW706 and was wai ti ng for them to cal l
San Pedro radar system on the sector verti cal di spl ay. ne
transponder Code 7700 z/ appear on hi s hori zontal di spl ay
pri or to assuming control responsi bi l i ty. Ee observed a
apFroximately 5 miles northwest of the marker for RW706. ne
also heard an emergency beacon si gnal on the VBF Guard
Channel B/ which he was monitoring. H e di d not see the Code
7700 on the verti cal di spl ay. The Code 1700 target appeared
The code 7700 then moved i n a wide. counterclockwise.
about two sweeps before the target of RW106 disappeared.
circular path, first toward the south-southeast and then
toward the northeast. It disappeared i n the vi ci ni ty of
observed. Statements from other control l ers i n the center
Norton AFB, approximately 10 mi nutes after i t was first
confirmed that the Code 7700 was recei ved on the Boron and
Mt. Laguna radar systems, but not on the San Eedro system.
Code 1700 but was unsuccessful. NO expl anati on has been
The Safety Board attempted to i denti f y the source of the
Code 7700.
found for the f ai l ure of the San Pedro system t o receive the
1.9 communications
between ei ther RW706 or BuNo450 and the respecti ve ground
There were no reported di f f i cul ti es wi th communications
facilities contacted by each.
1.10 Aerodrome and Ground Faci l i ti es
Not appl i cabl e.
1.11 Fl i sht Recorders
f l i ght data recorder. Model EA-542, Serial No. 1810. The
RW706 was equipped wi th a Sundstrand Eata Control
outer case sustai ned extreme external heat and f i r e damage.
but onl y minor mechanical damaqe. The metal f oi l was
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resi due requi red extensi ve cl eani ng to expose the recorded
i ntact, but deposits of soot. molten metal. and other
traces were f ai nt and di f f i cul t to i denti f y i n certai n areas
parameters. A l l parameters were functi oni ng; however, the
af ter the cl eani ng process. The total el apsed time of
recordi ng was 8 minutes 55 seconds. Based on al ti tude
information prior to departure from Los Angeles, the
recorder was recordi ng al ti tude 51 f eet low. The recorded
val ues at time 8 minutes 54.6 seconds were + 0.749. 0410.
327 knots. and 15.125 feet. During the following 0.6-second
time period. the verti cal accel erati on trace moved to + 5-09
at 8 minutes 55.2 seconds and i nstantaneousl y t o -1.89. The
l ast recorded parameter val ues pri or to electrical power
l oss at 8 minutes 55.2 seconds were -1.89. 0410. 327 knots,
and 15.150 feet.
voice recorder. Model V-557. serial number unknown. The
RW706 al so was equipped wi th a United Control cockpi t
f i re damage consumed the dust cover. and al l thermal-
protecti ve water and glycol had been expended. There was no
deformation of the stai nl ess steel magazine, hut onl y i ron
oxide dust was found i n the tape storage compartment. A s a
resul t. no data were avai l abl e.
BuNo458 was not equipped wi th any f l i ght recorders and
none were requi red.
1.12 Wreckaae
over approximately 2
square
miles. The DC-9 crashed i n a
The main wreckage of the two ai rcraf t was scattered
canyon wi th approximately 600 slopes. Structure from
Fuselage Stati on (FS) 427 aft, i ncl udi ng wings and empennage
was located i n thi s area. One piece of P-4E af t fusel age
of the F-4E had become entangl ed i n electrical wi ri ng which
structure was also found at the DC-9 crash site. Thi s piece
was i nstal l ed between PS318 and FS1099 of the DC-9.
canyon approximately three quarters of a mile southeast of
The F-4B main wreckage si te was l ocated i n another
the DC-9. The onl y major structure not i denti f i ed at thi s
top. af t, fusel age structure and the empennage.
site i ncl uded most of the ri ght outer wing, the centerl i ne.
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removed, and a ful l -scal e three-dimens.iona1 mockup of thi s
Wreckage porti ons
of the DC-9 forward fusel age were
secti on was made. A si l houette of the F-4B was then
constructed wi th lumber. Thi s si l houette was pl aced i n
vari ous posi ti ons and attitudes to attempt t o match the two
di sti nct damage paths through the DC-9. One path was l ong
and narrow, ori ented at an angl e of 300 to the CC-9 fusel age
reference plane, and passed through the fusel age i n the area
below the main passenger l oadi ng door and f i r st 10 windows.
The other path was rectangul ar and passed through the
forward, lower, cockpit area. When the F-4B verti cal
stabi l i zer was posi ti oned at approximately FSllO (the
fusel age area beneath the windscreen) on the left si de of
the X- 9 the ri ght wing was i n the damage area under the
cabi n door and windows. Both damage paths were on a
descending angl e of approximately 200 through the DC-9.
However, both damage swaths were l arqer than the F-4B
either di recti on. It i s not known whether the downward
structure, and' thi s angl e coul d vary as much as 100 i n
rel ati ve f l i ghtpaths of the two aircraft or the progressi ve
traj ectory of the two swaths resul ted pri mari l y from the
di si ntegrati on of the F-4B structure as it passed through
the OC-9.
1.13
however, the F-OB caught fi re fol l owi ng the col l i si on.
No evidence of i n-f l i ght fi re was found on the DC-9:
There was a severe ground f i r e at each of the main crash
ai r traf f i c control uni t, and approximately 72 of f i cers and
sites. A total of seven fi re trucks, two hel i copters, one
men responded t o the f i r e alarm.
1.14 Survi val ASDeCtS
the X-9.
Thi s was a nonsurvi vabl e acci dent for the occupants of
of the F-4B. The RIO
successful l y ejected
and he was
The midair col l i si on was survi vabl e for the
occupants
subsequentl y rescued uni nj ured. The pi l ot was not able to
eject and the F-4B col l i si on wi th the ground was non-
survi vabl e.
BuNo458 was equipped wi th a Martin-Baker H7 rocket
ej ecti on seat i n each cockpit. Thi s seat was not designed
to be fi red through the canopy, and i ncorporated a canopy
r-
L
- 11 -
i nterrupter block i n the actuati on l i nkage t o Frevent such
an occurrence.
The f ront seat face curtai n. the primary means of f i ri ng
the seat. was not recovered. The al ternate f i ri ng handle
had been actuated. Di storti on of the actuati on l i nkage
i ndi cated that the canopy i nterrupter block prevented
f urther movement of the mechanism and subsequent ej ecti on of
the pi l ot.
I n addi ti on to the canopy unlock system provided i n the
ej ecti on sequence, two manually operated systems are
unlock the canopy. cases have been reported wherein the
provided. However, regardless of which method is used t o
f ront canopy f ai l ed t o j etti son when the af t canopy was
j etti soned first.
j etti son
mechanism was i nsti tuted t o i ncorporate ballistic
As a resul t of these Occurrences a change i n the canopy
canopy thrusters t o assure that the canopy would separate
from the ai rcraf t. Thi s modi fi cati on had not been i nstal l ed
i n BuNo458. Thi s change was being i ncorporated i n al l F-4B
at MCAS E l Tor0 was scheduled to begi n i n J ul y 1971.
ai rcraf t on a fleetwide basis. and modi fi cati on of ai rcraft
1.15 Tests and Research
A radar f l i ght check of the San Pedro radar was
maintenance had been performed on the system between the
conducted on J une 8. 1971. usi ng an F-4B. Routine scheduled
time of the acci dent and the f l i ght check. The RI O had not
been formal l y i ntervi ewed by Safety Board i nvesti gators at
that time. Consequently. the f l i ght track was onl y an
was capable of tracki ng the primary target of the F-4B above
approximation of the presumed track. The San Eedro system
never seen the radar perform so well.
1.500 feet. Several control l ers commented that they had
The Safety Board coordi nated w i t h the Federal Avi ati on
Administration (FAA) and the U. S. Marine Corps t o conduct
another f l i ght check of the San Pedro radar on J une 16,
1971. The track of BuNo458 described by the RI O was
dupl i cated as cl osel y as possible on three runs. wi th some
vari ati ons i n the al ti tude on one run. Three addi ti onal
runs were conducted i n the general area the f l i ght
traversed. but wi th f l i ght track and al ti tude vari ati ons as
suggested by the wi tness group. The radarscope, channel,
- 12 -
and control setti ngs were the same as at the time of the
acci dent, except that the secondary target was of f set so
that it would not i nterf ere wi th tracki ng the E-UB primary
target. Tracking conti nui ty was poor and the primary target
was vi si bl e less than 50 percent of the time. The secondary
target di d provi de assi stance i n fol l owi ng the aircraft
movement duri ng voi ds i n the primary target coverage.
Photographs of the test runs. as di spl ayed on a maintenance
monitor, were taken on vi rtual l y every sweep of the antenna.
These photographs were studi ed by the ai r traffic control
group. The examination corroborated the i ni ti al reacti on t o
demonstrated that the primary target alone was not of
the tracki ng qual i ty
of the F-4B target. but it al so
suf f i ci ent strength t o assure noti ce by a control l er who was
unaware of the ai rcraf t
presence.
The F-4B i n each test was not confi gured the same as
BuNo458 at the time of the acci dent. The f i r st test F-4B
was i n a cl ean confi gurati on, and the second F-4B test
aircraft was equipped wi t h two l arge wing tanks. A baggage
tank was i nstal l ed on the fusel age centerl i ne of BuNo458.
Consequently. BuNo458 represented a larger ref l ecti ve cross-
secti on f or radar detecti on than the first test ai rcraf t.
val i di ty
of the f l i ght checks also was compromised by such
and less ref l ecti ve surface than the second ai rcraf t. The
vari abl es as meteorol ogi cal phenomena and deteri orati on i n
operati ng parts of the radar OX improved performance due t o
replacement of f ai l ed parts.
A vi si bi l i ty study was conducted t o determine the
physi cal l i mi tati ons t o vi si on from the cockpi t of each
aircraft. A f l i ghtpath f or each ai rcraf t was reconstructed.
rates for the l ast 40 seconds also was reconstructed.
(See
(See
Attachment
1.)
The col l i si on
geometry and
closure
Attachment 2. ) The f l i ghtpath of RW706 was based on the
f l i ght recorder data. and the F-4B f l i ghtpath was predi cated
on the statement of the RI O. A dual l ens camera was used t o
record a panoramic view from the desi gn eye-reference poi nt
These bi nocul ar photograFhs show the posi ti on of each air-
at each creumember@s stati on. (See Attachments 3 and 4.)
hi s fi xed-eye-reference poi nt. Natural l y. any movement from
craf t i n the fi el d of vi si on of each crewmembex. based on
thi s posi ti on would af f ect the l ocati on of the other
aircraft i n hi s fi el d of vi si on.
he
so
rY
st
CY
Ft
:e
I 1
?.
I.
:0
:0
'f
0
s
B
t
e
-
I
?
1
I
I
!
1
I -
- 13 -
Douglas Corporation provided i nformati on concerning rol l and
I n the course of thi s i nvesti gati on, the McDonnell-
pi tch rates for the F-4B ai rcraf t. The fol l owi ng has been
extracted from the suppl i ed data:
Ful l Sti ck 112 1/4
subj ect Throw Stick Throv Stick Throw
What would be the maxi-
mum rate of steady nose-
darn pi tch? -10 deq./sec. -4 deg./sec. -2. 5 deg./sec.
Concerning the nose-
down pi tch rate, what
would be the time
interval requi red from
to ;
the first control i nput
(a) Achieve i ni ti al air-
craf t movement?
(h) Achieve the maximum
0. 10 sec.
steady nosedown
pi tch rate 7.0 sec.
How many degrees nose-
down would have been
achieved at the poi nt
that the maximum pi tch
rate had been attai ned 15.0 deg.
Al ti tude l ost and ai r-
speed at 200 nosedown
pitch: a) al t. loss 16 ft.
b) KTAS 420
Al ti tude l oss and ai rspeed a 200
nosedown f l i ghtpath angle:
0. 10 sec. 0. 10 sec.
6. 5 sec. 6. 0 sec.
9.0 deg. 5. 0 deg.
210 f t. 590 ft.
4 26 436
a) alt. l oss
b) XTAS 424 430 437
180 f t. 385 f t. 620 ft.
I n addi ti on to the dove, the data i ndi cated that a
bank of 300 coul d he achieved i n as l i ttl e time as 0.75
the maneuver, the time t o achi eve a gi ven bankl pi tch
second. If rol l -and-pi tch control i nputs are coupled duri ng
I
- 14 -
achieved as the resul t of two separate maneuvers. I n thi s
i tti tude is less than the timerequi red,i f the atti tude is
i nstance. the data i ndi cate that a 200 nosedown, 300 l eft
bank atti tude could be achieved i n less than 3 seconds.
1.16 Other
The Staff Vice Presi dent. Fl i ght Operati ons for A i r
west. stated that attempts were made t o f oster crew
vi gi l ance and scanning by minimizing crew duti es i n the
cockpit. use of checklist procedures. encouraging use of the
trai ni ng program.
However. the vari ous manuals and
trai ni ng
autopi l ot
as much
as possible.
and through emphasis i n thei r
programs di d not speci f i cal l y contai n any statement rel ati ng
t o lookout doctri ne or scanning techniques, nor di d the
company have any pl an t o implement such a program.
The pi l ot of BuNo458 recei ved trai ni ng i n l ookout
doctri ne and scanning techni ques i n f l i ght school. After
addi ti onal trai ni ng on scan techni ques wi th emphasis on
assignment to the squadron, the pi l ot and RI O received
tactical i ntercept and pursui t. Each pi l ot and RI O recei ves
formal upgradinq and refresher vi si on trai ni ng at least once
reminders in lookout doctrine duri ng bri ef i ng for each
every 3 years. Addi ti onal l y, the crews routi nel y i ncl ude
mul ti pl e aircraft fl i ght.
2- ANALYSI S AND CONCLUSIONS
2.1 hal v s k
(a) ATC and Radar Factors
control l er wi th a
vi sual presentati on which
w i l l assist him
The
primary
functi on of radar is to
provi de
the
i n the control and separati on of known traffic. It al so
provi des the control l er wi th another limited capabi l i ty -
that of Lroviding separati on of i denti f i ed from uni denti fi ed
workload permits. I n some cases. due to the technical
traf f i c through the medium of the traf f i c advi sory when
not been achieved. Because of the ni x of known and unknown
l i mi tati ons of the radar equipment, adequate separati on has
traf f i c it i s not onl y incumbent upon aircrews to mai ntai n a
hi gh degree of vi gi l ance to nsee and avoid. kut al so upon
the control l ers i n monitoring the radar display. I n this
acci dent three independent radar systems f ai l ed to detect
the primary target of EuNo458 and as a resul t no warning was
hi s
is
ef t
4ir
cew
the
the
tir
ing
ing
:he
>ut
:er
led
res
on
Ice
ide
Ich
.he
! i m
SO
ed
en
a1
as
wn
on
a
is
ct
as
-
- 15 -
given t o the crew of RW706 regardi ng the di recti on and
di stance of the hazard. I f the crew of R6706 had been
provided wi th thi s i nformati on their chances of seei ng and
avoiding the other aircraft would have been enhanced. One
sol uti on to the l i mi tati ons of radar would be the
establ i shment of some minimum standard of ref l ecti ve
capabi l i ty for al l aircraft and the i ncorporati on of some
necessary t o meet the standard, as previ ousl y recommended by
form of si gnal enhancement equipment aboard al l ai rcraf t, as
the Board. (See Report Number: NTSE-AAS-70-2, pages 119-
128.)
The radar coverage chart (cl assi f i ed for mi l i tary
securi ty) for the San Pedro system i ndi cates that the
radar line of si ght coverage. The l i mi tati ons to radar
col l i si on occurred at an al ti tude which is wi thi n the basic
the control l er workload. Other f actors af f ecti ng detecti on
advisory servi ce wi thi n that coverage area i ncl ude more than
of primary targets include:
(1) Radar cross-secti on presented by the desi gn
(2) weather condi ti ons such as preci pi tati on
(3) Ground cl utter
(4) El i nd spots
and confi gurati on of the aircraft
and temperature i nversi ons
the ai rcraf t radar cross-secti on and a temperature
I n thi s i nstance, detecti on of BuNo458 was hampered by
inversion. Although si mul ati ons of the f l i ghtFath i ndi cate
l ow probabi l i ty of such detecti on i s dramatized i n the
that the primary target was i ntermi ttentl y detectabl e, the
following computation:
The total el apsed time a target woul d have been
detectable was 120 seconds, equal t o 10 sweeps of the
mi nute), the ai rcraf t would travel 1.4 miles duri ng
antenna. A t approximately 420 knots (7 miles per
each sweep. The target would actual l y move a total of
di spl ay. The smal l time element involved and short
2.5 i nches, or 0.2S-inch/swee~, across the 21-inch
di stance moved, i n combination wi th the probabi l i ty of
less than 50 percent primary target tracki ng
conti nui ty, i ndi cate that it would have been extremel y
di f f i cul t for the control l ers to di f f erenti ate between
was di spl ayed at al l .
normal cl utter and an aircraft return, i f any target
- 16 -
wi th the R-18 sector were suf f i ci entl y l i ght to permit radar
The volume of traf f i c and control l er workload associated
traf f i c advi sori es i f requested. Advi sori es on possi bl e
aircraft duri ng the time period surroundi ng the col l i si on.
confl i cti ng traffi c were being gi ven to other control l ed
All four control l ers associated wi th the acti vi ty at the
vi ci ni ty of RW706. Consequently, the Board concludes that
posi ti on stated that no primary targets were observed i n the
no readi l y di scerni bl e target from EuNo458 was displayed.
If a request f or radar advi sori es had alerted the
control l ers to the presence of an aircraft i n that area, any
i ntermi ttent or questi onabl e target sighted coul d have been
tentati vel y i denti f i ed as EuNo458. The R-18 control l er
these circumstances.
could have advi sed RW706 of the conf l i cti ng traffic under
(b) RePOrtS of Aircraft Acrobatics
was focused on wi tness reports of an aircraft
performing
During the i nvesti gati on consi derabl e
publ i c
attenti on
acrobatics i n the vi ci ni ty of the collision. The RIO
testified that onl y one ai l eron rol l was performed by the
pi l ot of BuNo458, as he l evel ed off at 15,500 feet. An
was i nsuf f i ci ent time avai l abl e f or any repeated maneuvers
anal ysi s of the f l i ght from NAAS Fal l on i ndi cates that there
to have been performed. The wi tnesses might have been
observi ng another aircraft, or they were actual l y viewing
the qyrati ons of BuNo458 fol l owi ng the col l i si cn. Whereas
no specific Federal Avi ati on Regul ati on Frohi bi ted the
duri ng the maneuver was unquesti onabl y minimal due to the
ai l eron roll, the abi l i ty of the crew to see other aircraft
rapi dl y changing atti tude and the accel erati on forces
imposed. The Board concludes that the ai l eron rol l had no
were separated by approximately 13 miles at the time.
other si gni fi cance t o the acci dent, si nce the tu0 ai rcraf t
maneuver i n other than an acrobatic area.
However, it was imprudent of the pi l ot to perform such a
(c) gnerati onal Factors
of VPR and IFR traffi c, wi th each ai rcraft ccmplying wi th
This acci dent is another example of a heterogeneous mix
appl i cabl e regul ati ons, resul ti ng i n a midair col l i si on.
combined t o provi de the condi ti ons sui tabl e for a. midair
Several factors i n the operati on of the two ai rcraf t
col l i si on.
- 17 -
1. ODeration of BuNo458
Mechanical di f f i cul ti es wi th BuN0458. and the resul ti ng
operati onal deci si ons. &laced the aircraft at l ow al ti tude
and hi gh airspeed, i nstead of i n the APC. as would normally
be expected on cross-country f l i ghts. The transponder had
f ai l ed on the previ ous day. making entry
i nto the posi ti ve
traf f i c control
faci l i ty.
When the oxygen
system
al so
control
ai rspace dependent
on the di screti on of the ai r
became defecti ve, wi th no opportuni ty to repair either
system, the deci si on to proceed to MCAS E l Tor0 at
rel ati vel y l owal ti tude was the obvious sol uti on t o both
problems. The transponder was not required, and cockpit
pressuri zati on negated the physi cal need for supplemental
oxygen, even i f the leak depleted the enti re supply. The
oxyqen leak di d i ncrease. and most of the f l i ght to NAAS
Fallon was flown. wi thout supplemental oxygen. A t thi s
complete the f l i ght wi th the defecti ve systems. An
point. the pi l ot was i nstructed by higher authori ty to
was the hi gh-crui si ng airspeed, which is typi cal of modern
addi ti onal si gni f i cant f actor i n the operati on of BuNo458
j et ai rcraf t. The high airspeed was used to avoid hi gh
encountered at slower airspeeds. Consequently. the proba-
speci fi c f uel consumFtion and the less stable f l i ght regime
bi l i ty of vi sual detecti on was minimized by the speed. si ze.
and unexpected presence of BuNo458.
the pi l ot of BuNo458, consi derati on of traffi c and weather
I n addi ti on t o these operati onal constrai nts imposed on
condi ti ons was also evidenced i n the planning and conduct of
the f l i ght.
volume of traffi c i n the Los Angeles area to al ter hi s
The
pi l ot of BuNo458
was
suf f i ci entl y
aware of the heavy
f l i ght t o the east i n order to avoi d any conf l i ct. He
further demonatrated concern for adequate vi gi l ance by
climbing t o 15.500 f eet because of the deteri orati ng
vi si bi l i ty. However. the advantage which would have accrued
from the devi ati on around Los Angeles was l argel y of f set by
the subsequent climb t o hi gher al ti tude. Thi s placed
EuNo458 i n the airspace segment normally used by eastbound
traf f i c climbing to the hi gh-al ti tude route structure.
si gni f i cant ef f ect on the collision. First he di d not
Two other deci si ons by thepi l ot of BuNo458 also had a
attempt to request radar traffi c advi sori es. Thi s would
have al erted the appropri ate control l er that a
- 18 -
nontransponder target was i n the area and undoubtedly would
have resul ted i n an attempt to establish radar
i denti fi cati on. Even i f radar contact had not been
accomplished at that time, t he general l ocati on would have
been establ i shed, and traffic advi sori es coul d have been
i ssued accordingly. I n sFi te of the fact that crews
advi sori es are i ssued i n specific terms
(clock code
and
sometimes do not si ght the traf f i c even
though
the
di stance) the i ssuance of a general warning (geographic
l ocati on and direction of f l i ght) would have served to
narrow the fi el d of search. thereby i ncreasi ng the
probabi l i ty of detecti on.
mapping exerci se at a time when he was traversi ng an area of
Secondly. he requested the RI O to conduct a radar
dense traffic. Although it may be argued that outsi de
vi si bi l i ty from the rear cockpit is rel ati vel y poor, al l
been used. If any radar exerci se were t o have been
possible assi stance i n mai ntai ni ng a l ookout should have
conducted, it should have been i n the search mode. Even i n
the degraded condi ti on of the radar. thi s would have been
preferable.
2. Overation of RW706
operati on shows that at 8 minutes 54.6 seconds. the verti cal
An anal ysi s of the f i nal 0-6 second of f l i ght recorder
accel erati on transducer sensed a Fosi ti ve g force. moving
from +0,74g and cul mi nati ng i n a +5.08g readi ng at 8 minutes
55.2 seconds. A t the i nstant the styl us recorded thi s, it
moved i nstantaneousl y to a -1.89 reading. The return to.
and overtravel beyond. a +l g (normal) posi ti on (-1.8g) . wi th
response or normal i zi ng of the spri ng-restrai ned seismic
no measurable el apsed time. strongl y suggested
rapi d
mass i n the el ectromechani cal transducer after high
exci tati on i n the posi ti ve di recti on. These g recordi ngs
were made possible by the recordi ng rate of 10 per second
f or thi s parameter, whereas the other three parameter rates
are one per second.
The Safety Eoard bel i eves that these excursi ons on the
accel erati on trace resul ted from shock l oadi ng at impact and
not from any attempted evasi ve maneuver by RW706.
7
- 19 -
the col l i si on, thi s i ndi cates that either they did not see
Since the crew of RW706 took no evasi ve acti on prior to
BuNo458 or saw it too l ate to take appropri ate acti on.
There are several f actors which i ndi vi dual l y or col l ecti vel y
could have reduced the abi l i ty of the DC-9 crew to see and
avoid the F-4B. The crew probably engaged the autopi l ot to
maintain climb schedule and. under radar control , probably
expected traf f i c advi sori es of converqing targets from the
control l er. Further reducti on i n outsi de vi gi l ance might
determining 'or
changing
vari ous radio frequenci es, adj usti ng
have resul ted from such normal cockpi t functi ons as
setti ngs or control s of the f l i ght director or thrust
levers. However. the probable reasons why the RW706 crew
di d not see BuNo458 were: (1) both aircraft had a nearl y
constant rel ati ve heari ng to each other; (2) the hi gh
cl osure speeds; (3) the l ack of conspi cui ty of EuNo458; and
doctri ne and scanni ng techniques.
(4) the l ack of recurrent trai ni ng i n ef f i ci ent l ookout
(d) Human Factors i n Target Detecti on and Assessment
4) i ndi cates that at l east 40 seconds pri or to impact,
The Board's cockpit vi si bi l i ty study (Attachments 3 and
BuNo458 was less than 45O to the l eft of the DC-9 captai n's
and first of f i cer's normal si ght l i ne. ApFrOXimately 35
was then climbing on a constant heading. Although the
seconds pri or to col l i si on, RW706 completed a l eft turn and
target si ze of BuNo458 was small at this time (0.017-inch) .
the smoke tr ai l from engi ne exhaust would have at least
tri pl ed the ef f ecti ve target si ze. The vi sual angl e
subtended by such a target would be approximately 10.8
mi nutes of arc. The empi ri cal l y deri ved threshold for
detecti on is nominally 4 minutes of arc. A t approximately
15 seconds before the col l i si on, j ust pri or to the onset of
the '#blossoming effect81 which occurred as the i ntruder
target si ze i ncreased dramatically, the si ze of BuNo458 and
a smoke trai l twice its l ength would have grown t o
apFroximately 0.117-inch. I n the next 10 seconds, the
target si ze would triple, i n the l ast 5 seconds it would
expand to f i l l the enti re vi sual fi el d. These f i gures are
predicated on the constant foreshortened l ength of BuNo458
which would result from the rel ati ve posi ti ons of the two
- 20 -
aircraft, and no attempt was made t o adj ust f or the target
size duri ng the evasi ve acti on taken by BuNo458-
The cockpi t vi si bi l i ty study (Attachments 3 and 4) also
indicates tbat RW706 would have been approximately 390 t o
the ri ght of the normal si ght l i ne of the pi l ot of BuNo458
and approximately 370 for the RIO, for the l ast 40 seconds
the foreshorteni ng due to angular displacement, 35 seconds
prior t o col l i si on. The target si ze of RW706, al l owi ng f or
prior t o impact was approximately 0.037-inch. A t thi s poi nt
which is well wi thi n the detectable threshol d mentioned
the target would subtend approximately 7 minutes of arc,
earlier. NO addi ti on to target size was made f or engi ne
exhaust because one engi ne was modified, which reduced the
vi si bl e smoke emission. Thi s would have presented less than
optimum densi ty for detection. During the f i nal 15-second
period prior t o col l i si on, the target si ze of RW706
blossomed rapi dl y, tri pl i ng in si ze between 15 seconds and 5
seconds and then expanding t o f i l l the enti re vi sual fi el d
i n the f i nal 5 seconds,
Although the F-4B and Dc-9 target images were
theoreti cal l y of suf f i ci ent si ze t o permi t detecti on at 35
contri buted i n thi s case t o reduce the l i kel i hood of
seconds prior t o col l i si on, a number of factors coul d have
detecti on at that time. I n the anal ysi s of any midair
col l i si on, laboratory data on human response and
The extent t o which these data vary depends on the ef f ect of
capabilities 9/ must be adj usted to real-world condi ti ons.
many factors; i.e., 'windshield refractance, surface
irregularities and cl eanl i ness, si ze and l ocati on of
windshield frames., the background agai nst which a target is
viewed, atmospheric l i ght scatter: and viewer trai ni ng,
degrees
at the time a target is wi thi n a
perceptible
abi l i ty, and preoccupation: A l l
may be involved to varyi ng
threshol d. The extent to which these f actors af f ected
detecti on of RW706 or BuNo458 cannot he determined
precisely. However, the vari ous studi es comparing
l aboratory data t o real-world si tuati ons show dramatic
reducti on i n the probabi l i ty of vi sual detecti on due to the
f actors l i sted above.
/
A nonstructured or i l l -defi ned .homogeneous background
presents a l ess-than-desi rabl e fi el d when the search f or a
target is conducted, The lack of defi ned background
texture, coupled wi th a constant background hue, can
severel y limit not onl y the detectabi l i ty of a target but
trget
al so
' t o
10458
londs
I f or
:onds
loint
.oned
arc,
lgine
the
cond
than
IW706
.nd 5
'ield
were
.t 35
have
! of
,dai r
and
,om.
It Of
,face
t is
Of
.ing,
'ying
ible
lined
cted
ri ng
,ati c
the
ound
or a
ound
but
can
7
- 21 -
al so the abi l i ty t o percei ve target motion. once the tarqet
is detected.' While the effects of atmospheric l i ght
scatter, and the reported haze l ayer at 9.000 feet cannot be
quanti tati vel y determined i n thi s acci dent. it is reasonabl e
to surmise that RW706 presented less than optimum
conspi cui ty when viewed agai nst the haze layer. Moreover,
its motion rel ati ve to the background haze would be
di f f i cul t t o detect. Had either ai rcraf t di spl ayed hi gh
i ntensi ty strobe l i ghts. the i ncreased conspi cui ty probably
would have enhanced earl y detecti on of each aircraft.
ai rhorne targets i s the myopic nature of the human eye when
'Another f actor which can af f ect the detectabi l i ty of
an ai r-to-ai r search is being conducted. The condi ti on
resul ts from the tendency of the eye to focus at
apFroximately 20 feet duri ng a vi sual search i nto an
essenti al l y empty vi sual fi el d. Although thi s condi ti on i s
more preval ent at extremely high al ti tudes where the hori zon
becomes i l l -defi ned and high ambient l i ghti ng becomes a
factor, it is al so possible that a myopic condi ti on coul d
aqai nst
an i l l -defi ned homogeneous f i el d. The
possi bi l i ty
exi st at markedly lower al ti tudes when a pi l ot is
searchi ng
therefore exi sts that the crews of RW706 and BuNo458 coul d
have been subj ect t o some degree of myopic vi si on wi t h a
resul tant reducti on i n their abi l i ty to detect a small
target.
Fi nal l y, the effecti veness of crew scanni ng is dependent
on trai ni ng and the time shari ng of acti vi ti es i nsi de and
outsi de of the cockpi t. Based on a fixed-eye reference
point. nei ther target uas masked by i nterveni ng cockpit
target was i n
the peri pheral vi sual f i el d lo/
of al l
structure f or
any si gni f i cant period of
time; however. each
crewmembers. The l ack of rel ati ve motion of ei ther target
i n the peripheral vi si on of any crewmember could have made
earl y detecti on of the other ai rcraf t hi ghl y unl i kel y.
Si mi l arl y, the small si ze and lack of rel ati ve movement of
either target, even though detected at 35 seconds pri or t o
col l i si on, would undoubtedly have precluded accurate
assessment of the verti cal and hori zontal separati on or rate
of change of target si ze. Thus even i f the EC-9 and F-4
assessment of the col l i si on geometry coul d have been
crews detected the other aircraft. the cues for accurate
marginally adequate.
decreased from 20 to 10 seconds pri or t o the col l i si on the
It may be
postul ated that as
the cl osure di stance
I
target would become better defi ned and RW706's climb
atti tude coul d be more accuratel y di scerned by the pi l ot of
BuNo458. Thus a si ghti ng duri ng the period between 20 and
10 seconds pri or to col l i si on might not have been
i nterpreted as an imminent col l i si on threat because of the
smal l ness of the target si ze. However, target si ze
near the hori zon would have suggested that a col l i si on
notwithstanding, the fi xed beari ng of RW706 and its l ocati on
threat exi sted and that he shoul d maneuver to assure a
comfortable separation. Moreover, the F-4B pi l ot's military
f l yi ng experi ence, i ncl udi ng tactical i ntercept trai ni ng
ri ght
turn or other maneuver which would have i ncreased the
should have i ncreased the l i kel i hood of the i ni ti ati on of a
miss-distance. The lack of any such maneuver i ndi cates that
he di d not si ght the DC-9 i n suf f i ci ent time to have
executed an appropri ate maneuver to avoid the col l i si on.
I n l i ght of the above di scussi on of the l i kel i hood of
early detecti on, the Safety Eoard concludes that al though
occurred as much as 35 seconds prior to col l i si on, it is
detecti on of RW706 by the pi l ot of EuNo458 might have
more l i kel y that it occurred at some time markedly less than
20 seconds pri or to the col l i si on.
The possi bi l i ty of an early detecti on of BuNo458 by the
crew of RW706 was considered. HOWeVer, wi th BuNo458 located
near the hori zon and on a constant or nearl y constant
beari ng, earl y detecti on probably would have Frompted the
and
seri ousl y
to consi der al teri ng thei r climb schedul e or
crew of RW706 to monitor
the progress of
BuNo458 thereafter
headinq t o ensure safe passi ng separation. Assuming
conti nued assessment by the RW706 crew, as the range
decreased, the l i kel i hood of their making a precauti onary
al terati on i n f l i ghtpath would seemto i ncrease. Therefore,
i n the absence of any such devi ati on i n f l i ghtpath, the
Safety Board concludes that it i s most l i kel y that the crew
of RW706 never saw BuNo450, or saw it moments prior to the
col l i si on and had no time t o i ni ti ate an evasi ve maneuver.
I n order to determine a l i kel y time f or detecti on of
RW706 by the pi l ot of BuNo450, it was necessary to consi der
the RlO's warning coi nci dent wi t h the rol l i ng maneuver as a
starti ng poi nt, together wi th ai rcraf t response times and
col l i si on si tuati ons. The data suggest that it would take
l aboratory data suggesti ve of pi l ot response times i n
0.24 second t o accommodate t o foveal vi si on, cnce a target
was detected. Neural processes would take an addi ti onal 0.3
8
h
e
3
I
I
V
*i
C
i
r
i
- 23 -
have el apsed duri ng recogni ti on and assessment of the
second. The data f urther suggest as much as 3 seconds coul d
vari ous cues and determi nati on that a potenti al threat
exi sted. Approximately 2 seconds coul d have then el apsed
while deci di ng whether an evasi ve maneuver was necessary and
could have elapsed for human motor
response.
Ai rcraf t
i f so, the type of maneuver to i ni ti ate. Another 0.5 second
performance data i ndi cate approximately 3 seconds coul d have
been requi red for ai rcraf t response, depending cn the rate
and type of control i nput. Based on the RIO's testimony and
anal ysi s of other events, the pi l ot's parti ci pati on i n the
radar mapping exerci se was completed approximately 20
seconds prior t o the col l i si on. However, thi s remaining 20
seconds was most l i kel y not enti rel y spent i n constant
vi sual search of surrounding ai rspace. Such i ntracockpi t
duti es as monitoring the atti tude i ndi cator to mai ntai n
fl i qhtpath atti tude. ai rspeed, and status of ai rcraf t
subsystems would have occupied some f i ni te amount of thi s
time. Thus. the timeavai l abl e f or detecti ng any outsi de
target coul d have been si gni f i cantl y less than 20 seconds.
performing a noncontinuous
vi sual search of the surroundi ng
It is postul ated that 10 seconds coul d have been spent
ai rspace, whi l e the remaining 10 seconds were shared wi th
scanning cockpit di sFl ays. Because the DC-9 target was very
small, stati onary, and l ocated i n hi s peri pheral vi si on, it
is most l i kel y that the pi l ot di d not see the DC-9 unti l
j ust moments before the col l i si on.
unexpected appearance of the DC-9, together wi th its
The completely
dramatic growth i n si ze duri ng the 10 seconds prior t o
col l i si on rendered proper assessment of the si tuati on
extremely di f f i cul t i f not impossible. The Safety Foard
concludes therefore, that it is l i kel y that the pi l ot of
EuNo458 detected RW706 less than 10 seconds before the
col l i si on and that the evasi ve maneuver was i ni ti ated
approximately 2 t o 4 seconds before col l i si on. Within the
f i nal remaining 2 t o 4 seconds a l ef t r ol l was made as an
attempt t o avoid a col l i si on. A more appropri ate maneuver
consi stent wi th previ ous trai ni ng would have been a rol l to
the ri ght to i ncrease miss-distance. However, the Board
maneuver would have assured safe passage of the F-4.
cannot determine wi th certai nty that even thi s type of
/
accurate assessment of the col l i si on geometry by the
pi l ot
The Board f urther concludes that the vi sual cues f or
of BUN0458 probably were inadequate. Then, when target
range had been reduced suf f i ci entl y to afford improved
vi sual cues, the time remaining was so bri ef as t o make
- 24 -
unduly di f f i cul t the accurate assessment of the geometry and
proper response.
(e) Consi derati on of See and Avoid Concept
11/ pl aces the burden on both crews to see and avoid other
Secti on 91.67 of the Federal Avi ati on Regul ati ons (FAR)
ai rcraf t. Assuming detecti on of the other ai rcraf t, FAR
91.67(c) placed an addi ti onal responsi bi l i ty on BuNo458 t o
respect the ri ght of way of RW706
-
Nonetheless, as can be appreci ated from the foregoi ng
anal ysi s of this col l i si on, the l i kel i hood of a pi l ot's
ei ther not seei ng an i ntruder at al l or seei ng the i ntruder
evasi ve maneuver based on incomplete vi sual cues, is hi ghl y
and mi si nterpreti ng vi sual cues and then attempti ng an
these si tuati ons is often hi ghl y complex, and i n many cases
probable. The problem-solving process requi red of pi l ots i n
the problem is i mFossi bl e to sol ve i n timet o avoi d a
col l i si on. Thi s is demonstrated by the f act that the crew
of BuNo458 had recei ved recent trai ni ng i n l ookout doctri ne
and scanning techni ques but were unable to avoi d the
col l i si on.
trai ni ng on l ookout doctri ne or scanni ng techni ques, and no
Conversely, the crew of RW706 recei ved no formal company
Although A i r West pi l ots are eval uated for %l ertnessm, thi s
such trai ni ng i s requi red by either thecompany or the FAA-
eval uati on appears to encompass condi ti ons i nsi de the
cockpit as well as outsi de. There are no def i ni ti ve
criteria to determine how ef f ecti vel y a pi l ot mai ntai ns a
proper lookout. It may be argued that previ ous mi l i tary
trai ni ng i n lookout doctri ne and scanni nq techni ques,
excel l ent time-sharing f or
responsi bi l i ti es
i nsi de and
coupled wi th
years of f l yi ng
experi ence, would resul t i n
outsi de. However, it is equal l y true that years of
experi ence wi thout constant review and improvement would
resul t i n establ i shment and rei nforcement of impoper habit
patterns. Overcoming such a behavi oral pattern, which
i nvol ves no consci ous process, would requi re a concerted
retrai ni nq program wi th periodic recurrent trai ni ng. The
Board bel i eves it si gni f i cant that there is no i ndi cati on
that the crew of RW706 ever saw BuNo458 under these
posi ti on taken
many times before that f or certai n
circumstances. The Board,
therefore.
rei terates the
ope:
sim;
SY s
and
the
tY F
re1
thj
ass
mol
ai l
bel
Eo:
st1
Rea
av.
of
qr
an
fa
co1
in
a
cc
PI
cl
tt
2 ,
:y and
(FAR)
other
:, FAR
' 8 t o
l ot's
going
ruder
9 an
ts i n
i ghl y
cases
oid a
crew
tri ne
the
wny
nd no
FAA,
thi s
i ti ve
the
ins a
i tary
: i n
and
Of
tould
tabi t
ihich
!rted
The
Ition
.hese
the
,tai n
ws,
operati onal condi ti ons, the "see and avoid" concept is
simply i nadequate and the development of col l i si on avoidance
systems must be vi gorousl y pursued.
Whereas thi s acci dent resul ted from hi gh cl osure rates
and, consequently, smal l tarqet si ze unti l shortl y before
the col l i si on, the Board al so recogni zes the more common
type of midair col l i si on occurri ng between ai rcraf t at
thi s l atter type of col l i si on, the detectabi l i ty and
rel ati vel y low cl osure rates. The Board bel i eves that f or
ai rcraf t can be enhanced by proper pi l ot techni ques and a
assessment of the col l i si on threat from an i ntrudi ng
more thorough understandi ng of vi sual phenomena4 The Safety
mard's publ i cati ons a/ rel ated to mi dai r col l i si ons
between ai rcraf t i n vi sual meteorol ogi cal condi ti ons have
Recommendations have been sent t o the FAA, the ai r carriers,
stressed the need f or i ncreased pi l ot vi gi l ance.
commercial operators, pi l ot associ ati ons, and the many
of pi l ots t o the mi dai r-col l i si on threat. I t is therefore
avi ati on-ori ented i nterest groups t o i ncrease the awareness
grati fyi ng to see that many of the professi onal publ i cati ons
and meetings of these organi zati ons are focusi ng on the many
f acets of thi s problem.
i n the Los Angeles area, si nce the acci dent. Thi s acti on is
Si mi l arl y, a termi nal control area has been implemented
a posi ti ve steF toward reduci ng the threat of mi dai r
col l i si ons, but the Board bel i eves the concept would not
prevent the recurrence of thi s acci dent. Estatl i shment of
climb and descent corri dors, as previ ousl y recommended by
the Eoard would tend t o el i mi nate thi s type of accident.
2. 2 Conclusions
(a) Fi ndi nas
1. Both ai rcraf t were airworthy.
2. A l l flightcrew members were qual i fi ed.
3. RW706 was operati nq i n accordance with an
Los Angeles ARTCC.
I FR f l i ght pl an under radar control of the
4. BuNo458 was operati ng i n accordance wi th a
VFR f l i ght pl an and was not under control
I
\
- 26 -
of the ATC system.
5. The ai r traf f i c control l ers were quaaified
for thei r assi gned duti es.
6. BuNo450 was not detected on radar because of
cross-secti on, and a low l evel temperature
an i noperati ve transponder, the ai rcraf t radar
i nversi on i n the area.
7. There was no restri cti on t o i n f l i ght vi si bi l i ty
i n the area of the acci dent.
8. The pi l ot of BuNo450 exerci sed Foor judgment
i n performing an ai l eron rol l , but the r ol l
di d not contri bute t o the acci dent.
9. The pi l ot of BuNo458 attempted to eject from
the ai rcraf t, but he was unable tc do so because
the forward canopy di d not jettiscn.
10, If BuNo458 had requested radar traf f i c advi sori es,
the control l er coul d have advi sed RW706 of the
presence of Bum458 and the probabi l i ty of
avoiding the col l i si on would have i ncreased
si gni fi cantl y.
11. USMC flightcrews receive trai ni ng i n lookout
doctri ne and scanning technique.
12. No formal trai ni ng or eval uati on of crew
scanni ng techni que and lookout doctrine is
accomplished by A i r West.
13. Both ai rcraf t were theoreti cal l y cf suf f i ci ent
si ze t o permi t detecti on by each other at 35
seconds pri or to col l i si on. However, detecti on
and assessment were probably compromised by
contrast and l ocati on i n
the peri Fhera1 vi sual
target si ze due t o hi gh cl osure rate, target
f i el d, and other vi sual l i mi tati ons.
14. A t 35 seconds &fore impact, both a.i rcraf t
were on an essenti al l y constant rel ati ve
because each target would be near the minimum
bearing and would have'been di f f i cul t t o detect
detectable si ze and would remain rel ati vel y
bot
tha
the
hiq
are
ef f
avo
I CKE
ea1
inc
Sa J
Fec
I
- 27 -
stati onary.
15. I n view of the absence of evasi ve acti on
of heading, climb profile or airsseed) it
on the part of RW706 (Le., no al terati on
di d not si ght BuNo458 i n time to i ni ti ate
is logical to conclude that the crew
such evasi ve acti on.
16, The pi l ot of the F-4B probably fi rst observed the
target of the X - 9 at about 8 t o 10 seconds
pri or to col l i si on, devoted the first porti on
of thi s brief peri od t o assessi ng such cues as
rel ati ve bearing, speed, and climt angl e, and
i ni ti ated a ref l ex evasi ve maneuver approxi-
mately 2 t o 4 seconds pri or t o the col l i si on.
(b) Probable Cause
that the probable cause of thi s acci dent uas the f ai l ure of
The Nati onal Transportati on Safety Board determi nes
both creus to see and avoid each other but recogni zes that
they had only marginal capabi l i ty t o detect, assess. and
avoid the col l i si on. other causal f actors i ncl ude a very
hi gh Cl OSUXe rate, comingling of IFR and VFR traf f i c i n an
area where the l i mi tati on of the ATC system preclud.es
effecti ve separati on of such traf f i c, and f ai l ure of the
crew of But40458 t o request radar advi sory service,
parti cul arl y consi deri ng the f act that they had an
inoperable transponder.
3. RECOMMENDATIONS
Safety Board recommends that the Admi ni strator of the
As a resul t of this acci dent the Nati onal Transportati on
Federal Avi ati on Administration:
1. I nstal l vi deo tape at al l FAA ATC radar di spl ays,
both term-nal and en route f or use as an
i nvesti gati on tool. ( A- 72- 200)
2. I nstal l an open #*areap1 microphone at each terminal
and center sector posi ti on to record al l conversati on
at the control Fosi ti ons. ( A- 72- 201
3. Establ i sh climb and descent corri dors extendi ng from
the top of the TCA's to the base of APC, to remain i n
- 28 -
top of the TCA's. (A-72-202)
effect unti l the base of APC bas been lowered to the
4. Establ i sh more def i ni ti ve procedures for the guidance
of control l er personnel i n handl i ng Code 7700
ai rcraf t. (A-72-203)
5. Review radar performance monitoring procedures to
assure that al l radar f aci l i ti es are capable of
recei vi ng Code 7700 transponder returns. (A-72-204)
The Nati onal Transportati on Safety Eoard
recommended (A-71-52) that the FAA take t he fol l owi ng
also
action:
Coordinate wi th the Department of Defense, and. i n areas
where a large i ntermi x of ci vi l and military traf f i c
exi sts, develop a program to i nsure that appropri ate
graphi cal depi cti ons of airspace uti l i zati on and typi cal
flow patterns are prominently di spl ayed at al l ai rports
and operati onal bases f or the benefi t of al l airspace
users.
The Federal Avi ati on Admi ni strati on responded, i n a
letter dated November 10, 1971, as follows:
i ssued 9 November 197 1.
"Thi s is i n response to your saf ety recommendation, A-71-52.
"Recommendation number 4 of our Near Midair Col l i si on Report
of J ul y 1969 is similar to your recommendation.
" AS a resul t of that recommendation we:
1. Developed a new Part 4 o f the Airman's I nformati on
Manual i n J anuary 1970 (Graphic Noti ces and Supplemental
I nformati on). A s graphi cs are made availalcle. they are
i ncl uded i n the semiannual Part 4 or are carried i n the
every 28-day Part 3, unti l they can be transferred to
Part 4.
2. Developed vari ous types of graphi c di spl ays of normal
I FR and VFR routes.
3.
4.
" I n
A r 4
COl
evq
NA,
f 0
"AS
da
ti
D
in
"Ai
wc
Ct
ma
1
1
the
,rice
700
to
of
4)
Is0
i ng
eas
f i c
ate
cal
rts
ace
a
52 ,
ort
ion
tal
are
the
to
mal
I
a
7
.e
0
a
ly
r
f
,i
i
P
0
n
-
F
t
n
d
rI
- 29 -
3. Developed graphics f or the 22 large termi nal hubs.
Fi fteen are publ i shed i n the AI M, and the remaining
seven are i n vari ous stages of
processing.
4. Dweloped graphi cs for other than large huts i ncl udi ng
A i r Force Bases. Ei ght are published i n the AI M and
three are i n the f i nal stages of development. Nine of
the el even di spl ay A i r Force Base acti vi ti es.
I n addi ti on t o the above, we have developed a VFR Terminal
Area Chart (copy enclosed) which we w i l l be testi ng and
evaluating. Thi s chart of Chicago Area deFicts the Terminal
Control Area, VFR and I FR routes and mi l i tary operati ons at
NAS Glenview. The chart i s designed for use by pi l ots and
f or di spl ay at al l ai rports and operati onal bases.
As you can see, we have expanded upon the ori gi nal recommen-
ti on of thi s expansion, we w i l l coordi nate f urther wi th the
dati on i n our Near Midair Col l i si on Report. A s a continua-
Department of Defense to i ncorporate other mi l i tary bases
i nto the program.
After review of the material we have outl i ned above, we
would appreci ate any f urther comments you may have con-
cerni ng thi s matter. Io
On February 8, 1972, the Safety Board f urther recom-
mended (A-72-12 6 13) that theFAA:
1. Develop VFR Terminal Area Charts, similar to that
TCAs and, i f feasible, for other l arge ai r traf f i c
prototype portrayi ng the Chicago TCA, f or al l other
hubs.
2. I ni ti ate a program to publ i ci ze the exi stence of,
and the l ocati on of, these graphi cs f or prospecti ve
users. The program should i ncorporate, i n part.
Examograms and. i n airmen examinations. questi ons
ref erri ng t o these graphics.
The Federal Avi ati on Admi ni strati on concurred wi th these
recommendations i n a letter, dated February 15, 1972.
Other recommendations (A-71-46 thru 51) were sent to the
Department of Defense on November 2, 1971, sugqesti ng the
fol l owi ng acti ons:
- 30 -
1. Review the f easi bi l i ty of restri cti ng al l types of
excess of the FAR l i mi tati ons, to desi gnated :
low-level trai ni ng, which requi res ai rspeeds i n
restricted areas and low-level navi gati on routes. !
2. Rephrase the wording contai ned i n your al ti tude/
airspeed l i mi tati ons, and del i neate expl i ci tl y
those i nstances wherein airspeeds i n excess of the
The Board bel i eves that the excepti ons should be
10,000 feet/250 KI AS l i mi tati ons are authori zed.
limited t o the following:
loa. Cl i mbs and descents to traf f i c patterns,
and low-level navi gati on routes.
authori zed and/or desi gnated trai ni ng areas
"b. Those i nstances where safety of either crew or
ai rcraf t requi re operati ons i n excess of the
l i mi tati on.
3. Explore the f easi bi l i ty of usi ng the ai r i ntercept
radar on al l mi l i tary aircraft to provi de col l i si on
avoidance assi stance as an addi ti onal aid t o the
"see and be seen" concept; and should thi s prove
the radar f or thi s purpose on al l f l i ghts where its
feasi bl e, i nsti tute and establ i sh procedures t o use
use is not requi red for more urgent military
mission requirements.
4. I nsti tute a program to provide more publ i ci ty t o
the exi stence, functi on, and use of the FAA Radar
Advisory Servi ce i n those i nstances where VFR
areas. Consi derati on shoul d be gi ven to making the
f l i ght is requi red through hi gh-densi ty traffi c
request f or such service a mandatory procedure.11
December 2, 1971, as follows:
The Department of Defense responded, i n a letter dated
Transportati on Safety Board saf ety recommendations A-71-
"Thi s letter is i n response to the Nati onal
48 thru 51, which you forwarded to Secretary Lai rd on 9
November 197 1.
mi l i tary servi ces f or their consi derati on. I amadvi sed
"These recommendations have been referred to the
that duri ng thei r i ni ti al review the recommendations
!
!
, '
L
C
L
- 31 -
were consi dered sound and would be implemented to the
extent feasible. The details of such acti on are being
staffed. The resul ts of this staf f i ng will be the
promulgation of specific i nstructi ons and guidance to
their operati ng commands.
"Thank you for your hel pful recommendations which
are so i mportant t o our mutual i nterest i n achi evi ng the
greatest degree of air safety."
The saf ety Board previ ousl y made recommendations on the
problem of midair col l i si ons i n the Boardas special acci dent
- 1968" which was released i n J ul y 1969. and the *Report of
prevention study "Midair Col l i si ons i n U- S. Ci vi l Avi ati on
Proceedings of the Nati onal Transportati on Safety Board i nto
which was released February 22. 1971.
the Midair Col l i si on Problem - November 4 through 10. 1969"
BY THE NATIONAL TRANSPORTATION SAFETY BOARD:
/S/ J OHN H. REED
Chairman
/ s / FRANCIS H. McADAMS
Member
/ s / I SABEL A. BURGESS
Member
/ s / WILLIAM R. HALEY
Member
LOUI S M. THAYER, Member, was absent, not voti ng.
September 22, 1972
- 32 -
FOOTNOTES
hour clock.
Airspace wi thi n which al l traf f i c i s under positive
control . and al l aircraft must operate i n accordance
wi th I nstrument Fl i ght Rul es (I FR) - A t the time of the
acci dent, the posi ti ve control began at Fl i ght Level
240.
A col l ocated very high frequency omnirange and ul trahi gh
frequency tacti cal ai r navi gati onal aid. The DME
feature gi ves a sl ant range measurement t o the f aci l i ty.
Le.. radar, data. tower. etc.. but who is not checked
A control l er qual i fi ed i n t h e type of work bei ng done,
out i n the specific posi ti on of a f aci l i ty, i.e.. R-18,
A l l times herei n are Paci f i c dayl i ght, based on the 24-
D-18. etc.
MTI is a f eature of the di spl ay which tends to el i mi nate
returns from stati onary targets. It i s i nf i ni tel y
adj ustabl e wi thi n the range capabi l i ty of the
radarscope. and has si x preselected l evel s of si gnal
attenuati on avai l abl e.
PRF was designed to vi rtual l y el i mi nate any bl i nd speed
effect which coul d occur when targets are travel i ng
tangent to the antenna. wi thi n the range of the MTI
sel ecti on. Such targets would otherwise not appear on
the radarscope due t o apparent l ack of motion.
transponders.
Guard channel is the i nternati onal emergency frequency.
It is 121.5 MHZ f or very high frequency (VBF) communi-
cati ons.
A study of Requirements f or a pi l ot Warning I nstrument
for Vi sual Ai rhrne Col l i si on Avoidance. sperry
Gyroscope Company. Great Neck. Long I sl and. December
dl., WADC Technical Report 58-399, November 1958, Wright
1963; and Vi si on I n Military Aviation. J .W. Wulfeck. et
A i r Development Command. Wright-Patterson AFB. Ohio.
code 7700 is a uni versal l y used emergency code for
- 33 -
1p/ Foveal vi si on takes place wi thi n 200 of the center
outsi de this 200 cone of foveal vi si on.
porti on (fovea) of the eye. Peri pheral vi si on occurs
- 11/ FAR 91.67 states i n part: "When weather condi ti ons
permit, regardless of whether an operati on is conducted
vi gi l ance shal l be maintained by each person operati ng
under I nstrument Fl i ght Rules or Vi sual Fl i ght Rules,
an aircraft so as to see and avoi d other aircraft i n
secti on gi ves another aircraft the ri ght of way, he
compliance wi th thi s section. when a rul e of thi s
under. or ahead of it. unl ess well clear." FAR
shal l gi ve way to that ai rcraf t and may not pass over,
category are converging at approximately the same
91.67 (c) provi des that: "When ai rcraf t of the same
al ti tude . . . the aircraft t o the other's ri ght has
the ri ght of way. . . .In
- 12/ Midair Col l i si ons i n U.S. Ci vi l Aviation-1966; Aircraft
Accident R epor t NTSB-AAR-69-2; Aircraft Accident Report
NTSE-AAR-69-4; Ai rcraf t Accident R epor t NTSE-AAR-70-15;
and Report of Proceedings i nto the Midair Col l i si on
Problem NTSE-AAS-70-2.
I
- 34 -
APPENDI X A
I NVESTI GATI ON AND HEARI NG
1. J nvesti qati on
The Board recei ved noti f i cati on of the acci dent at
approximately 1830 on June 6. 1971. from the Federal
Avi ati on Administration. An i nvesti gati ng team was
immediately di spatched to the scene of the acci dent.
Control , Witnesses. Weather.
Human Factors.
Structures.
Working groups were
establ i shed f or Operati ons A i r Traffic
Powerplants. Systems. and Fl i ght Recorder. I n addi ti on the
maintenance records f or each aircraft were reviewed. The
EedeKal Avi ati on Admi ni strati on, Department of Navy. Hughes
A i r West. McDonnell-Douglas Corporation, and A i r Li ne Pi l ots
Associ ati on al l parti ci pated i n the i nvesti gati on as
completed on J une 19, 1971.
i nterested parties. The on-scene i nvesti gati on was
2. Hearinq
J ul y 27 to J ul y 30, 1971. Parties t o the Hearing i ncl uded
A publ i c heari ng was held at Pasadena. Cal i forni a. on
the Federal Avi ati cn Administration. Department of Navy.
Hughes A i r West. McDonnell-Wuglas Corporation, A i r L i ne
Fi l ots Associ ati on and Ai rcraf t Owners and Pi l ots
Association.
3. ReDorts
rel eased by the Board on J ul y 26, 1971. A sunmary of the
A prel i mi nary f actual report of the i nvesti gati on was
testimony was i ssued on Auqust 20. 1971.
izs!
trar
aiq
accl
i n
Mar c
was
tra
air]
had
corn1
hou:
on
cer-
l i m
hou
the
f or
22 .
18.
16.
e m
con
f l j
ai I
I
IX A
I
hes
.OtS
was
as
lded
, on
VY .
.ots
iine
was
the
- 35 -
APPENDIX B
crew I nformation
transport pi l ot certificate
No. 474317. wi th rati ngs i n
Captain
Theodore Nicolay. aged 50. hel d ai rl i ne
ai rpl ane mul ti engi ne land. F-27. DC-3. and DC-9. He had
accumulated 15,490 total f l yi ng hours. i ncl udi ng 2.562 hours
i n the DC-9. He completed hi s l ast profi ci ency check on
March 8. 1971. and hi s FAA first-class medical certificate
was i ssued on J anuary 25. 1971. wi th no l i mi tati ons.
Fi rst Offi cer Price Bruner, aged 49, hel d ai rl i ne
transport pi l ot certificate NO. 611777. wi th rati ngs i n
ai rpl ane mul ti engi ne land. F-271227. DC-3. DC-9 and
commercial pri vi l eges i n ai rpl ane si ngl e-engi ne land. He
had accumulated 17,128 total f l yi ng hours, i ncl udi ng 272
hours i n the DC-9. He completed hi s last Profi ci ency check
on December 7. 1970. and hi s FAA first-class medical
certi f i cate was i ssued on Cecember 18. 1970, wi th no
l i mi tati ons.
hours. i ncl udi ng about 1 hour 50 minutes f l i ght time, when
The fl i ghtcrew members had been on duty approximately 6
the acci dent occurred. Thei r rest peri od pri or t o reporti nq
for duty was 18 hours 13 minutes.
22, 1959.
Hostess J oan R. Puylaar. aged 34. was hi red on August
18, 1963.
Hostess Particia Shelton. aged 28. was hi red on October
16, 1967.
Hostess Helena Koskimies, aged 30. was hi red on October
emerqency recurrent trai ni ng i n September 1970.
A l l cabi n crewmembers completed thei r prescribed
commercial pi l ot certificate No. 1619834. wi th rati ngs i n
Fi rst Li eutenant James R. Phi l l i ps, aged 27. hel d
ai rpl ane si ngl e- and nul ti engi ne land. H e al so hel d a val i d
f l i ght i nstructor certificate. He had accumulated 440 total
- 36 -
military f l yi ng hours, i ncl udi ng 170 hours i n the F-4B. He
al so had accumulated approximately 400. hours i n ci vi l
ai rcraf t. He completed hi s last Naval A i r Trai ni ng and
Operating Procedures Standardi zati ons Programs (NATOPS)
f l i ght check on December 8 , 1970, possessed a Standard
I nstrument Card, and passed hi s annual medical examination
on J une 23, 1970, wi th no l i mi tati ons.
First Li eutenant Chri stopher E. Schiess, aged 24, j oi ned
the U. S. Marine corps on November 7, 1969, and completed
hi s RIO trai ni ng J anuary 3, 1971. He had accumulated 195
total f l yi ng hours, i ncl udi ng 89 hours i n the F-4B. He was
medical examination on J ul y 13, 1970.
cuzrent on al l prescribed trai ni ng and passed hi s annual
4 minutes, i ncl udi ng 1 hour 53 minutes f l yi ng time at the
Both crewmembers had been on duty approximately 7 hours
time of the accident. Thei r rest peri od pri or to reporti ng
for this f l i ght was 19 hours 10 minutes.
was
Yorl
Fr a
of i
94 1.'
w i t
ST8
- PO9
am
t h f
the
ret
s q
to
aC
i n
w i
en
2s
~
- 37 -
APPENDIX C
Aircraft I nformation
was owned by the C.1-T. Corporation. 650 Madison Avenue. New
N9345.
a McDonnell-Douglas DC-9-31. seri al NO. 47441.
York. New York, 10020. and operated by Hughes A i r West, San
Zrancisco I nternati onal Ai rport. San Francisco, California,
94128. It had been flown a total of 5,542 hours at the time
of the acci dent. A review of the records i ndi cated that al l
with or were scheduled f or completion. Pratt 6 Whitney
appl i cabl e Ai rworthi ness Di recti ves ei ther had keen complied
JT8D-7 engi nes were i nstal l ed as follows:
Posi ti on seri al Number Time Si nce Overhaul
1
2
P65704-D
P654152-WD
5265.69
2263.06
the center of gravi ty was 21 percent MAC. Both are wi thi n
The ai rcraf t weighed 86,518 pounds at engine start and
the al l owabl e limits.
Bureau Number 151458, a McDonnell-Douglas F-4B. was
recei ved on Apri l 15. 1964. and had been operated by vari ous
squadrons of the U. S. Marine Corps. A t the time of the
acci dent, it was assi gned t o VMFA-323. and had keen flown a
total of approximately 2.030 hours. A review of the records
i ndi cated that the ai rcraf t was maintained i n accordance
with the appropri ate regul ati ons. General Electric 579-8
engi nes were i nstal l ed as follows:
Posi ti og Serial Number Time Since Overhaul
1
2
401437
421669
842.5
258.8
- 38 -
engine st art . Both the takeoff weight and center of gravity
The ai rcraf t weighed approximately r)3,310 pounds a t
were within prescribed limits.
PRIOR TO EVASI VE MANEUVER
DC-9-31
14Y MAG
400K TAS 420K TAS
COMPUTED RANGES, BEARINGS, AND CLOSURI
TRUE NORTH
ATTACHMENT 2
1 RANGES, BEARINGS, AND CLOSURE RATES
1 4 5 O MAG
420K TAS
TRUE NORTH
4 MAGNETIC NORTH / I I LATERAL VISIBILITY
60 55 50 45 40 35 30 25 20 15 IO 5 0
I l l 1 I I I I I I l l l i
w
Vl
20-
15-
t3
z 0-
w IO- LL
L3 3
I 5-
_I
-
m
- - 5-
Ln
-
>-10-
2 3
4
<-15-
-
x -20- 0 L3
u
>
-25-
-30-
20-
0-
1 - 5-
i -10-
>
CAPTAINS SIDE WINDOW
LEFT
I
ZERO
REFERENCE
CAPTAIN S
FRONT WINDSHIELD
co-PILOTS
FRONT WINDSHIELD
-30- I
F-4 CALCULATED FLIGHT PATH
LEFT
I I I I I I I I I I I I I I I
60 55 50 45 40 35 30 25 20 15 10 5 0 5 11
LATERAL VISIBILITY -
i
LATERAL VISIBILITY - DEGREES
35 30 25 20 15 10 5 0 5 IO I5 20 25 30 35 40 45 50 55 60
1 1 1 1 I l l ~ 1 1 1 1 1 1 l 1 1 1 I l
LEFT RIGHT
CAPTAIN' S
FRONT WINDSHIELD
co-PILOT' S
ZERO
REFERENCE
sec
20 to 3 sec
IGHT PATH
SIDE WI NDOW
co-PILOT'S
SIDE WI NDOW
DC-9
REFER
LATERAL VISIBILITY - DEGREES
ATTACHMENT 3
45 50 55 60
I l l 1
SIDE WINDOW
co-PILOT'S
SIDE WINDOW
CLEAR AREAS REPRESENT
BINOCULAR VISION
I l l 1
45 50 55 60
MIDAIR COLLISION
NEAR DUARTE. CALIFORNIA
JUNE 6, 1971
T1 - 1
30 7
, , , 2 5 C
Y
% 2 0 c
2 n 5'15t-
I 10-
5-
m
- O+
-4
c
' z- - 10
D- 40
2
-
-
5 --15
--25
--30
IATERAL VlSlBlLlN
VISIBILITY IS COMPI
--20 ZERO REFERENCE /
--25
- -30
LEFT
140 130 120 110 100 90 80 70 60 50 40 30 20 10 0
LATERAL VISIBILITY
I MONOCULAR VISION ONLY.
SHADED AREAS REPRESENT
I I I I
0 100
I ~ I I I I I I I I I I I
90 100 110 120 130
ZERO REFERENCE
LEFT RIGHT
I
0 100 90 80 70 60 50 40 30 20 10 0 10 20 30 40 50 60 70 80 90 100 110 120 130
1 1 l l 1 1 1 1 1 1 l 1 1 1 I 1 1 1 l 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
I
LATERAL VISIBILITY - DEGREES
ATTACHMENT 4
0 100 110 120 130 140
I I I I I I I I I I I I
F-4B VISIBILITY FROM RIO'S DESIGN EYE REFERENCE, POINT
ATED FLIGHT PATH
'0 100 110 120 130 140
I l l l l l l l l l l l
NATIONAL TRANSPORTATION SAFETY BOARD
WASHINGTON, O.C.
HUGHES AIR WEST DOUGLAS DC-9-31, N9345
U.S. MARINE CORPS F-4B, BUN0 151458
MIDAIR COLLISION
NEAR DUARTE, CALIFORNIA
JUNE 6, 1971