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Un accidente de aviación que me impactó

N-27UA

Uno de los accidentes aviación que más me ha impactado, fue el ocurrido a la aeronave N-27UA, un DC-8-
61F, carguero, operado por la línea aérea Norteamericana Fineair, cuando despegaba desde la pista 27 del
Aeropuerto Internacional de Miami Florida, el día 07 de agosto del 1997, después del mediodía. El aparato
estaba cargado con 16 pallets que pesaban 87,923 libras, principalmente, de “cuts” telas cortadas, para la
industria de zona franca de República Dominicana. El avión despego con un peso aproximado de 315,000
lbs.

El aparato completaba una operación para la aerolínea dominicana Aeromar Airlines. La tripulación del
vuelo estaba integrada personas conocidas, en especial dos buenos amigos que eran el Copiloto R.
Mccormick de apena 26 años de edad y el encargado de seguridad de carga a bordo, un joven cubano
apellido Franco, que había llegado a Miami como exiliado político hacia apena unos meses antes.

Como el despachador de vuelo de Aeromar Airline en Santo Domingo/Miami, ese día bien temprano en la
mañana, había llamado a Leónidas Castillo, Coordinador de Carga de la empresa Aeromar en el Aeropuerto
Las Américas, para saber el estatus del vuelo, el peso estimado y tipo de carga saliendo desde Las
Américas a Miami. Leónidas me comunicó que el vuelo estaba retrasado, lo que no era raro en Fineair. Esa
mañana, según Leónidas, se trababa de un cambio de avión por asuntos operacionales.

Cerca de las 12:00 del mediodía, me comuniqué con operaciones de Fineair de Miami donde me
informaron que el vuelo estaba cargado y próximo a salir. Arranqué para el aeropuerto conduciendo con
tranquilidad. Sin embargo, todo se derrumbó cuando el Jefe de operaciones de Aeromar aquí en Santo
Domingo, me llamó comunicándome que el vuelo Fineair 101 se había caído, justo cuando despagaba
desde la pista 27 del Aeropuerto Internacional de Miami.

Lo único que se me ocurrió en ese momento fue “orillarme” a la derecha en el paseo de la autopista y
estacionandome frente a la bomba de combustible de antes del peaje y mirar hacia el aeropuerto sabiendo
la gravedad de la situación. Después de respirar profundo, continué hacia el depósito de carga de Aeromar
en el AILA, donde encontré un escenario difícil en el que todos especulaban sobre la posible causa del
accidente.

Aunque no hablé de ello en ese momento, por mi mente pasó el tema del procedimiento de cargue de los
aviones de Finar en Miami. No fue una ni dos ni tres, sino muchas las veces que le hablé de ese asunto. El
problema era que, en muchos casos, cuando había posiciones sin pallets en el avión, estos se corrían,
cambiando de posición en vuelo, debido a que en algunos casos, Miami no aseguraba, los candados que
fijan los pallets al piso del avión, los “perros”, como decían los cargadores aquí en Las Américas. En
ocasiones pallets pesados se trancaban entre sí, y despegarlo era toda una odisea y asunto de horas.

Las consecuencias de ese accidente fueron devastadores, tanto para Fineair como para Aeromar Ailines.
Ambas organizaciones, sobre todo sus ejecutivos pagaron caro los errores cometidos en el procedimiento
de cargue en Miami. En mi caso particular estaba plenamente consciente del asunto y de mi
responsabilidad en el proceso de carga aquí en Santo Domingo. A pesar que no era mi responsabilidad
hacerlo debido a que lo había un supervisor de cargue del avión, siempre estaba presente “enganchao” en
el DC-8, chequeando que los pallets se colocaran según las instrucciones de la hoja de carga y que
además estuvieran correctamente asegurados con los "perros".

El proceso de investigación de la NTSB de los Estados Unidos determinó que temas relacionados con el
cambio de avión y el peso de la carga tumbaron el avión, pero por las experiencias vividas yo me atrevo a
decir que pallets sueltos que rodaron mucho tuvieron que ver con el evento. Los accidentes de aviación
andan por ahí, esperando solamente que cualquier persona se corra el chance de cometer un error o aun
peor, de repetirlo.

Estado: Final
Fecha: jueves 7 agosto 1997
Hora: 12:36

Tipo: McDonnell Douglas DC-8-61F


Operador: Fine Air
Registración: N27UA
Numéro de série: 45942/349
Año de Construcción: 1968
Horas Totales de la Célula: 46825
Ciclos: 41688
Motores: 4 Pratt & Whitney JT3D-3B
Tripulación: Fatalidades: 3 / Ocupantes: 3
Pasajeros: Fatalidades: 1 / Ocupantes: 1
Total: Fatalidades: 4 / Ocupantes: 4
Víctimas en Tierra: Fatalidades: 1
Daños en la Aeronave: Destruido
Consecuencias: Written off (damaged beyond repair)
Ubicación: Miami International Airport, FL (MIA) ( Estados Unidos de América)
Elevación del lugar del
2 m (7 feet) amsl
accidente:
Fase: Ascenso Inicial (ICL)
Naturaleza: Carga
Aeropuerto de Salida: Miami International Airport, FL (MIA/KMIA), Estados Unidos de América
Santo Domingo-Las Américas International Airport (SDQ/MDSD), República
Aeropuerto de Llegada:
Dominicana
Número de Vuelo: 101A
Descripción:
Fine Air Flight 101 was originally scheduled to depart Miami for Santo Domingo at 09:15 using another DC-8
airplane, N30UA, to carry cargo for Aeromar. Due to a delay of the inbound aircraft, Fine Air substituted
N27UA for N30UA and rescheduled the departure for 12:00. N27UA arrived at Miami at 09:31 from San Juan,
Puerto Rico, and was parked at the Fine Air hangar ramp. The security guard was not aware of the airplane
change, and he instructed Aeromar loaders to load the airplane in accordance with the weight distribution
form he possessed for N30UA. The first cargo pallet for flight 101 was loaded onto N27UA at 10:30 and the
last pallet was loaded at 12:06. The resulting center of gravity (CG) of the accident airplane was near or
even aft of the airplane’s aft CG limit. After the three crew members and the security guard had boarded
the plane, the cabin door `was closed at 12:22. Eleven minutes later the flight obtained taxi clearance for
runway 27R. The Miami tower controller cleared flight 101 for takeoff at 12:34. Takeoff power was selected
and the DC-8 moved down the runway. The flightcrew performed an elevator check at 80 knots. Fourteen
seconds later the sound of a thump was heard. Just after calling V1 a second thump was heard. Two seconds
later the airplane rotated. Immediately after takeoff the airplane pitched nose-up and entered a stall. The
DC-8 recovered briefly from the stall, and stalled again. The airplane impacted terrain in a tail first, right
wing down attitude. it slid west across a road (72nd Avenue) and into the International Airport Center at
28th Street and burst into flames.
Investigation showed that the center of gravity resulted in the airplane’s trim being mis-set by at least 1.5
units airplane nose up, which presented the flightcrew with a pitch control problem on takeoff.

Probable Cause:

PROBABLE CAUSE: "The National Transportation Safety Board determines that the probable cause of the
accident, which resulted from the airplane being misloaded to produce a more aft center of gravity and a
correspondingly incorrect stabilizer trim setting that precipitated an extreme pitch-up at rotation, was (1)
the failure of Fine Air to exercise operational control over the cargo loading process; and (2) the failure of
Aeromar to load the airplane as specified by Fine Air. Contributing to the accident was the failure of the FAA
to adequately monitor Fine Airs operational control responsibilities for cargo loading and the failure of the
FAA to ensure that known cargo-related deficiencies were corrected at Fine Air."

Board Meeting : Uncontrolled Impact with Terrain, Fine Air Flight 101,
Douglas DC-8-61, Miami, Florida, August 7, 1997
6/16/1998 12:00 AM
Executive Summary

On August 7, 1997, at 1236 eastern daylight time, a Douglas DC-8-61, N27UA, operated by Fine Airlines Inc. (Fine Air) as flight
101, crashed after takeoff from runway 27R at Miami International Airport, Miami, Florida. The three flightcrew members and one
security guard on board were killed, and a motorist was killed on the ground. The airplane was destroyed by impact and a
postcrash fire. The cargo flight, with a scheduled destination of Santo Domingo, Dominican Republic, was conducted on an
instrument flight rules flight plan and operated under Title 14 Code of Federal Regulations Part 121 as a Supplemental air carrier.
The National Transportation Safety Board determines that the probable cause of the accident, which resulted from the airplane
being misloaded to produce a more aft center of gravity and a correspondingly incorrect stabilizer trim setting that precipitated an
extreme pitch-up at rotation, was (1) the failure of Fine Air to exercise operational control over the cargo loading process; and (2)
the failure of Aeromar to load the airplane as specified by Fine Air. Contributing to the accident was the failure of the Federal
Aviation Administration (FAA) to adequately monitor Fine Air's operational control responsibilities for cargo loading and the failure
of the FAA to ensure that known cargo-related deficiencies were corrected at Fine Air.

Safety issues discussed in this report include the effects of improper cargo loading on airplane performance and handling,
operator oversight of cargo loading and training of cargo loading personnel, the loss of critical flight data recorder information,
and FAA surveillance of cargo carrier operations.

Recommendations

As a result of the investigation of this accident, the National Transportation Safety Board makes the following
recommendations to the Federal Aviation Administration:

Require all 14 Code of Federal Regulations Part 121 air carriers to provide flightcrews with instruction on mistrim cues that
might be available during taxi and initial rotation, and require air carriers using full flight simulators in their training programs
to provide flightcrews with Special Purpose Operational Training that includes an unanticipated pitch mistrim condition
encountered on takeoff. (A-98-44)

Conduct an audit of all Code of Federal Regulations Part 121 supplemental cargo operators to ensure that proper weight and
balance documents are being used, that the forms are based on manufacturer's data or other approved data applicable to the
airplane being operated, and that FAA principal inspectors confirm that the data are entered correctly on the forms. (A-98-45)

Require carriers operating under 14 Code of Federal Regulations Part 121 to develop and use loading checklists to positively
verify that all loading steps have been accomplished for each loaded position on the airplane and that the condition, weight,
and sequencing of each pallet is correct. (A-98-46)

Require training for cargo handling personnel and develop advisory material for carriers operating under 14 Code of Federal
Regulations Part 121 and principal operations inspectors that addresses curriculum content that includes but is not limited to,
weight and balance, cargo handling, cargo restraint, and hazards of misloading and require all operators to provide initial and
recurrent training for cargo handling personnel consistent with this guidance. (A-98-47)

Review the cargo loading procedures of carriers operating under 14 Code of Federal Regulations Part 121 to ensure that
flightcrew requirements for loading oversight are consistent with the loading procedures in use. (A-98-48)

Evaluate the benefit of the STAN (Sum Total Aft and Nose) and similar systems and require, if warranted, the installation of a
system that displays airplane weight and balance and gross weight in the cockpit of transportcategory cargo airplanes. (A-98-
49)

Require all principal inspectors assigned to 14 Code of Federal Regulations Part 121 cargo air carriers to observe, as part of
their annual work program requirements, the complete loading operation including cargo weighing, weight and balance
compliance, flight following, and dispatch of an airplane. (A-98-50)
Review its national aviation safety inspection program and regional aviation safety inspection program inspection procedures
to determine why inspections preceding these accidents failed to identify systemic safety problems at ValuJet and Fine Air
and, based on the findings of this review, modify these inspection procedures to ensure that such systemic indicators are
identified and corrected before they result in an accident. (A-98-51)

Evaluate the surveillance programs to ensure that budget and personnel resources are sufficient and used effectively to
maintain adequate oversight of the operation and maintenance of both passenger and cargo carriers, irrespective of size. (A-
98-52)

Require an immediate readout of all 11-parameter retrofitted flight data recorders (FDRs) to ensure that all mandatory
parameters are being recorded properly; that the FDR system documentation is in compliance with the range, accuracy,
resolution, and recording interval specified in 14 Code of Federal Regulations Part 121, Appendix B; and require that the
readout be retained with each airplane's records. (A-98-53)

Require maintenance checks for all flight data recorders (FDRs) of aircraft operated under 14 Code of Federal
Regulations Parts 121, 129, 125, and 135 every 12 months or after any maintenance affecting the performance of the FDR
system, until the effectiveness of the proposed advisory circular and new FAA inspector guidance on continuing FDR
airworthiness (maintenance and inspections) is proven; further, these checks should require air carriers to attach to the
maintenance job card records a computer printout, or equivalent document, showing recorded data, verifying that the
parameters were functioning properly during the FDR maintenance check and require that this document be part of the
permanent reporting and recordkeeping maintenance system. (A-98-54)

Provide FAA principal avionics inspectors with training that addresses the unique and complex characteristics of flight data
recorder systems. (A-98-55)

Create a national certification team of flight data recorder (FDR) system specialists to approve all supplemental type
certificate changes to FDR systems. (A-98-56)

Direct the principal maintenance inspector assigned to Fine Air to reexamine the airline's continuing analysis and surveillance
program and take action, if necessary, to ensure that repetitive maintenance discrepancies are being identified and
corrected. (A-98-57)

Amend 14 Code of Federal Regulations Part 121.563 to specifically require that all discrepancies be logged when they occur
and be resolved before departure through repair or deferral in consultation with (the certificate holder's or contracted)
maintenance personnel. (A-98-58)

Accident Overview
History of Flight
Photo of Fine Air DC-8
Photo copyright Alan Rossmore - used with permission

Fine Air Flight 101, a McDonnell Douglas DC-8-61, was a scheduled cargo flight from Miami International Airport (MIA), Miami,
Florida, to Santo Domingo, Dominican Republic. The flight had originally been scheduled for a 0915 Eastern Standard Time
(EST) departure with a different airplane. However, the intended airplane was delayed en route, so the accident airplane was
scheduled as a replacement. The accident airplane N27UA arrived at MIA at approximately 0930, and was parked at the Fine Air
ramp.

Flight 101 was scheduled to carry cargo for Aeromar C por A (Aeromar), a Dominican Republic corporation operating out of
Miami. The first cargo pallet was loaded onto the accident airplane shortly before 1000, and the crew was notified to arrive for a
1200 departure. Following crew arrival, and a preflight inspection performed by the flight engineer, the crew started engines, and
requested taxi clearance at approximately 1230. The airplane was cleared to taxi to runway 27R, and during the one minute taxi,
the crew performed control checks. At 1234:31, the flight was cleared for takeoff, and the airplane began its takeoff roll at 1235.
The investigation determined, via the cockpit voice recorder (CVR), that the first officer was flying the airplane.

Photo of Accident airplane just after takeoff


Photo copyright Aad Rehorst - used with permission
Photo of Fine Air DC-8 accident
Photo copyright Aad Rehorst - used with permission

During takeoff rotation, the CVR recorded the captain saying, "easy, easy, easy easy," in response to what the investigators later
concluded was a more rapid than normal rotation, resulting from the airplane's extreme aft loading, and an incorrect stabilizer
trim setting. Seven seconds later, following liftoff, the first officer called, "gear up," followed almost immediately by, "what's going
on?" Within one second the sound of the stabilizer trim in motion was recorded, rapidly followed by the sound of the stick shaker
(stall warning). Over the next seven seconds, the stabilizer trim was used multiple times, as recorded on the CVR, in what the
investigators concluded were attempts to trim the airplane nose down, and help correct an increasing pitch attitude. The stick
shaker briefly stopped approximately 14 seconds after the "gear up" call, but was reinitiated 5.8 seconds later, and continued
until impact.

A Fine Air captain who witnessed the accident stated that takeoff rotation was "not smooth," and that after the airplane became
airborne, it attained an extreme pitch attitude, making it possible to see the tops of the wings and fuselage. An MIA tower
controller stated that after rotation the airplane pitched up to approximately 70 degrees before the nose dropped. He stated that
the airplane crashed in a tail first attitude with the right wing slightly low.

The airplane crashed at 1236:25.4, approximately 30 seconds after lifting off. The airplane crashed about 3000 feet west of the
departure end of runway 27R. Wreckage extended roughly along the extended runway centerline for 575 feet beyond the initial
point of impact. The four people on board the airplane, and one person on the ground were killed. The airplane was destroyed by
impact and postcrash fire.

Fine Air and Aeromar


On November 10, 1992, Fine Airline Services, Inc. (Fine Air) received FAA authorization to operate under 14 CFR part 119.21 as
a supplemental cargo carrier, and further to operate under 14 CFR part 121. The company was incorporated in 1989 to provide
cargo services between the United States and the Central America and Caribbean regions. At the time of the accident, Fine Air
had a "wet lease" agreement with Aeromar, a freight forwarding company. Aeromar was established in 1968, and had offices in
Miami, and Santo Domingo, Dominican Republic.

In May, 1997, Fine Air and Aeromar signed a "wet lease" agreement, under which Fine Air agreed to carry Aeromar's freight.
Aeromar agreed to "provide fuel, loading and unloading at all stops, landing fees, duties, permits, over flight, taxes, parking
fees....ground handling and all other flight related expenses." The agreement further specified that Fine Air would maintain
operational control of the aircraft at all times, and Fine Air would utilize their own flight crewmembers. Training and airplane
maintenance would be conducted under Fine Air; and servicing of the aircraft would be done under the supervision of Fine Air
employees. Aircraft dispatch functions were also to be performed by Fine Air personnel.
Photo of Fine Air Crash Site

In October, 1997, in a letter to Fine Air, the FAA characterized the "wet lease" agreements as transportation agreements,
perhaps even charter agreements, but reiterated that since Fine Air intended to operate under 14 CFR part 121, no aspect of
operational control could be negotiated away from Fine Air. The letter further stated that " the loading of cargo as it relates to
weight and balance requirements, cargo restraint requirements and hazardous materials requirements, is an aspect of
operational control and must be under the control of, and be the responsibility of, Fine Air Services, Inc."

Results of inspections, one conducted by the Department of Defense, and another by the FAA, noted a number of discrepancies
in Fine Air's operations. Most notably, as related to this accident, the FAA found discrepancies with regard to weight and balance
procedures. The inspection determined that Fine Air had "no standards and schedules for the calibration of commercial scales
used to determine cargo weights at Miami" and "loading schedules instructions...do not include instruction for calculation of
weight and balance." The FAA inspection team also determined that Fine Air manuals did not "include procedures for weighing
aircraft required by 14 CFR Part 121.135(b)(20)."

Weight and Balance diagram from Accident Airplane


– From NTSB Accident Report
View Larger

Cargo Loading
For normal operations, actual loading of cargo was performed and supervised by Aeromar personnel. At the time of the accident,
for operations conducted at Miami, Fine Air personnel did not actively, or regularly, participate in supervision of cargo loading.
Fine Air did perform the weight and balance calculations associated with a given flight, and transmitted the loading information to
Aeromar, but did not verify that the airplane was loaded in accordance with the transmitted loading instructions. Per Fine Air
operational procedures, the flight engineer was responsible to verify the loading and weight and balance of the airplane, and to
verify that at least three pallet locks were engaged in an occupied posiiton. During the investigation, a Fine Air representative
acknowledged however, that it would be considered unusal for a flight engineer to perform this inspection during routine
operations in Miami. This was considered an action more related to "outstation" operation, at locations other than Miami.
Photo of Ball Mat System on a 747-400

Aeromar loading personnel did not receive any classroom training, but rather were trained by participating in actual aircraft
loading. Investigators concluded that this was an effective method of training relative to the physical loading of the airplane, but
concluded that the significance of effects that cargo loading and distribution could have on airplane center of gravity, and
consequently on airplane handling characteristics, were not understood by loading personnel. Flight 101 had originally been
scheduled for another airplane. The intended airplane, N30UA was delayed en route, and would not arrive in time for its
scheduled departure as flight 101. Aeromar therefore requested another airplane. Fine Air substituted the accident airplane,
N27UA, and rescheduled the departure. This change of airplanes required a series of significant paperwork changes to
accommodate the different airplane. Original loading documents for N30UA had stated a cargo weight of 87, 923 pounds, an
airplane Center of Gravity (CG) of 30 percent of Mean Aerodynamic Chord (MAC), and a corresponding takeoff trim setting of 2.4
units airplane nose up (ANU). Pallet positions 2 and 17 were scheduled to be empty. To accommodate the weight limitations for
N27UA, the replacement airplane, which was slightly heavier than N30UA, weight and balance calculations were redone, and the
pallet loading sequence was modified to provide a takeoff CG of 30 percent for the replacement airplane. The modified pallet
loading sequence required moving the pallet in position 13 to position 17, and leaving position 13 vacant. Additionally, 1000
pounds of weight needed to be removed from position 10. Fine Air stated that the redefined load sheet was faxed to Aeromar,
but the investigation could find no evidence that the Aeromar security guard, who was responsible for the cargo, picked up, or
was aware of, the revised paperwork. As a result, investigators determined that the replacement airplane, N27UA, was originally
loaded per the instructions intended for N30UA.

Photo of Properly loaded and netted cargo pallets


Photo copyright Steven Fox - used with permission

The accident airplane was equipped with a cargo handling system intended to accommodate eighteen 88 by 125 inch pallets.
Palletized cargo was loaded through the cargo door in the front of the fuselage via a hydraulic lift and conveyor system to move
pallets into the airplane. Once inside the cargo door, the pallets move on a "ball mat," which is a floor mounted device containing
roller balls that allow the cargo to be rotated in any direction. Aft of the ball mat, a pallet retention system (floor locks) was
installed to provide restraint for palletized cargo.
The cargo floor was configured with five guide tracks, with encased roller bearings to ease movement of cargo pallets forward or
aft of the main cargo door. Retractable pallet locks, referred to as "bear traps" were installed at 89 inch intervals along the guide
tracks. Each of the 85 pallet locks included a folding lock mechanism, allowing pallets to move over them, and were comprised of
both a forward, and aft pawl, in order to restrain cargo both forward and aft of the locking mechanism. When raised, and locked
in position, the locks engage the edges of adjoining cargo pallets and provide both longitudinal and vertical restraint. Additional
rails were installed along the cabin walls to prevent cargo contacting the sidewalls of the airplane fuselage. The loading system
was designed such that pallets 1 through 17 were to be loaded with the 88 inch dimension longitudinal to the fuselage, and pallet
18, since it would be installed in the tapering portion of the aft fuselage would be rotated 90 degrees such that the 125 inc h
dimension was longitudinal. A video illustrating the functioning of the cargo locks is available at the following link: Bear Traps

Illustration of Available Pallet Positions

On the accident flight, the cargo was cut denim material that was delivered to the Aeromar warehouse by a freight transfer agent.
Shipping documents indicated that the cargo weighed 89,719 pounds. The cargo was weighed after arriving at the Aeromar
warehouse, and again after having been palletized. The initial weighing confirmed the weight listed on the shipping documents,
and the second weighing listed the weight as 88923 pounds.

According to the accident report, about 39000 pounds of cargo arrived in rectangular polyethylene wrapped containers known as
"big paks," and the remaining approximately 51000 pounds was contained in boxes. All of the cargo was loaded onto pallets, in
preparation for loading onto the accident airplane. Four big paks were arranged onto a pallet, and two more were stacked on top
of these. The pallets themselves were large, flat metal sheets, resembling a "cookie sheet." This entire arrangement was then
wrapped in black plastic, and secured to the pallet with netting, which was roped to the corners of the pallet. The boxed cargo
had also been loaded onto pallets at the Aeromar warehouse.

Photo of Fine Air Cargo Loading


Photo copyright Marlo Plate - used with permission

In information conveyed to the investigators, it was stated that the cargo weight did not include the weight of each metal pallet,
covering, or netting. Because of this oversight, the weight of the payload was incorrect by as much as 4,400 lbs.

The cargo loading process involved five "loaders," a loading supervisor, and a security guard. A Fine Air supervisor was also
present, but was driving a forklift, and not functioning in a supervisory capacity. The Aeromar loading supervisor told
investigators that he was responsible for managing the loading process, and ensuring that all pallet locks were in place when the
loading was complete. The security guard was responsible to mark the pallets with their assigned position, and to tell the loaders
where to position each pallet. The security guard had the weight and balance information as computed for the flight, although
investigators determined that he may not have picked up revised loading instructions transmitted to Aeromar when the load was
recalculated for the replacement airplane. Pallets were individually identified by letter, "A" through "P," in this case, and then
identified by number for their position on the airplane. For example, pallet "A" was identified to be placed in position 18, the most
aft location.
Photo of Pallet lock in locked position
Photo copyright Steve Fox - used with permission

Illustration of Pallet lock depicted in the locked position


View Larger

A pallet was loaded into position 18 (the aft end of the cargo compartment), and position 17 was left vacant. The pallet locks
were placed up in front of position 17, and pallets were loaded forward of that position. The loading supervisor told investigators
that as subsequent pallets were loaded, the pallet locks could not be extended. This was the result of cargo extending beyond
the edges of the pallets, preventing the pallets from fitting snugly against each other, and interfering with the pallet locks. An
examination by the loading supervisor determined that pallets locks were not engaged on pallet positions 3 through 10. Three
pallets were removed and following a conversation between the Aeromar loading supervisor and the Fine Air supervisor; the Fine
Air supervisor told the loaders to move everything aft such that the vacant position 17 was occupied. He also told them to turn
pallet 4 around. Investigators determined that, based on statements from the Fine Air supervisor, he had intended that pallet 4 be
rotated 180 degrees, enabling engagement of the pallet locks, but his order was misinterpreted, and the pallet was only rotated
90 degrees. This pallet, which now occupied all of position 5, and part of position 4, was then tied down and secured with snap
rings, and the locks were engaged at the forward end of the pallet.

Following the loading of the cargo, investigators determined, based on statements from the Fine Air supervisor that pallet
positions 1 and 3 were occupied, and the locks were engaged. Pallet position 2 was empty. The pallet in position 4 was rotated
90 degrees from its intended position, and all other positions aft of pallet 4 were occupied, including position 17, which was
specified in loading instructions to be empty. Thus, the final loading did not reflect either of the planned loads for N30UA or
N27UA.

Following the accident, investigators found "considerable evidence" that few of the cargo locks were engaged. Sixty cargo locks
(of the 85 installed) were recovered, and of those 60, 57 were found in the unlocked position, and there was no evidence that
locks had failed during the accident.

Weight and Balance


The NTSB accident report listed the weight and balance for Flight 101 as follows:

Basic Operating Weight: 145,949 pounds


Cargo Weight: 87,823 pounds
Zero Fuel Weight: 233,982 pounds
Maximum Zero Fuel Weight: 234,000 pounds
Takeoff Fuel: 48,500 pounds
Gross Takeoff Weight: 282,482 pounds
Maximum Takeoff Weight (Runway 27R): 315,400 pounds
Maximum Landing Weight: 252,000 pounds
Fuel Burn to SDQ: 31,875 pounds
Center of Gravity: 30.0 percent mean aerodynamic chord (MAC)
Aft CG Limit: 33.1 percent MAC
Stabilizer trim setting: 2.4 units
Takeoff Flap Setting: 15 degrees

Photo of DC-8 cargo deck showing rollers and cargo locks


Photo copyright Carsten Bauer - used with permission

Photo of Wreckage showing unlocked pallet lock - NTSB docket photo

Investigators determined that the load sheet for the accident airplane contained a number of errors. Following the accident, it was
determined that the weight listed for the pallet in position 17 was low by 100 pounds. Further, load calculations accounted for
1000 pounds of weight that was supposed to have been removed from the pallet in position 10, but, in fact, was not removed.
Therefore, the cargo weight should have been 88923 pounds, rather than the 87823 pounds that was used in the weight and
balance calculations.

It was also determined that the load sheet used for the accident airplane was for a DC-8-62/63. The accident airplane was a DC-
8-61. This error resulted in an airplane center of gravity that was farther forward than shown on the load sheet. Also, according to
investigators, the weight for the pallet in position 18 (the most aft) was listed as 6088 pounds. Post-accident calculations
revealed that the maximum weight at this position should not have exceeded 3780 pounds.
Based on testimony from the cargo loaders, the investigation determined that the accident airplane had originally been loaded
per the plan specified for the originally designated airplane (N30UA), with positions 2 and 17 empty. Based on testimony, a
second loading scenario was developed by the investigation. Relative to the intended loading configuration, pallets in position 5
and aft were moved back one position, thereby occupying position 17. Pallet 4 was rotated 90 degrees, and pushed back into
position 5, overlapping into part of position 4. This assumed scenario also included 6950 pounds loaded onto the pallet in
position 10 (including 1000 pounds that had not been removed). This loading resulted in a calculated CG of 32.4 percent MAC.
The addition of 275 pounds (4400 pounds total) per pallet, to account for the weights of the pallet, and packing materials, moved
the CG slightly further aft to 32.7 percent MAC. With an assumed cargo weight of 88, 923 pounds, moving 13 pallets aft, and
rotating pallet 4, the CG moved aft from 24 percent MAC with a recommended takeoff trim setting of 5.4 units ANU, to 32.4
percent MAC requiring a trim setting of 1.0 unit ANU. Assuming a cargo weight of 94119 pounds, which accounted for the
additional weight of packing material on each pallet, the calculated CG became 32.8 percent MAC, requiring a trim setting of .9
units ANU. When correctly set, the stabilizer trim setting will cause the airplane to be "in trim," requiring very little pilot control
force, at a specific, scheduled airspeed following liftoff. An animation illustrating the effects of various cargo loadings and the
flight path of the airplane after takeoff is available at the following link: Effects of Cargo Loading
In 2011, the Ground Handling Operations Safety Team (GHOST), a British Civil Aviation Authority (CAA)/industry group
committed to develop strategies to mitigate the safety risks from aircraft ground handling and ground support activities, released
a video titled "Safety in the Balance." The video explains airplane loading, and the critical effects that weight and balance can
have on flight safety. The 21 minute video is available at the following link: Safety in the Balance
Horizontal Stabilizer Trim

Photo of DC-8 Horizontal Stabilizer


Photo copyright Edward Kehler - used with permission

The horizontal stabilizer is an inverted airfoil providing a counteracting force to the wing lift and pitching moments, and the aircraft
weight. The horizontal stabilizer balances the forces to maintain a desired pitch attitude or speed. The horizontal stabilizer is
composed of two main components, the trimmable stabilizer, and elevator. The stabilizer is moved by an electrical switch on
either pilot's control wheel, or alternatively, by a pair of handles, known as "suitcase handles," due to their resemblance, located
next to the captain's seat. The stabilizer position (trim setting) is also indicated next to the captain's seat. When trimming the
airplane, the horizontal stabilizer is moved by an electric motor, attached to a jack screw.
Training Manual Description of DC-8 Trim Controls- illustration
The terms center of lift and center of gravity are commonly used to reference locations where lift and weight are acting. The
center of gravity will move forward or aft over a small range as fuel is used. The center of lift can move forward or aft due to
changes in lift resulting from speed or weight changes (fuel burn). Additionally, the center of lift moves aft as Mach number
increases. On swept wing aircraft, due to the wing sweep, the center of lift and center of gravity have a greater range of
movement. This in turn requires a larger balancing force from the horizontal stabilizer. The effects of various loading schemes on
airplane center of gravity and horizontal stabilizer position is illustrated in the following animation: Airplane CG

Illustration of Effect of Stabilizer Trim on Balancing Tail Load

Airplane Handling Characteristics and Flight Crew Actions


Following the accident, the NTSB conducted a series of piloted simulations intended to evaluate airplane handling characteristics
throughout the range of weights and centers of gravity that may have existed for the accident flight. Test results at a CG of 33
percent MAC suggested that the airplane retained sufficient control authority to prevent the pitch up and stall. AT 35 percent
MAC, events progressed much more rapidly, and though sufficient control authority was available to control or prevent the pitch
up and stall, pilot action was required to be immediate. Pilots in the simulation exercises commented that their efforts to control
the airplane were successful largely because they were anticipating the pitch up characteristics. Test conditions at CG positions
aft of 35 percent MAC exhibited increasing early rotation and pitch up characteristics, not representative of the flight recorder
data. Based on comparison with flight recorder data, investigators concluded that the CG at takeoff was near, or even slightly aft
of the aft limit of 33.1 percent MAC.
Photo of DC-8 Flight Deck – Trim indicator is to left of throttle levers
Photo copyright Luis H Aular – used with Permission
View Larger

Photo of a Typical Cargo Pallet

Weight and balance information provided to the flight crew listed an airplane center of gravity at 30 percent MAC, based on the
load plan prepared by dispatchers. Considering another loading scenario, resulting from testimony of Aeromar cargo loaders,
Fine Air personnel, and documented pallet weights, investigators calculated a takeoff CG of 32.8 percent MAC. Investigators also
noted that a relatively small addition to, or redistribution of cargo could have moved the CG aft of the 33.1 percent aft limit. The
numerous loading errors, and errors in documentation, made it impossible for investigators to precisely determine the weight and
CG at takeoff. The cargo weight of 88,923 pounds could actually have been as high as 94,119 pounds, 5,196 pounds heavier
than listed on the airplane load sheet. Depending on the weight distribution in the cargo compartment, this could have had a
significant effect on airplane handling characteristics during takeoff.

Investigators concluded that the flight crew recognized a problem in the airplane pitch response almost immediately upon
rotation. A CG position more aft than calculated, in combination with a trim setting based on a more forward CG (trim setting
would be more nose up than necessary) would exacerbate the pitch up characteristic, and require a more immediate reaction by
the flight crew than was actually performed. Investigators believed that an immediate and abrupt forward control motion was
counterintuitive to the crew, and explained the delay in making full nose down control inputs. There was also a delay in
application of nose down trim inputs which further inhibited recovery from the pitch up. Investigators stated that if the first officer
had been more aggressive in applying both nose down elevator and trim, he might have been able to control the pitch up and
avoid stalling the airplane. The safety board ultimately concluded that the mistrim of the airplane, based on incorrectly loaded
cargo, "presented the flightcrew with a situation that, without prior training or experience, required exceptional skills and reactions
that cannot be expected of a typical line pilot."

Conclusion
The NTSB concluded that this accident was the result of multiple errors made during cargo loading, and calculation of the
airplane center of gravity. Investigators determined that the airplane weight and center of gravity had been significantly
miscalculated, and the resultant takeoff trim settings provided to the crew were incorrect. The NTSB further concluded that while
the airplane retained sufficient control authority to effect a recovery from the rapid pitchup, the crew had not been trained to
expect, or respond to, the encountered situation, especially in light of their having properly set the takeoff trim according to the
dispatch paperwork. The NTSB did not fault the crew for their operation of the airplane.
Following the accident, Fine Air instituted a new training program for cargo loaders, covering "Aerodynamics, Physics and Theory
of Flight," including aircraft weight, lift, stalls, center of lift, and CG. In another training area, "Weight and Balance for Ground
Handlers," subjects included "proper use of company weight and balance data" and "effects of improper weight distribution on
flight characteristics." A section on pallet building outlines the "proper use of the warehouse load sheet," cargo and weight
distribution, legal ramifications if pallet weights are not correct, and the importance of correct weights on aircraft performance."
Proper cargo loading procedures and installation of pallet locks were also included in the curriculum.

Vuelo 101 de Fine Air


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Vuelo 101 de Fine Air

Fine Air DC-8-61F N29UA, nave hermana del avión del accidente

Accidente

Fecha 7 de agosto de 1997

Resumen Pérdida de control en el despegue debido a una


carga incorrecta de la aeronave

Sitio Aeropuerto Internacional de Miami , Florida ,


Estados Unidos

Muertes totales 5 (4 tripulantes y 1 en tierra)

Aeronave

Tipo de aeronave McDonnell Douglas DC-8-61 (F)

Operador Buen aire

Registro N27UA
Origen del vuelo Aeropuerto Internacional de Miami

Destino Aeropuerto Internacional Las Américas

Ocupantes 4

Los pasajeros 1

Personal 3

Fatalidades 4

Sobrevivientes 0

Bajas terrestres

Muertes en tierra 1

El vuelo 101 de Fine Air era un vuelo de carga programado desde el Aeropuerto Internacional de Miami al
Aeropuerto Internacional de Las Américas , operado por McDonnell Douglas DC-8-61F N27UA, que se estrelló
después del despegue el 7 de agosto de 1997 en el Aeropuerto Internacional de Miami. [1] Las 4 personas a
bordo y una persona en el suelo fueron asesinadas. [2] [3]

Contenido

 1aeronave
 2Tripulación y pasajero
 3Crash
 4determinacion NTSB
 5En la cultura popular.
 6referencias

Avion [ editar ]
El avión involucrado en el accidente fue un McDonnell Douglas DC-8-61F de 29 años , C / n / msn: 45942/349,
registro N27UA, operado por Fine Air , con un total de horas de fuselaje de avión de 46,825 y 41,688 ciclos.

Tripulación y pasajeros [ editar ]


Había tres miembros de la tripulación y un guardia de seguridad a bordo. El Capitán, Dale Patrick "Pat"
Thompson, de 42 años, ha estado con Fine Air desde 1993. Tuvo un total de 12,154 horas de vuelo,
incluyendo 2,522 horas como capitán del DC-8 en Fine Air. El primer oficial, Steven Petrosky, de 26 años de
edad, contratado el 15 de agosto de 1994, tenía un total de 2,641 horas de vuelo, de las cuales 1,592 horas
fueron con Fine Air en DC-8 y registraron 614 horas como primer oficial y 978 horas como vuelo. Ingeniero,
todo en el DC-8. El ingeniero de vuelo Glen Millington, de 35 años, se unió a Fine Air en 1996. Había
registrado un total de 1,570 horas de vuelo, incluidas 683 horas como ingeniero de vuelo DC-8 en Fine Air.
Crash [ editar ]
Esta sección no cita ninguna fuente . Por favor, ayuda a mejorar esta
sección mediante la adición de citas de fuentes confiables . El material sin fuente
puede ser desafiado y eliminado . ( Febrero de 2018 ) ( Aprenda cómo y cuándo eliminar este
mensaje de plantilla )

La aeronave, con destino a Santo Domingo , perdió el control poco después de la V1 . Tras la rotación, la
carga se desplazó hacia la popa en la cubierta de carga principal porque ninguno de los candados de la
plataforma estaba enganchado verticalmente a las plataformas de carga en la plataforma principal. El avión se
cargó con dos posiciones de paletas vacías que permitieron un desplazamiento significativo del centro de
gravedad hacia la popa hacia los espacios vacíos.
Las entrevistas a la tripulación en tierra encontraron que el vuelo estaba rutinariamente lleno de paletas y que
las cerraduras rara vez estaban involucradas en algunas opiniones, y además se dijo que esto se debía a que
se pensaba que eran irrelevantes si las paletas no se podían mover. Los palets se sujetan por rieles a los
lados para que no se muevan en dirección ascendente, pero solo los seguros retráctiles se pueden detener
hacia adelante y hacia atrás. El exceso de inclinación en la rotación en V1 hizo que la aeronave se inclinara
bruscamente hasta el punto de que el flujo de aire hacia los motores se redujo significativamente (similar a
soplar a través de la apertura de una botella de soda para hacerla silbar por la caída de presión) y causando
Los motores se detienen. El avión luego se inclinó hacia atrás aterrizando boca abajo sobre su vientre en el
suelo. Además, la aeronave estaba sobrecargada aproximadamente 2700 kg. aunque dado el proceso de
pesaje de palés, se creía que esto era más común de lo que se pensaba de antemano. Los pilotos, que
partían de la antigua pista 27R (ahora 26L) intentaron recuperarse, pero la aeronave detenida no tenía ningún
empuje hacia delante, lo que hacía que las superficies de control fueran inútiles. La aeronave de lanzamiento
hacia adelante perdió rápidamente el impulso hacia adelante y levanta con sus alas cortando el flujo de aire
perpendicular a la orientación de levantamiento adecuada. El DC-8 se estrelló en su vientre en un campo
directamente al oeste del final de la pista (aproximadamente 300 yardas) viajando en línea recta. La aeronave
de lanzamiento hacia adelante perdió rápidamente el impulso hacia adelante y levanta con sus alas cortando
el flujo de aire perpendicular a la orientación de levantamiento adecuada. El DC-8 se estrelló en su vientre en
un campo directamente al oeste del final de la pista (aproximadamente 300 yardas) viajando en línea recta. La
aeronave de lanzamiento hacia adelante perdió rápidamente el impulso hacia adelante y levanta con sus alas
cortando el flujo de aire perpendicular a la orientación de levantamiento adecuada. El DC-8 se estrelló en su
vientre en un campo directamente al oeste del final de la pista (aproximadamente 300 yardas) viajando en
línea recta.
El DC-8 perdió la instalación de carga de transporte automático en el extremo sur del Miami City Rail Yard
justo al norte del final de la pista, y también las instalaciones de operaciones de carga ocupadas a lo largo del
muy ocupado alimentador de la calle NW 25th al área de carga del aeropuerto solo para El sur del final de la
pista. La aeronave apenas perdió dos fábricas, un edificio comercial y el Centro de Distribución Budweiser en
una zona no incorporada de Miami, Florida, entre los suburbios residenciales más poblados de Miami Springs
y Doral. Se deslizó a través del campo abierto y en NW 72nd Ave, una carretera que normalmente está llena
de tráfico durante la hora del almuerzo, pero estaba sorprendentemente tranquila a las 12: 36p EST cuando
se detuvo. Los restos del avión se deslizaron rápidamente a través de la carretera y en el estacionamiento de
un mini-centro comercial al otro lado de la calle del campo vacío; Sacó 26 autos en el lote. En ese momento,
el mini centro comercial era un centro de distribuidores de partes de computadoras que se especializaba en el
comercio sudamericano.
Los restos del avión quedaron a cuatro pies de las entradas de tres tiendas. Echaba de menos dos
automóviles ocupados y un camión que esperaba la señal de tráfico en la intersección de NW 31st Street y
NW 72nd Avenue, a menos de 30 yardas (27 m) de distancia. Dentro de uno de los autos en el
estacionamiento estaba sentado un hombre que acababa de llegar a su tienda en el mini-centro comercial
después de recoger el almuerzo para él y su esposa. No pudo salir del auto y quedó atrapado en la bola de
fuego que envolvía la avenida de varios carriles, el campo y el estacionamiento.
Cinco personas murieron en total: los tres miembros de la tripulación, un guardia de seguridad de la compañía
en el vuelo y el hombre en el estacionamiento. En los minutos posteriores al choque, la policía fue alertada de
un incendio en NW 72nd Ave, solo para descubrir que era un accidente aéreo. Durante casi 45 minutos,
informes mixtos afirmaron que el avión era un vuelo de pasajeros, pero dentro de la hora, la torre de control en
MIA confirmó que era el vuelo 101 de Fine Air Cargo. Agentes especiales de seguridad de la FAA que
trabajan en una oficina en una propiedad del aeropuerto (en ese momento) respondieron a la escena y
simultáneamente a las oficinas de Fine Air Cargo donde tomaron posesión de la documentación del vuelo. Se
recuperó parte de la documentación relevante de los recipientes de basura, lo que provocó la apertura de una
investigación criminal y, en última instancia, los cargos de destrucción y encubrimiento de pruebas.

Determinación NTSB [ editar ]


La Junta Nacional de Seguridad del Transporte determina que la causa probable del accidente, que resultó de
una carga incorrecta del avión para producir un centro de gravedad más a popa y un ajuste de ajuste del
estabilizador correspondiente incorrecto que precipitó una inclinación extrema en la rotación, fue (1) la
incapacidad de Fine Air para ejercer el control operativo sobre el proceso de carga de carga; y (2) la falla de
Aeromar para cargar el avión según lo especificado por Fine Air. Contribuyó al accidente el hecho de que la
Administración Federal de Aviación (FAA) no supervisara adecuadamente las responsabilidades de control
operacional de Fine Air para la carga de carga y que la FAA no se asegurara de que las deficiencias
conocidas relacionadas con la carga se corrigieran en Fine Air. [4]