Kansas City International Airport
Aircraft Accident/Incident Report

Kansas City, Missouri 64195
Thursday, February 16, 1995 20:27 CST

NTSB Narrative Summary Released at Completion of Accident

THE AIRPLANE CRASHED IMMEDIATELY AFTER LIFTOFF DURING A THREE-ENGINE TAKEOFF. FLIGHTCREW HAD SHORTENED REST BREAK; REST PERIODS NOT REQUIRED FOR FERRY FLIGHTS. FLIGHTCREW FATIGUED FROM LACK OF REST, SLEEP, AND DISRUPTION OF CIRCADIAN RHYTHMS. FLIGHTCREW DID NOT HAVE ADEQUATE, REALISTIC TRAINING IN THREE-ENGINE TAKEOFF TECHNIQUES OR PROCEDURES. FLIGHTCREW DID NOT ADEQUATELY UNDERSTAND THREE-ENGINE TAKEOFF PROCEDURES, INCLUDING SIGNIFICANCE OF VMCG. FLIGHT ENGINEER IMPROPERLY DETERMINED VMCG SPEED, RESULTING IN VALUE 9 KNOTS TOO LOW. DURING FIRST TAKEOFF ATTEMPT, CAPTAIN APPLIED POWER TO ASYMMETRICAL ENGINE TOO SOON, WAS UNABLE TO MAINTAIN DIRECTIONAL CONTROL, AND REJECTED THE TAKEOFF. CAPTAIN AGREED TO MODIFY PROCEDURE BY ALLOWING FLIGHT ENGINEER TO ADVANCE THROTTLE, A DEVIATION OF PRESCRIBED PROCEDURE. FAA OVERSIGHT OF OPERATOR WAS INADEQUATE BECAUSE THE POI AND GEOGRAPHIC INSPECTORS WERE UNABLE TO EFFECTIVELY MONITOR DOMESTIC CREW TRAINING AND INTERNATIONAL OPERATIONS. EXISTING FAR PART 121 FLIGHT TIME LIMITS & REST REQUIREMENTS THAT PERTAINED TO THE FLIGHTS THAT THE FLIGHTCREW FLEW PRIOR TO THE FERRY FLIGHTS DID NOT APPLY TO THE FERRY FLIGHTS FLOWN UNDER FAR PART 91. CURRENT ONE-ENGINE INOPERATIVE TAKEOFF PROCEDURES DO NOT PROVIDE ADEQUATE RUDDER AVAILABILITY FOR CORRECTING DIRECTIONAL DEVIATIONS DURING THE TAKEOFF ROLL COMPATIBLE WITH THE ACHIEVEMENT OF MAXIMUM ASYMMETRIC THRUST AT AN APPROPRIATE SPEED GREATER THAN GROUND MINIMUM CONTROL SPEED.

NTSB Probable Cause Narrative

(1) THE LOSS OF DIRECTIONAL CONTROL BY THE PILOT IN COMMAND DURING THE TAKEOFF ROLL, AND HIS DECISION TO CONTINUE THE TAKEOFF AND INITIATE A ROTATION BELOW THE COMPUTED ROTATION AIRSPEED, RESULTING IN A PREMATURE LIFTOFF, FURTHER LOSS OF CONTROL AND COLLISION WITH THE TERRAIN. (2) THE FLIGHTCREW'S LACK OF UNDERSTANDING OF THE THREE-ENGINE TAKEOFF PROCEDURES, AND THEIR DECISION TO MODIFY THOSE PROCEDURES. (3) THE FAILURE OF THE COMPANY TO ENSURE THAT THE FLIGHTCREW HAD ADEQUATE EXPERIENCE, TRAINING, AND REST TO CONDUCT THE NONROUTINE FLIGHT. CONTRIBUTING TO THE ACCIDENT WAS THE INADEQUACY OF FEDERAL AVIATION ADMINISTRATION OVERSIGHT OF AIR TRANSPORT INTERNATIONAL AND FEDERAL AVIATION ADMINISTRATION FLIGHT AND DUTY TIME REGULATIONS THAT PERMITTED A SUBSTANTIALLY REDUCED FLIGHTCREW REST PERIOD WHEN CONDUCTING A NONREVENUE FERRY FLIGHT UNDER 14 CODE OF FEDERAL REGULATIONS PART 91. (NTSB REPORT AAR-95/06)

Event Information

Type of Event Accident
Event Date 2/16/1995
Event Day of the Week Thursday
Time of Event 2027
Event Time Zone Central Standard Time
Event City KANSAS CITY
Event State MISSOURI
Event Country --
Zipcode of the event site 64195
Event Date Year 1995
Event Date Month 2
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude --
Event Location Longitude --
Event Location Airport KANSAS CITY INTERNATIONAL
Event Location Nearest Airport ID MKC
Indicates whether the acc/inc occurred off or on an airport On Airport
Distance from airport in statute miles 1
Degrees magnetic from airport 280
Airport Elevation 1026
Weather Briefing Completeness Not pertinent
Investigator's weather source Weather Observation Facility
Time of the weather observation 1950 Central Standard Time
Direction of event from weather observation facility (degrees) 110
Weather Observation Facility ID KCI
Elevation of weather observation facility 1019
Distance of event from weather observation facility (units?) 1
Time Zone of the weather observation CST
Lighting Conditions Night/Dark
Lowest Ceiling Height --
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 20
Air Temperature at event time (in degrees celsius) -1
Dew Point at event time (in degress fahrenheit) --
Wind Direction (degrees magnetic) 210
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 4
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) --
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries 0
On Ground, Minor Injuries 0
On Ground, Serious Injuries 0
Injury Total Fatal 3
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 3
Investigating Agency NTSB
NTSB Docket Number (internal use) 1265
NTSB Notification Source --
NTSB Notification Date Feb 16 1995 12:00AM
NTSB Notification Time 2130
Fiche Number and/or location -used to find docket information IMAGE
Date of most recent change to record May 13 2002 2:12PM
User who most recently changed record NTSB\HAMG
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N782AL
NTSB Number DCA95MA020
Missing Aircraft Indicator N
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage Destroyed
Aircraft Fire Ground
Aircraft Explosion Ground
Aircraft Manufacturer's Full Name Douglas
Aircraft Model DC-8-63
Aircraft Series Identifier DC-8-63
Aircraft Serial Number 45929
Certified Max Gross Weight 220226
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft --
Number of Engines 4
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection 100 Hour
Date of Last Inspection Feb 11 1995 12:00AM
Airframe hours since last inspection 12
Airframe Hours 77096
ELT Installed No
ELT Activated Unknown
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name Airolease Finiancial Group Trustee
Aircraft Owner Street Address --
Aircraft Owner City Miami
Aircraft Owner State FL
Aircraft Owner Country USA
Aircraft Owner Zipcode --
Operator is an individual? No
Operator Name AIR TRANSPORT INTERNATIONAL LIMITED LIABILITY CO
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address 3800 Rodney Parham Road
Operator City Little Rock
Operator State AR
Operator Country USA
Operator Zip code 72212
Operator Code IXXA
Owner has at least one certificate --
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Ferry
Second Pilot on Board Yes
Departure Point Same as Event Yes
Departure Airport Code MCI
Departure City --
Departure State --
Departure Country --
Departure Time 227
Departure Time Zone CST
Destination Same as Local Flt --
Destination Airport Code CEF
Destination City WESTOVER AFB
Destination State MA
Destination Country USA
Specific Phase of Flight Takeoff
Report sent to ICAO? --
Evacuation occurred No
Date of most recent change to record May 13 2002 2:11PM
User who most recently changed record NTSB\HAMG
Since inspection or accident Time of Accident
Event Location Runway Number and Location 1L
Runway Length 10801
Runway Width 150
Sight Seeing flight No
Air Medical Flight No
Medical Flight --