Aircraft Accident/Incident Report

San Francisco, California
Tuesady, February 19, 1985 10:16 PST

NTSB Narrative Summary Released at Completion of Accident

WHILE ABV A CLOUD LAYER (TOP AT FL 370) NR THE JET STREAM, AUTOPLT WAS ENGAGED & WAS IN THE PERFORMANCE MNGMNT SYS (PMS)MODE. THE PMS PROVIDED PITCH GUIDANCE TO HOLD FL 410, ROLL GUIDANCE TO AILERONS & SPOILERS FOR ROLL CTL & AUTOTHROTTLE TO MAINT .85 MACH (254 KIAS). ACFT ENCOUNTERED CLR AIR TURBC & AIRSPEED BGN TO VARY BTN .84 & .88 MACH. PMS BGN MOVING THROTTLES FORE & AFT TO HOLD .85 MACH. DRG AUTOTHROTTLE ADJUSTMENTS, #4 ENG THRUST DECREASED & 'HUNG' AT APRX 1.0 EPR & AIRSPEED BGN DECREASING. FLT ENGINEER ATMTD TO MANUALLY RCVR THE #4 ENG THRUST, BUT DID NOT CLOSE THE BLEED AIR VLV BFR ADJUSTING THE #4 THROTTLE. THE #4 ENG REMAINED AT APRX 1.0 EPR. AS THE ACFT SLOWED, AUTOPLT TRIMMED TO HOLD ALT & HDG TIL THE PLT DISENGAGED IT. AT THAT TIME, ACFT ROLLED/YAWED RGT & ENTERED AN UNCTLD DSCNT INTO THE CLOUDS. AS IT BROKE OUT OF THE CLOUDS AT 11,000', CREW RCVRD & LVLD AT 9500'. DRG DSCNT/RCVRY, ACFT WAS DMGD BY ACCELLERATION FORCES & HI SPEED. THERE WAS EVIDENCE THE PLT WAS PREOCCUPIED WITH ENG PRBLM, DIDN'T MONITOR INSTRUMENTS & OVER-RELIED ON AUTOPLT.

NTSB Probable Cause Narrative

Not Yet Reported

Event Information

Type of Event Accident
Event Date 2/19/1985
Event Day of the Week Tuesday
Time of Event 1016
Event Time Zone Pacific Standard Time
Event City SAN FRANCISCO
Event State CALIFORNIA
Event Country --
Zipcode of the event site
Event Date Year 1985
Event Date Month 2
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude --
Event Location Longitude --
Event Location Airport
Event Location Nearest Airport ID
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 0
Degrees magnetic from airport 0
Airport Elevation --
Weather Briefing Completeness Full
Investigator's weather source Pilot
Time of the weather observation 0
Direction of event from weather observation facility (degrees) 0
Weather Observation Facility ID
Elevation of weather observation facility 0
Distance of event from weather observation facility (units?) 0
Time Zone of the weather observation
Lighting Conditions Day
Lowest Ceiling Height 11000
Lowest Non-Ceiling Height 0
Sky/Lowest/Cloud Conditions Unknown
Sky Condition for Lowest Ceiling Unknown
Visibility Runway Visual Range (Feet) 0
Visibility Runway Visual Value (Statute Miles) 0
Visibility (Statute Miles) 0
Air Temperature at event time (in degrees celsius) --
Dew Point at event time (in degress fahrenheit) --
Wind Direction (degrees magnetic) 0
Variable Wind Indicator Unknown
Wind Speed (knots) 0
Wind Velocity Indicator Unknown
Wind Gust Indicator Unknown
Wind Gust (knots) 0
Altimeter Setting at event time (in. Hg) 29
Density Altitude (feet) -24536
Intensity of Precipitation Unknown
METAR weather report --
Event Highest Injury Serious
On Ground, Fatal Injuries 0
On Ground, Minor Injuries 0
On Ground, Serious Injuries 0
Injury Total Fatal --
Injury Total Minor --
Injury Total None 271
Injury Total Serious 2
Injury Total All 2
Investigating Agency NTSB
NTSB Docket Number (internal use) 930
NTSB Notification Source --
NTSB Notification Date Feb 19 1985 12:00AM
NTSB Notification Time 1500
Fiche Number and/or location -used to find docket information 27874
Date of most recent change to record Feb 26 2001 8:35AM
User who most recently changed record dbo
Basic weather conditions Instrument Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N4522V
NTSB Number DCA85AA015
Missing Aircraft Indicator N
Federal Aviation Reg. Part Part 129: Foreign
Type of Flight Plan filed IFR
Flight plan Was Activated? --
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name BOEING
Aircraft Model 747 SP-09
Aircraft Series Identifier 747 SP-09
Aircraft Serial Number 4522V
Certified Max Gross Weight 700500
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/Foreign Oper.
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 279
Number of Engines 4
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection Continuous Airworthiness
Date of Last Inspection Feb 2 1985 12:00AM
Airframe hours since last inspection 206
Airframe Hours 10193
ELT Installed No
ELT Activated Unknown
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name WILMINGTON TRUST COMPANY
Aircraft Owner Street Address
Aircraft Owner City WILMINGTON
Aircraft Owner State DE
Aircraft Owner Country
Aircraft Owner Zipcode
Operator is an individual? --
Operator Name CHINA AIRLINES
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address
Operator City TAIPEI
Operator State OF
Operator Country
Operator Zip code
Operator Code
Owner has at least one certificate Yes - certificate holder
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation Unknown
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not Scheduled
Indicates Domestic or International Flight International
Operator carrying Pax/Cargo/Mail Passenger Only
Type of Flying (Per_Bus / Primary) Unknown
Second Pilot on Board Yes
Departure Point Same as Event No
Departure Airport Code
Departure City TAIPEI
Departure State OF
Departure Country
Departure Time 0
Departure Time Zone
Destination Same as Local Flt --
Destination Airport Code KLAX
Destination City LOS ANGELES
Destination State CA
Destination Country
Specific Phase of Flight Descent
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Sep 28 2001 1:08PM
User who most recently changed record dbo
Since inspection or accident --
Event Location Runway Number and Location 0
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --