timothycummings

Essential Thoughts for Mission Essential Professionals

TWELVE MISTAKES, NINE MILES HIGH AND SIXTEEN MINUTES FROM HOME

Flight 107 baaa-acro.com Flight 107 baaa-acro.com

A TRILOGY OF MISSION COMPLACENCY

Part One: Twelve Mistakes: Touchdown on the Highway

On the morning of Saturday, May 30, 1970, an oddly plaintive, rumbling sound loudly travelling northeast to southwest, forged a path over my head. The sky was overcast and I did not see the source of the noise but I knew what it was. It was an airplane in trouble, its engines laboring greatly, and for it to be as loud as it was, I knew it was too low to the ground. Less than four miles away it completed its fall from the sky.

Minutes earlier, Flight 701, a chartered plane carrying passengers to Florida, had taken off from the DeKalb Peachtree Airport, ten miles northeast of downtown Atlanta. It flew into an overcast sky with a low ceiling, the cloud cover a mere 400 feet above the ground, light rain falling through fog making visibility one mile. The aircraft, chartered to fly twenty-nine prospective real estate buyers to Florida, was a Martin 404 with a passenger capacity of forty. The crew consisted of a captain, first officer, and two flight attendants. Eight days earlier the nineteen-year old plane successfully underwent its annual inspection and had flown only seventeen hours since the inspection. Its two radial piston engines each turned a 3-blade propeller with a diameter just over thirteen-feet.

Before take-off, a flight attendant asked passengers sitting at the back of the cabin to move up nearer the front to balance the plane. Moving from their seats in the rear of the seventy five-foot long aircraft may have saved their lives. The normal pre-flight activities were taking place in the cockpit as, outside, a fuel truck manned by two men pulled up. One was a Navy veteran with some experience around aircraft, the other worked for the company anywhere from sixteen- to twenty-hours on weekends and attended a technical school on weekdays. Their employer had no formalized training program or an established system of checking the knowledge of linemen who refueled the planes. Instead, the manager relied on new employees picking up what they needed to know from their more experienced co-workers. The linemen fueling the plane had both worked for the fuel company less than a year. The senior of the two men decided these engines had been converted into turbo-prop engines and use the kerosene-based fuel known as “Jet A” instead of the aviation fuel (“Avgas”) they really burned.

Captain James Cannin, a 57-year old man with nearly 26,000 hours of command time and 1,200 hours flying a Martin 404, instructed First Officer Robert Feldmiller to observe the refueling of the aircraft. From two different locations, under a wing and also from a hangar, probably to avoid the moderate rainfall at the time, he watched the refueling but did not notice the words “TURBO FUEL” in large letters on both sides of the fuel truck nor “JET A” in two places on the right side of the truck parked next to his plane. Neither did he notice the placard placed next to the fuel meter by the linemen which read “TURBO FUEL FLAMMABLE”. The unobservant first officer, despite having over 1,700 hours in 404s, failed to see that the type of fuel being added was incompatible with the engines on which his life would depend minutes.

To the linemen, it was business as usual. They knew they were adding the lower octane jet fuel, and intended to do so due to their misidentification of the engine type. The lineman who selected which fuel to use assumed the 404’s engines had been converted because he had seen similar looking aircraft that did use Jet A turbo fuel. As fuel flowed through a nozzle-mounted hose, the full-time lineman operated the fuel truck and the part-time lineman was on the first wing, and later, the second, handling the nozzle. To access the fill port on each side, he removed a cover plate for each of the overwing fuel filler caps that were clearly marked “Fuel – 100 OCTANE MIN.” Had he been thinking he would have realized what he was preparing to send into the wing tanks was the wrong fuel, but instead, one hundred gallons of Jet A fuel was added to each wing tank. The plane’s total fuel load would then be 800 gallons which was 58% of the Martin’s total fuel capacity, more than enough to make it to Fort Myers. They also added fifty-seven quarts of reciprocating engine oil, which should have alerted them to their error on the choice of fuel: Why put reciprocating oil in a turbo-prop engine which is not a reciprocating engine. It is a turbine engine. When refueling had been completed, Feldmiller drained the fuel sumps but did not detect any water or contamination. In fact, the entire fuel supply was now contaminated because of the mixing of the two mismatched fuels. The captain asked the full-time lineman to also drain the sumps. He noted the fuel had kerosene in it because it was “slippery” but still hadn’t made the connection between the fuel and the oil he had just added.

Martin 404 Engine by Chris Cummings

The sales slip was presented to Captain Cannin. This was the final hope the fueling mistake would be understood, but sadly, he did not notice what the form said: fuel grade JET, quantity 200 gallons, price $0.46 per gallon, total amount $92.00. In his hands was paperwork which unmistakably stated his plane just took on an incompatible fuel type. If he missed that information, he still could have taken action had he noticed the cost: The Avgas they expected to have taken on cost $0.34 per gallon, not the $0.46 shown and would have made the amount on the slip $68.00. In all, a dozen errors were made: Misidentifying the engine type by the senior lineman (#1), ignoring the markings on the overwing fill ports by the junior lineman (#2, #3), the First Officer not taking note of the truck markings and placard (#4, #5, #6, #7), the addition of reciprocating engine oil (#8), failure by both the senior lineman and first officer to understand what their fuel inspections actually meant (#9, #10), and finally, the failure of the Captain to read and understand what the sales slip said by way of the fuel type and cost of the fuel clearly written on it (#11, #12). All of this would create a manmade storm through which they would not be able to fly. The last Saturday in May, 1970 had just been needlessly altered for themselves and the flight attendants, their passengers and an entire family doing their grocery shopping with a neighbor boy fifteen miles away.

Flight 107 had a normal engine start and run up. The engines checked out just fine so they taxied to runway 2 Right and took off. As they climbed to their assigned altitude of 4,000 feet, the water injection system used to increase thrust was turned off and the crew made contact with Atlanta Departure Control who identified them on the radar. While still climbing, engine number 2 experienced detonation and/or preignition conditions, either of which would brutally affect it. As its temperature increased it swiftly lost power. The engine, rated for 2,400 horsepower during take-off and 1,800 horsepower in normal flight, showed on cockpit instrumentation as producing a useless 100 horsepower, benefitting the plane little. The pilots also observed its fuel flow rate had decreased perilously below normal. Deciding it was due to carburetor icing, they turned on heat to clear the carburetor of ice, started its fuel boost pump and pushed the throttle of the left side engine, number 1, to maximum. Turning the heat on was precisely the wrong reaction – it would exacerbate the overheating problem dramatically. When the cylinder head temperature pegged out at 300 degrees Fahrenheit, the highest reading on their gauge, they opened the cowl flap to stream outside air over the cylinder head to cool it and used the engine primer in an increasingly desperate fight to stay in flight. This action would also have an result completely different than what they intended. What little cooling that was gained was ineffective because of the extreme temperature, but more importantly, an open cowl added drag and disrupted the aerodynamic configuration of the airframe.

Five minutes after going “wheels up” the captain declared an emergency at 9:21 am and was given clearance to Atlanta International Airport and as instructed, flew on a vector heading of 200 degrees to avoid high antennas. It was still overcast and they continued to lose altitude.

At 9:27 am, about the time they passed over me, they saw that the cylinder head temperature for engine 1 was rising rapidly to an equally unsafe level as number 2 did minutes before. Feldmiller open its cowl flaps to cool it off. With both cowls open, the proper thrust/drag balance was destroyed. And then, even as their new destination was being readied to bring them in, engine 1 stopped producing power. The crew felt the plane yaw as it had nothing to power its flight. They were eleven miles away from the main airport flying what amounted to a 43,500 lbs. glider. Just then, they broke through the low ceiling formed by the incessant cloud layer and Cannin saw Interstate Highway 285. He knew it was their only chance of landing in a relatively open space in the built and populated environment below them. On the radio they reported they were over an expressway. Then, with almost no discernible pause: “We’re going down.”

Captain Cannin skillfully brought the plane in, missing a high voltage line and bridge in his path before his Martin 404 touched the earth one last time. Controllers tried to contact the flight at 9:28 am but there was no reply. The tortured journey in the air was over. A whole new nightmare was bursting forth on the ground.

Gripped in the fight of their lives coaxing their plane to the airport, the pilots hadn’t announced anything to the passengers. The “No Smoking” sign was off and some were smoking as the irrevocably dead plane soared downward. The right main and nose landing gear were down and locked and wing flaps were retracted. Some passengers suspected a crash was imminent as they saw how close the highway was and seeing trees pass but the amount of time since penetrating the clouds and seizing the opportunity to land had been so brief the impact astonished everyone.

Captain Cannin made the emergency landing on the grass strip between the west- and eastbound lanes. The plane slid for 1,200 feet and due to the left landing gear not being locked in position, started turning steadily to the left, causing it to cross over the eastbound lanes, where it immediately slid over a car with the Barron family inside. Jim, Pat and their sons Steve and Burt were joined by 7-year old Danny Rosher, a neighbor who went shopping with them that ordinary Saturday. All five were killed.

Cabin Looking Aft by Chris Cummings

The plane, with the car pinned underneath, traveled 2,600 feet down the highway surface then slid up an embankment, which seconds before had been a nondescript on ramp from Moreland Avenue, then smashed into the top of the bridge abutment at the same time the left wing was broken into three sections. At the same time the last half of the plane was sheared away. Beginning just behind the wings, the violence dealt by the impact and long slide westward was increased by riding on top of the Barron’s car and completed when the immovable bridge broke the plane in an upward forty-five degree angle cut starting at the plane’s bottom all the way to the top of the fuselage. A hole as big as the cabin itself was created and everything from mid-section of the passenger cabin was gone. A flight attendant, who had risen seconds before impact to retrieve a notebook which had fallen from the overhead, was propelled rearward even though the captain landed on the only suitable terrain, the strip of median separating the north lanes from the lanes on its south side. A passenger who attempted to grab her as she flew past was unsuccessful, and she was thrown out the ugly opening left when the rest of the plane ripped away as she was flying backward towards it. She landed among seats that had been ripped from their floor mounts, and amidst this path of wreckage, she would survive.

In a continuous movement the plane jumped over the abutment and rotated to the right, stopping on the bridge facing slightly to the northwest. The fuel tank contained in the wing was breached but no fire resulted. Inside the plane, passenger Delma Mathes was mortally injured but would be the only fatality on the plane. In all, twenty-seven passengers and the crew of four needed medical attention and some injuries were very serious. My across-the-street friend’s father was a district fire chief and responded to the site. He agreed that the scene, as one police officer described it, “was horrible”. An hour and fifteen minutes after the crash, the National Transportation Safety Board was notified of the crash which took six lives and it mobilized to investigate the mishap.

The NTSB recognized that two hundred gallons of Jet A fuel lowered the octane rating of the correct fuel onboard, causing higher engine temperatures, severe internal detonation and “extensive and sustained” power loss. Its report concluded the “probable cause of this accident was the loss of effective engine power because of improper fuel having been placed in the tanks by relatively untrained personnel. A contributing factor was that the flight crew did not detect the error.”

As one who heard the plane pitifully thunder over, I wouldn’t have said “probable”.

The aircraft was mechanically and structurally suitable for flight that day and all other pre-flight checks were satisfactorily completed. The crash and resulting loss of 6 lives was set in motion when the lineman assumed the Martin 404 had converted turbo-prop engines. He probably made up his mind without even seeing the aircraft since the fuel truck he drove over had only one fuel type on it: Jet A. That, along with the following eleven mistakes were made because every person was detached from their duties. They were complacent. How could four professionals neglect confirming the fuel type was correct? Flying planes involves several mission essential items. Are you and your staff trained to resist mission complacency?

To write “Touchdown on the Highway”, I relied a great deal on the NTSB report and archival news sources and am grateful I learned Mrs. Barron’s name was Pat from her cousin who posted on line. And lastly: The most useful source for the piece was my own memory. Forty-three years hence, the sound of Flight 107 floundering, not flying, over me has not diminished.

“TWELVE MISTAKES: Touchdown on the Highway” is the first of a three part series. Parts two and three address the orbiters Challenger and Columbia. Please watch for the rest of TWELVE MISTAKES, NINE MILES HIGH AND SIXTEEN MINUTES FROM HOME – A Trilogy of Mission Complacency:
Part Two: Nine Miles High: Incident at Max Q
Part Three: Sixteen Minutes From Home: No Commonality

Postscript: The NTSB recommended to the Administrator of the Federal Aviation Administration that changes be made to the regulations to provide an adequate color coding system for aircraft refueling. Not only were fill points on planes color coded for the correct fuel, fuel itself was manufactured with dye so handlers had another means to verify that fuel type they were handling was the correct one for the plane they were servicing. The dozen mistakes made before chartered Flight 107 got underway have saved countless lives.

A special thanks to Chris Cummings for permission to use his photographs of a restored Martin 404. To view more of his wonderful images visit http://www.chriscummings.cc/air/Musuem,%20Flights%20and%20Air%20Shows/Airline%20History%20Musuem%20(Connie,%20404)/Martin%20404/index.html

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This entry was posted on April 20, 2013 by .
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