FINE AIR DC-8 ACCIDENT AT MIAMI 07 AUG 1997

(From Flight Safety Foundation website and NTSB accident Report)

Executive Summary

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 flight crew 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 flight crew with a pitch control problem on takeoff.

FINDINGS (Findings that are relevant to pilots are being reproduced here from the NTSB accident report, which can be accessed at http://www.ntsb.gov/doclib/reports/1998/AAR9802.pdf):

• The center of gravity (CG) of the accident airplane was near or even aft of the airplane’s aft CG limit.
• The center of gravity shift resulted in the airplane’s trim being mis-set by at least 1.5 units airplane nose up (2.4 minus 0.9 units at 94,119 pounds).
• The aft center of gravity (CG) location and mis-trimmed stabilizer presented the flight crew with a pitch control problem; however, because the actual CG location could not be determined, the severity of the control problem could not be determined.
• The mistrim of the airplane (based on the 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.

PROBABLE CAUSE: "The National Transportation Safety Board determines that the probable cause of the accident, which resulted from the airplane being mis-loaded 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."