1947 — July 13, Burke Air Transport flies into ground (pilots asleep?), 4M SW Melbourne, FL–14

Compiled by Wayne Blanchard 10-12-2023 for upload to: https://www.usdeadlyevents.com/

–14  Aviation Safety Network. Burke Air Transport crash SW of Melbourne FL, 7-13-1947.

–14  Civil Aeronautics Board. AIR. Burke Air Transport – Melbourne, Florida, July 13, 1947.

Narrative Information

Civil Aeronautics Board, Accident Investigation Report:

“The Accident 

“At approximately 0430, July 13, 1947…a DC-3C airplane owned and operated by Andrew J. Burke, crashed 4 miles southwest of Melbourne, Florida. The aircraft was destroyed and of the 36 occupants, 12 passengers and the two pilots were fatally injured.

“History of the Flight 

“The flight originated in San Juan, Puerto Rico, July 11, 1947, departing at 1445, for Newark, New Jersey. Henry Hein was pilot for the entire flight, however, Roderick MacKinnon, the co-pilot, joined the flight in Miami, Florida, flying to Miami from San Juan at approximately the same time as co-pilot in another DC-3 airplane, NC-79023. The third member of the crew was Maria Riveria, stewardess. Several intermediate stops were made, the first being at Ciudad Trujillo, Dominican Republic, where additional northbound passengers were taken aboard. The flight then proceeded to Miami, landing at 2235. It was serviced, and at 2354 again took off. The next landing was made at Augusta, Georgia, at 0439, July 12, 1947 After a brief stop there of six minutes the trip continued, and at 0812 the flight arrived in Baltimore where the airplane was fueled to capacity. At 0930, the flight took off for Newark, arriving at Newark at 1035 the morning of July 12, 1947.

“In Newark the fuel tanks were filled to capacity, 33 passengers were taken aboard, and at 1845, July 12, 1947, 8 hours after arrival in Newark, the flight took off with the same crew for the return trip to San Juan. A landing was made at Augusta just after midnight, 0013, July 13, 1947, at which time 150 gallons of fuel were taken aboard. At 0134 the flight departed for Miami.

“The last communication from the crew was at 0303, the morning of July 13, at which time they reported to the Jacksonville Airway radio that they were at 2,000 feet. One and one-half hours later the aircraft was observed approximately 2 1/2 miles west of Melbourne, Florida, flying southeast at an altitude of from 300 to 500 feet. The engines were heard to sputter and misfire as the aircraft proceeded ahead on a straight course. Altitude was gradually lost, the landing lights were turned on, and seconds later the aircraft struck the ground *** 1/2 miles southwest of Melbourne.

“Investigation

“No radio contact was made with Melbourne Radio, nor was there any indication that Captain Hein attempted to reach the Melbourne-Eau Gallie Airport. This airport is located 3 miles northwest of the city of Melbourne, and is equipped with a lighted tetrahedron and a revolving beacon. NC-79024 passed 3 miles to the right of this field and crashed approximately 6 miles south of it. Malabar Field could possibly have been used. It was only 2 miles west of the point of the crash, however, this field was not lighted and Captain Hein may not have been aware of its location. The “fasten seat belt” sign over the forward compartment door was never lighted, nor was any warning or instruction given to the passengers to fasten their seat belts. An examination of all safety belts in the aircraft indicated that none, including those in the cock-pit, had been buckled.

“Propeller markings on the ground, and gouges made by the engine nacelles indicated that the aircraft struck the ground in nearly a level attitude, and at a very low angle of descent. A great deal of tearing and crushing resulted, however, from the trees and tree stumps which studded the area in which the airplane crashed….Though the fuselage and empennage had been badly torn by tree stumps, all control cables and surfaces were accounted for. An inspection of them indicated no structural failure or mechanical malfunction prior to the time of impact. The flaps and landing gear were found in a fully retracted position….

“Maintenance was at first accomplished in Newark and Miami. Two months prior to the accident Mr. Burke transferred this activity to a repair agency in San Juan after which only “turn around” maintenance was done in Newark. The facilities of the repair agency in San Juan were inspected. It was found that no hangars were available, that many parts installed in engines and aircraft were used parts, and that equipment to test spark plugs, ignition harnesses, and other engine and aircraft components either did not exist, or had to be borrowed….

“Discussion

“Many deficiencies in maintenance and operation have been found in the activities of this particular non-scheduled carrier. These irregularities do not constitute sufficient facts from which to state categorically the cause of the accident. Considerable evidence does exist, however, from which the probable cause can be deduced.

“The existence of 70 gallons of gasoline in the right main fuel tank and 30 gallons in the right auxiliary would seem to eliminate the possibility of fuel starvation. The flight actually had sufficient fuel in the two right tanks alone to continue to Miami. Since all fuel strainers were found clean and fuel was present in the lines and the carburetors, it appears unlikely that any difficulties were experienced in the operation of the fuel system….

“…this flight was observed flying 2 ½ miles west of Melbourne at 300 to 500 feet. Had the left engine stopped at that time for want of fuel, Captain Hein most certainly would have attempted to obtain additional power from the right engine. Since six spark plugs were defective in that engine, it may have failed to respond to the sudden increase in manifold pressure. Instead of producing full power it may have sputtered and misfired as one of the engines was observed to do by those on the ground.

“The most significant facts are that no warning was given to the passengers to fasten their seat belts, and that the crew did not fasten their own. Had the pilot anticipated a crash landing, it could be expected that he would have turned the ‘fasten seat belt’ warning sign on, or would have at least secured himself. It is also significant that 6 miles, or 2 to 3 minutes, before crashing the pilot passed within 3 miles, of an airport equipped for night landing without turning toward that airport or making any attempt to reach it The only possible conclusion to be reached from these facts is that the emergency, regardless of what its nature may have been, came to the notice of the flight crew suddenly.

“Had mechanical trouble developed in the vicinity of Melbourne, and had Captain Hein maintained the 2,000 foot altitude he reported having over Jacksonville, he would have had little difficulty in reaching the Melbourne-Eau Gallie airport for an emergency landing. If trouble occurred prior to the time of reaching the vicinity of Melbourne while the flight was cruising at 2,000 feet, ample time would have been available to report the emergency before descending to 500 feet over Melbourne. It appears, therefore, that not only did the emergency develop suddenly, but also that the low flight over the vicinity of Melbourne did not result because of any mechanical difficulty.

“An additional factor was present. This is to be found in an examination of the pilot’s and co-pilot’s flying time and rest periods during the course of the flight. They both left San Juan at approximately 1445, July 11, and arrived in Miami 7 hours and 47 minutes later. This flight in itself would normally be considered a full day’s flying. But, within an hour and 20 minutes after landing at Miami, Captain Hein and Mr. MacKinnon took off for Newark, arriving at 1035 the next day. These two pilots had at that time been flying, with the exception of short shops at Ciudad Trujillo, Miami, Augusta, and Baltimore, for a period of 19 hours and 45 minutes. Eight hours after their arrival at Newark, they again took off for San Juan. Certainly, the period of 8 hours in Newark was not sufficient for adequate rest, especially in view of the fact that a considerable part of that time was necessarily expended in caring for the aircraft after landing, eating, and in preparation for the flight South. At 1845, the evening of the same day that they had arrived in Newark, they started back on their return trip, and with the exception of an hour and 20 minutes stop at Augusta, flew until 0430 the next morning, the time of the crash.

“In a period of 37 hours and 45 minutes, these two pilots were in the air for more than 23 hours, and had little, if any, opportunity for rest on the ground. There is no direct evidence in the record to indicate that the pilots were asleep, but under such circumstances, it would not be surprising if they were. In fact, it would be more surprising, if while cruising on automatic pilot during the early morning hours, they did not fall asleep.

“Many events in the cockpit immediately prior to the crash can only be surmised. Little imagination is required, however, to visualize the pilots sitting in the semidarkness of the cock-pit, fatigued by long hours of flying, actually asleep as the aircraft cruised on automatic pilot, gradually losing altitude. Then, either by virtue of the loss of power in the left engine, or because of the very imminence of the crash itself, they awoke, confronted with an emergency which neither time or immediate available power permitted them to correct. We cannot know what transpired in the cockpit, but all evidence of record indicates this to be the most probable cause of the accident.

“Findings

“….

“6. Proper records for the maintenance and the operation of the aircraft were not maintained from the date of certification.

“7. The carburetor on the left engine, and 10 spark plugs from both engines were found defective.

“8. The aircraft departed from Newark for subject flight with an overload of 2,047 pounds.

“9. The pilot and the co-pilot had less than 8 hours rest on the ground in a period of 37 hours and 45 minutes, 23 of which were spent in the air.

“10. No contact was made by the flight with any airway radio station to report an emergency.

“11. No attempt was made by the crew to land at the Melbourne-Eau Gallie airport, which was equipped for night landing, and located 3 miles east of the aircraft’s flight path, and 6 miles north of the crash.

“12. The safety belts for the flight crew were not fastened, nor did the flight crew warn the passengers to fasten theirs prior to the crash.

“13. The airplane was observed flying 2 ½ miles west of the city of Melbourne at an altitude of from 300 to 500 feet at which time an engine was heard to misfire. The aircraft lost altitude gradually until it struck the ground in nearly a level attitude.

“Probable Cause

“The Board determines that the probable cause of this accident was the pilots flying for long periods of time without adequate rest resulting in their inability to remain fully awake and alert.”  (Civil Aeronautics Board. AIR. Burke Air Transport – Melbourne, Florida, July 13, 1947.)

Sources

Aviation Safety Network, Flight Safety Foundation, Database, 1947. Burke Air Transport DC-3 crash SW of Melbourne FL, 7-13-1947. Accessed 10-12-2023 at:

https://aviation-safety.net/database/record.php?id=19470713-0

Civil Aeronautics Board. Accident Investigation Report. Burke Air Transport – Melbourne, Florida, July 13, 1947 (File No. 1-0071-47). Washington, DC: CAB, 12-9-1947. Accessed 10-12-2023 at: https://rosap.ntl.bts.gov/view/dot/33308