1974 — Jan 30, Pan American flight 806 landing crash/fire, Pago-Pago, American Samoa-97

–97 AP. “Pago Pago Crash of Pan Am Jet…Pilot Error.” Republican-Courier, Findlay, OH, 12-20-1974, 11.
–97 Eckert. “Fatal commercial air transport crashes, 1924-1981.” AJFMP, 3/1, Mar 1982, Table 1.
–97 Gero. Aviation Disasters…World’s Major Civil Airliner Crashes Since 1950. 1996, p. 122.
–97 NTSB. AAR. Pan Am World Air…Pago-Pago, American Samoa, Jan 30, 1974. 1974.

Narrative Information
NTSB: “Synopsis

“About 2341, American Samoa standard time, on January 30, 1974, Pan American World Airways Flight 806, crashed 3,865 feet short of runway 5 at Pago-Pago International Airport. The flight was making an ILS approach at night. Of the 101 persons aboard the aircraft, only 5 survived the accident. One survivor died of injuries 9 days after the accident. The aircraft was destroyed by impact and fire.

“The National Transportation Safety Board determines that the probable cause of the accident was the failure of the pilot to correct an excessive rate of descent after the aircraft had passed decision height. The flightcrew did not monitor adequately the flight instruments after they had transitioned to the visual portion of an ILS approach. The flightcrew did not detect the increased rate of descent. Lack of crew coordination resulted in inadequate altitude callouts, inadequate instrument cross¬checks by the pilot not flying the aircraft, and inadequate procedural monitoring by other flight crewmembers. Visual illusions produced by the environment may have caused the crew to perceive incorrectly their alti¬tude above the ground and their distance to the airport. VASI was avail¬able and operating but apparently was not used by the crew to monitor the approach.” (NTSB 1974, 1)

History of the Flight

“On January 30, 1974, Pan American World Airways, Inc., Flight 806, a Boeing 707-321B, N454PA, operated as a scheduled international passenger flight from Auckland, New Zealand, to Los Angeles, California. En route stops included Pago-Pago, American Samoa, and Honolulu, Hawaii.

“Flight 806 departed Auckland at 2014 with 91 passengers and 10 crewmembers on board. It was cleared to Pago-Pago on an instrument flight rules (IFR) flight plan.

“At 2311:55, Flight 806 contacted Pago-Pago Approach Control and reported its position 160 miles south of the Pago-Pago airport. Approach control responded, “Clipper eight zero six, roger, and Pago weather, estimated ceiling one thousand six hundred broken, four thousand broken, the visibility-correction, one thousand overcast. The visibility one zero, light rain shower, temperature seven eight, wind three five zero degrees, one five, and altimeter’s two nine eight five.”

“At 2313:04, Pago-Pago Approach Control cleared the flight to the Pago-Pago VORTAC. Flight 806 reported leaving flight level (FL) 330 at 2316:58 and leaving FL-200 at 2324:40. Pago-Pago Approach Control cleared, the flight at 2324:49: “. . . Clipper eight zero six, you’re cleared for the TLS DEE runway five approach 2/ via the two zero mile arc south-south¬west. Report the arc, and leaving five thousand.” At 2330:51, the flight requested the direction and velocity of the Pago-Pago winds and was told that they were 3600 variable from 020° at 10 to 15 knots.

“At 2334:56, the flight reported out of 5,500 feet and that they had intercepted the 226° radial of the Pago-Pago VOR. The approach con¬troller responded, “Eight oh six, right. Understand inbound on the localizer. Report about three out. No other reported traffic. Winds zero one zero degrees at one five gusting two zero.”

“At 2338:50, Approach Control said, “Clipper eight oh six, appears that we’ve had power failure at the airport.” The copilot replied, “Eight oh six, we’re still getting your VOR, the ILS and the lights are showing.” At 2339:05, Approach Control asked, “See the runway lights?” The flight responded, “That’s Charlie.” The approach controller then said, ” . . . we have a bad rain shower here. I can’t see them from my position here.” At 2339:29, the copilot said, “We’re five DME now and they still look bright.” Approach Control replied, “‘key, no other reported traffic. The wind is zero three zero degrees at two zero, gusting two five. Advise clear of the runway.” At 2339:41, the flight replied, “Eight zero six, wilco.” This was the last radio transmission from the flight.

“According to the cockpit voice recorder (CVR), the last 59 seconds of the flight were routine. The captain asked the first officer about visual reference with the runway, and the first officer answered that the runway was visible. Windshield wipers were turned on and the flaps were set at the 50° position, which completed the checklists for landing.

“At 2340:22.5, the first officer stated, “You’re a little high.” Four seconds later, a sound similar to electric stabilizer trim actuation could be heard on the CVR.

From 2340:29.5 to 2340:34, the radio altimeter warning tone sounded twice. At 2340:33.5, the first officer interrupted the second warning tone with, “You’re at minimums.”

“At 2340:35, the first officer reported, “Field in sight”. Seconds later, the first officer stated, “Turn to your right”, followed by “Hundred and forty knots.” This was the last transmission recorded on the CVR. There had been no comments made by either the flight engineer or the pilot who occupied the jumpseat (as to abnormalities in airspeed, altitude, or rate of descent indications).

“At 2340:42, the aircraft crashed into trees at an elevation of 113 feet and about 3,865 feet short of the runway threshold. The first impact with the ground was about 236 feet farther along the crash path.

“The aircraft continued through the jungle vegetation, struck a 3-foot¬high lava rock wall, and stopped about 3,090 feet from the runway thresh¬old. The aircraft was destroyed by impact and the subsequent fire.

“The accident occurred during the hours of darkness at 14° 20′ 55″ S. latitude and 170° 43’ 55″ W. longitude. There were no ground wit¬nesses to the accident.” (NTSB 1974, 1-3) ….

“Fire was evident during the last 350 feet of the wreckage pattern. The aircraft fuselage from the aft pressure bulkhead forward through the cockpit area was gutted by fire. From the wing trailing edge forward, the top of the fuselage and the fuselage sidewalls were consumed down to a point about 4 feet above the window line. The passenger cabin floor and contents were consumed from the aft pressure bulkhead forward to the cock¬pit.

“The cockpit area was extensively damaged by fire. Many of the instru¬ments and instrument panels were melted, and no valid information was obtained from them.” (NTSB 1974, 8) ….

“Except for the third officer, who occupied the copilot seat, all fatally injured persons died of smoke inhalation, massive first-, second- and third-degree burns, and complications from those massive burns. Toxicological examinations of the casualties revealed, in each case, significant levels of carbon monoxide and hydrogen cyanide. These gases are normal byproducts of aircraft fires. The third officer, who survived the crash but later died of his in¬juries, received traumatic leg and arm injuries and severe burns.” (NTSB 1974, 9) ….

“This was a survivable accident.

“Passengers who survived the accident said that the impact forces were slightly more severe than a normal landing. No damage to the cabin interior was reported. Large fires were seen outside the right side of the air craft. One person opened an overwing exit on the right side of the air¬craft; flames came in through the exit, and he closed it. Other survivors opened the left overwing exits, and all the survivors except the copilot escaped through those exits. The copilot was assisted in his escape by two other cockpit crewmembers and left the aircraft through a hole in the cockpit wall.

“The surviving passengers reported that some passengers rushed toward the front and rear of the cabin before the aircraft stopped. The sur¬vivors did not hear instructions regarding escape from the aircraft after the accident. Most of the survivors suffered burns and other injuries after they escaped from the cabin.

“Postaccident investigation revealed that the forward and the rear entry doors were not opened or used for escape. The forward door was opened about 2 to 3 inches, but the aft door was closed. The forward galley service door could not be identified in the wreckage. The rear galley service door was found in place and locked.” (NTSB 1974, 10) ….

“The aircraft was carrying restricted cargo. The cargo, listed as article No. 727 by the International Air Transport Association (IATA) Restricted Articles Regulation, was Ethyl Methyl Ketone Peroxide (MEK Peroxide). IATA regulations specify the maximum quantity that may be packed in any one outside container is kilogram (one pound) or k litre (one pint). Compatible plastic tubes of not over 5cc (1/6 fluid ounce) capacity each, packed with sufficient noncombustible cushioning and ab¬sorbent material which will not react with the contents and which will prevent breakage or leakage shall be packed in fiberboard containers up to a maximum net quantity of kilogram or k litre. No more than 24 of these containers should be packed into 1 container, providing the net quantity does not exceed 1 kilogram (2 pounds), or 1 litre per container.

“The NEK peroxide was diluted to 59.8 percent peroxide with hydro¬quinone. This inhibitor increased the flashpoint from 1250 F to 1800 F, in addition to inhibiting it chemically. The cargo consisted of 200 20- cc bottles, with 50 bottles per 1 gallon tin. The bottles were placed in plastic bags and then in the tins. Perlite was placed beneath, around, and above the bags. The tins were sealed. The four tins were then placed in a fiberboard carton. The weight of the MEK peroxide in the carton was 4 kilograms.

“The shipper, who was responsible for identifying the material as hazardous, believed that the flashpoint of the material was the only cri¬terion for classifying material as hazardous. Consequently, the freight forwarder and the carrier were not advised that the material was hazard¬ous. Further, since the flight dispatch papers did not identify the material, the flightcrew was unaware of the nature of the cargo.” (NTSB 1974, 10-11) ….

“This was a survivable accident. The cabin remained intact; the crash forces were within human tolerances; and occupant restraint was maintained throughout the accident. The only traumatic injuries were those to the copilot. The survival problems stemmed from postcrash factors.

“Three major postcrash survival problems were: (1) The cabin crew did not open the primary emergency exits, (2) the passenger reactions to the crash, and (3) passenger inattentiveness to the pretakeoff briefing and the passenger information pamphlet….It is unlikely that all of the passengers could have escaped from the aircraft through the left overwing exits. However, it is possible that there would have been more survivors had the passengers acted according to preflight instructions and proceeded to the nearest exit, instead of moving toward the main exits through which they had originally entered.” (NTSB 1974, 14) ….

“The approach was not stabilized, and the aircraft struck the ground short of the runway. This cannot be attributed to a problem with the aircraft or its systems. Therefore, the Safety Board evaluated the opera¬tional and human-factor aspects of the approach, including flightcrew’s training and qualifications, and the effects of illusions during landing approaches at night.” (NTSB 1974, 15) ….

“The captain was flying by reference to his instruments, and he re¬mained on instruments, with the first officer primarily “heads up” until about 2340:13.

“About 700 feet, or 23 seconds, before impact, the captain apparently went visual to complete the landing. Within 3 seconds after the captain went visual, the first officer said, “You’re a little high.” Four seconds later, the CVR recorded a sound similar to the electric stabilizer trim actuator. A major change in the approach profile was recorded. The rate of descent increased from a 690 fpm average to 1,470 fpm and continued at the latter rate until impact.

“The captain probably did not refer to the instrument panel to moni¬tor the ILS presentation, the vertical speed indicator, or the barometric altimeter after he went visual. These flight instruments would have indicated that the aircraft was below the glide slope and was descending too rapidly to complete the landing safely.” (NTSB 1974, 16) ….

“Numerous studies conducted on the effects of the visual illusion phenomenon have established they contribute to disorientation and faulty horizontal distance judgments by flightcrews.

“Rain can affect the pilot’s perception of distance to the approach and runway lights by the diffusion of their glow (haloing) and thus cause the lights to appear less intense. This would lead the pilot to conclude that the lights were farther away than they actually were. On occasion, rain causes lights to appear larger (but not brighter) and the pilot be¬lieves he is closer than he actually is. In either case, the pilot would be prompted to descend to an altitude comparable to the perceived runway elevation.

“Another illusion, runway foreshortening, could have had an effect on the crew. The heavy rain pattern, which was moving slowly down the run¬way toward the approach end, would have caused the physical dimensions of the runway to appear to decrease, thereby leading the pilots to be¬lieve that they were high on the approach.

“Regardless of the illusions present when the descent rate was in¬creased, pilot technique, cockpit discipline, and crew coordination were disregarded when the captain allowed the aircraft to depart from an estab¬lished, normal rate of descent.” (NTSB 1974, 17)
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Sources

Associated Press. “Pago Pago Crash of Pan Am Jet…Pilot Error.” Republican-Courier, Findlay, OH, 12-20-1974, p. 11. Accessed 12-18-2021 at: https://newspaperarchive.com/findlay-republican-courier-dec-20-1974-p-11/

Eckert, William G. “Fatal commercial air transport crashes, 1924-1981.” American Journal of Forensic Medicine and Pathology, Vol. 3, No. 1, March 1982, Table 1.

Gero, David. Aviation Disasters: The World’s Major Civil Airliner Crashes Since 1950 (Second Edition). London: Patrick Stephens Limited, 1996.

National Transportation Safety Board. Aircraft Accident Report. Pan American World Airways, Inc. Boeing 707-321B, N454PA, Pago Pago, American Samoa, January 30, 1974 (NTSB-AAR-74-15). Washington, DC: NTSB, adopted November 8, 1974. Accessed at: http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR74-15.pdf