1946 — Oct 17, National Air Transport Service landing crash in adverse weather, Laramie, WY–13
Latest edit 11-5-2023 by Wayne Blanchard for upload to: http://www.usdeadlyevents.com/
— 13 Aviation Safety Network. Accident Descrip. National Air Transport Service, 10-17-1946.
— 13 Bureau of Aircraft Accidents Archives. “Crash of a Douglas C-47 in Laramie: 13 killed.”
— 13 CAB. Accident Investigation Report. Nat. Air Trans. Service, Laramie, WY Oct 17, 1946.
Narrative Information
Aviation Safety Network, Flight Safety Network, Database, 1946, p. 26:
“Date: Thursday 17 October 1946
“Time: 00-57
“Type: Douglas C-47A-20-DK (DC-3)
“Operator: National Sir Transport Service
“Registration: NC38942
“MSN: 12971
….
“Crew: Fatalities: 3 / Occupants: 3
“Passengers: Fatalities: 10 / Occupants: 10
“Total: Fatalities: 13 / Occupants: 13
….
“Location: Laramie, Wy – USA
“Phase: Approach (APR)
“Nature: Domestic Non Scheduled Passenger
“Departure airport: Oakland Municipal Airport – USA
“Destination airport: Cheyenne Airport, WY – USA
“Narrative:
“NATS C-47 registered NC38942 departed Oakland Municipal Airport at 18:42 for a flight to Newark via Cheyenne. Oakland Airway Traffic Control Center authorized instrument flight via Airway Green 3 at an altitude of 11,000 feet to Salt Lake City and 13,000 feet to Cheyenne. At 21:54 Salt Lake ATC instructed the crew to cruise to Cheyenne Airport at 15,000 feet. At that time the weather at Cheyenne was being reported as: ceiling 100 feet, visibility 1/4 mile. By 22:30 the weather at Cheyenne had worsened to a reported zero ceiling and zero visibility. Prior to reaching Laramie the aircraft was cleared from 15,000 feet to 14,000 feet and at 00:05 the flight reported over Laramie. Weather at Laramie was reported ceiling indefinite, 400 feet overcast; visibility 20 miles; light rain. The captain decided to divert to Laramie and he was cleared for an instrument approach. At 00:40 the crew reported outbound on the northwest approach leg preparing for the final instrument approach. By that time visibility had dropped to 2 miles in light snow. Five minutes later the plane passed over the airport at a low altitude. A couple of minutes later the airplane’s left wing tip struck the ground while the aircraft was in a left bank of at least 70 degrees, and while dragging along the ground for a distance of approximately 75 feet, the aircraft crashed and disintegrated. (Aviation Safety Network. National Air Transport Service, 10-17-1946.)
Bureau of Aircraft Accidents Archives:
“Circumstances: Enroute, the crew was informed that weather conditions in Cheyenne were poor and was rerouted to Laramie. Unfortunately, upon arrival, weather conditions were not so good with light snow and a visibility of two miles. The captain decided to attempt to land but was unable to locate the airport and passed over without seeing it. Shortly later, while at an altitude of 75 feet and in a left bank of 70°, the aircraft hit the ground with its left wing, crashed and burned. All 13 occupants were killed.
Civil Aeronautics Board. Accident Investigation Report (Docket No. SA-128, Fine No. 6966-46):
“The Accident
“NC-38942, a Douglas DC-3, owned and operated by NATS Air Transportation Service, crashed near Laramie Airport, Laramie, Wyoming, at 0057 October 17, 1946, while attempting an approach under extremely adverse weather conditions. The aircraft was demolished by impact and all 13 occupants were fatally injured.
“History of the Flight
“NATS Air Transportation Service had arranged a non-scheduled flight between Oakland, California and Newark, New Jersey, originating at Oakland October 16, 1946 and with the first stop scheduled for Cheyenne, Wyoming. NC-38942, hereinafter referred to as Aircraft 942, departed Oakland Municipal Airport at 1842 October 16, 1946 under an instrument flight rules clearance with its destination Cheyenne and its alternate airport Denver, Colorado….
“Prior to reaching Laramie the aircraft was cleared from 15,000 feet to 14,000 feet and at 0005 October 17 the flight reported over Laramie. Laramie Radio informed the pilot of the latest Laramie weather observation: Ceiling indefinite, 400 feet overcast; visibility 20 miles; light rain. In reply to a request from the flight for a change in flight plan to land at Laramie, Denver Airway Traffic Control issued a clearance requiring Aircraft 942 to descend from 14,000 feet to 11,000 feet. ‘if the visibility remains 3 miles at all times.’ However, when this clearance was relayed to the flight by Laramie Radio the pilot replied that he was in the clouds at 14,000 feet and that descent in accordance with contact flight rules would not be possible. An amended clearance was prepared by Airway Traffic Control and the flight was instructed to descend to 11,000 feet on the southeast leg of Laramie Radio Range in order that adequate separation be provided between Aircraft 942 and other flights at lower altitudes on Airway Green 3. Shortly thereafter, Laramie Radio instructed the flight that an instrument approach could be made to Laramie in any manner the pilot desired. At 0025 the flight reported that it was making its descent to 11,000 feet on the right side of the southeast leg. Another report was received from the flight at 0040 when it was outbound on the northwest approach leg preparing for the final instrument approach. At this time Laramie Radio transmitted the 0040 weather observation: Precipitation ceiling 400 feet, sky obscured; visibility 2 miles, light snow.
“Denver Airway Traffic Control became apprehensive concerning the rapidly lowering weather conditions at Laramie and a check was made of the weather conditions at other airports in that area. It was learned that the weather at Sheridan, Wyoming, 245 miles north of Laramie, was satisfactory for contact operations, Since the fuel supply of Aircraft 942 was no known, Denver Airway Traffic Control instructed Larame Radio to obtain a report of the total fuel on board during the next contact with the aircraft. Denver Airway Traffic Control further advised Larame Radio to suggest to the pilot that he proceed to Sheridan if he had enough fuel. This interphone conversation was made between Laramie Radio and Denver Airway Traffic Control at 0050 at which time the weather at Laramie was: Precipitation ceiling 400 feet, sky obscured; visibility ½ mile, snow. However, no further radio contact was had with the aircraft and the information concerning fuel supply was not obtained.
“The aircraft was first seen passing over the airport at a low altitude at 0045. At approximately 0053 one of the aircraft communicators at Laramie, while standing outside the communications building at Laramie Airport, heard the aircraft pass over the field at a low altitude and in an easterly direction. Shortly after the aircraft passed over the airport the engines stopped suddenly and the communicator heard a sound resembling impact of an aircraft with the ground. Subsequent search efforts by the Wyoming State Police and airport personnel disclosed that the aircraft had crashed approximately one mile northeast of Laramie Airport.
“Investigation
“At the time of the accident the aircraft was heading in a northerly direction. The left wing struck the ground while the aircraft was in a left bank of at least 70 degrees, and while dragging along the ground for a distance of approximately 75 feet, the left wing failed at the outer panel attachment. The left engine and landing gear struck the ground almost simultaneously, followed immediately by impact of the nose and the right engine in that sequence. At this point the aircraft disintegrated and parts and contents of the aircraft were strewn in the direction of motion an additional 950 feet.
“Examination of the wreckage disclosed that the landing gear was extended at the time of the accident. The damage sustained by the propellers indicated that both engines were developing considerable power at impact. A measurement of the gasoline in the fuel tanks disclosed approximately 150 gallons remaining. However, inasmuch as the fuel lines were broken as a result of impact, it was estimated that approximately 20 gallons had escaped prior to the time this measurement was taken. No indication was disclosed of malfunctioning of any part of the aircraft while in flight….
“In each Airway Traffic Control Center throughout the United States is located personnel of the Weather Bureau who are assigned to a Flight Advisory Weather Service, commonly referred to as FAWS, whose function it is to assist Airway Traffic Control in providing all pilots in flight with continuous information regarding factors that might affect the safety of their flying operations. Statements of FAWS personnel at both the Salt Lake and Denver centers indicate that during the period of this flight these personnel were completely engaged in such routine meteorological duties as plotting synoptic charts and pseudo adiabatic diagrams, that they were unaware of the presence of Aircraft 942 in their respective regions, and furthermore, that no specific request was made for their assistance by Airway Traffic Control.
“Discussion
“It is apparent that the pilot was forewarned concerning the general weather conditions east of the Continental Divide. At all times after entering the Denver region the flight was provide complete information concerning the actual conditions at its destination and alternate airport. The activities of the aircraft communicators at Laramie indicate that they were cooperating with the flight to the best of their ability. Several reports were furnished to the flight concerning the weather conditions at Laramie and the pilot was well aware of the existing conditions while approaching Laramie. It must be concluded, therefore, that, although the pilot was not informed while en route of the later forecasts for the Denver – Laramie – Cheyenne area, this fact did not materially affect the conduct of the flight in this instance. Having been advised prior to departure from Oakland that he could not except weather conditions at his destination or alternate to remain above minimums throughout the period, it is apparent that the pilot exercised poor judgment in his failure to select an alternate airport outside the area affected by the frontal system in the vicinity of Cheyenne and in his failure to request later information while en route concerning weather conditions forecast for his destination and alternate.
“Having learned that both his destination and alternate had formed to below minimum safe weather conditions and having been advised that the weather at Laramie was being reported as below safe minimums, the pilot would have been expected to request assistance from Laramie Radio in selecting another alternate at which more favorable weather conditions were anticipated. However, the pilot elected to attempt an approach at Laramie. The judgment of the pilot can be questioned, furthermore, because of his repeated attempts at aligning the aircraft with a runway at Laramie after having observed that the weather conditions at that station were extremely adverse. Inasmuch as the pilot at this time had almost two hours fuel aboard it would still have been possible for him to proceed to a suitable alternate for a safe landing. In attempting to keep the field in sight while circling the area at a very low altitude the pilot evidently momentarily lost control of the aircraft by permitting it to bank excessively and before recovery could be completed the wing tip struck the ground and the crash resulted.
“The Flight Advisory Weather Service was instituted jointly by the Civil Aeronautics Administration and the Weather Bureau in order to utilize personnel and facilities most effectively in implementing a weather information service to itinerant pilots. The Board’s study of FAWS operation indicated a lack of clear definition of the responsibility of the various personnel of both agencies who participated in this service, particularly with respect to its initiation to itinerant flights. Although the flight was apparently not affected by the lack of assistance by Airway Traffic Control in providing amended forecasts for the Denver – Laramie – Cheyenne area, it must be concluded that the functions of the Flight Advisory Weather Service were not accomplished in this instance in that the services of the FAWS units in Denver and Salt Lake City were at no time requested by their respective Airway Traffic Control centers. Had there been proper coordination between Airway Traffic Control and the Flight Advisory Weather Service personnel, Airway Traffic Control might have been able to recommend a suitable alternate airport in sufficient time to have avoided the accident. The lack of definition of responsibility indicated above was further reflected in the variance with which this service was administered in the other Civil Aeronautics Administration regions. Since the date of this accident, however, the Civil Aeronautics Administration and the Weather Bureau have revised the manual of standard procedures for flight assistance service and clarified this question adequately. In operations of the nature of this flight, the primary responsibility for issuance of flight information now rests with the airway traffic controller and it is believed that this definition of responsibility will assure improved service in the future.
“Findings
….
- Prior to departure from Oakland, California, the crew were advised of the probability of below minimum weather conditions at both Cheyenne and Denver which were selected as destination and alternate airport, respectively.
“3 Approximately at the time the flight entered the Salt Lake region the forecasts for both Cheyenne and Denver predicted below minimum weather conditions at both stations at approximately the time the aircraft was expected to arrive in that area, but these forecasts were not transmitted to the flight nor was any request made by the pilot for later forecasts.
“4. When the flight was in the vicinity of Salt Lake City, Airway Traffic Control cleared Aircraft 942 to Cheyenne Airport at which weather conditions were being reported as: Ceiling Zero, visibility ¼ mile.
“5. Shortly before reaching Laramie, Wyoming, the flight was advised that the weather conditions at Denver were reported as: Ceiling 500 feet, visibility 10 miles, visibility northwest 4 miles.
“6. Upon reaching Laramie the flight requested and received a change of light plan to land at Laramie and was advised that Laramie weather was being reported at: Ceiling 400 feet, visibility 20 miles.
“7. At 0040, prior to establishing a final instrument approach, the flight was advised that the weather conditions at Laramie were being reported as: Ceiling 400 feet, visibility 2 miles, light snow.
“8. The flight completed its instrument approach and circled for approximately 12 minutes in the vicinity of Laramie Airport attempting to align the aircraft with a runway.
“9. Although Airway Traffic Control attempted to provide the pilot with information concerning a suitable alternate airport while the flight was in the vicinity of Laramie, this message was not initiated in sufficient time to be considered by the flight crew.
“10. The pilot, in attempting to keep the airport in sight, momentarily lost control of the aircraft permitting it to bank excessively and, before recovery could be accomplished, and left wing tip struck the ground.
“11. The aircraft was demolished upon impact and all occupants were fatally injured.
“Probable Cause
“On the basis of the above, the Board determines that the probable cause of this accident was the action of the pilot in maneuvering the aircraft at a dangerously low altitude under extremely adverse weather conditions in an attempt to land. A contributing factor was the negligence of the pilot in planning a flight into an area in which adverse weather conditions were forecast without making adequate provisions for a suitable alternate airport.” (CAB. Accident Investigation Report. Nat. Air Trans. Service, Laramie, WY Oct 17, 1946.)
Sources
Aviation Safety Network, Flight Safety Network, Database, 1946, p. 26. National Air Transport Service, DC-3 approach crash Laramie WY 10-17-1946. Accessed 11-5-2023 at: https://aviation-safety.net/database/record.php?id=19461017-0
Bureau of Aircraft Accidents Archives. “Crash of a Douglas C-47 in Laramie: 13 killed.” Accessed 11-5-2023 at: https://www.baaa-acro.com/zone/wyoming?page=5
Civil Aeronautics Board. Accident Investigation Report. NATS Air Transportation Service, Laramie, Wyoming, October 17, 1946. Washington, DC: CAB, July 30, 1947, 14 pages. Accessed at: https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwj8h9bMp62CAxV2nokEHUp6CZcQFnoECA8QAQ&url=https%3A%2F%2Frosap.ntl.bts.gov%2Fview%2Fdot%2F33284%2Fdot_33284_DS1.pdf%3F&usg=AOvVaw1sG24llTskFJtjTj5tacrx&opi=89978449