1965 — Nov 11, United Air 227 Approach Crash, Fire, Salt Lake City Airport, UT — 43

— 43 Aircraft Crashes Record Office (Geneva, Switzerland). Utah.
— 43 AirDisaster.Com. Accident Database. Accident Synopsis 11111965.
— 43 CAB. AAR. United Air Lines…Salt Lake City, Utah, November 11, 1965.
— 43 NFPA. “The Major Fires of 1965.” Fire Journal, Vol. 60, No. 3, May 1966, p. 53.
— 43 NFPA. “The Salt Lake City Airport Crash.” Fire Journal, Vol. 60, No. 4, July 1966, pp. 7.

Narrative Information

AirDisaster.com: “The aircraft impacted approach lights short of the runway while attempting to land in adverse weather conditions.” (AirDisaster.com. Accident Database. Accident Synopsis 11111965.)

CAB: “United Air Lines, Inc., Boeing 727, N7030U, operating as Flight 227, crashed during an attempted landing at Salt Lake City Municipal Airport, Salt Lake City, Utah, at approximately 1752 m.s.l., on November 11, 1965. Of the 85 passengers and a crew of 6 aboard, there were 43 fatalities, including 2 passengers who succumbed in the hospital several days after the accident. The 48 survivors included all crewmembers.

“The flight, scheduled from LaGuardia Airport, New York, to San Francisco International Airport, San Francisco, California, with several intermediate stops, departed Denver at 1654. Shortly after 1748 the flight advised ” . . . Have the runway in sight now, we’ll cancel and standby with you for traffic.” The high, straight-in approach continued under Visual Flight Rules (VFR). Impact occurred 335 feet short of the runway threshold, the main gear sheared, and the aircraft caught fire and slid approximately 2,838 feet on the nose gear and bottom fuselage surface, finally coming to rest approximately 150 feet off the east side of the runway….

“Flight 227 departed Denver at 1654 in accordance with an Instrument Flight Rules (IFR) flight plan. The assigned cruising altitude was Flight Level 310 and the estimated time en route was 57 minutes. Approaching the Salt Lake City area… At 1738:05 the ARTCC controller notified the flight that they were 60 miles east of Lehi and they responded, “Okay we’ll start her down.” The flight proceeded in accordance with radar vectors, passing 5 miles south-southwest of Lehi where a radar handoff to Salt Lake City Approach Control was effected. New clearance altitudes were given during the continuous descent and at 1747:00 the approach controller advised, “United seventy two twenty seven . . . five miles south of Riverton Fan Marker coming on localizer course cleared for ILS runway three four left approach.” At 1748:10, in response to the controller’s request for the aircraft’s altitude, the pilot replied “Okay we’re slowed to two fifty (Knots) and we’re at ten (10,000 feet) we have the runway in sight now, we’ll cancel and standby with you for traffic.” Control of the flight was transferred to the tower and at 1749:40 landing clearance was issued. At 1752:1 the tower controller reported on the interphone to the watch supervisor, “…United’s on fire just landed.” The accident occurred in darkness….

“The initial Impact occurred 335 feet short of the threshold of Runway 34L at Salt Lake City Municipal Airport, and prior to contacting the threshold lights the lights and left main landing gear began to separate from their attachment points. The aft lower portion of the fuselage contacted the runway and the aircraft continued sliding on the fuselage and nose gear approximately 2,838 feet. During the skid it veered to the right and came to rest 150 feet cast of the runway on a heading of 123 degrees. The No. 1 engine separated and came to rest approximately 140 feet north of the aircraft….

“There was no evidence of inflight fire. The survivors who were seated in the aft right portion of the cabin observed the fire initially enter the cabin from under seat 18E (right window seat) and erupt up the inside wall. Time estimates ranged from “immediately” to “one or two seconds after impact.”

“Two airport crash trucks arrived at the accident site within approximately 3-1/2 minutes. They were positioned on either side of the aircraft tail section where the flames seemed to originate. The fire was essentially contained within the fuselage which materially reduced the effectiveness of the fire-fighting efforts. The flames persisted, and there was a temporary cessation of fire-fighting until the water supply could be replenished by additional personnel and equipment from the Salt Lake City Fire Department. These units had been simultaneously notified of the accident and arrived within approximately 10 minutes. The fire was finally brought under control at about 1830.

“This was a survivable accident. There were 91 persons aboard the aircraft and 50 were successful in evacuating, although many were severely burned and some sustained injuries during their egress. The remaining 41 occupants were overcome by dense smoke, intense heat, and flames, or a combination of these factors, before they were able to escape. There were no traumatic injuries which would preclude their escape. Two survivors died in the hospital several days after the accident, bringing the total number of fatalities to 43 passengers.

“All emergency exits were available and used. The sliding windows in the cockpit were actuated and used by the captain and first officer. The press of passengers crowding in the area of the main loading door hampered the attempts of the stewardess to open it. However, the second officer succeeded in opening it completely, inflating the slide, and then directing the evacuation of passengers through this exit. The galley door, on the right side between rows 8 and 9, and the overwing emergency exit windows on either side at rows 12 and 14 were all opened by passengers. The emergency slide at the galley door was not actuated until a UAL stewardess who had been riding as a passenger, was able to instruct a man to activate it. Both were outside the aircraft at that time.

“When the aircraft came to a complete stop, the stewardess who was occupying the jump seat on the aft passenger entry door, opened this door to see if the ventral stairway could be used for egress. However, the nose high attitude of the aircraft due to the extended nose gear and sheared main gear prevented the stairway from opening more than about six inches. Two men who were seated in the aft cabin area, preceded her into the stairwell. When she attempted to return to another exit the flames and smoke had blocked them off. They huddled as far from the approaching fire as possible, and at the suggestion of the stewardess began pounding on the fuselage and yelling to the firemen outside. The stewardess extended her arm through the narrow opening and succeeded in attracting the attention of firemen outside. A hose was passed into the stairwell and one of the men sprayed the surrounding area. All three persons were successfully rescued from the aircraft through the large hole which had burned through the aft cabin wall on the right side. Although there is no exact timetable for this unprecedented rescue it is estimated that the time envelope from impact to discovery of the survivors was approximately 23 minutes and that the rescue was completed between 25 and 30 minutes after the accident.

“The flight crew testified regarding the sequence of events on the final approach as follows:

“CAPTAIN – At approximately 6,500 feet m.s.l. he stopped the first officer from adding power. He estimated that 15-20 seconds later, at approximately 5,500 feet m.s.l., the first officer moved the thrust levers forward. When the engines did not respond, he moved the thrust levers to the takeoff power position, and assumed control of the aircraft. He estimated that this occurred about 1-1/4 miles from the runway at an altitude of 1,000 feet (5,226 feet m.s.l.), and at least 30 seconds prior to impact. Although he glanced at the engine instruments, he did not recall any readings.

FIRST OFFICER – Approximately 1-1/2 to 2 minutes prior to impact he attempted to apply power but the captain advised him to wait. About 30 seconds later he moved the thrust levers half way. When he realized that nothing was happening, he reached to apply full power but the captain was already on the controls. He estimated that full power was applied approximately 5-10 seconds. but no more than 15 seconds prior to impact. He did not observe the engine instruments, and he neither heard nor felt any engine response.

SECOND OFFICER – On short final the first officer started to apply power but the captain brushed his hand away and said “not yet.” Finally the captain applied about half throttle movement 7-8 seconds prior to impact. He did not observe the engine instruments, but he heard the engines respond normally.

Many survivors, including two stewardesses, seated in the aft cabin section, and several eyewitnesses stated that the engines did spool-up 5 prior to impact.

Analysis

“…there is no evidence of…circumstances which would unduly delay response from the three engines. Therefore, it is concluded that if power application had been initiated at the proper time, sufficient power would have been available to successfully complete the landing in the normal manner….

“Approximately one minute prior to impact, the rate of descent was approximately 2,300 feet per minute, nearly three times the recommended rate of descent for landing approaches, and the aircraft was still 1,300 feet above the normal glide slope. The captain’s testimony indicates that it was about this time that he advised the first officer to wait before adding power. He further testified that he realized he was in trouble at 1,000 feet and 1-1/4 miles from the runway. The flight recorder indicates this point was passed about 30 seconds prior to impact. He indicated that thrust lever movement to the takeoff power position had failed to bring a response from the engines, although he did not recall the engine instrument readings. It was his opinion that the best indication of engine response was “. . . the seat of the pants.”

The time estimates between the captain’s power application and impact varied markedly among the flight crew. However, it appears that the 5-10 second estimate of the first officer, and 7-8 second estimate of the second officer are more in consonance with each other, and the testimony of eyewitnesses and passengers than the 30 seconds estimated by the captain…. Despite the high rate of descent and position well above the glide slope portrayed on the instruments, and the previously mentioned guidelines for landing approaches, the crew continued the approach. This action was not only contrary to recommended procedures, but well beyond the parameters which are expected of a prudent pilot….

“Both pilots testified that they had previously experienced the stickshaker during training flights demonstrating approaches to a stall, but in the seconds immediately prior to impact they were reluctant to pull very hard on the control column for fear that the aircraft might stall. The captain did not execute a 360-degree turn in order to lose additional altitude in the approach, because in his judgment it was not needed and if the power had responded at the proper time the descent rate could have been arrested and a normal landing effected. The first officer did not execute a 360-degree turn because it was the captain’s prerogative.

“The entire jet training record of the captain reflects a spread of grading which ranges from unsatisfactory to above average. This variation is typified in his inability to complete the DC-8 training program due to “. . . unsatisfactory performance in the areas of command. judgment. Standard Operating Procedures, landing technique and smoothness and co-ordination.” In the B-720 two years later he received above average grades for his command ability and judgment, qualities which do not normally vary so drastically. Grading on his landing techniques, ILS approaches, and adherence to proper procedures and tolerances also varied through his B-720 and B-727 instrument proficiency checks. Maneuvers rated below average on a given check ride were graded above average on the second attempt or on a subsequent flight, where a recheck was necessary. The comments of the two FAA inspectors who observed the B-720 and B-727 initial qualification flights of the captain give considerable insight into the captain’s attitude. Both inspectors reported that they believed that while the captain had the training and ability to fly the aircraft well, he would deviate from accepted procedures and tolerances enough to make the maneuver unsatisfactory. Repetition of the maneuver following a discussion of the acceptable tolerances would result in a satisfactory performance….

“…the responsibility and authority which the pilot-in-command has in the operation of a transport airplane also requires the exercise of sound judgment. Fulfillment of the pilot-in-command responsibility demands self-discipline in adherence to tested and approved procedures. In this instance the captain did not follow the approved procedure with regard to rate of descent during the final approach to the Salt Lake City Airport.

“The training records of this captain indicated a pattern of below average judgment, as well as a tendency to deviate from standard operating procedures and practices. Indeed, it is significant that in this case the history not only reflects an apparent indifference toward adhering to acceptable procedures and tolerances in general, but specifically during the landing or ILS approach phases of flight.

“The aeronautical knowledge and skill levels required for an airline transport pilot may be determined through testing, but the less tangible aspect of mature judgment may not be so readily measured or determined. Pilot-in-command aptitude should be evaluated through supervisory observation of piloting performance in the carrier’s day to day operation. Safety in air transportation requires the air carrier to identify those pilots in need of more training and train them; and particularly to identify those pilots who are marginal or who have demonstrated a failure to adhere to proven procedures and reassign them to duties compatible with their capabilities and limitations….

“The Board determines the probable cause of this accident was the failure of the captain to take timely action to arrest an excessive descent rate during the landing approach….

“The impact of the crash did not produce any traumatic injuries which would have precluded the escape of every passenger. On the contrary, it was the speed with which the passengers progressed toward the exits that prevented the stewardess from reaching her assigned duty station for evacuation. Following the accident the stewardesses recommended that they be seated near emergency exits for all takeoffs and landings. This practice has been adopted by UAL as standard procedure on all B-727 flights. Inasmuch as all emergency exits were used during the evacuation it is not known how many additional lives, if any, might have been saved if the stewardess had been able to carry out her assignments….

“The Board is concerned that the procedures for pilot testing prevailing at the time of this accident were such that an individual with the pilot behavioral characteristics of the pilot in this case could qualify and be retained as pilot-in-command of a B-727 aircraft. The Board therefore recommends that both the Federal Aviation Agency and the air carriers re-examine existing procedures to the end that all feasible steps may be taken to make sure that airmen who serve as pilots-in-command of commercial aircraft, and in particular high-speed jet aircraft such as the B-727, possess not only the requisite technical skills, but the necessary qualities of prudence, judgment and care as well.

“The Board is also concerned about the loss of life in this survivable accident and recommends that the crash fire prevention research programs underway be pressed with vigor, and that each improvement be incorporated at the earliest possible moment.” (CAB. AAR. United Air Lines… Salt Lake City, Utah, November 11, 1965.)

NFPA: “….The accident to the United Air Lines Boeing 727 at the Salt Lake City Airport at approximately 5:53 pm (MST), November 11, 1965, was, to put it succinctly, a tragedy, and, worst yet, a fire tragedy….

“The following report will concern itself solely with the significant fire factors following initial ground contact, as reported to the NFPA from various authoritative sources.

“After touchdown both main landing gears separated from the aircraft. The right gear, wheels, and main strut were pulled into the fuselage between the wing trailing edge and the intake of the right (No. 3) engine — the location of the rear cargo pit, which lies immediately below the last few rows of passenger seats in the cabin. Almost simultaneously, the left main gear separated from its attach point, traveled to the rear, and cleared the fuselage, but struck the left (No. 1) engine, knocking it loose. The nose gear, however, remained attached and continued to support the aircraft in a nose-high attitude as it skidded down the runway…

“It was the action of the right gear that produced the almost instantaneous outbreak of fire. When this gear punctured the fuselage, the main cabin floor and its supporting members were buckled. Located in this area also, and within a few inches of the “underbelly” skin of the fuselage, were the fuel lines that supplied the No, 2 and No. 3 engines and the alternating cur-rent power buses from the engine-driven–generators. Although the fuel lines are double-walled (with the space between the inner and outer walls void and drained to the outside ), both “walls” (aluminum) were shattered. This allowed fuel — Jet A-kerosene, pres¬surized to 35 psi – to flow into the cargo pit…The electrical lines were also broken by the force of the gear’s impact. Most probably the fuel ignited from the severed electrical buses. One survivor described the resultant fire as a “flame thrower,” on the inside of the cabin as well as outside. It is assumed that the boost pumps continued to pres¬surize the fuel, which flowed for about 25 seconds,’ until the power failed….

“What happened next, only a few seconds after ini¬tial ground contact, appears to have sealed the fate of the 41 passengers who died before they were able to evacuate the aircraft (two other passengers succumbed later in the hospital, raising the total number of fatali¬ties to 43). Of the survivors, all six crew members and 29 of the passengers sustained serious injuries (24, burns; six, third-degree burns); 13 survivors escaped with minor or no injuries.

“The testimony of survivors clearly indicates that the fire was first observed in the aft cabin followed by heavy, dense smoke. Fuel also poured from the broken fuel lines outside the fuselage, supporting a fire below and aft of the No. 3 engine. In an incredibly short time the fire flashed over the cabin interior surfaces, igniting even the clothing of many of the passengers. Within an estimated five seconds, dense black smoke had pene¬trated the upper levels of the cabin all the way to the forward section…As the No. 2 (center) and No. 3 (right) engines decelerated, smoke, products of com¬bustion, and some raw fuel from the exterior fires may have been ingested and forced through the ventila¬tion ducts into the cabin, intensifying the adverse atmospheric conditions within the cabin.

“If the cabin emergency lights did operate, the dense smoke obscured them, so that they were of no value to those seeking escape. The fire in the aft cabin had caused passengers in that area to unbuckle their seat belts and start to move into the aisle and forward. The aircraft had still not come to rest; but when it did, it was in about a 10-degree nose-up attitude. The burning kerosene was giving off very heavy smoke, since at this time there was little free air available for complete combustion of the fuel. Evidence indicates that many passengers became disoriented in the smoke-filled cabin….

“Within about a minute the fire had extended in a “flashover” manner to the front of the cabin, the cause of the flashover being two separate, almost si¬multaneous conditions that certainly affected the sur¬vivability of the cabin for those who had not escaped. First, opening all the emergency exits provided a fresh supply of oxygen ( air) in the cabin. (A light wind was almost directly from the tail.) The unburned products of combustion, which were very heavy in the cabin, were thus ignited by the already severe fire in the aft end of the cabin. Second, the fuel-fed fire in the aft cabin area far exceeded the design criteria of the flame resistance of the cabin interior finishes and materials. The limit of survivability had obviously been reached except for those trapped in the ventral stairwell, and at this point in time the Airport department crash crews either had not yet left their station or were just leaving. Death must have come from massive bronchial spasms producing suffocation following depletion of any air that may have been in the lungs of the victims and forced inhalation of the heated fire gases. Autopsies indicated carboxyhemo¬globin saturations above 10 per cent for 38 of the vic¬tims. Thermal burns involving over 50 per cent of the body surface were evident in all the fatalities, but the victims also displayed marked smoke inhalation. Thus it is safe to assume that, for the most part, the burns followed suffocation….

The Lessons

“Looking objectively at this accident for the lessons to be found in it, we may note the following points:

1. In previous aircraft crash-fire accidents the main fire has been initially exterior to the occupied fuselage sections, with flames entering the cabin areas be¬cause of failure of the skin from heat exposure or rup¬ture of wing center section tankage, or through the wing “roots” ( where the wing adjoins the fuselage). In these “normal” crash-fire behavior patterns, the se¬verity of the fires has been influenced primarily by fuel tank failures and massive fuel spillage. In this accident, failure of the gear and the impact did not destroy the tightness of the integral fuel tanks in the wings. The landing gear pulled free before tank rup¬ture, fulfilling a Boeing design criterion. After fire extinguishment all the fuel tanks were found intact and 3,450 gallons of kerosene was pumped out of the tanks during salvage operations. The fuel prob-lem in this case came solely from the rupture of the interior lines running from the wing tankage area to the rear mounted engines and only a few gallons ac¬tually burned — almost certainly less than 100 gal¬lons.

2. Although aircraft structures have been improved for more and more resistance to crash impact forces and good progress has been made in delethalizing cabin seats and equipment from the viewpoint of oc¬cupant injury, fire, regardless of its source and how it is fed, is becoming more crucial as far as accident survivability is concerned.

3. Detailed testimony from survivors shows that many passed by usable exits. This can be attributed, in part, to the dense, choking smoke that prevented the crew and others from giving instructions, since speech was impossible and visibility was near zero within seconds following the initial outbreak of fire. If the emergency lights did operate, they could not be seen. Many of the passengers were so disoriented as to their location they did not know which way to turn. From data on the location of the bodies recovered, it is evident that many in the rear seats ran forward, even before the aircraft stopped skidding. The greatest concentration of bodies was just forward of the center galley area in the aisles around Seat 6… The reason for the forward movement of the passengers is that the earliest sign of fire was in the aft section of the cabin. Also, other experience indicates that people naturally tend to try to escape exactly the same way they entered the aircraft — in this case, by the forward entrance.

4. The cabin interior materials used in modern-day jet aircraft must meet prescribed FAA tests for flame resistance; but several recent aircraft cabin fires point an accusing finger at cabin interior finishes. This sub¬ject was discussed at the 1966 NFPA Aviation Fire Safety Seminar held during the NFPA Annual Meet¬ing (see Fire Technology, November 1966). Perhaps, it would not be reasonable to expect any materials to withstand the type of flame attack prevailing in this acci¬dent. In this fire, however, the materials clearly contrib-uted to the extent of the fire, if not to the loss of life….

7. While not a factor in this accident, the fire de¬partment response time was not favorable. Efforts must be made to speed up fire department response to the scene of every airport fire emergency. Particular attention should be given to the problems of accelerat¬ing and increasing the cross-country mobility of airport rescue and fire-fighting vehicles (see NFPA No. 414), strategically locating airport fire stations for immediate access to the approach and departure ends of the run¬ways, and even improving fire station interior layout to minimize the time fire and rescue crews take to get equipment on the roll. An instantaneous alarm has little value if there are unnecessary delays in “reaction time.”…

(NFPA. “The Salt Lake City Airport Crash.” Fire Journal, Vol. 60, No. 4, July 1966, pp. 5-10.)

Sources

Aircraft Crashes Record Office (Geneva, Switzerland). Utah. Accessed 3-12-2009 at: http://www.baaa-acro.com/Pays/Etats-Unis/Utah.htm

AirDisaster.com. Accident Database. Accident Synopsis 11111965. Accessed at: http://www.airdisaster.com/cgi-bin/view_details.cgi?date=11111965&reg=N7030U&airline=United+Airlines

Civil Aeronautics Board. Aircraft Accident Report. United Air Lines, Inc., Boeing 727, N7030U, Salt Lake City, Utah, November 11, 1965. Washington, DC: CAB, June 7, 1966, 25 pp. Accessed at: http://dotlibrary1.specialcollection.net/scripts/ws.dll?file&fn=8&name=*P%3A%5CDOT%5Cairplane%20accidents%5Cwebsearch%5C111165.pdf

Faith, Nicholas. Black Box: Why Air Safety Is No Accident. London: Boxtree, 1996.

National Fire Protection Association. “The Major Fires of 1965.” Fire Journal, Vol. 60, No. 3, May 1966, pp. 52-54.

National Fire Protection Association. “The Salt Lake City Airport Crash.” Fire Journal, Vol. 60, No. 4, July 1966, pp. 5-10.