Who Was Responsible: Avianca Zero Five Two, Jan. 25, 1990

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smhusain_1
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Who Was Responsible: Avianca Zero Five Two, Jan. 25, 1990

Post by smhusain_1 » Sun Jun 15, 2014 3:05 am

In this accident, in my opinion the captain could have exercised his emergency authority by disregarding the ATC instructions after the overshoot. He was hampered by his English. But this is not his first time to New York. He should never have allowed his reserve to be consumed and acted much before, asserted more to get what he wanted, divert to Boston--SMH

AVIANCA ZERO FIVE TWO, JAN. 25, 1990
B707, Medellin (Colombia) to JFK, New York City (USA)
Air Traffic Controllers have been tracking a massive low pressure system moving East through the Great Lakes and a couple of other systems are converging affecting North East. Weather at JFK at near minimums. NTSB Investigator: Washington Centre directive to Air Traffic Controllers at Kennedy Airport to accommodate 33 aircraft landings per hour. Controllers cannot use Runway 13 R & L because it conflict with other airports and wind. Controllers averse to this directive as it affect air safety. Foreign traffic is advised to be given airborne holds. Scenario by morning is set for this accident to happen.

Crew: experienced, and into New York several times on behalf of Avianca.
Captain, age 51, seasoned pilot with company for 27 years. English comprehension poor
First Officer, age 28: 4 months on 707, all communication with ATC handled by him.
Flight Engineer: experienced but 4 months only on 707 after training. He monitors loading of 13, 000 lbs of fuel making a total of 80,000 lbs on board = Destination plus 2 hours.

Total souls on board: 158, 85 survivors are pulled out of the wreck.

AVA 052 departs just after 1500 from Medellin. Weather by evening deteriorates at Kennedy causing massive delays in arrivals. Fog and rain closes the main runway at JFK and only one runway is available for landing, Runway 22. Several planes abort landing due weather. Windshear alert at 1500 feet at JFK.

AVA 052 is not aware of the deteriorated weather, and neither receives nor request weather at Kennedy while en route, and for the filed alternate, Boston. The company has a dispatch office in Miami; it is made to hold at Norfolk, VA by Washington Centre (ATC). New York City is less than 40 minutes away.

Washington Centre advises AVA 052 to make a right 360 degree turn near Norfolk and gives holding instructions: Avianca zero five two, clear to Norfolk VORTAC, hold south on 174 (Radial 174), with right turns and 20 mile legs.

This area in the North East corridor of USA is one of the most congested airspace in the world. Incoming traffic from overseas is routinely directed by a pipeline of controllers before being cleared to land at one of the three major airports in the New York area, JFK, La Guardia (LGA), and Newark NJ (EWR). Avianca was handled by more than 6 Air Traffic Controllers.

AVA 052 circles for 19 minutes over the Virginia coast.

Washington Centre: Avianca zero five two Heavy expedite descent through FL 330. Leave FL 330 within three minutes.

AVA 052 is unaware of weather at JFK. Weather on final approach at JFK--mist, rain with sudden violent winds, and windshear. Avianca has used up fuel for the journey and the crew is considering a diversion to Boston, just 210 miles from New York.

First Officer requests information from Washington Centre on delays to Boston. Washington controller requests another colleague for that who forgets about AVA 052's request due workload, and the crew waits for an answer that never comes. Fuel is 89 minutes left.

First Officer requests Boston weather again on captain's directive, and is advised that New York Centre may have to hold you for about thirty minutes, expect clearance on course. Aircraft is advised to check for an alternate.

First Officer: Descending to FL 190 and expecting information about Boston.

Washington Centre advises Boston is open, and if they are accepting Boston as the alternate. Flight Engineer checks fuel status with regard to Boston as alternate but before they can respond, they are directed to another holding at this time.

Washington Centre: Avianca zero five two Heavy, make a right turn now to intercept the Cameron 2 Arrival, cleared on course, maintain FL 190. (Flight Level 190).

AVA 052 now holds at Cameron, off the New Jersey Coast.

Control is transferred to New York Centre:

Avianca zero five two descend and maintain one-four thousand (14, 000 feet on QNH). Expect further clearance at 0139 (Z).

39 aircraft are trying to land at JFK and dozens waiting to takeoff.

Kennedy Approach: Avianca zero five two Heavy, Runway Visual Range (RVR) at JFK on Runway 22 Left is 2400 feet, can you accept the approach?

The pilot can see less than half a mile forward at touchdown height.

First Officer: That is affirmative sir

The foul weather is making aircraft overshoot and come around for a second attempt.

Kennedy Approach: Avianca zero five two, continue to left heading 230, vectors for holding at Cameron again.

First Officer requests estimates from Kennedy Approach

Kennedy Approach: Avianca zero five two, I might be able to get you in right now, standby.

Kennedy Approach: Avianca zero five two, we just got off the line; it is indefinite holding at this time. Avianca zero five two turn left heading 090 (degrees), Hold at Cameron, maintain one-one thousand (11,000 feet).

Avianca 052 circles around for another 25 minutes and has been made to hold 3 times in the air, a total of 48 minutes by now. By 2055 EST, the crew is resigned or too timid to complain.

Kennedy Approach: Avianca zero five two, Expect Further Clearance time (EFC) at 0205(Z). Expect further clearance in twenty minutes.

First Officer: Requests priority, running out of fuel

Kennedy Approach: How long can you hold and what is your alternate?

Flight Engineer calculates remaining fuel

First Officer: Yes sir, we'll be able to hold for five minutes that is all we can do.

Kennedy Approach: Roger, and what is your alternate?

First Officer: We said Boston; its full of traffic I think

Kennedy Approach: Avianca zero five two, say your alternate again

First Officer:]It was Boston, but we can't do it now, we'll run out of fuel

Kennedy Approach: Avianca zero o five two clear to land at Kennedy via heading zero four zero (040 degrees), maintain one-one thousand (11,000 feet) and speed one eight zero (180 knots)

Control is handed to another controller, who is not updated on the low fuel state of Avianca 052. Option to divert not available because of low fuel.

Kennedy Approach: Descend and maintain seven thousand (7000 feet)

First Officer reads back and says descending

Kennedy Approach: Before you go, there is a windshear alert on final at fifteen hundred feet (1500 feet), turn left heading zero niner zero (090).

Low level windshear at 500 feet AGL not passed to aircraft.

First Officer reads back and acknowledges instructions

Captain has been hand flying the aircraft as the auto pilot is unserviceable from start in Colombia. After more than six hours of manual flying the aircraft, the physical and mental stress is taking its toll now. Holding has been for 1 hour and 17 minutes up till now.

Crew believes that Avianca 052 is being cleared for a priority landing now, fuel remaining is 30 minutes. Go around procedure (overshoot) is discussed by the crew. Flight Engineer advises that power be applied gently and no rapid acceleration, and to maintain minimum nose up attitude during overshoot so as to not uncover the fuel booster pumps inlet ports in fuel tanks enabling engine flame out. 17 miles to go.

Kennedy Approach: Avianca zero five two, descend and maintain 3000 feet

Kennedy Approach: Avianca zero five two, contact Kennedy Tower on 119.1, Good Day.

Tower controller's shift is ending.

Kennedy Tower: Avianca zero five two Heavy, Kennedy Tower, Runway 22 Left, you're number three (3), following 727 traffic on a niner mile final.

First Officer says Roger and reads back

Captain is advised by First Officer to delay lowering landing gear as the nose attitude would rise then.

Kennedy Tower: Avianca zero five two, what is your airspeed?

First Officer: Avianca zero five two, one four zero knots (140)

Kennedy Tower: Avianca zero five two, can you increase your speed 10 knots?

Captain to First Officer: one zero?

First Officer: Okay one zero knots, increasing

Kennedy Tower: increase-increase, ten knots more

Captain to First Officer: tell me things louder because I am not hearing it

Gear is lowered on captain's command.

Kennedy Tower: Avianca zero five two, 22 Left, wind 190 at 20 (wind is from the left on Runway 22L at 20 knots), clear to land.

First officer: Avianca zero five two Heavy, wind check please?

Kennedy Tower: 190 at 20

Kennedy Tower: Avianca zero five two, say airspeed

First Officer: one four five Knots (145)

Captain confirms from First Officer: Clear to land now?

Flight Engineer: Standby! Flaps fifty (50 degrees)?

Captain: Flaps 50 (degrees)

Flight Engineer: Landing checklist complete.

Captain is concerned about the fuel situation, first attempt only possible because of fuel, talks aggressively to First Officer on Flaps 50 command

Flight Engineer doesn't emphasize low fuel situation and present approach is only one possible because only 10 minutes of fuel left.

Stabilized at 1000 feet on the Instrument Landing System (ILS).

Violent windshear felt at 500 feet AGL forces them to slow the plane down. Downdrafts are pushing the aircraft towards the ground. Change of 40 knots in wind speed in last 1000 feet of descent, turbulence. Middle Marker light flashes in cockpit. Aircraft sinks dangerously below glideslope.

Captain desperately searches for runway which is shrouded in low fog and mist. Captain increases power, gives a command for landing gear up and executes a missed approach. Aircraft is 2 miles from Runway at 200 feet AGL, well below the glideslope.

Fuel remaining is 9 minutes. Aircraft almost crashes on this approach due to severe downdrafts. Captain executes a missed approach, steep climb attitude, fast acceleration, and aggressive handling of controls is noticed by passengers

Captain to First Officer: Request another traffic pattern

First Officer: Executing a missed approach, Avianca zero five two Heavy

Flight Engineer to captain: smooth with the nose-smooth with the nose (attitude, because of low fuel)

Kennedy Tower: Avianca zero five two you are making a left turn, correct sir?

Captain to First Officer: tell him we are in an emergenccy

First Officer: That's right, two thousand feet, one eight zero on heading, and we'll try again, we are running out of fuel

Captain to First Officer: What did he say?

First Officer to captain: I already advised that we are going to attempt again

Captain to First Officer: Advise him that we are in an emergency, do you tell him?

First Officer to captain: Yes sir, I already advised him. (Does not re-advise low fuel state to Tower)

Tower controller at the end of his shift transfers Avianca 052 to Approach Control: Avianca zero five two contact Approach control on 118.4 (VHF frequency).

First Officer: Approach, Avianca zero five two Heavy we just missed, a missed approach and we are maintaining two thousand.

Captain: Flaps 14

Kennedy Approach: Avianca zero five two heavy, New York, good evening, climb and maintain 3000 (feet)

Captain to First Officer: Advise him we don't have fuel

First Officer: climb and maintain 3000 (feet). We are running out of fuel sir!

Kennedy Approach: Okay fly heading 080

Captain to First Officer: Did you already advise him we don't have fuel?

First Officer to captain: Yes sir, I already advised him. We are going to maintain three thousand and he going to get us back

Kennedy Approach: Avianca zero five two Heavy, I am going to turn you about fifteen miles North East and then bring you back on the approach. Is that okay with you and your fuel?

Captain to First Officer: What did he say?
Flight Engineer: the guy is angry I guess so

First Officer to captain: thank you very much

First Officer did not feed the captain correctly on communication with ATC. On the way, a 360 degrees turn (full circle) executed, aircraft vectored around Long Island. The crew allowed the
Approach Control to vector it way out of the original pattern of 15 miles north of the outer marker again, equivalent of holding another fifteen or twenty minutes

Captain to First Officer: Did you get clearance yet?

First Officer: Can you give us a final yet? Avianca zero five two Heavy

Kennedy Approach: Avianca zero five two Heavy, Affirmative sir, turn left Turn Left 040 (degrees), climb and maintain 3000 (feet).

First Officer: Negative Sir, we are running out of fuel

Kennedy Approach: Turn left heading 310 Sir

Captain to First Officer: Set Flaps 14

Kennedy Approach: Okay you are number two for the approach. Just have to give enough room so you can make it without having to come out again

First Officer: Okay we're number two and flying three six zero now

Kennedy Approach: Avianca zero five two heavy turn left 330

Lights flickering intermittently

First Officer: Three-three zero on the heading, Avianca zero five two

Amber low fuel light comes on Flight Engineer panel

Flight Engineer: Flame out on engine number four (4),

Captain: Flameout on engine

Flight Engineer: Flame out engine number three (3)

First Officer: Avianca zero five two we just lost two engines and we need priority please!

Kennedy Approach: Avianca zero five two, turn left heading 250, intercept the Localizer

First Officer: Two five zero, Roger

Captain to First Officer: Select the ILS

Kennedy Approach: Avianca zero five two, you are one five miles from the outer marker. Maintain two thousand until established on the Localizer, cleared for ILS 22 Left

First Officer: Avianca zero five two Roger

Captain to First Officer: Did you select the ILS?

All engines flame out now. In the cabin besides the screams, the sound of wind against fuselage.
6 ½ hours after leaving Colombia, aircraft drops from the sky in the landing attitude. AVA 052 is missing somewhere over New York. Aircraft drops from the sky in the landing attitude 15 miles North East of Kennedy and crashes in a wealthy neighborhood of Long Island near Colts Neck.

FAA Investigators found struggling to remove aircraft black box.

At NTSB Lab Flight Data Recorder (FDR) found tampered in the short time on ground after crash and evidence destroyed[/color]. Cockpit Voice Recorder (CVR) recovered and heard.

Who is responsible for Flight 052 running out of fuel? 72 dead (pax + crew)
It was apparent from the CVR that the captain did not understand the First Officer's radio communication made in English wit the Tower. The scenario the captain confronted was made by a lot of other people along the way. Captain advised First Officer nine times to clarify or pass on information to ATC. He was sucked into the situation by the Air Traffic Controllers.

Serious breakdown of communications:
I. Among pilots in cockpit-captain advised First Officer nine times to convey urgency, emergency to the ATC
II. Pilots talking to controllers
III. Controllers talking to the pilots
IV. Among controllers, so they did not convey on hand offs the urgency of the situation

No Auto Pilot to fly the ILS

Windshear information was given for 1500 feet only.Low level windshear information at 500 feet not conveyed to pilots catching them off guard in low visibility, mist and rain[

FAA (Government) took the position that the Avianca failed to communicate the nature of the problem by using the term “priority" to communicate their situation. Pilot never declared an emergency, so no one knew they had a problem but saying you're getting low on fuel and saying you cannot make your alternate, the word emergency is not necessary.

The First Officer had used the term priority again when they had lost two engines. In Spanish, the word priority means first, attend to me, run to me, I need you right now. Does priority in other languages mean that you can wait? Priority means a priority.

NTSB concludes that Air Traffic's handling of AV 052 was proper considering the information they were getting from the flight crew. Air Traffic Control is found blameless. Avianca sues FAA which employs the air traffic controllers saying they should have done more. Flight 052 told them they were running out of fuel. The FAA settles and ends up paying 40% of the estimated 200 million dollar compensation due to the victims.]Plane went down and half the people lost their lives because of a word?

Courtesy National Geographic