February 22, 1998 Close-Up: Investigating TWA Flight 800

Email this article |Print this article

by	The Editors of AVweb
	Documents Provided by the NTSB This report originally appeared in the February 1998 issue of NTSB REPORTER. Illustrations added by AVweb.

About NTSB Reporter ... NTSB Reporter is a unique magazine for pilots, mechanics, or anyone who has a serious interest in aviation safety. Each month, this outstanding publication brings you the kind of detailed accident investigation data exemplified by the preceding report on the Jessica Dubroff accident. No opinions, no speculation, no advertisements...just 100% hard data from NTSB investigations of notable air carrier, military and general aviation accidents, plus late-breaking news briefs on aviation safety topics. AVweb's editor-in-chief Mike Busch has been a subcriber for more than a decade, and thinks NTSB Reporter is a must-read for every serious student of aviation safety. Subscribe on-line and help support continued continued free access to AVweb and AVflash.

HISTORY OF THE FLIGHT:

On July 17, 1996, at 2031 e.d.t., a Boeing 747­131, registration numberN93119, crashed into the Atlantic Ocean, about eight miles south of East Moriches, New York, after faking off from John F. Kennedy International Airport (JFK). The airplane was being operated on an instrument flight rules (IFR) flight plan under the provisions of Part 121, on a regularly scheduled flight to Charles De Gaulle International Airport (CDG), Paris, France, as Trans World Airlines (TWA) Flight 800. The airplane was destroyed by explosion, fire, and impact forces with the ocean. All 230 people aboard were killed.

FLIGHT INFORMATION: The flight departed from TWA Terminal 5, gate 27. Scheduled departure time was 1900 e.d.t. Actual departure time was 2002. The one hour and two minute delay in departure was due to a passenger/luggage mismatch and a piece of disabled ground equipment. The scheduled en route time was six hours and nine minutes. The flight was normally scheduled to terminate in Paris, but was extended to Rome due to cancellation of a company Kennedy/Rome flight earlier in the day. A crew change was planned in Paris.

Total persons aboard the aircraft was two hundred thirty (230). Eighteen (18) were active crew, seventeen (17) were deadheading crew, and one hundred ninety five (195) were passengers.

Takeoff was planned, and occurred, on runway 22R which is 10,500 feet in length and has a slope of 0.00 degrees. Based on a temperature of 71 degrees Fahrenheit (22 degrees Celsius) and a flap setting of 10 degrees, takeoff speeds were calculated as a Vat (takeoff decision speed) of 113 knots, a Vr (takeoff rotation speed) of 146 knots, and a V2 (takeoff safety speed) of 153 knots. Engine pressure ratio (EPR) settings were 1.330 standard and 1.455 maximum.

The dispatch release provided information that for flight 800 the takeoff weighs was 590,441 pounds.

Based on the directed location and the program weight of the passengers, fuel, and cargo, the plane's takeoff center of gravity in mean aerodynamic chord (MAC) was calculated to be 18.4 percent, and the horizontal stabilizer takeoff trim setting was 6.1 unite nose up.

The dispatch release for the flight contained three open minimum equipment list items:

1. 27­51­2. Number 2 left canoe flap track fairing missing. Notice to dispatch is required due to performance penalty and a placard is required.

2. 78­1­3. Number 3 engine thrust reverser inoperative. This must be noted to the flightcrew and the associated systems for stopping the aircraft must be operational. The thrust reverser must be deactivated and the aircraft placarded.

3. 34­23. One of the two weather radar transmitters inoperative. One may be inoperative and the flightcrew must be advised with the aircraft properly placarded.

The Operations Group reviewed TWA procedures, voice recorder information, flight recorder data, radar data, and performance data during the course of the investigation. This review provided no evidence that flight 800 wee operated in a manner inconsistent with either Federal Air Regulations of TWA procedures.

CARGO: This flight was designated a "LIFE GUARD" flight because it was carrying human eyes. These were carried in a special container on the flight deck.

A review of the cargo manifest and shipping documents was conducted by the operations group during the investigation. No evidence wee found that TWA or regulatory requirements for packaging, labeling or loading were not complied with.

WEATHER INFORMATION: Recorded weather et John F. Kennedy International Airport (JFK) at 1950 e.d.t., was clear skies with 25 miles visibility, temperature 71 degrees F., dew point 68 degrees F., wind from 220 degrees magnetic heading at 4 knots and an altimeter setting of 30.09. There were no remarks.

The 1950 e.d.t., recorded weather at Islip, New York (ISP), which is the nearest reporting station to the accident site, was scattered clouds at 2,500 feet, 8 miles visibility, temperature 69 degrees F., dew point 68 degrees F., wind from 190 degrees magnetic at 3 knots, and an altimeter setting of 30.09. Remarks were-haze.

A radiosonde balloon launched from Upton, New York, reached an altitude of 13,451 feet above sea level at 1934 e.d.t. The readings at that altitude showed the wind from 297 degrees magnetic at 18 knots. At 1939 e.d.t., the readings at 14,326 feet above sea level were winds from 300 degrees magnetic at 20 knots.

CREW INFORMATION: There were four flight deck crewmembers on duty. One captain was serving as a check airman and wee the pilot in command. He was occupying the right seat and wee filling the duties of the first officer on this flight. According to TWA, he had approximately 4,700 hours in this make and model aircraft and approximately 17,000 total flight hours. He held a first class medical certificate with no limitations.

He joined TWA as a pilot in 1964. He flew the Convair 880, Lockheed 1011, Boeing 727 and 707. He received a type rating on the Boeing 747 in 1974, and qualified as a check airman on 747's in 1993.

A second captain was occupying the left seat and was receiving a second Initial operating experience. training flight as part of his qualification as a captain on the Boeing 747 type aircraft. He was filling the role of captain on this flight. According to TWA, he had approximately 5,490 hours in type and 18,800 total flight hours. He held a first class medical certificate with the limitation that he possess glasses for near vision. He joined TWA in 1965. He wee a captain on the Boeing 707 and Lockheed 1011. He received a type rating on the Boeing 747 in 1990 and started captain training on the Boeing 747 in 1996.

A flight engineer was occupying the jump seat across from the engineer panel. He was a check engineer conducting training of a "new hire" flight engineer. According to TWA, his flight engineer experience on the Boeing 747 was approximately 3,047 flight hours. He held a first class medical certificate with the limitation that he wear glasses for near and distant vision.

The other flight engineer was a "new hire" with TWA and had no previous experience as a flight engineer. He was on his sixth leg of initial operating experience as a flight engineer on the Boeing 747 and had no previous flight engineering experience. According to company procedures, he should have been occupying the flight engineer station and according to TWA records, he had approximately 2,520 total flight hours and approximately 30 hours flight engineer experience, all of which was in the Boeing 747. He held a first class medical certificate with no limitations.

A review of flight time limits, duty period limits, and rest requirements was conducted by the operations group during the investigation. The review provided no evidence that any flight deck crewmember was violating any of the limits established by regulation and/or the pilots' working agreement.

AIRCRAFT INFORMATION: The accident aircraft was a Boeing 747­131. It was manufactured in 1971. According to the flight operations manual, the maximum certified gross weight of this aircraft wee 734,000 pounds.

According to a cargo service employee who was working the flight, while the aircraft was at the gate he was asked by a crewmember about the heat in the aft cargo compartment. He stated that the compartment was "hot.. The crewmember then acid something about "okay that's the reason for the lights

There is an aft cargo overheat sensing system associated with the aft cargo heat system. According to the TWA aircraft operating manual, when the temperature reaches approximately 110 degrees Fahrenheit, heat to the compartment is automatically eliminated. When the temperature drops below approximately 80 degrees Fahrenheit, the automatic control is reactivated. According to a TWA check engineer interviewed during the investigation, curing warm days, it is not uncommon for this light to come on during the time the aircraft is parked at the gate, and once the cargo doors are closed the light extinguishes. The aft cargo overheat light must be extinguished prior to taxi.

During the time the aircraft was on the ground at JFK, after its arrival from Athens, Greece, and prior to its departure for Paris, TWA maintenance personnel worked on the number three engine thrust reverser. In an interview with the mechanic who worked on the reverser, he said he was unable to correct the problem due to limited ground time and he mechanically locked the thrust reverser in the forward thrust position in accordance with maintenance directives and reported his activities appropriately. Investigation confirmed reporting of this maintenance activity.

During the time the aircraft was being fueled at JFK, the automatic (volumetric) shutoff to the fueling system activated before it should have. The automatic shutoff is designed to prevent more fuel than is desired from being pumped into the aircraft's tanks. According to the person who was fueling the aircraft and TWA maintenance personnel, this is a common occurrence. The fueler stated during an interview that he reported the shutdown and a TWA mechanic came out and "pulled a circuit breaker and fuse. and he finished fueling the aircraft manually. According to the fueler, when he finished refueling the aircraft, the mechanic reset the fuse and circuit breaker. This activity was confirmed during interviews with the TWA mechanics who were involved.

According to the fueling record, the airplane carried a total of 181,800 pounds of fuel for the flight, including 300 pounds remaining in the center wing tank after the flight from Athens.

COCKPIT VOICE RECORDER: The CVR unit arrived in the NTSB's Washington lab in a large cooler still submerged in water. The exterior of the CVR was extremely dented and distorted. The front panel of the CVR was ripped from the unit and was only being held on by the underwater locating beacon mount. The normal carrying handle was missing. The data plate that is normally attached to the front panel was also missing and never recovered.

The protective dust cover had to be cut in several places before it could be removed. The interior crash enclosure appeared to be in good condition. There were only a few minor scratches and dents noted. The interior tape reel assembly was wet. Several small thin plastic reel pieces were broken off and were found loose inside of the enclosure. The recording media was wet, but otherwise appeared to be in good condition. The tape was not broken or physically damaged from the accident. There were no signs of any fire or heat damage noted to either the exterior or the interior of the unit. The underwater locator beacon that was installed on the CVR was slightly dented and scratched, but operated normally when tested in the lab.

The recording consisted of four channels of good quality audio information. One channel contained the cockpit area microphone audio information. The other three channels contained the Captain's, the First Officer's, and the Second Officer's radio/intercom information.

The recording starts at 1959:40 e.d.t., and continues uninterrupted until 2031:12 e.d.t., when electrical power was removed from the unit. When the recording starts, the Kennedy gate agent is in the cockpit telling the crew that they are ready for departure. The aircraft's door is closed and the crew requests push­back from the gate at 2001:42. During the push­back and before taxi, the crew starts the number 1, 2, and 4 engines. The flight contacts ground control at 2008:13 and requests taxi clearance. During the taxi, the crew starts the number 3 engine at 2014:29. The flight is cleared for takeoff on runway 22 right at Kennedy at 2018:21.

The takeoff and climb appear normal. The flight contacts Kennedy departure control at 2020:14. They are subsequently turned over to Boston Center at 2023:37. Boston Center instructs the crew to continue their climb and maintain fifteen thousand feet at 2030:15. The acknowledgment of this transmission at 2030:19.2 is the last radio transmission received from the aircraft. The recording stopped at 2031:12.

TWA 800 CVR Transcript Legend RDO = Radio transmission from accident aircraft CAM = Cockpit Area Microphone sound or source ­1 = Voice identified as Captain (left seat) ­2 = Voice identified as First Officer (right seat) ­3 = Voice identified as Second Officer ­4 = Voice identified as Instructor Flight Engineer ­? = Voice unidentified TWR = JFK Local Controller (tower) DEP = New York Radar Departure Controller CTR = Boston ARTCC Controller (center) FIC = TWA Flight Information Controller * = Unintelligible word (...) = Questionable text [...] = Editorial insertion ­ = Pause

Only radio transmissions to and from the accident aircraft were transcribed. The recording began at the gate with conversations regarding loading of passengers. We pick up the transcript after the flightcrew contacted the tower local controller.

2017:18 TWR: TWA eight hundred heavy caution wake turbulence from a seven fifty seven runway two two right taxi into position and hold.

2017:24 RDO­2: TWA's eight hundred heavy lifeguard position and hold two two right.

2017:24 CAM­1: position and hold two two right.

2017:31 CAM­1: will you alert the cabin please.

2017:40 CAM­3: flight attendants please be seated for takeoff.

2017:55 CAM­4: * * * *.

2018:03 CAM­2: now that's better.

2018:04 CAM­3: now it's coming on *.

2018:06 CAM­1: I'll just extend it out to that line.

2018:07 CAM­3: * sure *.

2018:09 CAM­2: yeah that's one of the ways you test yourself too is whether when you get rolled out is the whole airplane longitudinally lined up.

2018:15 CAM­1: yeah.

2018:21 TWR: TWA eight hundred heavy lifeguard wind's two four zero at eight runway two two right cleared for takeoff.

2018:27 RDO­2: TWA's eight hundred heavy lifeguard cleared for takeoff two two right.

2018:31 CAM­1: before takeoff checklist.

2018:33 CAM­3: before takeoff checklist. icing considerations?

2018:34 CAM­1: checked.

2018:35 CAM­3: cabin alert?

2018:36 CAM­1: checked.

2018:36 CAM­3: transponder?

2018:37 CAM­1: that's checked.

2018:39 CAM­3: ignition?

2018:40 CAM: [ sound of click].

2018:41 CAM­1: flight start.

2018:42 CAM­3: body gear steering?

2018:43 CAM­1: disarmed.

2018:44 CAM­2: clocks.

2018:46 CAM­3: before takeoff checklist is complete.

2018:48 CAM­1: thank you.

2018:49 CAM­4: get right up in there.

2018:51 CAM: [ sound of increasing engine noise].

2018:59 CAM­1: trim throttles.

2019:14 CAM­2: eighty knots.

2019:23 CAM­2: Vee one.

2019:35 CAM­2: Vee R.

2019:41 CAM: [sound of two clicks].

2019:43 CAM­1: gear up.

2019:44 CAM­2: gear up.

2020:00 TWR: TWA eight hundred heavy contact New York departure one three five point niner good evening.

2020:05 RDO­2: TWA's eight hundred heavy good night.

2020:14 RDO­2: Kennedy departure TWA's eight hundred heavy lifeguard leaving nine hundred climbing five thousand.

2020:19 DEP: lifeguard TWA eight hundred heavy New York departure radar contact climb and maintain one one thousand.

2020:24 RDO­2: TWA's eight hundred heavy climb and maintain one one thousand.

2020:29 CAM­1: climb to one one thousand and maintain.

2020:44 DEP: TWA eight hundred heavy turn left heading one five zero.

2020:47 CAM­1: left to one five zero.

2020:48 RDO­2: TWA's eight hundred heavy turn left heading one five zero.

2020:51 CAM­1: flaps five.

2020:53 CAM­2: flaps five.

2021:11 CAM­1: flaps one.

2021:12 CAM­2: flaps one.

2021:26 CAM­1: flaps up.

2021:29 CAM­2: say what?

2021:29 CAM­1: flaps up.

2021:30 CAM­2: flaps up.

2021:48 CAM­1: climb thrust.

2022:01 DEP TWA lifeguard TWA eight hundred heavy turn left heading zero seven zero.

2022:07 RDO­2: TWA's lifeguard eight hundred heavy turn left heading zero seven zero.

2022:11 CAM­1: left zero seven zero.

2022:29 DEP: TWA eight hundred heavy or lifeguard TWA eight hundred heavy turn left heading zero five zero vector climbin' around traffic.

2022:35 RDO­2: TWA's eight hundred heavy turn left heading zero five zero.

2022:41 CAM­1: left zero five zero climb vector.

2022:44 DEP: TWA eight hundred heavy the traffic in the turn will be three o'clock and five miles northeast bound four thousand nor­ is a company seven two five five in trail will be a Saab­Fairchild when you're out of five I'll have on course.

2022:54 RDO­2: TWA's eight hundred heavy understand.

2022:58 CAM­1: he's at three o'clock?

2023:00 CAM­2: yeah.

2023:02 CAM­2: that's the problem.

2023:19 DEP TWA eight hundred heavy direct Betty resume own navigation.

2023:22 RDO­2: TWA's eight hundred heavy direct Betty own navigation.

2023:26 CAM­1: direct Betty and our own nav.

2019:52 CAM­1: that's alive.

2023:37DEP: TWA lifeguard TWA eight hundred heavy contact Boston one three two point three.

2023:38 CAM­2: huh.

2023:39 CAM­1: direct Betty. correct?

2023:42 RDO­2: TWA's eight hundred heavy ah say again the frequency.

2023:44 DEP: one three two point three.

2023:46 RDO­2: TWA's eight hundred heavy good day.

2024:01 CAM: [ sound of noise of recording tape].

2024:30 CAM­1: seems like a home sick angel here (*/ awesome).

2024:36 CAM­2: it's bleeding off airspeed that's why.

2024:38 CAM­1: yeah *.

2024:41.7 RDO­2: New York center TWA's lifeguard eight hundred heavy eight thousand two hundred climbing one one thousand.

2024:48 CTR: TWA eight hundred Boston center roger climb and maintain one three thousand.

2024:53.4 RDO­2: TWA's eight hundred heavy climb and maintain one three thousand.

2024:57 CAM­1: climb and maintain one three thousand.

2025:31 CTR TWA eight hundred what's your rate of climb?

2025:34.5 RDO­2: TWA's eight hundred heavy ah about two thousand feet a minute here until accelerating out of ten thousand.

2025:41 CTR roger sir climb and maintain flight level one niner zero and expedite through fifteen.

2025:47.1 RDO­2: TWA's eight hundred heavy climb and maintain one niner zero and expedite through one five thousand.

2025:53 CAM­1: climb to one nine zero expedite through one five thousand.

2025:57 CAM­3: pressurization checks.

2025:59 CAM­3: (takeoff) thrust go on cross feed?

2026:02 CAM­?: ah.

2026:04 CAM­1: yeah.

2026:07 CAM­3: I'll leave that on for just a little bit.

2026:12 CAM­3: is that right?

2026:13 CAM­4: yes.

2026:24 CTR:TWA eight hundred amend the altitude maintain ah one three thousand thirteen thousand only for now.

2026:29 CAM­1: thirteen thousand.

2026:30.3 RDO­2: TWA's eight hundred heavy okay stop climb at one three thousand.

2026:35 CAM­1: stop climb at one three

thousand.

2026:51 CAM­1:*.

2026:59 CAM­2: twelve for thirteen.

2027:35 CAM:[sound of click].

2027:47 CAM: [sound of altitude alert tone].

2028:13 CTR: TWA eight hundred you have traffic at one o'clock and ah seven miles south bound a thousand foot above you he's ah Beech nineteen hundred.

2028:20.6 RDO­2: TWA's ah eight hundred heavy ah no contact.

2028:22.5 RDO­3:FIC TWA eight hundred.

2028:25 FIC: TWA eight hundred.

2028:25.7 RDO­3: Eight hundred with an off report ah plane number one seven one one nine we're out at zero zero zero two, and we're off at zero zero one nine, fuel one seven nine decimal zero, estimating Charles De Gaulle at zero six two eight.

2028:4 FIC: TWA eight eight hundred got it all.

2028:44.8 RDO­3: Thank you.

2029:15 CAM­1: look at that crazy fuel flow indicator there on number four.

2029:23 CAM­1: see that.

2029:35 CAM­1: some where in here I better trim this thing (in/up).

2029:39 CAM­2: huh?

2029:39 CAM­1: some place in here I better find out where this thing's trimmed.

2030:15 CAR TWA Bight hundred climb and maintain one five thousand.

2030:18 CAM­1: climb thrust.

2030:19.2 RDO­2: TWA's eight hundred heavy climb and maintain one five thousand leaving one three thousand.

2030:24 CAM­1: Ollie.

2030:24 CAM­3: huh.

2030:25 CAM­1: climb thrust.

2030:28 CAM­1: climb to one five thousand.

2030:35 CAM­3: power's set.

2030:42 CAM: [sound similar to a mechanical movement in cockpit]

2031:03 CAM: *.

2031:05 CAM: [sounds similar to recording tape damage noise].

2031:12 — end of recording.