NTSB · Safety Recommendation
Safety Recommendation A-69-012
Recommendation
1. THE PROVISIONS OF BOEING SERVICE BULLETIN NO. 2384, WHICH CALLS FOR MODIFICATION OF THE THRUST LEVER ADVANCEMENT FROM 42 DEGREES (OR 33 DEGREES) TO 25 DEGREES TRAVEL, BE REQUIRED BY ISSUANCE OF AN AIRWORTHINESS DIRECTIVE TO ALL OPERATORS OF B-707/720 AIRCRAFT. 2. AIR CARRIER COCKPIT CHECKLISTS BE REVIEWED IN AN EFFORT TO INSURE THAT EACH LIST PROVIDES A MEANS OF REMINDING THE CREW, IMMEDIATELY PRIOR TO TAKEOFF, THAT ALL ITEMS CRITICAL FOR SAFE FLIGHT HAVE BEEN ACCOMPLISHED.
Safety Issue and Context
PAN AMERICAN CLIPPER, N799PA, A BOEING 707-321C, CARGO/MAIL FLIGHT BOUND FOR VIETNAM VIA TOKYO, JAPAN, CRASHED ON TAKEOFF FROM RUNWAY 23, ELMENDORF AFB, ANCHORAGE, ALASKA, AT APPROXIMATELY 0615 A.S.T. 1 ON DECEMBER 26, 1968. THE AIRCRAFT WAS DESTROYED. THE ACCIDENT WAS FATAL TO ALL THREE CREWMEMBERS, WHO WERE THE ONLY OCCUPANTS ABOARD THE AIRCRAFT.
Response History
July 3, 1969 · Recipient Response · FAA
-From G.S. Moore, Acting Deputy Administrator: This is in response to your letter of 18 June 1969, concerning cockpit checklists.
We agree that each air carrier and commercial operator should have a system established to assure that all check-list items have been accomplished before takeoff, and that whenever a checklist item is deliberately repositioned contrary to a previously completed checklist, there must be a method; visual reminder or a procedure, to assure that the item is reaccomplished to preclude the possibility of omission.
We are preparing instructions to our field offices requiring principal operations inspectors to review the aircraft cockpit checklists and associated procedures of their assigned air carriers to assure that the air carrier has a satisfactory means of reminding the flight crew that all items critical for safe flight have been accomplished immediately prior to takeoff.
May 9, 1969 · Recipient Response · FAA
5/9/69 The FAA administrator concurred in the first recommendation by issuing an airworthiness directive on May 28, 1969, that applied to the takeoff aural warning system of all Boeing 707/720 and 727 series aircraft. In response to the second recommendation, reference was made to a telegraphic notice that was issued on December 31, 1968, to all operators of Boeing 707/720 aircraft to be alert to the possibility of the takeoff warning system not operating during cold weather conditions. It also recommended that flightcrews double check proper positioning of flaps, speed brakes, and stabilizer trim during cold weather operations.
Inasmuch as the December 31, 1968, notice pertained only to Boeing 707/720 aircraft, an air carrier operations alert was issued to the field on February 4, 1969.
This alert covered all aircraft provided with takeoff warning systems, and directed principal inspectors to ensure that the operators concerned establish a procedure requiring flightcrews to double-check positioning of wing flaps, speed brakes, and elevator/stabilizer trim during cold weather operations. 7/3/69 in responding, the FAA stated that instructions were being prepared to their field offices requiring principal operations inspectors to review the aircraft cockpit checklists and associated procedures of their assigned air carriers to assure that the air carrier has a satisfactory means of reminding the flightcrew that all items critical for safe flight have been accomplished immediately prior to takeoff.