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AIRCRAFT ACCIDENT REPORT

VIEWS: 14 PAGES: 55

									SA-421                                             FILE NO. 3-1127
AIRCRAFT ACCIDENT REPORT
                MARTIN 404, N464M
            8 STATUTE MILES WEST OF
            SILVER PLUME, COLORADO
                OCTOBER 2,1970

           Adopted DECEMBER 24, 1970




                               NATIONAL TRANSPORTATION SAFETY BOARD
                                      Washington, 0. C. 20591
                                    REPORT NUMBER: NTSB-AAR-71-4




    For m l e by National Technical Inlormation Service (NTIS). U S Department of Commerce, Springneld,
    VB. 22151. Annual subscription price $20.00 Domestic; $25.00 Foreign: Single copy $3.00; MicroRche $0.95.
                     MARTIN    0.
                              4 4 N464M
       a STATUTE mms WEST OF SILVER P         comm
                                          L ~ .
                      OCTOBER 2
                              .    1970


                     TABLE OF COIbTENTS




       Synopsis  ..................                           .
                                                              1


 .     Probable Cause...............                          2
1      Investigation ...............                          3
       History of the Flight   ...........                    3
11
 .
1.2    Injuries to Persons  ............                      a
                   . . . . .. .. .. .. ........... .. .. ..
1.3    Damage to Aircraft                                     a
14
 .     Other Dsmage                                           a
1.5
 .
16
                        ............
                     ..............
       Crew Information                                       9
       Aircraft Information                                   9
                        ...........
                              ..
                      . . . . . . .. .. .. .. .. .. ...
       Meteorological Information                             10
       Aids to Navigation                                     10
1.9                 ...
       Communications                                         10
11
 .0                                .......
       Aerodrome and Ground Facilities                        10
11
 .1                  ..............
       Flight Recorders                                       10
1.12   Wreckage ..................                            10
1.13   Fire   ....................                            17
11
 .4                  ..............
       Survival Aspects                                       17
1.15                  .............
       Tests and Research                                     la
 .6
11                    .............
       Other Information                                      la
2.
2.1
                            ..........
       Analysis and Conclusions
       Analysis ..................                            23
                                                              23
22
 .     Conclusions ................                           31
                     ..............
           (a) Findings                                       31
                          ...........
           (b) Probable Cause                                 32
3.     Recommendations  ................                      32
       Appendices
r
SA- 421                                                                                 F i l e No. 3-1127


                         NATIONAL TRANSPORTATION SAFETY BOARD
                               WASHINGTON, D. C. 20591
                               AIRCRAFT ACCIDEW REPOIPT


Adopted:       December 2 4 , 9 7 0
                                      MARTIN 404, N464M
                                                                                                       -
                 8 STATUTE       MILES WEST O SILVER PLUME, COLORADO
                                             F
                                       OCTOBER 2, 1970


                                              SYNOFSIS

         O October 2, 1970, Martin 404, N464~, was operated f o r t h e purpose
           n
of t r a n s p o r t i n g t h e Wichita S t a t e University f o o t b a l l team from Wichita,
Kansas, t o Logan, Utah. Following a r e f u e l i n g s t o p a t Denver, Colorado,
the f l i g h t proceeded v i a a "scenic" r o u t e up Clear Creek Valley, toward
Loveland Pass ( e l e v a t i o n 11,990 f e e t mean sea l e v e l ) and t h e Loveland s k i
r e s o r t area.+he           mountains on e i t h e r s i d e of t h e f l i g h t p a t h ranged from
12,477 f e e t m.s.1. t o 13,234 f e e t m.s.l.&At                approximately 1300 m.d.t.,
t h e a i r c r a f t crashed i n t o t h e base of Mount Trelease, 8 miles west of

          -
Silver Plume, Colorado. The e l e v a t i o n of t h e c r a s h s i t e i s 10,750 f e e t
m.s.1.

     Of t h e 40 persons on board, 30, including t h e c a p t a i n and a stew-
ardess, received fatal i n j u r i e s . Two of t h e surviving passengers l a t e r
succmbed t o i n j u r i e s received i n t h e crash.

          I n v e s t i g a t i o n revealed that t h e a i r c r a f t f i r s t s t r u c k t h e t o p s of
t r e e s at an e l e v a t i o n o f 10,800 f e e t m.s.1.            i n a h e a v i l y wooded a r e a .
The a i r c r a f t continued on a heading of 215' magnetic, on a 4" descending
f l i g h t p a t h , f o r a d i s t a n c e of 425 f e e t from t h e point of i n i t i a l t r e e
contact. The a i r c r a f t was destroyed by f i r e and impact.

     Subsequent teardown of t h e engines and examination of t h e p r o p e l l e r
mechanism showed t h a t both engines were producing power a t impact.

   - Weather conditions i n t h e crash a r e a and along t h e f l i g h t p a t h from
Denver, Colorado, t o Logan, Utah, were reported t o have been c l e a r .
There were no known r e p o r t s of turbulence, o r up- and downdraft a c t i v i t y ,
and none was r e c a l l e d by t h e sunriving c o p i l o t o r passengers.

      Eyewitnesses l o c a t e d a t about t h e 11,900-foot e l e v a t i o n a t Loveland
Pass were looking down a t t h e a i r c r a f t when it came i n t o view around
Mount Sniktau. Angular measurements made from t h e i r viewpoint, and t h e
testimony of most o t h e r witnesses, i n d i c a t e d t h a t t h e a i r c r a f t was at
                                                 -   2 -

approximately 11,000 feet m.s.1. i n                                        y
                                               t h e v i c i n i t y of ~ r Gulch. The
v a l l e y width i n t h e a r e a immediately west of Dry Gulch i s 3,000 f e e t
at t h e 11,000-foot contour.
                                                                                                              1
     'The        Board determines t h a t t h e probable cause of t h i s a c c i d e n t
was t h e i n t e n t i o n a l operation of t h e a i r c r a f t over a mountain v a l l e y
                                                                                                              w
route at an a l t i t u d e from which t h e a i r c r a f t could n e i t h e r climb over
                                                                                                              t
t h e o b s t r u c t i n g t e r r a i n ahead, nor execute a s u c c e s s f u l course r e v e r s a l .
                                                                                                              o
S i g n i f i c a n t f a c t o r s were t h e overloaded condition of t h e a i r c r a f t , t h e
v i r t u a l absence of f l i g h t planning f o r t h e chosen r o u t e of f l i g h t from
Denver t o Logan,% l a c k of understanding on t h e part of t h e crew of
t h e performance c a p a b i l i t i e s and l i m i t a t i o n s of t h e a i r c r a f t , and t h e
l a c k of o p e r a t i o n a l management t o monitor and a p p r o p r i a t e l y c o n t r o l t h e
a c t i o n s of t h e flightcrew.
r
                                             - 3 -
                                     1. INVESTIGATION             .
1.1 History of t h e F l i g h t

      O October 2, 1970, two Martin 404 a i r c r a f t , N470M and N464~,
        n
were t o be used t o t r a n s p o r t t h e Wichita S t a t e University f o o t b a l l
team and a s s o c i a t e d personnel t o Logan, Utah. Both a i r c r a f t were
owned by t h e Jack Richards A i r c r a f t Company, I n c . , of Oklahoma City,
Oklahoma. The f l i g h t c r e w s f o r each a i r c r a f t were provided by Golden
Eagle Aviation, I n c . , a l s o w i t h headquarters i n Oklahoma City, Oklahoma.
The f i r s t o f f i c e r f o r N464M,M.
                                         r   Ronald G. Skipper, was t h e president of
Golden Eagle Aviation, Inc. The c a p t a i n f o r N464M, Dsnny E. Crocker, had
been h i r e d by Golden Eagle Aviation, I n c . , as a mechanic, and was used
only occasionally as a p i l o t on an " i n d i v i d u a l c o n t r a c t o r " b a s i s , accord-
ing t o  Mr
          .    Skipper.

         F l i g h t planning f o r t h e t r i p was accomplished by      M.
                                                                            r
                                                                      Ralph H i l l ,
f i r s t o f f i c e r f o r N47OMJ and approved by Captain Leland Everett.- Weather
conditions over t h e e n t i r e route were not considered t o be a f a c t o r . The
f l i g h t plan provided f o r a d i r e c t heading between Oklahoma City, Oklahoma,

                           -
and Wichita, Kansas, and from Wichita t o Denver, Colorado, under Visual
Flight Rules (VFR).

         From Denver t o Logan, Utah, t h e proposed r o u t e of t h e f l i g h t was
v i a Airway Victor 4 t o Laramie, Wyoming, and thence t o Logan by way of
Rock Springs, Wyoming.-This r o u t i n g would provide an i n i t i a l f l i g h t -
path p a r a l l e l t o t h e mountain ranges, allowing ample time f o r t h e air-
c r a f t t o reach a s a f e en route a l t i t u d e p r i o r t o t u r n i n g westward over
t h e mountains.-A copy of t h i s f l i g h t p l a n was given t o F i r s t Officer
Skipper f o r t h e use o f t h e crew on N464M.

         O t h e morning of October 2, 1970, t h e a i r c r a f t were f e r r i e d t o
          n
Wichita, Kansas, a r r i v i n g at approximately 0750 m.d.t. 1 Neither air-
                                                                         /
c r a f t was serviced with f u e l o r A
                                        D1       9
                                               f l u i d t h e r e . Hofjever, 5 g a l l o n s
of o i l were placed i n each engine supply tank on N464M. Catering s u p p l i e s
and f o o t b a l l gear were placed on each a i r c r a f t , and t h e passengers boarded.

         O departure from Wichita a t 0908, t h e r e were 36 passengers, a
            n
regular crew of three,and a f r i e n d o f t h e crew who was t o serve as a n
a d d i t i o n a l assistant stewardess on ~464M. There were 35 passengers and
a crew o f t h r e e on N470M.

-/
1    A times h e r e i n a r e mountain d a y l i g h t , based on t h e 24-hour clock.
      l

-
2/   AD1   --Anti- detonation i n j e c t i o n ; t h e use of a n a l c o h o l and water
     mixture t o allow t h e engine t o develop a d d i t i o n a l power f o r takeoff
     o r climb purposes f o r up t o 2 minutes.
                                                -4-
          Both a i r c r a f t proceeded toward Denver, Colorado, f o r a planned                           w
r e f u e l i n g stop. En r o u t e t o Denver, t h e f i r s t o f f i c e r of N464M, while              C
v i s i t i n g with passengers i n t h e cabin, advised some of them that t h e                            t
f l i g h t would t a k e t h e "scenic route" from Denver t o Logan and t h a t he                         a
would p i n t out t h e s k i r e s o r t s and s i g n i f i c a n t p o i n t s of i n t e r e s t .

         O arrival a t S t a p l e t o n I n t e r n a t i o n a l Airport, Denver, Colorado, a t
           n
approximately 1119, both a i r c r a f t were serviced with. f u e l and o i l . Neither
a l c o h o l nor AD1 f l u i d was added a t t h i s stop. N464M received 12 g a l l o n s
of o i l f o r each engine and 721 g a l l o n s of 100-octane gasoline, which f i l l e d
t h e tanks and brought t h e t o t a l f u e l load t o 1,370 g a l l o n s .

         Minor maintenance involving t h e s e r v i c i n g of t h e main landing gear
shock s t r u t s on N464M w i t h air and o i l was performed. During t h i s time,
F i r s t Officer Skipper purchased a e r o n a u t i c a l s e c t i o n a l c h a r t s f o r t h e
contemplated scenic route.-He made t h e d e c i s i o n t o purchase t h e s e c h a r t s
a f t e r departure from Wichita. According t o F i r s t Officer Skipper, t h e
decision t o proceed v i a t h e scenic r o u t e was made without b e n e f i t of any
discussion with Captain Crocker. Captain Crocker, however, was aware of
t h e i n t e n t i o n t o depart from t h e previously prepared f l i g h t p l a n and t o
proceed on a southwesterly course from Denver.-While on t h e ground a t
Denver, he had advised Captain Everett and one of t h e passengers t h a t
t h e y were planning a scenic f l i g h t v i a Loveland Pass.

     - n departure from Denver,
     O                                       N470M proceeded northbound according t o
t h e o r i g i n a l f l i g h t plan and subsequently landed s a f e l y a t Logan, Utah.

          N464M, with F i r s t Officer Skipper at t h e c o n t r o l s and occupying
t h e l e f t s i d e p i l o t s e a t , departed from Runway 35 at S t a p l e t o n I n t e r -
n a t i o n a l Airport a t 1229.

      'When       N464M was approximately one-fourth t o one-half a mile beyond
t h e departure end of Runway 35, t h e A i r T r a f f i c Control S p e c i a l i s t who
cleared t h e f l i g h t f o r takeoff observed that it appeared t o be at a
f a i r l y low a l t i t u d e and t h a t a n unusual mount of black smoke was coming
fo t h e r i g h t engine. H advised N464~ h i s observation and asked if
 rm                                   e                  of
t h e r e was a problem. The r e p l y was "No, we're j u s t running a l i t t l e r i c h ,
i s all." This w s t h e last communications contact with N464M. The air-
                           a
c r a f t was last observed by t h e air t r a f f i c c o n t r o l s p e c i a l i s t approxi-
mately 4 miles north of t h e departure end of Runway 35, s t i l l on a
n o r t h e r l y heading.

          With respect t o t h e f l i g h t p a t h a f t e r departure from S t a p l e t o n
I n t e r n a t i o n a l Airport, r
                                  M.   Skipper t e s t i f i e d t h a t t h e r e was no s p e c i f i c
conversation w i t h Captain Crocker concerning t h e route, and that t h e r e
was no flight planning as t o r o u t i n g o t h e r t h a n t h e i n t e n t i o n " t o go t o
Logan d i r e c t , o r as d i r e c t as possible." H s t a t e d that a f t e r t a k e o f f ,
                                                                e
t h e f l i g h t proceeded north until t h e y i n t e r c e p t e d t h e airway between
Denver and KrenmiLing, Colorado, a t which point t h e y made a t u r n t o t h e
                                             - 5 -
west on t h e airway. Thereafter he was given heading d i r e c t i o n s by
                          e
Captain Crocker. H d i d not r e c a l l t h e exact r o u t e , but r e c a l l e d t h a t
the a i r c r a f t was turned s l i g h t l y south, o f f t h e airway, t o go through
a pass i n order t o follow a v a l l e y . He believed that t h e f l i g h t
proceeded past Nevadaville and i n t e r c e p t e d t h e v a l l e y i n t h e v i c i n i t y
of Idaho Springs, Colorado. T h i s ’ f l i g h t p a t h was confirmed by eyewitnesses
on the ground who observed t h e a i r c r a f t at various s t a g e s i n t h e f l i g h t . 3/
F i r s t Officer Skipper s t a t e d t h a t t h e f l a p s were r e t r a c t e d a f t e r takeoff  -
and t h a t a climb had been maintained continuously a t about 165 BMEP 4/
power s e t t i n g on each engine and a n i n d i c a t e d a i r s p e e d of approximatsly
140 knots. H did not r e c a l l t h e r a t e of climb.
                    e

      After i n t e r c e p t i n g Clear Creek Valley, t h e f l i g h t proceeded along
U. S. Highway 6, s l i g h t l y south of it, p a s t Georgetown and S i l v e r Plume,
 .
Colorado, toward Loveland Pass.-The e l e v a t i o n a t Georgetown i s 8,512
m.s.1.        and a t S i l v e r Plume i s 9,118 f e e t m.s.1. Thereafter, t h e
valley f l o o r continues t o r i s e , reaching a n e l e v a t i o n of 11,990 f e e t
m.s.1. at Loveland Pass.--’

  4 In t h e a r e a west of Georgetown, t h e mountains on e i t h e r s i d e of
Clear Creek Valley range from 12,477 f e e t m . s . 1 . t o over 13,000 f e e t
m.s.1.

   -Across       t h e end of t h e v a l l e y a t t h e Loveland s k i r e s o r t a r e a , t h e   :
                                                                                                       !
ground r i s e s r a p i d l y from t h e v a l l e y f l o o r at 10,600 f e e t m.s.1.     to
12,700 f e e t m.s.1.          a t t h e Continental Divide, d i r e c t l y ahead on a                .-
westward f l i g h t p a t h .

       Pilots of a n a i r c r a f t proceeding westward along Clear Creek Valley
a t an a l t i t u d e of 11,000 f e e t or l e s s would not have a view of t h e end
of t h e v a l l e y u n t i l i n t h e v i c i n i t y of Dry Gulch, s i n c e it would be c u t
             on
off by Mut Snlktau ( e l e v a t i o n 13,234 f e e t ) .

   d & Skipper t e s t i f i e d t h a t i n t h e v i c i n i t y o f Dry Gulch, “We were
      l .
i n t h e v a l l e y . It began t o look t o m as i f we were not going t o climb
                                                 e
so a s t o have clearance, s u f f i c i e n t clearance, over w h a t I now know t o
be t h e Continental Divide ahead of us. I s a i d something t o t h e e f f e c t
t o Captain Crocker t h a t maybe we should r e v e r s e course and g a i n some
-.
3    See Appendix G         --   “’Flightpath A s Described By Witnesses             .“
     Brake Mean E f f e c t i v e Pressure- - equivalent t o approximately 1,400
     horsepower at 2,400 r.p.m.          The Martin 404 Airplane F l i g h t Manual
     l i s t s 2,400 ??.p.m. f o r climb purposes en r o u t e .

5f   Mean sea l e v e l .
                                                      - 6-
     a l t i t u d e . I i n i t i a t e d a t u r n t o t h e r i g h t . We.were t o t h e l e f t side.
'    s l i g h t l y of t h e valley." I n continuing testimony,                   Mr. Skipper said:
I
     "I i n i t i a t e d a t u r n of approximately 45" change i n heading, a medium
     bank t u r n which i n m mind i s somewhere between 20 and 30 degrees,
'                                      y
     and as I was r o l l i n g out of t h i s t u r n , Captain Crocker s a i d ' I ' v e got
     t h e airplane.'+He i n i t i a t e d a l e f t t u r n , t h e a i r c r a f t began v i b r a t i n g ,
     he put t h e nose down, and s h o r t l y t h e r e a f t e r we crashed." H a l s o    e
     t e s t i f i e d that t o h i s knowledge t h e a i r c r a f t was operating properly
     up u n t i l t h e moment t h e v i b r a t i o n occurred.

              The a i r c r a f t f i r s t s t r u c k t r e e s at t h e 10,800-foot l e v e l on
     Mount Trelease ( e l e v a t i o n 12,447 f e e t m.s.l.), and came t o r e s t on
     t h e ground some 425 f e e t beyond t h e point of i n i t i a l impact at a n
     e l e v a t i o n of 10,750 f e e t m.s.1.             Ten persons and F i r s t Officer Skipper
     survived t h e impact and f i r e , and were subsequently t r a n s p o r t e d t o
     h o s p i t a l s i n Denver, Colorado. 'The time of t h e crash was approximately
     1300 according t o eyewitnesses and one of t h e surviving passengers.

         Twenty-six eyewitnesses who saw t h e a i r c r a f t at various p l a c e s
 along t h e f l i g h t p a t h provided statements concerning t h e i r observations.
-Most describe t h e a l t i t u d e as low o r very low. Many were concerned
 t h a t t h e a i r c r a f t was i n danger because of t h e low a l t i t u d e over t h e
 mountainous t e r r a i n . - ~ A l l who observed t h e a i r c r a f t along t h e last
 10 miles of f l i g h t i n Clear Creek Valley s t a t e d t h a t t h e a i r c r a f t was
 below t h e mountaintops a t a l l times. A p i l o t employed by a major air-
 l i n e as a f l i g h t engineer observed t h e a i r c r a f t as it passed over
 Georgetown, Colorado. H estimated t h a t t h e a i r c r a f t a l t i t u d e was
                                      e
 between 1,000 and 1,500 f e e t above Georgetown, and t h a t it appeared
 t o be climbing a t a slow airspeed. The engines appeared t o be operat-
 ing normally.

                   n
                 A engineer f o r t h e Martin Marietta Corporation a l s o observed t h e
       a i r c r a f t as it passed over Georgetown, Colorado. H s t a t e d : "I had
                                                                            e
       been a m i l i t a r y p i l o t of multi-engine a i r c r a f t during World W a r I1 and
       was awed by t h e aspect of such a l a r g e a i r c r a f t c r u i s i n g up t h e v a l l e y
       at approximately 500 t o 1,000 f e e t above t h e t e r r a i n . The engines
        sounded as though t h e y were t h r o t t l e d back and not a t high r.p.m.,
       a condition not i n keeping with what would be expected i f t h e a i r c r a f t
       was attempting t o c l e a r t h e Continental Divide. When t h e plane made a
       t u r n t o t h e r i g h t , I noticed a mushiness t o i t s f l i g h t c h a r a c t e r i s t i c s .
        Both engines appeared t o be running normally, no smoke, f i r e o r sounds
        of missing o r backfiring." H a l s o s t a t e d : "After studying t h e power
                                                  e
        curves of t h i s a i r c r a f t i n t h e Martin 404 Airplane F l i g h t Manual dated
        September 10, 1951,Yt appears t h e plane was w e l l above t h e c r i t i c a l
    ';:engine a l t i t u d e , and it d i d n ' t appear t o be much above t h e minimum
     ' . c o n t r o l speed of 110 mph."

           Another witness, a p i l o t familiar with t h e Loveland Pass a r e a ,
      observed t h e a i r c r a f t as he was d r i v i n g eastward on U. S. Highway 6
                                           -7-
about 2 miles e a s t of Dry Gulch. He stated,-"Thinking                    i t must be i n
trouble, I stopped t h e c a r t o g e t out and look and l i s t e n . My i n i t i a l
and fr f e e l i n g was t h a t t h e plane was i n s e r i o u s t r o u b l e a s it was
     im
below t h e l e v e l of t h e mountains on e i t h e r s i d e t h a t form t h e v a l l e y ,
and I didn't see how it could possibly t u r n around.'-Also, it was i n
nose high a t t i t u d e and f l y i n g a t a low r a t e of speed, obviously s t r a i n i n g
t o gain a l t i t u d e , b u t b a r e l y keeping up with t h e r i s e of t e r r a i n . I have
driven over t h i s r o u t e countless times and know t h a t t h e steepness of
the slope increases r a d i c a l l y i n only 3 o r 4 miles from where he was and
that t h e plane could never make it.'& He a l s o s a i d t h a t both engines
sounded good as t h e a i r c r a f t passed over him, and he d i d not observe any
sign of smoke from e i t h e r engine.

         A witness, located on U. S . Highway 6 west of t h e crash s i t e , f i r s t
observed t h e a i r c r a f t a t Dry Gulch. The d i s t a n c e from h i s l o c a t i o n t o
Dry Gulch was approximately 5,000 f e e t . A s i g h t l i n e bearing from h i s

                            i
point of observation e l e v a t i o n 10,650 f e e t m.s.1.) t o where he saw t h e
a i r c r a f t measured 4 1 2' upward.

         Two witnesses at t h e ll,9OO-foot a l t i t u d e l e v e l on t h e e a s t s i d e
of Loveland Pass were looking down a t t h e a i r c r a f t when t h e y observed
it make a r i g h t t u r n a c r o s s t h e highway j u s t e a s t of Dry Gulch, and a
l e f t t u r n while over t h e timber on t h e northwest s i d e of t h e highway,
before crashing i n t o t h e mountain. A s i g h t l i n e bearing taken from
t h e i r point of observation t o t h e point of t h e t u r n near Dry Gulch
measured 4 1/4" downward. One of t h e s e witnesses believed t h a t t h e
propellers stopped revolving immediately p r i o r t o contact with t h e
trees. The other believed both p r o p e l l e r s were t u r n i n g slowly.

     Two other witnesses, who were on U. S . Highway 6 almost d i r e c t l y
opposite t h e subsequent crash s i t e , estimated t h a t t h e a i r c r a f t was
only about 100 f e e t above t h e highway as it was coming toward them, and
seemed t o be l o s i n g a l t i t u d e .

         The a i r c r a f t made a s t e e p t u r n i n f r o n t of them, with a bank angle
t h a t permitted them t o see t h e t o p s of t h e p l a n e ' s wings and t h e t o p
of the fuselage. Seconds l a t e r , t h i s couple observed t h e a i r c r a f t
s t r i k e t h e t r e e s . According t o them, t h e r e was no smoke coming from
the engines. The p r o p e l l e r s were t u r n i n g slowly.

      Two witnesses, one i n Georgetown and one l o c a t e d approximately
1-1/2 miles e a s t of t h e crash s i t e , reported hearing t h e engine(s)
make a sound similar t o backfiring. One of t h e s e witnesses t e s t i f i e d
that when he was halfway between t h e Bethel and S i l v e r Plume campgrounds,
he f i r s t saw t h e a i r c r a f t as it passed over t h e highway. He stopped h i s
car and observed t h e a i r c r a f t through a pair of binoculars. He s t a t e d
                                              - a-
that he read two of t h e numbers on t h e a i r c r a f t as "4" and "M" when
t h e a i r c r a f t was 3/4 t o 1 mile past h i s p o s i t i o n , and t h a t t h e s e numbers
were on t h e s i d e of t h e a i r c r a f t , on t h e fuselage, d i r e c t l y forward of
t h e t a i l s e c t i o n . H t e s t i f i e d t h a t he c a l l e d t h e F A F l i g h t Service
                               e                                                A
S t a t i o n (FSS) i n Denver t o inform t h e F A of h i s observation. However,
                                                            A
t h e telephone l o g s i n t h e F A FSS do not r e f l e c t t h a t such a c a l l was
                                         A
received.

         Eight of t h e surviving passengers were interviewed. A confirm                  l
t h a t t h e a i r c r a f t was continuously below t h e mountaintops while f l y i n g
up Clear Creek Valley. None r e c a l l e d any i n d i c a t i o n s t h a t t h e engines
were not running normally. Several r e c a l l e d t h a t t h e a i r c r a f t was
banked sharply j u s t before impact.,The                        banks upset a stewardess who
was serving refreshments t o t h e passengers.- Three described t h e air-.
c r a f t as shaking o r v i b r a t i n g coincident with, o r immediately following,
t h e i n i t i a t i o n of t h e r a p i d banks. One survivor, who had been standing
i n t h e doorway t o t h e p i l o t ' s compartment and immediately behind t h e
two p i l o t s , s t a t e d t h a t t h e v i b r a t i o n f e l t l i k e "a boat slapping water."
While he was standing i n t h e doorway, he overheard t h e p i l o t s discussing
t h e e l e v a t i o n of t h e mountain peak ahead, and about that time t h e quick
                                                              e
r i g h t t u r n and l e f t t u r n were made. H d i d not r e c a l l any conversation
between t h e two p i l o t s o t h e r t h a n t h i s . The engines sounded normal t o
him and, u n t i l t h e r i g h t t u r n was i n i t i a t e d , it d i d not seem t o him t h a t
t h e p i l o t s were overly concerned about t h e f l i g h t .

1.2    I n j u r i e s t o Persons

       Injuries                      -
                                     Crew                 Bssengers                      Others

       Fatal                          2                         28                          0
       Nonfatal                       1                          9                          0
       None                           0                          0                          0

          Post-mortem examination of t h e c a p t a i n did not r e v e a l any evidence
of p r e - e x i s t i n g disease o r physical impairment t h a t would have adversely
a f f e c t e d t h e performance of h i s d u t i e s .

1.3 Dynage t o A i r c r a f t
        The a i r c r a f t was destroyed by impact with t r e e s and t h e ground, and
t h e f i r e which occurred a f t e r impact.

1.4    Other Damage

       A nmber of t r e e s up t o 2 f e e t i n diameter were destroyed.
                                 -   9-
1.5 Crew Information
    The crewmembers were properly certificated to conduct this flight.
(For detailed information, see Appendix B )
                                         .
 .
1 6 Aircraft Information
     N464M, serial No. 14151, was one of 14 Martin 404 aircraft purchased
in "as is" condition by the Jack Richards Aircraft Company on February 16,
1968, pUrsUant to a purchase agreement with the Fairchild Hiller Corpora-
tion. Prior to the acquisition by Fairchild Hiller Corporation, ~ 4 6 4 ~
had been owned and operated in airline service by Ozark Air Lines, Inc.
According to Ozark Air Lines records, N464~ was last operated in airline
service on a flight terminating in St. Louis, Missouri, on June 7, 1967.
Total airframe time then was 38,593:26 hours; time since overhaul was
13,586:14. The time since overhaul on the left engine was lOll:O5 hours
and on the right engine 1747:14 hours.

     N464M subsequently was ferried to Las Vegas, Nevada, where it was
to be maintained in operational, or fly-away, status. This fly-away
storage procedure consisted of regular inspections and engine runups
at approximately 2-week intervals. The aircraft remained in storage
status at Las Vegas until August 30, 1970, at which time an "annual" 61
inspection was partially completed by Mr. Donald R. Sizemore, who he12
an Inspection Authorization issued by the Federal Aviation Administration
(FAA).      Sizemore signed the aircraft logbooks on September 8, 1970,
indicating completion of the annual inspection. However, at that time,
a required X-ray inspection of the engine mounts had not been completed.
Because of this, he held the logbooks in his possession until the X-ray
examination could be accomplished. Accordingly, on September 14, 1970,
the aircraft was flown, pursuant to a ferry permit, from Las Vegas,
Nevada, to the Jack Richards Aircraft Company's facilities in Oklahoma City,
Oklahoma.
     The captain who flew N464M on this ferry trip testified that in his
opinion,". .    this airplane appeared to be as good as the ones I have
been flying every day for an air carrier. It was in good condition."

     On September 15, 1970, the X-ray inspection was accomplished and
                         r
the X-rays submitted to M . Sizemore for examination. He testified

-
&/ An "annual" inspection is required by Part 91 of the Federal Aviation
   Regulations (FAR) in order for an aircraft to be operated in passenger-
   carrying activities. The inspection must be accomplished in accordance
   with Part 43 of the FAR'S and the aircraft approved for'returnto
   service by a person authorized by the FAA.
                                            -   10   -
t h a t following h i s examination, he made a p p r o p r i a t e e n t r i e s i n t h e
logbooks. O September 20, 1970, he r e l e a s e d the,logbooks t o t h e
               n
Jack Richards A i r c r a f t Company. H t e s t i f i e d t h a t a t t h a t time, he
                                           e
considered t h e a i r c r a f t airworthy and duly l i c e n s e d f o r passenger
travel.

          Since t h e s e a t l o c a t i o n of a l l passengers and t h e l o c a t i o n of a l l
baggage could not be determined, t h e p r e c i s e c e n t e r of g r a v i t y of t h e
a i r c r a f t a t impact could not be computed. The gross weight computations
a r e contained i n Appendix C t o t h i s r e p o r t .

1.7 Meteorological Information
    %The weather was c l e a r i n t h e v i c i n i t y of t h e c r a s h s i t e . There was
no evidence of turbulence o r up- or downdraft a c t i v i t y . Witness e s t i m a t e s
of t h e outdoor temperatures i n t h e v i c i n i t y of t h e crash s i t e ranged
from 55" F. t o 65" F. The wind condition at t h e crash s i t e was estimated
t o be 10 knots from a t r u e bearing of 350". Weather conditions a r e not
considered t o be a f a c t o r i n t h i s a c c i d e n t .

1.8    Aids t o Navigation

     Not a p p l i c a b l e . T h i s f l i g h t was conducted under Visual F l i g h t Rules
and a f l i g h t plan was not f i l e d .

1.9    Communications

     There were no communications with t h e f l i g h t a f t e r i t s d e p a r t u r e
from t h e v i c i n i t y of Stapleton I n t e r n a t i o n a l A i r p o r t .

1.10    Aerodrome and Ground F a c i l i t i e s

        Not a p p l i c a b l e .

 . 1
11 F l i g h t Recorders

            Neither a f l i g h t recorder nor a cockpit voice recorder was
i n s t a l l e d on N464M, nor were t h e s e required by Federal Aviation
Regulations.

1.12    Wreckage

        The crash occurred i n a h e a v i l y wooded a r e a . The t r e e s were up
t o 2 f e e t i n diameter. Many were more t h a n 5 f e e t high.
                                                      0

     The f i r s t t r e e s t r u c k by t h e a i r c r a f t was a t an e l e v a t i o n of
approximately 10,800 f e e t m.s.1.             Continuing along a magnetic heading
of 215", t r e e s were cut off on a descending slope of I t o 4 1/2'.     t                    The
                                            -   11   -
swath path indicated a l e f t bank angle of approximqtely 31". The
distance between t h e f i r s t t r e e s t r i k e and t h e t a i l of the.wrecked
a i r c r a f t was 425 f e e t . F i r s t evidence of f i r e was discovered on t h e
ground a t approximately 185 f e e t from t h e f i r s t t r e e contact. The
area of t r e e wreckage and burnout was approximately 350 f e e t i n width
at t h e widest point and 525 f e e t i n length from t h e f i r s t t r e e s t r i k e .
The slope of t h e t e r r a i n was 2' t o 31" 7/
                                            9'           -
         a.   Airframe

          Many pieces o f t h e a i r c r a f t were t o r n o f f as it descended
through t h e t r e e s . The wings were broken o f f a t t h e i r a t t a c h points.
They were t o r n apart and pieces were found along t h e t r e e swath path.

     The fuselage was e n t i r e l y burned down t o molten aluminum and
twisted longerons and s t r i n g e r s . It lay on i t s l e f t s i d e . The empennage
was severed from t h e fuselage, 2 f e e t forward of t h e a f t pressure btilk-
head. The v e r t i c a l s t a b i l i z e r leaned downhill a t a n angle of approxi-
mately 25'.  The rudder frame remained, burned out. Portions of t h e
elevator remained with t h e empennage. Elevator trim and s p r i n g t a b s
were found attached t o t h e remaining e l e v a t o r . The e l e v a t o r t a b was
positioned 3" up.

     Control cables l a y along t h e span of t h e wrecked fuselage.                 No
breaks were discovered.

      A portion of t h e h o r i z o n t a l s t a b i l i z e r remained with t h e empennage.
The measurement of t h e h o r i z o n t a l s t a b i l i z e r jackscrew was 1-1/2 inches
o r equivalent t o 3" of l e a d i n g edge tip. The h o r i z o n t a l s t a b i l i z e r
adjustment i s a flmction of t h e s e l e c t i o n of takeoff o r 12.5" of flaps.
The i n t e r a c t i n g mechanism, which causes t h e stabilizer t o move tip
when 12.5" of f l a p s are s e l e c t e d , was t o t a l l y destroyed by f i r e .

      A f l a p a c t u a t o r was found, minus a l l connecting hydraulic hoses.
It was f u l l y compressed. A second f l a p a c t u a t o r mintis a l l hoses was
found, measuring 3-3/4 inches extension. The f l a p s s e l e c t o r was i n
the takeoff position. The landing gear handle was i n n e u t r a l (up)
position. The t h r o t t l e quadrant l a y burned out i n t h e wreckage. N        o
control cables remained a t t a c h e d t o it. The r i g h t mixture c o n t r o l
was i n auto r i c h . The l e f t mixture c o n t r o l was f r e e t o move t o any
setting.

         b.   Systems

         Ground f i r e was of such duration and i n t e n s i t y that virtually
no meaningful information could be obtained from t h e a i r c r a f t systems.

-
7/   .   See Appendix H   --   Wreckage D i s t r i b u t i o n Chart.
                                               -   12   -
     Except f o r a burned out a l t i m e t e r , and a few b a t t e r e d instruments
found s e p a r a t e l y away from t h e main wreckage a r e a , no instruments,
panels, or any o t h e r components were recovered with any p e r t i n e n t
information. The barometric s e t t i n g on t h e a l t i m e t e r was 30.27 inches                Hg.
       c   .   Powerplant s

               1. On-Site I n v e s t i g a t i o n

     The p r o p e l l e r s and engines were found on t h e s i d e of a mountain and
were r e s t i n g on a n i n c l i n e i n excess of 3 0 " .

        The l e f t and right engines were found separated from t h e i r r e s p e c t i v e
p r o p e l l e r s . The f r o n t s e c t i o n cases of both engines were a t t a c h e d t o t h e
p r o p e l l e r s . The engine/propeller s e p a r a t i o n s occurred a t t h e f r o n t acces-
sory support p l a t e and case.

       (a) Left Propeller
          Two of t h e t h r e e blades remained a t t a c h e d t o t h e p r o p e l l e r assembly.
These blades were subsequently i d e n t i f i e d as Nos. 1 and 3 blades. The
other blade, which was subsequently i d e n t i f i e d as No. 2 blade, was
broken away from t h e p r o p e l l e r assembly, 18 inches out from t h e hub.
The blade was found about 50 f e e t below and i n l i n e with t h e separated
p r o p e l l e r blade assembly. The blade s e p a r a t i o n s were t y p i c a l of impact
f r a c t u r e s . A l l blades were accounted f o r .

          The blade t i p s of t h e a t t a c h e d blades were broken. A l l of t h e
blades were t w i s t e d and bent rearward. The separated blade was i n t a c t .
The p r o p e l l e r assembly was not damaged by t h e ground f i r e . The two
a t t a c h e d p r o p e l l e r blades were cut o f f by hand, and t h e p r o p e l l e r /
reduction gear assembly was removed from t h e accident s i t e .

       (b)      Right Propeller

          Two blades remained a t t a c h e d t o t h e separated p r o p e l l e r / r e d u c t i o n
gear assembly. These blades were subsequently i d e n t i f i e d as Nos. 1 and
2 blades. The No. 3 blade was separated at t h e blade shank. A s e c t i o n
of t h e separated blade was found about 150 f e e t t o t h e r e a r of, and i n
l i n e with, t h e separated r i g h t p r o p e l l e r assembly. One a t t a c h e d propel-
l e r blade was i n t a c t ; t h e second p r o p e l l e r blade had a s e c t i o n near t h e
t i p broken away.        A l l t h r e e blade assemblies were bent rearward and
t w i s t e d t o varying degrees.

         All blades were accounted f o r , and t h e blade s e p a r a t i o n s were a l l
i n d i c a t i v e of impact-type f r a c t u r e s .

      The p r o p e l l e r and separated reduction- drive gear housing bore
 some evidence of heat damage i n t h e v i c i n i t y of t h e b a r r e l halves.
                                            -   13   -
     The two attached blades were c u t by hacksaw from t h e p r o p e l l e r
hub, and propeller assembly was removed from t h e accident s i t e .

      (c)   Propeller Governors

     Only one p r o p e l l e r governor was recovered from t h e wreckage area.
The governor was found approximately 12 f e e t t o t h e r e a r of t h e pro-
peller assembly. The d a t a plate part number was 5Ul84gE; t h e s e r i a l
nmbers were WH51213 and O U 5 . The governor was not damaged except
for some s l i g h t heat discoloration. A s e c t i o n of reduction- drive gear
housing was attached t o t h e governor. It was determined (by matching
the section of drive gear housing attached t o t h e governor t o t h e
remains of t h e f r o n t accessory s e c t i o n housing) t h a t t h i s governor was
attached t o t h e r i g h t engine.

      (a)   Left Engine

      The power and accessory s e c t i o n s were i n t a c t . The a c c e s s o r i e s
mounted on t h e r e a r accessory case were a l l i n t a c t and d i d not appear
t o be damaged by impact forces. The only apparent component damage
occurred t o t h e carburetor and generator. The mixture c o n t r o l housing
was broken away from t h e carburetor, and t h e rear of t h e generator
housing was h e a v i l y burned.

     The power and accessory s e c t i o n s of t h i s engine evidenced indica-
tions of ground f i r e and h e a t damage, p r i m a r i l y i n t h e area of t h e re-
duction gear a r e a of t h e power section. The r e a r accessory case and
attached components evidenced i n d i c a t i o n s o f heat damage t o a generally
lesser degree than t h e power section.

     The cowling f o r t h i s engine was separated and e x t e n s i v e l y broken
up and fragmented. A few cowl f l a p a c t u a t o r s a t t a c h e d t o small s e c t i o n s
of cowl f l a p were found and were r e t r a c t e d o r i n t h e cowl closed p o s i t i o n .

      (e) Right Engine
      The engine was i d e n t i f i e d through a p a r t i a l l y a t t a c h e d s e c t i o n of
a supercharger which comprises t h e p r e s s u r i z a t i o n system t h a t i s mounted
on the r i g h t engine accessory pad of t h i s model a i r c r a f t . The power
section was b a s i c a l l y i n t a c t except f o r some separated c y l i n d e r heads.
The accessory s e c t i o n was almost t o t a l l y destroyed by ground f i r e . The
impeller drive s h a f t remained attached t o t h e power s e c t i o n and was
extensively damaged by ground f i r e . Several burned components were found
adjacent t o t h e r i g h t engine accessory a r e a . These a c c e s s o r i e s included
several r e a r accessory d r i v e gears and a separated main o i l screen. The
housing of t h i s screen was burned away. A separated generator was a l s o
found. The generator was completely burned and would not r o t a t e . A
blower clutch drive, s t a r t e r clutch, t h r e e valves with t h e valve springs
                                                                                                             F
                                                                                                             !

                                            -   14   -
attached, and a s e c t i o n o f c y l i n d e r head were found i n t h e a r e a adjacent                 !
t o t h e engine. The engine cowlings were separated a n d were almost t o t a l l y
destroyed. Some small s e c t i o n s of cowl f l a p , with t h e f l a p a c t u a t o r s
s t i l l attached, were found. These a c t u a t o r s were i n t h e r e t r a c t e d p o s i t i o n .

     Only one valve r e l a t e d t o e i t h e r t h e f u e l or engine hydraulic
system was found. The valve s e r i a l number was C-41-9788, p a r t number was
4-1846-2. The valve was removed from a $ + i n c h l i n e and w s found closed.
                                                                            a

       2.    I n v e s t i g a t i o n of Engines and P r o p e l l e r s at t h e Maintenance Base a t
             Frontier Airlines.

     The engines were removed from t h e accident s i t e on October 4, 1970,
and were t r a n s p o r t e d t o Denver on October 5, 1970, for disassembly and
examination. The p r o p e l l e r s were a l s o disassembled and examined.

       ( a ) Left Propeller, S/N A4929
         The reduction gear assembly r o t a t e d f r e e l y when turned a t t h e pro-
p e l l e r s h a f t . The v i s i b l e p o r t i o n of t h e blade bushings were a l l i n t a c t
and did not d i s p l a y any evidence of damage. The bushing a t t a c h i n g screws
and l o c a t i n g dowels were broken, which allowed t h e bushing assembly of
each p r o p e l l e r t o be displaced beyond i t s normal p o s i t i o n . The degree of
displacement was not determined. The blade shank r a d i u s of t h e t h r e e
blades displayed circumferential gouges from contacting t h e blade chafing
r i n g a t impact.

          The t h r e e blade s p i d e r shim p l a t e s were removed from t h e p r o p e l l e r
assembly. The No. 1 blade shim p l a t e was broken i n t o two p i e c e s and was
cracked a t t h e dowel pin hole. The f r a c t u r e was p a r a l l e l t o t h e p r o p e l l e r
s p i d e r shoulder. The No. 2 blade shim p l a t e was i n t a c t except for a crack
which was p a r a l l e l t o t h e p r o p e l l e r s p i d e r shoulder. The No. 3 blade shim
p l a t e was cracked i n t o t h r e e pieces and bore an impact mark t h a t was
p a r a l l e l t o t h e p r o p e l l e r s p i d e r shoulder. These impact marks and/or
f r a c t u r e s were determined t o correspond t o a p r o p e l l e r blade angle of
approxinmtely 32'". The dome angle was a l s o measured and computed t o be
32.9". The scavenge pump was removed. The pump was i n t a c t and contained
an extensive amount of d i r t and small p a r t s of t r e e limbs. N f o r e i g n metal
                                                                                   o
was found w i t h i n t h e pump c a v i t y a r e a .

       (b)    Right Propeller, S/N         A3696
          The condition noted f o r t h e r i g h t p r o p e l l e r was similar t o t h a t
noted for t h e l e f t p r o p e l l e r . The o i l scavenge pump was removed and
evidenced impact damage. The pump vanes were exposed and t h e d r i v e
s h a f t was broken. No evidence of f o r e i g n metal was observed. An ex-
t e n s i v e amount of mud and d e b r i s was found i n t h e pump c a v i t y a r e a .
                                              -   15   -
     The blade spider shim p l a t e s were removed from t h e p r o p e l l e r . The
No. 1 and No. 2 blade shim p l a t e s were broken i n t o two pieces.                The
fracture was p a r a l l e l t o t h e p r o p e l l e r s p i d e r shoulder. The No. 3
spider shim p l a t e was broken i n t o four pieces, and an impact mark was
visible which was p a r a l l e l t o t h e p r o p e l l e r s p i d e r shoulder. The
fractures and/or impact marks corresponded t o a p r o p e l l e r blade angle
of approximately 32". The dome angle w s a l s o measured and computed t o
                                                         a
be 32.9".

       ( c ) Right Propeller Governor, Woodward Part No. 5u1849F2,
             S/N WH51213 and/or OZA5
     The governor was disassembled t o determine t h e s e l e c t e d speed of
the engine. The distance from t h e head mounting surface t o t h e rack
spring s e a t measured 0.925 inch. This d i s t a n c e corresponds t o a gover-
nor speed of 2,400 r.p.m.
       (a)   Engine &amination

     Both engines were disassembled by conventional means, with t h e
exception that a c u t t i n g t o r c h was used i n order t o expedite t h e
removal of t h e impact-damaged exhaust c o l l e c t o r r i n g s of both engines.
A number of o t h e r non-engine s t r u c t u r a l p a r t s , such as cowl r i n g s and
sections of t h e f i r e w a l l , were a l s o removed by t h i s method.

         The cylinder b a r r e l s of both engines were securely a t t a c h e d t o
t h e i r respective crank cases. A of t h e i n t a c t c y l i n d e r s from both
                                           l
engines were borescoped a f t e r spark plug removal. There was no v i s i b l e
evidence of any i n t e r n a l damage o r p r e - e x i s t i n g d i s t r e s s noted t o t h e
cylinder b a r r e l walls, p i s t o n heads, valves, e t c .

         After removal of a r e p r e s e n t a t i v e number of c y l i n d e r s , t h e i n t e r n a l
components of t h e power s e c t i o n of both engines were examined v i s u a l l y .
!Chis examination revealed t h a t t h e ln rods, master rods, and p i s t o n
                                                     ik
                  o
skirts were n t damaged by t h e impact, nor d i d t h e s e components d i s p l a y
any evidence of p r e - e x i s t i n g d i s t r e s s . The l e f t engine master and l i n k
rods a l l moved f r e e l y , w i t h no evidence of binding noted. The master
rod cylinder f o r t h e r i g h t engine was crushed and damaged by t h e ground
f i r e , thus s e i z i n g t h e engine. However, t h e l i n k rods could be r o t a t e d
on t h e i r respective l i n k p i n s .

     Nine c y l i n d e r s were removed from each engine. The walls of a l l of
these cylinders bore p i s t o n s k i r t and r i n g markings c h a r a c t e r i s t i c of
storage i n a s t a t i o n a r y p o s i t i o n f o r a n extended period of time. The
piston r i n g s were not "feathered" as i n a normal engine; r a t h e r , t h e
                                          -   16   -
r i n g s were rounded and displayed both polished and d u l l f i n i s h e d a r e a s ,
c h a r a c t e r i s t i c of r i n g s t h a t have not seated properly during engine
operation a f t e r a n extended storage period.

             a
          Mw of t h e s p r k plugs were fouled w i t h o i l and heavy carbon d e p o s i t s .
The i n t a k e and exhaust p o r t s and p i p e s on t h e r i g h t engine had a heavy
coating of o i l , d i s t r i b u t e d uniformly throughout t h e p o r t c a v i t i e s and
pipes. The blower s e c t i o n on t h e l e f t engine displayed a uniformly
d i s t r i b u t e d , heavy coating of o i l .

     There was no evidence i n e i t h e r engine t o i n d i c a t e t h a t t h e engines
were not capable of producing power up t o t h e point of impact.

          I n order t o a s s e s s t o what e x t e n t , if any, t h e o i l d e p o s i t s found i n
t h e engines (and an o i l consumption of approximately 6 g a l l o n s per hour per
engine) might i n d i c a t e a p o t e n t i a l power l o s s , questions were asked of
Fratt & Whitney CB3 engine s p e c i a l i s t s . Testimony concerning t h e o i l
consumption was t h a t t h e r e i s no maximum s p e c i f i e d or permissible amount
per hour i f t h e engine i s otherwise operating normally, nor i s high o i l
consumption a n i n d i c a t i o n of p o t e n t i a l o r e x i s t i n g power loss. High o i l
consumption and t h e o i l coating found i n t h e i n t a k e and exhaust p o r t s and
t h e blower s e c t i o n could r e s u l t from seized p i s t o n r i n g s , causing blow-by,
and from leakage around t h e impeller s e a l s . I n t u r n , t h e s e conditions
could e x i s t as t h e r e s u l t of inadequate, long-term s t o r a g e p r a c t i c e s . One
i n d i c a t i o n of p o t e n t i a l high o i l consumption i s p i s t o n r i n g markings on
                                                                ..
t h e c y l i n d e r walls. One expert t e s t i f i e d , ' I .           I would c e r t a i n l y be
i n c l i n e d , i n f a c t I ' d be s t r o n g l y urged t o remove a couple of t h e j u g s
and have a look, because I would suspect p o s s i b l y t h a t t h i s i s t h e r e ,
that t h i s p a r t i c u l a r r i n g i s making t h i s mark, may possibly be s e i z e d
where it wouldn't f u n c t i o n properly when i t ( t h e engine) d i d start
operat ion. "

          Mr. Skipper t e s t i f i e d t h a t on takeoff a t Denver, t h e manifold pressure
on t h e engines of N464M was about 1 inch below t h e maximum allowable, or
about 58-1/2 inches. With respect t o t h i s statement, a Pratt & Whitney
performance engineer t e s t i f i e d that 58-1/2 inches of manifold pressure
would be normal a t t h e Stapleton I n t e r m t i o n a l Airport e l e v a t i o n , and
from that he would conclude that t h e engines were developing normal take-
off power. H f u r t h e r s t a t e d t h a t a t a power s e t t i n g of 165 BMEP and
                    e
2,400 r.p.m., t h e engines would be a t , o r very near, f u l l t h r o t t l e a t
12,000 f e e t m.s.1. on a standard day. If t h e temperature were higher
than t h a t f o r a standard day, f u l l . t h r o t t l e would be reached a t some
                                      -
a l t i t u d e below 12,000 f e e t . 1 /  0

-
10/    The a l t i t u d e a t which full t h r o t t l e i s reached, o r t h e supercharger
       i s no longer capable of supplying more air than i s necessary t o
       achieve a given brake horsepower i s known as t h e engine's " c r i t i c a l
       altitude."
                                            -   17 -
         I n normal climb, a d d i t i o n a l power can be achieved a f t e r f . .
                                                                                 u11
t h r o t t l e i s reached by i n c r e a s i n g t h e engine r.p.m. from 2,400 t o
2,600.

         -
1.13 F i r e

        F i r e occurred a f t e r ground impact. F i r s t evidence of f i r e was
                                                 8
discovered on t h e ground approximately 1 5 f e e t from t h e first t r e e
contact. The burned out area measured 350 f e e t wide and 525 f e e t long.
The a i r c r a f t fuselage was reduced t o molten aluminum from t h e aft pressure
bulkhead forward, except f o r a small s e c t i o n of t h e nose cone.

1.14   Survival Aspects

     N464M was configured as a s i n g l e - c l a s s s e r v i c e a i r c r a f t . The
pssenger compartment seated 40 passengers i n 10 rows of two double
seats each. The s e a t s i n row one were a f t facing; t h e o t h e r s e a t s
faced forward.

      Ten passengers and one p i l o t survived t h e i n i t i a l impact and f i r e .
One of t h e passengers had been seated i n Row             ;
                                                           4 two i n Row 7; two i n
Row 8; and t h r e e i n Row 9. One survivor w s standing i n t h e doorway
                                                        a
t o the cockpit and jumped i n t o t h e forward baggage compartment when he
recognized t h a t a crash was i m i n e n t . The surviving first o f f i c e r was
occupying t h e l e f t p i l o t s e a t at t h e time of impact.

     All but one of t h e surviving passengers had t h e i r s e a t b e l t s un-
fastened. They were thrown forward and t o t h e l e f t at impact. Escape
from t h e a i r c r a f t was through a h o l e i n t h e l e f t s i d e of t h e f u s e l a g e
and a hole i n t h e r i g h t s i d e of t h e cockpit.

         Rescuers f i r s t a r r i v i n g a t t h e scene b t a t e d t h a t t h e fuselage was
r e l a t i v e l y i n t a c t , with a small h o l e on t h e r i g h t s i d e and a l a r g e hole
on the l e f t . One rescuer r e l a t e d t h a t he observed f i r e i n t h e forward
baggage compartment a r e a . H w s about t o s t e p i n s i d e t h e f u s e l a g e t o
                                           e a
a s s i s t any survivors when an explosion occurred, and flames t r a v e l e d a f t
into the cabin.

     It i s believed t h a t m a n y of t h e persons f a t a l l y i n j u r e d i n i t i a l l y
survived t h e impact conditions. This i s based on statements from t h e
seriously i n j u r e d c o p i l o t who saw and t a l k e d t o passengers l y i n g i n t h e
forward baggage compartment through t h e p a r t i a l l y opened cockpit door,
albeit t h e opening i n t h e door was t o o small t o reach them. One of t h e
first rescuers on t h e scene of t h e accident r e l a t e d a l s o t h a t he saw
pssengers on t h e f l o o r i n t h e forward s e c t i o n of t h e cabin. They were
moving but making no e f f o r t t o e x t r i c a t e themselves. This r e s c u e r noted
that the s e a t s i n t h e a i r c r a f t resembled “broken f u r n i t u r e ” and .that many
                                              -   18 -
s e a t s were pushed t o g e t h e r i n t h e forward s e c t i q n of t h e cabin. One of
t h e s u r v i v o r s mentioned having t o f r e e himself from a s e a t which was on
t o p of him i n order t o make h i s escape.

1.15 T e s t s and Research
            Studies o f t h e performance c h a r t s i n t h e Martin 404 a i r p l a n e f l i g h t
manual (AFM) were made t o determine t h e o p e r a t i n g c a p a b i l i t i e s of t h e air-
c r a f t at a g r o s s weight of 48,165 pounds on departure from Denver at a
f i e l d e l e v a t i o n of 5,300 f e e t m.s.l., and a t a gross weight of 47,565
pounds                at an i n d i c a t e d a l t i t u d e of 1 , 0 feet m . s . 1 . w i t h a f r e e a i r
                                                                  100
temperature (FAT) of 50" F. Since t h e s e c h a r t s do not present information
f o r weights i n excess of t h e 44,gOO maximum c e r t i f i c a t e d gross takeoff
weight of t h e a i r c r a f t , e x t r a p o l a t i o n s from t h e climb performance data
                                                                                    A
were necessary. The s t u d i e s were accomplished by a n F A a e r o n a u t i c a l
engineer who had been responsible f o r determining that t h e Martin 404
performance s a t i s f i e d c e r t i f i c a t i o n requirements at t h e time of o r i g i n a l
c e r t i f i c a t i o n of t h e a i r c r a f t f o r use i n a i r l i n e passenger- carrying
a c t i v i t i e s . (The general information used f o r t h e purpose of c a l c u l a t i o n s
i n t h i s instance, and t h e r e s u l t s obtained a r e contained i n Appendix D
t o t h i s report - )

        Concerning t h e climb performance c a p a b i l i t y , t h e AFM notes t h a t
b e s t climb i s obtained with M TE0     power a t 130 knots and t h e f l a p s


       Stall b u f f e t on t h e Martin 404 begins a t approximately 6 knots
above stall speed. Testimony adduced during t h e public hearing held i n
connection with t h i s accident was t h a t t h e b u f f e t can "take t h e form of
anything from a noticeable shake i n t h e s t e e r i n g column, which, g e n e r a l l y
speaking, i s not audible o r n o t i c e a b l e t o passengers, t o a very pronounced
                                                                                      y
shaking of t h e a i r p l a n e which almost anyone would observe. M r e c o l l e c t i o
of t h e Martin 202-404 s e r i e s is, t h a t i n i t s c e r t i f i c a t i o n configuration,
it had a very pronounced s t a l l b u f f e t . There was no mistaking it when you
got i n t o t h e stall."

1.16     Other Information

           Aircraft of United S t a t e s r e g i s t r y , having a maximum c e r t i f i c a t e d
takeoff weight of 12,500 pounds or more, may be operated i n passenger-
carrying a c t i v i t i e s i n t h e United S t a t e s under more t h a n one p a r t of t h e
FAR'S. The determining f a c t o r s g e n e r a l l y r e l a t e t o t h e intended use of
t h e a i r c r a f t , t h e r e s p o n s i b i l i t y f o r i t s operation, and whether t h e
f l i g h t s a r e f o r compensation o r h i r e . It became apparent i n t h e e a r l y
s t a g e s of t h i s i n v e s t i g a t i o n t h a t t h e r e was a disagreement among t h e
t h r e e i n t e r e s t e d p a r t i e s concerning t h e designation of " operator." I n t h e

-/
11      Calculated weight of t h e a i r c r a f t at time of impact based upon f u e l
        burnof f   .
-/
12           -
        METO-Maximum Except Takeoff, o r t h e maximum continuous power.
                                               - 19 -
     course of the public hearing, an FAA witness t e s t i f i e d t h a t t h e F A           A
  , Considered Golden Eagle Aviation, Inc.,
   ,                                                      t o be t h e cjperator, and as such
  ' $id not   have t h e proper a u t h o r i t y for t h e o p e r a t i o n of Martin 404 air-
  &aft.       Both t h e Jack Richards Aircraft Company and Golden Eagle Aviation,
     Inc., contended t h a t t h e Wichita S t a t e University was t h e o p e r a t o r . It
     was the position o f Wichita S t a t e University o f f i c i a l s t h a t t h e y had
,. chartered t h e a i r c r a f t and Wichita S t a t e University was not t h e operator.
     The testimony of t h e t h r e e p a r k i e s concerning t h e c o n t r a c t u a l r e l a t i o n -
     ships may be summarized as follows:

  a.   Jack Richards A i r c r a f t Company, Inc.

        l.
       Er     Joseph H. Richards t e s t i f i e d t h a t he was t h e p r e s i d e n t and s o l e
  btockholder of t h e Jack Richards A i r c r a f t Company, Inc. The company's
  business involved a i r c r a f t s a l e s and both long- and short- term l e a s i n g
  of a i r c r a f t . The company did not s o l i c i t short-term l e a s e s (about
  5 percent of t h e t o t a l company b u s i n e s s ) , and it was necessary for such
  potential customers t o come t o Mr. Richards, r a t h e r t h a n t h e company
  seeking such customers. He t e s t i f i e d " I ' m r e a l l y not looking f o r t h e i r
                                                                            il
  business, but while my a i r c r a f t a r e s i t t i n g t h e r e , I wl l e a s e them
  out at times.      ..    .I' With respect t o t h e manner i n which t h e short- term
  $ease$ were accomplished, he s t a t e d "Usually, whoever t h e y send t o pick
  up the aircraft, I have them sign it if t h e y a r e an o f f i c e r , or, you
  know, e agent of t h e l e s s e e . If t h e y a r e not, I usually send t h e l e a s e
            n
  along (with t h e p i l o t s ) w i t h    s i g n a t u r e on them and w i t h a r e t u r n
  envelope, stamped, t h a t when t h e people a r r i v e , t h e y can have them s i g n it,
  &op it i n t h e m i, and r e t u r n it t o me." A sample of a l e a s e (involving
                          al
  e w i n 404 a i r c r a f t , n461.M) t o Wichita S t a t e University (WSU) f o r a
  t r i p from Wichita, Kansas, t o College S t a t i o n , Texas, and r e t u r n was
  submitted a s an e x h i b i t i n t h e public hearing. This l e a s e d i d not s p e c i f y
  asy payment for t h e use of t h e a i r c r a f t , and was undated.
          All agreements a s t o p r i c e and a v a i l a b i l i t y of a i r c r a f t were
  accomplished verbally, and no agreements i n w r i t i n g concerning t h e
  basis for any charges were ever made. With r e s p e c t t o t h e l e a s i n g of
  b r t i n a i r c r a f t f o r t h e Wichita S t a t e University 1970 f o o t b a l l season,
   &
  I.    Richards s t a t e d , "During t h e summer of 1970 I spoke with M r . B e r t
  Katzenmeyer concerning t h e l e a s i n g of a i r p l a n e s f o r t h e coming f o o t b a l l
  season. Although Mr. Katzenmeyer wanted t o l e a s e a n a i r p l a n e f o r t h e
  entire season i t w s agreed t h a t if t h e company had planes a v a i l a b l e , we
                                a
  would lease t o them on a s i n g l e - t r i p b a s i s . I explained t o Mr. Katzenmeyer
  that t h i s was t h e only way t h a t I could do it because t h e company w s                     a
  primarily i n t e r e s t e d i n s e l l i n g a i r p l a n e s and could not p o s s i b l y t i e
  up a plane for an e n t i r e season a t t h e p r i c e t h e University was w i l l i n g
  t o pay. Mr. Katzenmeyer s t a t e d t h a t he understood and agreed t o l e a s e
  planes from us when a v a i l a b l e a t an hourly r a t e of $125.00."

        Mr
         . Richards t e s t i f i e d that a l l of h i s c o n t a c t s were by telephone,
  Chat he had never v i s i t e d Wichita S t a t e University, t h a t no o f f i c e r s
i   of t h e University had c a l l e d on him i n Oklahoma, and that he had never
    met   Mr
           .
                                                    -   20   -
                  Bert Katzenmeyer (who was t h e A t h l e t i c Director of WSU and an
    o f f i c e r i n t h e WSU Physical Education Corporation (WSU/PEC)).                 A   l
                                                                                               l
    contacts by telephone were i n i t i a t e d by              M.
                                                                  r
                                                             Katzenmeyer, one i n November
    1969, and one i n J u l y 1970, a t which time v e r b a l agreements were reached
    f o r t h e use of Jack Richards A i r c r a f t Company a i r c r a f t . I n i t i a l l y ,
    M.
     r      Richards intended t o supply a E-6 a i r c r a f t . However, t h i s a i r c r a f t
    was damaged i n J u l y 1970 during a windstorm. Since it was not r e p a i r e d
    i n time, two Martin 404 a i r c r a f t were s u b s t i t u t e d .

             No payment was ever made by t h e WSU/FEC t o Jack Richards A i r c r a f t
    Company, nor was WSU ever b i l l e d f o r t h e use of any Jack Richards A i r -
    craft Company a i r c r a f t . Instead, a l l payments t o t h e Jack Richards
                                                                                                   S
    A i r c r a f t Company f o r use of a i r c r a f t i n t h e t r a n s p o r t a t i o n of WU
    a t h l e t i c teams were made by Golden Eagle Aviation, Inc.

    b.    Golden Eagle Aviation, I n c .

           Golden Eagle Aviation, Inc. (Golden Eagle) was incorporated on
    November 26, 1969, by            M.
                                      r          John P. Kennedy,    M.
                                                                      r            Bruce B n i e l s o n , and
    M.
     r     Ronald G. Skipper. The company business included c o n s u l t i n g
    s e r v i c e s t o p o t e n t i a l u s e r s of l a r g e a i r c r a f t , t h e supplying of f l i g h t
    crewmembers t o o p e r a t o r s of l a r g e a i r c r a f t , and airmail operations i n
    small a i r c r a f t pursuant t o a n a i r taxi c e r t i f i c a t e issued i n accordance
    w i t h Fart 135 of t h e Federal Aviation Regulations.

             I n a l e t t e r dated A p r i l 3, 1970, addressed t o              r
                                                                                  M. Robert Kirkpatrick,
    Business Manager of WSU/PEC, Golden Eagle offered t o provide s e r v i c e s f o r
                                                S
    t h e t r a n s p o r t a t i o n of t h e W U f o o t b a l l team during t h e 1970 season. This
    l e t t e r s t a t e d , "The t o t a l a d j u s t e d maximum p r i c e including a l l standard
    Gold Carpet s e r v i c e s and a i r c r a f t l e a s e i s $19,388 .60 ( n i n e t e e n thousand,
    t h r e e hundred eighty- eight and s i x t y cents)."
            O April 24, 1970,
             n                          M.
                                         rBert Katzenmeyer, A t h l e t i c D i r e c t o r of
    WSU/pEc, advised Golden Eagle, "May t h i s l e t t e r serve as acceptance
    of t h e Golden Eagle Aviation, Inc., b i d f o r c h a r t e r s e r v i c e f o r t h e
    Wichita S t a t e University f o o t b a l l team t r a v e l f o r f i v e games i n t h e
    f a l l of 1970 a t t h e p r i c e quoted of $19,388.60. Terms of t h i s c o n t r a c t
    a r e based upon your b i d , dated April 3, 1970, as submitted by l e t t e r t o
     l.
    Er     Robert Kirkpatrick, Business Manager."

         Subsequently, a s i x t h game was added t o *he WSU schedule, and
    Golden Eagle was asked t o submit a b i d f o r t h e e x t r a game. To t h i s
    request, Golden Eagle responded, "Our computed p r i c e , a l l t h i n g s i n -
    cluded and considered, on t h e September 12, 1970, f o o t b a l l flight t o
    College S t a t i o n , Texas, i s $5,000.''
by WSU f r o m t h e Jack Richards A i r c r a f t Company.

     When t h e DC-6 was damaged i n a windstorm, Golden Eagle d i d not
consider it necessary t o negotiate a new c o n t r a c t , but i n s t e a d simply
provided two crews f o r t h e replacement & r t i n 404 a i r c r a f t at no addi-
tiona1 cost..
         With respect t o t h e agreement,         M.
                                                    r
                                               B n i e l s o n t e s t i f i e d t h a t approxi-
mately $5,000 of t h e $24,388.60 contract p r i c e was f o r t h e l e a s e of t h e
a i r c r a f t . By verbal agreement between him an3              M.
                                                                    r
                                                                 Katzenmeyer, WSU
would write one check t o Golden Eagle, who i n t u r n would forward t h e
lease payment t o       r
                       M.   Richards. According t o              M.
                                                                  r
                                                              Skipper, t h i s arrange-
ment was f o r t h e purpose of "simplifying t h e bookkeeping."

                                                                                           r
                                                                                          M.
          With respect t o t h e o p e r a t i o n a l c o n t r o l of t h e a i r c r a f t , Canielson
t e s t i f i e d , "But i n p a r t i c u l a r , we wanted t o make sure t h a t t h e r e was no
misunderstanding t h a t Wichita S t a t e was t h e o p e r a t o r of t h e a i r c r a f t ,
that w were a c t i n g only as p i l o t s , and we would advise them as b e s t we
            e
                         e
could, because w had been knowledgeable i n t h e a v i a t i o n industry, and
we were i n t h e consulting business, and i f t h e r e was any way I could
find out for him o r h e l p him we would do t h i s . " I n response t o t h i s
advice, M r e Kirkpatrick informed him that he was aware of t h e r e g u l a t o r y
requirements and displayed a copy of t h e Federal Aviation Regulations.

      On t h e t r i p from Wichita t o Logan i n 1 ~ 4 6 4 ~ October 2, 1970,
                                                          on
 r
M. Skipper had a copy of  t h e l e a s e s on N464M'and N470M i n h i s possession
a t the time of t h e crash.The l e a s e s had been signed by Mr. Richards,
but had not been signed by any o f f i c i a l of WSU o r t h e WSlJ/FEC because,
according t o
M.
 r
                 Mr
                  .
                 Skipper, "It had not become convenient f o r m t o have
    Ketzemeyey sign them y e t . "
                                                                        e


c. Wichita S t a t e University
    Since i n t e r c o l l e g i a t e a t h l e t i c a c t i v i t i e s were not supported by
state appropriations, a s e p a r a t e , independent, nonprofit Wichita S t a t e
University Physical Education Corporation was organized t o manage WSU's
intercollegiate a t h l e t i c program.          M.
                                                   r            Bert Katzenmeyer was t h e a t h l e t i c
director.      Mr
                .      Robert Kirkpatrick was. t h e a s s i s t a n t a t h l e t i c d i r e c t o r
and a s s i s t a n t business manager of t h e a t h l e t i c corporation.             M.
                                                                                          r    Floyd
Farmer was o r i g i n a l l y employed by t h e corporation as t i c k e t manager.
Upon t h e death of      M.
                          r       Kirkpatrick i n m y 1970,         M.
                                                                     r           Farmer became t h e
assistant a t h l e t i c d i r e c t o r and assumed some of t h e business management

l
J     See Appendix E.
                                                -   22   -
r e s p o n s i b i l i t i e s previously performed by       r
                                                             M.
                                                          Kirkpatrick. These were
t h e persons i n WSU/PEC who entered i n t o t h e ' s e v e r a l agreements with
Golden Eagle, and o t h e r organizations before them, f o r t h e transpor-
t a t i o n of WSU a t h l e t i c teams. They were t h e only o f f i c i a l s having
d i r e c t contact with Golden Eagle o f f i c e r s .           M.
                                                                   r
                                                             Katzenmeyer and
M.
 r      Farmer were among t h e passengers who did not survive t h e crash of
~464~.
         According t o     Dr.    Clark D. Ahlberg, President of W U t h e d e t a i l s
                                                                                S,
of t h e c o n t r a c t s entered i n t o with Golden Eagle by              r
                                                                            M.   Kirkpatrick and
M.
 r      Katzemeyer were not discussed with him o r o t h e r o f f i c e r s of WSU.
H t e s t i f i e d t h a t h i s understanding of t h e arrangements with Golden Eagle,
   e
based upon b r i e f discussions with               M.
                                                     r Katzenmeyer, was t h a t WSU/PEC had
entered i n t o an arrangement w i t h an o r g a n i z a t i o n that provided a i r p l a n e s
and p i l o t s f o r a f e e t o perform c e r t a i n s e r v i c e s , and t h a t t h e organiza-
t i o n operated and owned t h e a i r c r a f t . P r i o r t o t h e a c c i d e n t , he had
never heard of t h e Jack Richards A i r c r a f t Company. H s t a t e d that
                                                                             e
M.
 r      Katzenmeyer could execute c o n t r a c t s f o r s e r v i c e s t o t h e WSU/PEC, but
did not have any a u t h o r i t y t o s i g n f o r o r bind WSU t o any c o n t r a c t . H                 e
advised t h a t p r i o r t o t h e 1969 season, when a n agreement was e n t e r e d
i n t o between WSU/PEC and Four Winds, Inc., t h a t                   M.
                                                                         r  Katzenmeyer had
informed him of d i f f i c u l t i e s i n arranging a s a t i s f a c t o r y c o n t r a c t with
a scheduled a i r c a r r i e r f o r c h a r t e r s e r v i c e s . The d i f f i c u l t i e s r e l a t e d
t o commitments t o cover a l l games, and t h e i n a b i l i t y t o schedule de-
p a r t u r e s t h a t would permit t h e team t o p r a c t i c e p r i o r t o a game. H             e
was not aware of any d i s s a t i s f a c t i o n with t h e subsequent agreements
entered i n t o with Four Winds, I n c .

          Following t h e accident, t h e records of WSU/PEC were examined, and
s e v e r a l pieces of correspondence between Messrs. Katzenmeyer, Kirkpatrick,
Farmer, and Golden Eagle were found. Two copies of a l e a s e between
Jack Richards Aircraft Company and WSU f o r a t r i p t o College S t a t i o n ,
Texas, were i n t h e records. These l e a s e agreements d i d not s p e c i f y any
payment f o r t h e use of t h e a i r c r a f t . There were no o t h e r l e a s e agree-
ments located.           r
                        D.      Ahlberg t e s t i f i e d t h a t following t h e accident he
t a l k e d with personnel i n t h e WSU/PEC o f f i c e s and s t a t e d , "It i s my
assumption, and t h e assumption of o t h e r s here a t t h e University t h a t
M.
 r      Katzenmeyer was simply agreeing t o accept planes. which                         M.
                                                                                          r
                                                                                         Richards'
company would f u r n i s h Golden Eagle Aviation, I n c . , as t h e y were unable
t o supply t h e i r own a i r c r a f t at t h e time." With r e s p e c t t o t h a t statement
Dr.     Ahlberg t e s t i f i e d , "Well, s i n c e t h e a c c i d e n t occurred, I have t a l k e d
with Mrs. Harmon and o t h e r people who made t r i p s , and discovered t h a t
t h e r e was a good d e a l of d i s p l e a s u r e on t h e p a r t of     M.
                                                                               r  Katzenmeyer and
M.
 r      Farmer t h a t t h e E - 6 which t h e y thought t h e y had contracted f o r was
not a v a i l a b l e , and t h a t t h e team had t o t r a v e l i n two planes r a t h e r t h a n
one. I had not been aware of t h a t u n t i l a f t e r t h e a c c i d e n t . Looking a t
.team f o r t h e 1970 season.  She sent i d e n t i c a l l e t t e r s t o s e v e r a l air-
-lines, Four Winds Travel Club, Golden Eagle, and o t h e r s . O t h e b a s i s       n
Ff the b i d s received, t h e c o n t r a c t f o r c h a r t e r s e r v i c e s f o r t h e o r i g i n a l
five "away games" was awarded t o Golden Eagle. She t e s t i f i e d t h a t she
had never seen a copy of any Federal Aviation Regulation i n t h e o f f i c e s
of   wsu/PEc.
d.   Additional I n f o m t i o n

      1. A search of t h e long- distance telephone c a l l s from t h e Wichita S t a t e
      University, o r charged t o t h e WSU/PEC c r e d i t card held by      Katzenmeyer,    M.
                                                                                               r
      did not disclose any telephone c a l l s t o t h e Jack Richards A i r c r a f t
      Company or t o      M.
                           r
                         Richards' home phone.

                                                        r
     M A search of tdhi e o f f i cl oecs aoccupied by M. Kirkpatrick and
     2.
        .
        rKatzenmeyer d not t e a copy of any Federal Aviation
     Regulation.

                                   r
                                   .
      3. M, John Kennedy and M Bruce b n i e l s o n were crewmembers on t h e
             r
      E - 6 leased t o WSU/pEC by Four Winds, I n c . , f o r t i e 1969 f o o t b a l l
     season.      I n t h e course of t h i s a c t i v i t y t h e y became w e l l acquainted
     with    .
             r
            M Katzenmeyer.
     by   .r.
          M John Kennedy was recornended him as p i l t , w e q u
        M Sack Richards, who put i n contact withaFouroWinds,l lInc.,a l i f i e d
          r w6.
     on the
                             2.    ANALYSIS AND CONCLUSIONS
2.1 Analysis

        b i n a t i o n of t h e wreckage disclosed no evidence of mechanical
failure of t h e airframe o r t h e a i r c r a f t c o n t r o l systems. Although ground
f i r e destruction precluded examination of some of t h e a i r c r a f t components,
it i s noted t h a t both p i l o t s appeared t o be s a t i s f i e d w i t h t h e a i r c r a f t ' s
perfomnce u n t i l a f t e r t h e r i g h t t u r n was executed by F i r s t O f f i c e r Skipper.
The only concern i n t h e cockpit, according t o                     r
                                                                     M.
                                                                    Skipper and t o t h e
pssenger standing behind t h e crew u n t i l seconds before impact, was t h e
elevation of t h e t e r r a i n ahead.
                                         -   24   -
         Most ground witnesses and t h e surviving passengers thought that
t h e engines were operating normally. However, two'witnesses described
a b a c k f i r i n g sound from t h e a i r c r a f t . I n considering t h e i r testimony,
t h e Safety Board notes t h a t one witness who reported t h e b a c k f i r i n g was
s i t u a t e d i n Georgetown. Five o t h e r witnesses i n t h e same l o c a t i o n ,
including t h e f a t h e r of t h e witness i n question, and a p i l o t employed
as a f l i g h t engineer by a major a i r l i n e , a l l s t a t e d t h a t t h e engine
sounds were normal.

          The o t h e r witness, l o c a t e d 1-1/2 miles e a s t of Dry Gulch, s t a t e d
t h a t t h e b a c k f i r i n g sound was so loud t h a t passengers i n t h e a i r c r a f t
d e f i n i t e l y should have been a b l e t o hear it. However, none of t h e
surviving passengers r e c a l l e d anything unusual about t h e o p e r a t i o n of
t h e engines. This witness a l s o t e s t i f i e d t h a t as t h e a i r c r a f t proceeded
away from h i s p o s i t i o n , he observed t h e e n t i r e a i r c r a f t f u s e l a g e was
dark green and t h e markings "4" and "M" were v i s i b l e on t h e f u s e l a g e
d i r e c t l y forward of t h e t a i l s e c t i o n . R e g i s t r a t i o n numbers on small
a i r c r a f t a r e painted on t h e fuselage i n t h e p o s i t i o n described by t h i s
witness. However, they a r e seldom found i n t h a t l o c a t i o n on a i r l i n e
a i r c r a f t . On N464M, t h e r e g i s t r a t i o n numbers were l o c a t e d on t h e
v e r t i c a l s t a b i l i z e r , not on t h e fuselage, and would be n e a r l y unreadable
from behind t h e a i r c r a f t at t h e angular bearing described by t h e witness.
So far as t h e fuselage i s concerned, t h e t o p was painted white, t h e r e
was a green s t r i p e i n t h e center, and t h e bottom was unpainted. The
Board concludes, t h e r e f o r e , t h a t t h i s witness a l s o may have been mistaken
i n t h e source of t h e sounds he heard, and t h a t t h e b a c k f i r i n g may have
come from l a r g e t r u c k s o r road c o n s t r u c t i o n machinery t h a t was being
operated i n t h e v i c i n i t y .

       While some witnesses reported a small amount of black smoke coming
from t h e r i g h t engine, t h o s e familiar with l a r g e a i r c r a f t d i d not consider
i t excessive, and most described it as similar t o a " r i c h " mixture b u t
not of any g r e a t concern. The f a c t that a r i c h mixture e x i s t e d on take-
o f f a t Denver was acknowledged by t h e crew. However, t h e r e i s no
evidence t h a t t h e r i c h mixture condition s e r i o u s l y a f f e c t e d t h e engine
performance. Examination disclosed t h a t on both p r o p e l l e r s , t h e blades
were off t h e low-pitch stops, i n d i c a t i n g t h a t both engines were t u r n i n g
and producing power a t impact.

      The v i b r a t i o n of t h e a i r c r a f t described by F i r s t Officer Skipper
and t h e survivors occurred concurrent with t h e attempt t o execute a
180" r e v e r s a l of course. The s e v e r e s t v i b r a t i o n occurred during t h e
l e f t bank, described by surviving passengers as "very, very steep" and
"awful sharp." One of them s t a t e d that t h e bank was reduced g r e a t l y
j u s t before t h e a i r c r a f t s t r u c k t h e t r e e s . The swath cut through t h e
t r e e s i n d i c a t e d a bank angle of 31". Ground witnesses l o c a t e d on
U S o Highway 6, only a few hundred f e e t from where t h e a i r c r a f t crossed
  .
t h e road i n f r o n t of them, s t a t e d t h a t t h e e n t i r e t o p of both wings and
                                            -   25   -


If an attempt i s made t o maintain a l t i t u d e and power i s not increased,
the airspeed w l decrease. I n a 60" bank, with f l a p s extended l . '
                il                                                         25,
$restall buffet wl be encountered at 134 knots c a l i b r a t e d airspeed,
                   il
and the a i r c r a f t w i l l be s t a l l e d at 128 knots. If f l a p s a r e not extended,
the s t a l l speed would be approximately 137 knots. Accordingly, t h e
                                                     .~                               ..
                                                                                       ~




Board believes t h a t t h e v i b r a t i o n was t h e r e s u l t of abrupt maneuvers
and a steep bank which induced p r e s t a l l b u f f e t , and was not t h e r e s u l t
of malfunction o f t h e a i r c r a f t , a i r c r a f t engines, o r c o n t r o l systems.
The 12.5' f l a p s e t t i n g found on t h e a i r c r a f t could have been s e l e c t e d
by Captain Crocker t o reduce t h e s t a l l speed. It i s a l s o p o s s i b l e t h a t
they may have been extended previously t o improve maneuvering s t a b i l i t y
i n the valley.
      In considering t h e o p e r a t i o m 1 f a c t o r s i n t h i s a c c i d e n t , t h e l a c k
of adequate f l i g h t planning f o r t h e a l t e r n a t e r o u t e segment from Denver
t o Logan i s i m e d i a t e l y apparent.       M.
                                                   r  Skipper t e s t i f i e d t h a t at t h e
start of t h e t r i p , he had i n h i s possession a f l i g h t p l a n prepared by
the f i r s t o f f i c e r of t h e o t h e r crew. T h i s f l i g h t p l a n c a l l e d f o r a
northbound departure from Denver, on e s t a b l i s h e d airways, v i a &ramie,
Wyoming. This route p a r a l l e l s t h e mountain ranges and o f f e r s ample time
t o climb t o a s a f e a l t i t u d e before t u r n i n g westward over t h e mountains.
The distance over t h i s r o u t e i s v i r t u a l l y t h e same as it i s over t h e
"scenic route" flown b y         M.
                                  r          Skipper. The change i n routing, t h e r e f o r e ,
was purely for s i g h t s e e i n g purposes,            r
                                                         M.     Skipper s e v e r a l times t e s t i f i e d
that Captain Crocker was t h e pilot-in-command of t h e t r i p and t h a t it
was Captain Crocker who made t h e decisions r e l a t i n g t o t h e f l i g h t . How-
ever, with respect t o t h e r o u t e between Denver and Logan, M, Skipper             r
also t e s t i f i e d t h a t a f t e r t h e f l i g h t departed from Wichita, it was he
who made t h e decision t o purchase c h a r t s a t Denver t o be used i n p o i n t i n g
out landmarks and points of scenic i n t e r e s t t o t h e passengers. Accordingly,
while Captain Crocker may have been d i s t i n g u i s h e d as t h e pilot-in-command
by virtue of t h e f a c t that he held a type r a t i n g on t h e a i r c r a f t and
!&,  Skipper did not, it i s t h e Board's opinion t h a t                   r
                                                                            M.     Skipper, i n h i s
capacity as president o f Golden Faagle, was i n f a c t t h e person who
decided the route t o be t r a v e l e d .

   The manner i n which t h e r o u t e from Denver was flown i s worthy of
cment    .
      A ground witnesses describe t h e a i r c r a f t as being extremely low
        l
over the mountainous t e r r a i n , and many described engine sounds as being
similar t o c r u i s i n g p w e r r a t h e r than t o climb power. From Idaho Springs
t o the point of crash, t h e a i r c r a f t was continuously below t h e mountain-
tops. Operation a t such a low a l t i t u d e could have been f o r s i g h t s e e i n g
                                              -   26   -
purposes only, since t h e a i r c r a f t was capable of climbing at a much
g r e a t e r r a t e t h a n was a c t u a l l y accomplished. By b e s t e s t i m a t e s , t h e
t o t a l time from departure a t Denver t o t h e time of crash was 25 t o 30
minut e s  .
           I n one-half t h a t time, t h e a i r c r a f t was capable of reaching a n
a l t i t u d e of 15,000 f e e t m.s.l., o r more, i f maximum continuous power
                            4
had been used. 1 / I n t h e event t h a t t h e crew d i d not wish t o use any
s e t t i n g higher G a n t h e r e g u l a r en r o u t e climb power t h a t        M.
                                                                                        r
                                                                                      Skipper
t e s t i f i e d he was maintaining, a climb maneuver could have been executed
which would have produced a s a f e a l t i t u d e before t h e f l i g h t proceeded
westbound toward t h e Continental Divide. E i t h e r procedure not only
would have r e s u l t e d i n ample clearance over t h e mountain ranges along
t h e f l i g h t p a t h , but would have provided t h e c a p a b i l i t y t o reach a s a f e
landing place i n t h e event of an engine f a i l u r e .

        r
        .
       M Skipper,             by h i s own testimony, was aware of t h e " d r i f t down" 15/
s a f e t y p r a c t i c e employed by a i r l i n e s and most o p e r a t o r s of l a r g e a i r c r a f t
when o p e r a t i n g over mountainous t e r r a i n . Notwithstanding, he flew t h e
a i r c r a f t i n t h e mountain v a l l e y below t h e mountaintops a t an a l t i t u d e
higher than t h e a i r c r a f t was capable of maintaining i n t h e event of a n
engine f a i l u r e .

          It must a l s o be presumed t h a t n e i t h e r      M.
                                                                  r Skipper.nor Captain Crocker
spent any time examining t h e c h a r t s f o r t h e r o u t e t o be flown, s i n c e
Mr.    Skipper did not r e t u r n t o t h e a i r c r a f t a f t e r he purchased them
u n t i l approximately 1 5 minutes before takeoff and, a t t h a t time, engaged
i n conversation with t h e passengers. If t h e c h a r t s had been studied, t h e
p i l o t s could have known t h a t t h e minimum a l t i t u d e necessary t o c l e a r
Loveland Pass a t t h e end of Clear Creek Valley, was 12,000 f e e t m * s . l .
 r
M.     Skipper was f l y i n g t h e a i r c r a f t a t reduced power a t approximately
1 , 0 f e e t m.s.1. when t h e f l i g h t reached Dry Gulch and t h e crew f i r s t
  100
discovered t h a t Clear Creek Valley was ending i n what has been described
as a "box canyon."

          The a l t i t u d e of t h e a i r c r a f t as it passed over Georgetown was
approximately 9,800 f e e t m.s.l., based upon witness observations and
measurements made therefrom. A t t h i s p o i n t , t h e a i r c r a f t was approxi-
mately 1,200 f e e t above t h e v a l l e y floor. A t t h e 140 knots i n d i c a t e d
                                      M.
                                       r
a i r s p e e d t e s t i f i e d t o by       Skipper, t h e a i r c r a f t would have been capable

-1
14      See Appendix D.

-
l5/     "D i t down" r e l a t e s t o t h e planning of a f l i g h t a t a n a l t i t u d e
              rf
        s u f f i c i e n t l y high so t h a t i n t h e event of engine f a i l u r e , t h e
        excess a l t i t u d e can be used t o provide clearance over t e r r a i n
        ahead as t h e a i r c r a f t proceeds t o a s u i t a b l e landing a r e a i n
        descending f l i g h t .
                                     -   27   -



-   (1) Two witnesses who observed the aircraft from above at
        Loveland Pass provided a sight line with a depression
        angle of 4-1/4”as measured by an Abney level. The air-
        craft was first observed when it was east of Dry Gulch.
        The distance was approximately 12,000 feet.

                 Diagrammatically:


Observer




                                                                Aircraft


        Angle A = 4-1/4’
        Line AC = 12,000

                   Bc                                          BC
        TAN A =    -,
                   AF?
                                              or   .0745   =   -
                                                               12,000’     or

        BC   =    9
                 8 4 feet
        Elevation of Observer                          _-
                                                   = 11,930 feet
                                                      - 894 feet
        Elevation of Aircraft                        11,006 feet

    (a) Another witness, located on U S. Highway 6 approximately
                                     .
        5,000 feet from Dry Gulch observed thg aircraft opposite
        Dry Gulch at an upward angle of 4-1/2 .
        By his observations:
        Angle A     =   4-112’
        Line AB         5,000 feet
                                           -   28 -

                        BC                                           BC
            TANA=E                         or              .0787 = 5000
            BC = 394 f e e t

            Elevation of Observer                     =   10,650 f e e t
                                                           + 394 f e e t
            Elevation of A i r c r a f t                  11,044 f e e t
     ( 3 ) Two other witnesses, located almost opposite t h e crash s i t e
     a t an e l e v a t i o n of 10,600 f e e t , estimated t h e height of t h e air-
     c r a f t a s 100 f e e t above them a s i t turned a c r o s s U. s. Highway 6.

     (4)      Another witness, a p i l o t , s t a t e d t h a t when t h e a i r c r a f t was
     2 miles e a s t of      Dry Gulch, i t was below t h e l e v e l of t h e mountains
     on e i t h e r s i d e of t h e v a l l e y . In h i s opinion, t h e a i r c r a f t could
     not have turned around, nor could it have climbed over t h e r i s i n g
     t e r r a i n ahead.

     Based upon t h e foregoing evidence and computations, t h e Board
concludes t h a t N464M was a t , or very near, an a l t i t u d e of 11,000 f e e t
m.s.1. when t h e r e v e r s a l t u r n a t Dry Gulch was attempted.

     With respect t o t h e a b i l i t y of t h e a i r c r a f t t o climb over t h e
mountains ahead, a review of t h e performance d a t a (Appendix D) show6
that i f maximum continuous power had been applied when t h e a i r c r a f t
was at Dry Gulch, a climb gradient of 4.57 percent could have been
achieved. This t r a n s l a t e s i n t o a climb c a p a b i l i t y of 240 f e e t p e r



it would have been impossible f o r t h e a i r c r a f t t o c l e a r t h e t e r r a i n
                      .-
ahead. (See Appendix 1 )

        Concerning t h e a i r c r a f t ' s a b i l i t y t o execute a r e v e r s a l t u r n ,
reference t o Appendix D i n d i c a t e s t h a t a t 140 knots i n d i c a t e d airspeed,
a 60" bank w i l l produce a t u r n r a d i u s of 1,490 f e e t . However, i n a
60" bank, even a t maximum continuous power, a l t i t u d e would be l o s t a t
a r a t e of about 340 f e e t per minute.

        A t 130 knots, t h e t u r n r a d i u s i n a 60" bank would be 1,300 f e e t .
However, t h i s would requi              t h e a i r c r a f t t o be operated c o n s t a n t l y a t
                                    T
only 2 knots above s t a l l peed, and w e l l i n t o t h e s t a l l b u f f e t range.
Entry i n t o t h e s t a l l b u f f e t boundary would r e s u l t i n a n i n c r e a s e i n t h e
r a t e of sink because of t h e drag induced by flow separation.

         Even if t h e p i l o t had possessed s u f f i c i e n t s k i l l t o operate t h e
a i r c r a f t within such extremely small t o l e r a n c e s , t h e r e would not have
                                           -   29   -
      s u f f i c i e n t space a v a i l a b l e t o execute t h e t u r n . A t t h e 11,000-foot
      UT, t h e      v a l l e y width at ground l e v e l i s about 3,000 f e e t i n t h e
      immediately beyond Dry Gulch. A t t h e 10,800-foot contour, t h e
    ey width at ground l e v e l i s only 2,400 f e e t . Trees extending upward
-,the        sound would reduce t h e a v a i l a b l e t u r n i n g space at t h e l0,gOO-
foot l e v e l a l s o t o 2,400 f e e t . Accordingly, t h e Board concludes t h a t
once the a i r c r a f t had reached t h e Dry Gulch a r e a , it was no longer
possible t o have executed a course r e v e r s a l . If t h e crew had been
concerned about t h e a i r c r a f t ' s a b i l i t y t o c l e a r t h e t e r r a i n ahead l e s s
than 1minute sooner, when t h e a i r c r a f t was s t i l l 1-1/2 t o 2 m i l e s e a s t
of Ihy Gulch, a successful turnaround could have been executed with use
of maximum continuous power and a bank angle of only 30". However, at
that p i n t on t h e f l i g h t p a t h , t h e crew would have been unable t o see
that the v a l l e y ended a t Loveland Pass, and t h u s t h e y proceeded i n t o a n
area from which an escape was not possible.
     A t t h e point where F i r s t Officer Skipper executed t h e right t u r n
toward Dry Gulch, Captain Crocker could not be sure of Skipper's
intentions since t h e r e had been no discussion i n t h e cockpit concerning
any specific procedure. The only conversation overheard by the survivor,
standing inmediately behind t h e crew, was a discussion of t h e height of
one of t h e mountains. It i s l i k e l y t h e r e f o r e t h a t Captain Crocker may
have believed t h a t F i r s t Officer Skipper's i n t e n t i o n was t o f l y up
Dry   Gulch.
       Since he had a good view of Dry Gulch out of h i s window, he could
see that i t s f l o o r extended only a few thousand f e e t before r i s i n g
rapidly toward t h e Continental Divide. Also, on completion of t h e t u r n ,
the a i r c r a f t was proceeding toward t h e r i s i n g ground of Mount T r e l e a s e .
Any decision t h a t was t o be made, had t o be made irmnediately. It i s
likely, therefore, t h a t t h i s i s what induced Captain Crocker t o t a k e
over the controls. The s t e e p l e f t bank w s t h e n necessary t o avoid t h e
                                                        a
mountain. I n t h e process, t h e a i r c r a f t was s t a l l e d , r e s u l t i n g i n a loss
of a l t i t u d e , and contact with t h e t r e e s .

      Since r e s i s t a n c e of modern a i r c r a f t s t r u c t u r e t o abrupt decelera-
t i o n i s generally assumed t o be equal t o or l e s s than t h e r e s i s t a n c e or
tolerance of humans t o such d e c e l e r a t i o n ,             t h e post-impact conditions
of.aircraPt s t r u c t u r e can t h e r e f o r e be applied as a p r a c t i c a l means t o
establish s u r v i v a b i l i t y of a n a c c i d e n t . The apparent i n t a c t n e s s of t h e
passenger cabin i n t h i s accident i n d i c a t e s such a survivable condition.
However, two o t h e r c r i t e r i a must be met t o i n s u r e s u r v i v a l : (1) t h e
occupant becomes involved i n t h e d e c e l e r a t i o n of h i s environment and ( 2 )
M e d i a t e access t o a means of escape.

6
l
J     Preston G and Pesman G., " Accelerations i n Transport Airplane Crashes,"
      NACA Technical Note 4158. Eiband, A., "Human Tolerance t o Rapidly
      Applied Accelerations" N S Memo 5-19-593, June 1959.
                               AA
                                                    -   30   -
             According t o r e s c u e r s , t h e s e a t s i n t h i s a i r c r a f t were pushed
    together i n t h e forward s e c t i o n o f t h e a i r c r a f i , i n d i c a t i n g t h a t
    f a i l u r e of s e a t tiedowns occurred a t some p o i n t during t h e crash
    sequence. Depending on t h e f a i l u r e mode and t h e moment of f a i l u r e i n
    t h e crash sequence, such s e a t f a i l u r e s may make t h e d i f f e r e n c e i n t h e
    s u r v i v a l o r non-survival of occupants i n a n otherwise t o t a l l y survivable
    accident.

            The s e a t , as t h e occupant's supporting s t r u c t u r e , t h e r e s t r a i n t
    system i n t h e form of a s e a t b e l t and t h e underlying floor s t r u c t u r e
    and s e a t anchorages a r e t h e media through which t h e occupant becomes
    involved i n t h e d e c e l e r a t i o n of t h e t o t a l a i r c r a f t s t r u c t u r e . F a i l u r e
    o f a n y o n e of t h e s e w i l l allow t h e occupant t o a c c e l e r a t e i n r e l a t i o n
    t o h i s environment a n d s t r i k e o b j e c t s o r s t r u c t u r e with a f o r c e
    exceeding t h e o v e r a l l crash d e c e l e r a t i o n .

             Although t h e peak magnitude and d u r a t i o n o f t h e main crash f o r c e
    cannot be c a l c u l a t e d with any degree of accuracy, t h e f o r c e s were
    considered t o be fairly moderate i n view of t h e i n t a c t n e s s of t h e
    fuselage, t h e low v e l o c i t y with which t h e a i r c r a f t s t r u c k t h e ground
    and t h e f a c t that many occupants survived t h e impact. Additionally, t h e
    f a c t t h a t a l l but one of t h e survivors who escaped d i d not have t h e i r
    s e a t b e l t fastened a t t e s t s t o t h e low v e l o c i t y at impact as w e l l as t h e
    f a c t t h a t a l a t e r a l force vector prevented them from gaining momentum
    w i t h i n t h e confines of t h e fuselage.

              It i s reasonable t o assume t h a t more occupants t h a n j u s t t h o s e who
    escaped had t h e i r s e a t b e l t unfastened. The ones who escaped were
    f o r t u n a t e t o remain conscious while o t h e r s d i d not o r were t o o stunned
    t o e f f e c t t h e i r escape. The f a i l u r e of many occupants t o evacuate must
    nevertheless be d i r e c t l y a t t r i b u t e d t o t h e s e a t f a i l u r e s as being t h e
    major i n j u r y producer. Indeed, t h e passengers' not being t i e d down may
    have been, i n i t s e l f , a major t r i g g e r i n g f o r c e i n t h e s e a t f a i l u r e s ,
    since passengers as " missiles" can induce f a i l i n g l o a d s on s e a t s ahead
    of them.

             This accident shows once more t h a t passengers can r e c e i v e needless
    i n j u r i e s i n s i d e i n t a c t fuselage s t r u c t u r e . The Board i s aware t h a t t h e
    present design "G" l e v e l s for t r a n s p o r t a i r c r a f t s e a t s and t h e i r t e s t i n g
    c r i t e r i a have been improved since t h e o r i g i n a l design of t h e Martin 404.
    Hence, without continued concern f o r t h i s problem, needless l o s s of l i f e
    can r e s u l t .

             F i n a l l y , w i t h regard t o - t h e problem i n t h i s a c c i d e n t concerning t h e
    i d e n t i f i c a t i o n of t h e operator who had t h e r e s p o n s i b i l i t y f o r compliance
    with t h e r e g u l a t i o n s a p p l i c a b l e t o t h e f l i g h t , it i s obvious that t h e r e
    was c l a s s i c disagreement %ng t h e p a r t i e s involved i n t h e f l i g h t . A              s




i
  previously s t a t e d i n t h i s r e p o r t , it was t h e p o s i t i o n o f t h e F A t h a t
                                                                                           A
 Wlden Eagle Aviation, Inc., was t h e operator. Both Jack Richards A i r -
'craft Company and Golden Eagle Aviation, I n c . , contend t h a t Wichita S t a t e
  University was t h e operator. It i s t h e p o s i t i o n of Wichita S t a t e Univer-
  sity t h a t they were not t h e operator but had been merely c h a r t e r i n g a i r
  aervice. This question w i l l be f u l l y resolved i n a proceeding s e p a r a t e
 and a p r t from t h i s accident i n q u i r y and f o r t h e purpose of t h i s r e p o r t
 the Board does not b e l i e v e it necessary t o r e s o l v e t h i s c o n f l i c t . For
 present purposes, it i s s u f f i c i e n t t o conclude from t h e post accident
  denial of t h e p a r t i e s that t h e y were t h e operator with t h e r e s p o n s i b i l i t y
 for the safe conduct of t h i s f l i g h t , t h a t t h e y d i d not acknowledge such
 responsibility at t h e time of t h e f l i g h t .

          It i s t h e view of t h e Board t h a t t h e numerous d e f i c i e n c i e s , unsafe
 practices, and d e v i a t i o n s from r e g u l a t i o n s , involved i n t h i s o p e r a t i o n ,
 are t y p i c a l of operations where none of t h e p a r t i c i p a n t s acknowledge
 responsibility f o r t h e s a f e conduct of a f l i g h t . A t h i s Board s t a t e d
                                                                        s
 i n a p r i o r accident r e p o r t , "It i s not unusual t h a t such o p e r a t i o n s
 are characterized by s a f e t y problems such as t h o s e found t o be present
                              7
 i n - t h i s operation." 1 / The Board b e l i e v e s t h a t t h e management required
 for a safe o p e r a t i o n a p p e a r s t o have been absent and was a s i g n i f i c a n t
 factor i n t h i s accident.

 2.2   Conclusions

        (a)   Findings

              1. There was no f a i l u r e o r malfunction of t h e a i r c r a f t ,
                 powerplants, o r c o n t r o l systems.

              2.    The crew was properly c e r t i f i c a t e d f o r t h e f l i g h t .

              3.    There was a c u r r e n t a i r w o r t h i n e s s c e r t i f i c a t e i n t h e
                    a i r c r a f t and a n annual i n s p e c t i o n had been performed.

          4
         .'         The a i r c r a f t was 5,i9O pounds over t h e maximum permissible
                    takeoff weight at Denver, and 2,665 pounds over t h e


          -
                    maximum c e r t i f i c a t e d takeoff weight a t impact.
              5.    The o r i g i n a l f l i g h t p l a n was a l t e r e d t o provide a " scenic
                    route" for s i g h t s e e i n g purposes.

              6.    The a i r c r a f t was operated over Clear Creek Valley a t a n
                    a l t i t u d e always below t h e mountaintops.


-
171    Aircraft Accident Report              -
                                             Douglas DC-3, N142D, NW Orleans
                                                                   6
       I n t e r n a t i o n a l Airport, Nw Orleans, Louisiana, March 20, 1969.
                                           e
                                               -   32   -
           '7.       After t h e f l i g h t reached t h e Dry Gulch a r e a , it was no
                     longer p o s s i b l e f o r t h e a i r c r a f t ' e i t h e r t o climb over
                     t h e t e r r a i n ahead, o r t o execute a course r e v e r s a l .

           -8.       None of t h e p a r t i c i p a n t s i n t h i s f l i g h t , t h e owner of
                     t h e a i r c r a f t , l e s s e e , or t h e company providing t h e crew
                     and o t h e r s e r v i c e s acknowledged t h a t t h e y were t h e
                     operator and accepted r e s p o n s i b i l i t y f o r t h e s a f e t y of
                     such f l i g h t .

       (b)       Probable Cause

              -The       Board determines t h a t t h e probable cause of t h i s a c c i d e n t
was t h e i n t e n t i o n a l oaera€Zon of t h e a i r c r a f t over a rfmritain v a l l e y
f o i X e % T - < n m W e From which t h e a i r c r a f t could n e i t h e r climb over
                                                                  ____c---_

                                                 o
                                                 n
t h e o b s t a n R t e r r a i na ahead, - s u c c e s s f u l course r e v e r s a l .
S i g n i f i c a n t f a c t o r s were t h e overloaded condition o r t h e a l r c r a f t , t h e
v i r t u a l absence of f l i g h t @arming f o r t h e chosen r o u t e of f l i g h t from
ew
D,                             a- lack of understandinn on t h e p a r t of t h e crew of t h e
performance c a p b i l i t i e s and l i m i t a t i o n s of t h e a i r c r a f t , and t h e l a c k
of o p e r a t i o n a l management t o monitor and a p p r o p r i a t e l y c o n t r o l t h e a c t i o n s
of t h e f l i g h t c r e w .

                                      3.    RECOMMENULTIONS
          The testimony given during t h e public hearing held i n connection
with t h i s accident i n d i c a t e d a widespread misunderstanding by educational
i n s t i t u t i o n and b u s i n e s s concern personnel of t h e problems and regula-
t i o n s involved i n t h e o p e r a t i o n of l a r g e a i r c r a f t , o r t h e r e s p o n s i b i l i -
t i e s of l e s s e e s o f a n a i r c r a f t . Accordingly, on November 9, 1970, t h e
Board issued a S a f e t y Information r e l e a s e recomending t h a t p o t e n t i a l
u s e r s of l a r g e a i r c r a f t on a short- term c h a r t e r b a s i s , question pro-
v i d e r s of such s e r v i c e s as t o t h e t y p e of operations f o r which t h e y
have been c e r t i f i c a t e d . Should t h e r e be any doubt as .to t h e proper
                                                                                  A
c e r t i f i c a t i o n , such u s e r s should consult t h e nearest F A o f f i c e f o r
advice. A copy of t h i s r e l e a s e i s included i n t h i s r e p o r t as Appendix F.

         A s noted i n t h i s r e l e a s e t h e S a f e t y Board i s aware of t h e i n v e s t i -
g a t i o n i n t o a l l c h a r t e r operations as ordered by S e c r e t a r y of Transporta-
t i o n Volpe. The Board i s i n accord with t h e need f o r such an i n v e s t i g a t i o n ,
and i s h o p e m t h a t t h e r e s u l t s w i l l e s t a b l i s h s a f e p r a c t i c e s i n a l l
charter o r leasing a c t i v i t i e s .
                                            -    33   -
         Concerning t h e suggested r e g u l a t o r y changes contained i n FAA's
    Notice of Proposed Rule W i n g 70-41, t h e Board. i s i n complete
:   agreement with t h e conclusion i n t h e n o t i c e t h a t t h e r e i s a need f o r
'   regulatory a c t i o n i n t h a t a r e a . Accordingly, t h e S a f e t y Board h a s
    forwarded comments on t h e p r o p o s a l t o F M Administrator S h a f f e r .
    These comments w e contained i n Appendix J t o t h i s r e p o r t .

         BY THE NATIONAL TRANSPORTATION SAFETY BIXRD:


                                         / S I        JOHN H. REED
                                                      Chairman


                                         / S I        OSCAR M. LAUREL
                                                      Member


                                         / S I        FRANCIS H. MA A S
                                                                  cDM
                                                      Member


                                         / S I        LOUIS M. THAYER
                                                      Member


                                         /SI          ISABEL A. BURGESS
                                                      Member


    December 24, 1970
                         INVESTIGATION AND HEARING




1. Investigation

     The National Transportation Safety Board received notification of the
accident about 1330, on October 2, 1970. An investigating team departed
from Washington, D. C. at 1930 that evening and arrived at the crash site
the following morning. Working groups were established f o r operations and
witnesses, structures and systems, powerplants, and human factors. Parties
to the investigation were Golden Eagle Aviation, Inc., Wichita State University,
the Federal Aviation Administration, the Rocky Mountain Rescue Group, and the
Alpine Rescue Team. There were no assignments to the working groups from the
Jack Richards Aircraft Company, since no representatives appeared at the scene.

    The on-scene phase of the investigation lasted six days.

2. Hearing

     A public hearing was convened October 21, 1970,in Wichita, Kansas, a d
lasted 3 days.

3. Preliminary Reports
     A preliminary report of this accident was not issued.
                               CREW DWORMATION



     Captain Danny E. Crocker, aged 27, possessed airline transport pilot
certificate No. 1625375, with ratings for airplane multiengine land, DC-3,
DC-6/7, and commercial privileges for M-202/404 and airplane single-engine
land. He also held a flight instructor certificate for airplanes and
instruments which expired April 30, 1969, and a mechanic certificate No.
2014532, with airframe and powerplant ratings. His FAA first-class
medical certificate was issued on August 21, 1970, with no limitations.
The last entry in his logbook is for the WSU trip to Amarillo and return,
on September 27, 1970, but there are no flight times listed for that or
any subsequent flights. Prior to that time, he ha.d accumulated approxi-
mately 2,452 total flying hours, of which 123 hours were in the Martin 404.

     Captain Crocker received an M-404 type rating for his commercial
pilot certificate on April 4, 1 6 . At that time, he had 1 hours and
                               99                          1
40 minutes in the aircraft. Since that time, he had accumulated 111
additional hours, of which 8 hours and 45 minutes were in the last 30
days prior to making any WSU trips.

     First Officer Ronald G. Skipper, a e i 35, possessed airline transport
                                       gc
pilot certificate No. 1429879, with ratings for airplane multiengine land,
DC-3, and commercial privileges for airplane single-engine land. He also
held a flight instructor certificate for airplanes and instruments which
expired January 31, 1969. His FAA first-class medical certificate was
issued on July 27, 1970, with the limitation, "Holder shall wear correcting
glasses while exercising the privileges of his airman certificate." He had
accumulated approximately 4,500 total flying hours, of which approximately
30 hours were in the M-404.
     Stewardess Judith K. Lane, aged 28, completed a 19-hour training
program on September 1, 1970. She had no prior aviation background.
                            WEIGHT AND BALAPJCE JXTA N464~

         The supervision and a c t u a l loading of N46bM was not observed by t h e
f i r s t o f f i c e r , nor did he have any knowledge of t h e weight and balance
computations f o r . a n y of t h e t h r e e l e g s flown. He s t a t e d t h a t t h e c a p t a i n
had presumably computed t h e weight and balance on each l e g . I n response
t o t h e c h e c k l i s t challenge f o r weight and balance, he had simply acknowl-
edged t h a t t h e y were checked. The first o f f i c e r had determined t h e V1 and
V speeds from t h e placard i n t h e a i r c r a f t by using takeoff weights given
  2
t o him by t h e captain, but he could not remember what t h e f i g u r e s were.
         The takeoff gross weight of N 4 6 4 ~                 was computed e a r l y i n t h e i n v e s t i -
gation based on preliminary information. This weight, 48,165.1 pounds, i s
subject t o c e r t a i n v a r i a b l e s , some of which a r e reasonably evident and
others which a r e more obscure. For example, a n i n s p e c t i o n of t h e baggage
on N470M revealed t h a t t h e r e were 27 player bags, r a t h e r t h a n 22 as l i s t e d
f o r t h a t a i r c r a f t . Presumably f i v e player bags i n i t i a l l y scheduled t o be
loaded on N464M were placed on N470M because of t h e random method of load-
ing, as a conscious e f f o r t t o equalize t h e two l o a d s o r by mistake.
Another r a t h e r obvious omission i s t h e personal luggage of t h e passengers.
Testimony a t t h e hearing i n d i c a t e d that t h e p l a y e r s c a r r i e d minimal over-
night equipnent, but t h e r e were r e p o r t s of handbags being c a r r i e d by some
of t h e o t h e r WSU personnel. Other v a r i a b l e s , f o r which no s p e c i f i c
r e s o l u t i o n was sought because of t h e i r nebulous nature, include t h e
q u a n t i t i e s of AD1 and a n t i - i c e f l u i d s , t h e a c t u a l weight of t h e c a t e r i n g
m a t e r i a l s , and even t h e i n d i v i d u a l l y l i s t e d weight of each player o r
passenger.

     The maximum c e r t i f i c a t e d gross weight f o r takeoff of a K-404 a t
Denver (5,330 f e e t m.s.1.) i s approximately 43,000 pounds, using ADI.

        The maximum allowable landing weight at Logan (4,453 f e e t m.s.1.) i s
a l s o 43,000 pounds. Based on t h e s e f i g u r e s , N464M exceeded t h e t a k e o f f
weight l i m i t a t i o n by approximately 5,165 pounds a t Denver. Assuming a
nominal f u e l burnoff of 200 gallons/hour and an estimated time en r o u t e
t o Logan of 2 hours 20 minutes ( r e p o r t e d by N470M), t h e landing weight
would have been approximately 45,369 pounds. This weight would have
exceeded t h e maximum landing weight f o r Logan by 2,369 pounds.

       The c e n t e r of g r a v i t y limits for N464M, expressed i n inches from
t h e datum p o i n t , 87 inches forward of t h e a i r c r a f t nose, are:

Condition                        Maximum Weight             Gear P o s i t i o n       C. G. Range

Takeoff                          44,900 pounds                    Down                 440.2    -   461.4
Takeoff and Landing              43,000 pounds                    Down                 439.2    -   461.4
Flight                           All Weight                       UP                   432.6    -   461.4
The d a t a required t o e s t a b l i s h t h e p r e c i s e c.g. of t h e a i r c r a f t i s not
a v a i l a b l e . However, t h e s e a t i n g of most passengers was w e l l e s t a b l i s h e d ,
and again working w i t h i n t h e framework of t h e b a s i c a l l y r e l i a b l e informa-
t i o n a v a i l a b l e two computations were made. I n t h e first i n s t a n c e , t h e 18
                                            -     2 -

p l a y e r bags and 100-pound weight t r a i n e r were assumed t o b e l o c a t e d i n
t h e a f t cargo compartment mid-range. T h i s weight was t h e n assumed t o be
i n t h e forwardmost cargo compartment. The computed c e n t e r of g r a v i t y
for each c o n d i t i o n r e s p e c t i v e l y was 462.95 and k58.95 i n c h e s from d t m
                                                                                           au .



                           WEIGHT AND BALANCE             DATA N464M
      Basic Rnpty Weight                                               31,486.5
      Captain Crocker                                   170 l b s .

      F/O Skipper                                       165
      Stewasdess Lane                                   120

      Baggage    ( 3 @ 15 l b s . )                     - lbs .
                                                         45
                                                        500               500 .o



      O i l (4.4 g a l . @ 7.5 l b s . )                330
      AD1 (12 g a l . @    7.8 l b s . )                 93.6
      Anti- Ice (15 gal. @        7.2 l b s . )          0
                                                        18
                                                        531.6             531.6


      Fuel   (1,370 g a l . @ 6 l b s . )                               8,220.0

      WSU Passengers and Baggage                                        7,307.0
       Passenger h      n and Baggage                                     120.0

       Takeoff Gross Weight                                            48,165.1
                                                                                APPENDIX D

                            Martin    404 Performance Information

1. General Information

     Airport

        Stapleton Field, Denver, Colo.
        Elevation:   5,300 f e e t .
        Takeoff Runway: No. 35; 11,500 f e e t long.
                      A 1
        Atmosphere: F T 7 ° F.; wind 030 @ 6 knots; dew point 300 F.

     Crash S i t e

        Elevation:             11,000 f e e t m.s.1.
        Ambient Temp. :            5 F.
                                   '
                                   0
        Standard Temp.:            2 ° F.
                                    0
        Density A l t . :      12,900 f e e t m.s.1.
     Airplane

        Gross weight a t takeoff a t Denver:           48,165 l b s .
        Gross weight a t impact:                       47,565 l b s .
        Wing f l a p position at impact:               12.5O(Takeoff & SE En route)
        Lateral a t t i t u d e a t impact :               -
                                                       31 degree l e f t bank
        Paver conditions at impact:                    2,400 'pm,
                                                              ...    165 bmep (1,400BHP)

2 M a x i m u m Permissible Takeoff & Landing Weights f o r Field Elevation of
 .                                                                                               5,300 f t .

                                               -
                                               WEI                            -
                                                                              DRY
               Max. Takeoff W t . :          42,975 l b s .                 39,500 lbs.
               M a x . Landing W t . :       42,500 l b s .                 37,975 l b s .
3.   Estimated S i n g l e - m i n e (SE) Takeoff C l i m b Performance i n f e e t per minute
     7f.p.m.) a t 48,165 l b s . , 5,300 f t . a l t i t u d e , V 7 speed, 12.gU f l a p , International
     Stmdard Atmosphere (EA)

               Gear Down:                                    5 f.p.m.                - 135 f.p.m.
               Gear Up :                                 + 255 f.p.m.                + 140 f.p.m.
4.   Estimated   Route Climb Performance a t 47,565 l b s . , 1 , 0 f t . a l t i t u d e ,
                                                               100
     Scheduled Wing Flap & Airspeed, E A , Straight & Turning Flight

                                         Calibrated
                                          Airmeed
                             Flap           ( C k1
                           Position       mph/kts        00        ----
                                                                    5
                                                                   1' 30° 5
                                                                          4
                                                                          ' 60°
     All- mine:                           163/141      + 8%         + 860    + 760 + 515             - 240
     Single-Engine:         25
                           1.'            142/124      - 40             -        -           -          -
                                                - 2 -


 .
5 Estimated All-Engine                 En Route Climb Gradient at       47,563 lbs., 11,000 f t .
    Altitude,       141 k t s . CAS, Flaps Up.
    Free A i r Temperature             (FAT)        Rate of Climb                   Gradient

         2 ° F. ( S )
          0        IA:                               + 8 9 f.p.m.          0.0525   (i.e.,     5.25%)
         50° F . (ISA + 30) :                        + 798 f.p.m.          0.0457   (i.e.,     4.5%)
6. Estimated Power-Off S t a l l i n g Speed           at   47,565 lbs., and Various B a n k   Angles;
    CAS mph/kts.

    B a n k Angle           00                 1'
                                                5              0
                                                               3'             45O                  6'
                                                                                                    0
    Flaps    0'
              :        115/100             1171102           124/107      137/119               1631141
    Flaps 12.5O:       104/91              106/92            112198       124/10a               14a/m
7 . Radius of Turn ( f e e t ) a t Various Bank Angles &Airspeeds (CAS) a t 11,000 f t .
    Altitude & 50u F. Temuerature. Flaus 12.5"

       Airspeed
     M.p.h
     __.-
             Kts.                                                                                  600




                    NOTE:        (s)   designates a s t a l l e d condition
                                                            APPENDIX   E




                          AVIATION SERVICES AGREEMENT



         THIS AGREEMENT, made this      ~"1"   a day   of    1970          ,
1970, between Golden Eagle Aviation, Inc., a corporation, hereinafter

referred to as "Contractor", and Wichita State University, hereinafter

referred to as "Customer";

         WITNESSETH:

         WHEREAS, Customer has leased (or, prior to the commencement of

the services provided for herein, will have leased), from %third

party, the following described aircraft:

                ONE DOUGLAS DC-GB

hereinafter referred to as "the Aircraft"; and

         WHEREAS, Customer desires to have Contractor provide, with

respect to the Aircraft, the services specified below, upon the terms

and conditions hereinafter set forth, and Contractor is willing so

to do;

         NOW, THEREFORE, Customer and Contractor do hereby agree as

follows:

         1.   SERVICES:    Contractor shall provide the following services

for the Aircraft during the period of time commencing on September

11, 1970, and ending on November 14, 1970:

                 (a) A fully qualified flight crew to fly the Aircraft

         to and from such points within the Continental United States

         as Customer may direct (or, if an itinerary is attached hereto,
        to f l y the Aircraft in accordance with said itinerary), said

        flight crew to consist of:          Captain

                                            First Officer

                                            Flight Engineer

                                            Two Cabin Attendants

                 (b) The following specified in-flight catering services

        See attached schedule and itinerary titled "1970           - Football
       Travel Plans".

                 (c) All fuel, oil and other fluids necessary for the

       operation of the Aircraft pursuant to their Agreement.

                 (d) Routine maintenance on the Aircraft.

        2.   COMPENSATION:       AS consideration for contractor's providing

the above specified services, Customer shall pay to Contractor a total

sum of $ 24.388.60

        3.   PAYMENT:     Customer shall pay to Contractor the sum of      -
                30                             upon signing this Aviation Service
Agreement, this sum to constitute an advance against the total of

        $24.388.30.

        In addition, the Customer shall pay to the Contractor on

        October 5, 1370        , 1970   the sum of    -4

                      , this   sum in addition to the advance to constitute pay-

ment in full of the Aviation Service Agreement.

        4.   CONTRACTOR'S PERSONNEL:          Contractor's personnel engaged in

the performance of this Agreement shall for all purposes remain ~ p l o Y e e s
of Contractor.       All members of the flight crew shall be licensed and

fully qualified in every respect to operate the Aircraft.

       5.   DELAYS OR CANCELLATIONS:     Contractor shall not be responsible

for delays or cancellations occasioned by labor disputes, weather, acts

of God, mechanical failure or .any other factors beyond the control of

Contractor.

       6.     INSJ?AN;iustomer,                nse, shall provide

for passenger   J
                &-          liability                    insurance

with limits satisfactory and in accordance with the FAA and CAB

regulations and shall furnish proof thereof to Contractor.

      7.    ENTIRE AGREEMENT:     This Agreement, and any schedules or

exhibits attached hereto, constitutes the entire agreement between

Customer and Contractor and shall not be modified or amended except

by writing signed by both parties.

       8.   COUNTERPARTS:      This Contract may be executed in numerous

counterparts, eacn such councerpart having the same effect as the

original contract.

       9.   CHOICE OF LAW:      This Contract shall be construed in all

respects pursuant to the Laws of the State of Oklahoma.

      IN WITNESS WHEMOF, the parties hereto have executed this

Agreement the day and year first above written.
                                                                APPENDIX F



NATIONAL TRANSPORTATJON SAFETY BOARD
                 DEPARTMENT OF TRANSPORTATION
                     WASHINGTON, D.C.--20591


                                                         For Release:

 SB 70-85                                        ADVANCE F o r
 (202) 382- 7273
                                                 A M Newspapers
 Office of the Chairman                          Monday, Nov. 9, 1970


         The National Transportation Safety Board today issued a
 statement regarding its recent public hearing in Wichita, Kansas,
 which was held as part of its investigation seeking t o determine
 the probable cause of the fatal accident involving a Martin 404
 a i r c r a f t carrying the Wichita State University football team, that
 occurred on October 2 , 1970, n e a r Silver Plume, Colorado.

         The testimony taken a t the hearing indicates that the acci-
 dent was operational in nature and that t h e r e w e r e no mechni-
 c a l failures or malfunctions affecting the performance of the
 a i r c r a f t . F u r t h e r analysis of this testimony and other related
 evidence i s required before conclusions can be drawn, the
 Board said.

          The Board i s now examining in detail the evidence relating
 to the performance capabilities of the a i r c r a f t , the flight planning
 by the pilots, particularly at d e p a r t u r e f r o m Denver and the con-
 t r o l , or lack thereof, exercised by various organizations p e r -
 taining to safety of the operations.

          The Board is aware of the use of l a r g e a i r c r a f t in passen-
  g e r - c a r r y i n g operations by individuals, corporations, and edu-
  cational institutions which have leased a i r c r a f t on an individual
  t r i p basis in o r d e r t o satisfy a requirement for infrequent,
  short duration a i r transportation. In certain instances, it
  would appear that the contractual relationships a r e designed
  t o make the l e s s e e the operator of the a i r c r a f t .
                                  - 2 -

If the lessee does not possess the necessary kndwledge of the
Federal Aviation Regulations, he may, through these contractual
arrangements, unknowingly become the operator of the a i r c r a f t ,
and thereby be obliged to assume responsibilities beyond his
capability.

      In view of the foregoing, the Safety Board has concluded
that the regulations and proc'edures governing passenger oper-
ations of large a i r c r a f t should be thoroughly examined with a
view in mind of making them more stringent and their applica-
bility more understandable. The Safety Board is pleased to
learn that the FAA has already taken action by publishing a
Notice of Proposed Rulemaking which would expand the defi-
nition of a commercial operator, and which would make P a r t
1 2 3 of the Federal Aviation Regulations applicable to education-
a1 institutions engaged in the carriage by airplane of students
o r other persons affiliated with it.

     The Board was also pleased to note that a thorough investi-
gation of all a i r c r a f t charter operations has been ordered by the
Secretary of Transportation, John A. Volpe, which we under-
stand will not include those c a r r i e r s regulated by the Civil Aero-
nautics Board, and that the F A A has taken steps to inform edu-
cational institutions of the aviation regulations incident to the
operation of large aircraft. The Safety Board believes these
actions a r e steps which will lead to s a f e r operations.

       However, the Board is concerned that many other potential
u s e r s of large a i r c r a f t do not have knowledge of the existing
Federal Aviation Regulations which have been designed to pro-
vide safety in air travel, o r that they may not have ready a c c e s s
to competent advice concerning proper methods of securing
charter services, a i r c r a f t rental, or leasing of aircraft. Ac-
cordingly, the Safety Board recommends that all potential u s e r s
of large aircraft on a short- term charter basis question pro-
viders of such services as to the type of operations for which
they have been certificated by the FAA. If at all in doubt as to
proper certification, such u s e r s should consult the nearest F A A
office f o r advice. In s o doing, they will be informed of the proper
procedures to insure that the proposed flight can be accomplished
with maximum safety.

     The Safety Board said i t would expedite the issuance of i t s
final report on this tragic accident which would include a formal
determination of probable cause and any appropriate recommen-
dations that would help prevent such accidents in the future.


                                # # # # #
                                              WITNESS GROUP CHART
                                                   APPENDIX G
                                            SILVER PLUME, COLORADO
                                                 OCTOBER 2, 1970




            CONTOUR INTERVAL 200 FEET
WITH SUPPLEMENTARY CONTOURS AT 100 FOOT INTERVALS
         TRANSVERSE MERCATOR PROJECTION
                   LEGEND 0
 1 ) TREE 56' TALL WITH TOP BROKEN OUT
2) SHORT PIECE OF 4" DIA. LIMB WITH CLEAN
      DIAGONAL CUT
3) 14" PIECE OF TRIM TAB (ORIGIN UNKNOWN)
4) 20" PIECE OF TAB (ORIGIN UNKNOWN)
5) FLAP-S LA1
6) OUTBOARD HALF OF LEFT HORIZONTAL STABILIZER
       ELEVATOR STABILIZER a ELEVATOR SEPARATED
 7) PIECE OF 6" DIA. TREE ON GROUND CUT IN 14" L O N G
      YELLOW MARKED SCARF
 8) PORTION OF WING LEADING EDGE
 9) Z'x4' PIECE OF WING SKIN AND Z ' x 2 ' PORTION OF
       CONTROL SURFACE (ORIGIN UNKNOWN)
IO) PORTION OF FLAP ORIGIN UNKNOWN
1 1 ) FLAP-SLAT
12) M A I N LANDING GEAR DOOR
13) PORTION OF TIP OF PROP BLADE 12" L O N G
14) GYRO PORTION OF FLUX GATE COMPASS
15) OUTBOARD 1 3 OF RIGHT STABILIZER a ELEVATOR
16) SMALL PIECE OF W I N G SKIN (ORIGIN UNKNOWN)
17) M A N Y SMALL ALUMINUM SCRAPS IN THIS
       GENERAL AREA (ORIGIN UNKNOWN)
18) M A I N LANDING GEAR DOOR, PORTION OF FLAP
       a ENGINE COWL (ORIGIN UNKNOWN)
19) 4 ' ~ 6 SECTION OF WING WITH LANDING LIGHT
              '
       ATTACHED (ORIGIN UNKNOWN)
20) RIGHT WING TIP
21) 3l.3' SECTION OF WING SKIN(0RIGIN UNKNOWN)
22) FUEL CELL DOOR WITH FUEL Q U A N I N TRANS.
23) AUX. CABIN PRESSURE REGULATER
24) BLADE FROM PROP. "B"
25) PORTION OF TOP WING SKIN (ORIGIN UNKNOWN)
26) 2'~:' SECTION OF W I N G TRAILING EDGE
27) 6'x16' SECTION OF LOWER FUSELAGE
          SKIN CARGO COMP.
29) FUEL CELL DOOR
30) MAJOR PORTION OF AIRSTAIR DOOR
31) PROP. "A"
32) PORTION OF FLAP, FUEL CELL DOOR W/FUEL
          QUANITY TRANS. GRND. SUPPORT AIRCOND.
          ACCESS DOOR
33) RCA RADAR ACCESSORY UNIT
34) FUEL CELL DOOR W/FUEL QUANITY TRANS.
35) PORTION OF FLAP, F l A P H l N G UNIT,
          UNDER W I N G REFUEL PORT
36) SECTION Of ENGINE COWL FLAP
37) LANDING LIGHT, FUEL CELL DOOR UNDER
          WING REFUEL PORT SMALL SECTION OF
          WING SKIN
38) Z ' X Z ' SECTION OF UPPER W I N G SKIN
39) TWO STEPS OF AIRSTAIR DOOR
/




        NATl




    GOLDEN I
                             LONGITUDE: 105O-52'-54"
                             LATITUDE:  3T-39l-8"

       NATIONAL TRANSPORTATION SAFETY BOARD

                      Washington, D.C.


            WRECKAGE DISTRIBUTION CHART
    GOLDEN EAGLE AVIATION INCORP. MARTIN 404, N646N
                NEAR SILVER PLUME, COLORADO
                       OCTOBER 2, 1970

I
12.100
                                                                     r.
I1,WO
I 1,700

I 1,500
          E                                          _______  .....  .ALL-ENGINE ENROUTE CLIMB GRADIENT
                                                           AT47.565 LBS., I1,WO'
                                                           FLAPS UP.
                                                                                ALTITUDE, 141 KCAS,

                                                                               N T DUE TO TURNING FLIGHT

                                                           G R A D I E M BASED ON ZERO WIND; ACTUAL
                                                           WINDATll,OW'=350'/IOK


                                                                                            CONTINENTAL DIVIDE
                                                                                                     12,517FT.
                                                                                                                 12,500

                                                                                                                 12.300

                                                                                                                 12,100

                                                                                                                 11,900   I



                                                                                                                          ",
                                                                                                                          r

                                                                                - -APPENDIX I
                                                                                                                 11.7W
                                                                                                                          -
                                                                                                                          f
                                                                                                                          z
                                                                                                                 11,500

                                                                                                                 11,300
                                                                                                                          2
                                                                                                                          ,>
                                                                                                                          Y

                                                                                                                 11.100

                                                                                                                 10,900


                              -,
                                                                            NEAR SILVER PLUME, COLORADO
                               .
                              -.                                                   October 2. 1970               10,700
          I GROUND SURFACE-
                                                                                                                 10,500

                                   DISTANCE (FEET)
7
                                                                        APPENDIX J

                                     DEPARTMENT OF TRANSPORTATION
                                NATIONAL TRANSPORTATION SAFETY BOARD
                                            WASHlmTou. D.C.   -1




     o
     -m               cO                                                December 28, 1970
    THE CHAl"MAN           pY



             Honorable John H. Shaffer
             Administrator
             Federal Aviation Administration
             Washington, D. C. 20590

             Dear    r
                     .
                    M Shaffer:
                    The National Transportation Safety Board has reviewed your
             N€" 70-41 concerning aircraft operations conducted by commercial
             operators, educational i n s t i t u t i o n s and other groups. W a r e i n com-
                                                                               e
             p l e t e agreement with t h e conclusion expressed i n your notice t h a t there
             i s a need for regulatory action i n t h i s area. This need was most recently
             highlighted by t h e f a c t s discussed at our hearing on the accident which
             occurred a t Silver Plume, Colorado, on October 2, 1970. However, on
             the basis of our consideration of t h i s problem, and our review of your
             notice, we have a question as t o whether the proposed amendment of
             Farts 1 1 and 123 of the Federal Aviation Regulations i s a significant
                        .
             s t e p i n the solution of the problem.

                   The problem with the existing regulatory scheme appears t o be
             the f a c t t h a t it requires a determination as t o the type of operation,
             "for compensation or hire," before one can identify the applicable
             operating rules. This i s basically a l e g a l determination and requires
             an expertise not present i n those charged with the responsibility of
             surveillance. The enforcement 'of such a scheme inevitably r e s u l t s
             i n time consuming investigations; a need f o r l e g a l review; and often
             requires l i t i g a t i o n i n the Federal courts t o obtain a resolution as t o
             whether the operation w s "for compensation or hire."
                                              a

                  It i s our view t h a t NPRM 70-41 i s a continuation of past approaches
             and may do l i t t l e t o resolve these d i f f i c u l t i e s . The amendment of Part 1.1
             proposes t o simplify the surveillance and enforcement problem by in-
             cluding i n the definition of "commercial operators" three specific types
                                      -2-
of operations. Each appears t o be based on past experience with
meat haulers, land companies, and Las Vegas hotels. W perceive e
the following problems i n u t i l i z i n g t h i s approach:

      1.    It ignores other types of operations and cannot,
            of course, include new types of subterfuges not
            yet identified.

      2.                     a t . ( ) il
            The proposed F r 1 1 1 wl s t i l l require l e g a l
            interpretation and present t h e same problem found
            with t h e existing regulation.

      3.    While the proposed Part 1 1 1 may have been primarily
                                            .()
            designed t o bring the so-called meat hauler operations
            within the ambit of "commercial operators," it appears
            t o be so broad t h a t it would extend t o the large portion
            of executive f l e e t s engaged i n transporting t h e i r owner's
            products. While such operations conducted i n large
            a i r c r a f t may require higher operating requirements, w     e
             -
            auestion whether there is a need for c e r t i f i c a t i o n of these
            operations.

       With regard t o t h e proposed amendment of Part 123, which would
require certification of educational institutions, w question the logic i n
                                                                e
extending t h i s part now applicable t o t r a v e l clubs, which a r e established
f o r the purpose of travel. Educational i n s t i t u t i o n s and other groups
generally have no intention of being the operator and a r e only seeking
inexpensive charter transportation. The problem i n t h i s area i s with
those arrangements which r e s u l t i n the educational i n s t i t u t i o n s Un-
knowingly becoming the operator. To our knowledge, there has been
no significant problem with i n s t i t u t i o n s which acknowledge that they
                        e
a r e the operator. W , therefore, question the need f o r Certification.

         I n l i g h t of the above, t h e Safety Board recommends t h a t t h e
notice be withdrawn o r substantially modified. W recognize that
                                                            e
t h i s i s a very complex problem which has plagued the F A f o r many,,
                                                                A
years and t h a t past attempts t o define "for compensation o r hire,
both by your agency and the courts, have not been too fruitful.                  The
requirement of such a legal t e s t as a basis f o r what operating rules
a r e t o be employed has resulted i n an excessive expenditure of man-
power for surveillance and prosecution, with these e f f o r t s a l m y s
a f t e r t h e f a c t when safety has already been compromised.
                                  - 3 -
     In recognition of the complexity of t h i s matter, we would          ~




therefore urge t h a t , before an amendment of the rules, Ohis matter
be given further review by the FAA, including any comments recom-
mended on t h i s pending notice and recornendations developed by the
Task Force presently studylng t h i s problem under the direction of
the Assistant Secretary f o r Safety and Consumer Affairs.

             e
      While w doubt t h a t there i s any magic formula by which t h i s
problem can be f u l l y solved, w believe certain alternatives should
                                  e
                           e
be again considered. W would suggest the following alternatives as
deserving consideration:

     1.   W e no change i n t h e regulation but undertake b e t t e r
          surveillance and more vigorous enforcement of existing
          rules.

     2.   Retain the existing definition of "conrmercial operator,"
          but include those types of operations which have been
          found, i n the past, t o be commercial operations by
          l i s t i n g them as examples under the r u l e .

     3.   In combination with 2. above, provide for a review by
           A
          F A of certain leases and agreements, prior t o execution
          but establish well-defined l M t s on what type of arrange-
          ments should be involved. This review could be limited
          t o agreements pertaining t o large aircraft and only those
          involving wet leases and dry leases when used i n combina-
          t i o n with crew service agreements, as i n a recent case.

     4.   Amend Fart 91 of t h e Federal Aviation Regulations t o
          require the application of additional operating and
          maintenance r u l e s t o a l l large a i r c r a f t . Complex j e t s
          of l e s s than 12,500 pounds could be included, i f appropriate.
          Such an amendment could provide that t h e operation of any
          large a i r c r a f t by persons other than those certificated
          under Fart 121 ( o r 135 where an air t a x i has large aircraft
          authority) must comply with such additional operating and
          maintenance rules. The identification of the
          rule should, of course, be l e f t t o your discretion.

-1
1   Such rules should include an upgrading of p i l o t proficiency, including
a requirement t h a t second-in-command crewmembers be trained t o per-
form assigned duties. Periodic recurrent training and requalification
checks should be required.
                                   - 4-
         Under t h i s proposal, the “for compensation or h i r e “ t e s t would
remain f o r determination as t o whether an operator requires c e r t i f i c a -
tion. However, during the time consumed by an exhaustive investiga-
tion, l e g a l review, etc., the public would a t l e a s t have the assurance
that the a i r c r a f t , irrespective of the type of operation, i s being operated
under a higher standard than t h a t presently prescribed by Rrt 91.
Hopefully, the operator/owner of a large a i r c r a f t , under these con-
ditions, would have t o meet the higher standards, irrespective of the
type of operation, and, therefore, would be l e s s inclined t o conduct
i l l e g a l operations. !Chis proposal would be subject t o the criticism
that it would be applicable t o executive f l e e t s and i n v i t e t h e i r opposi-
tion. However, t h i s criticism may be somewhat negated when it i s
recognized t h a t t h e ‘cost of c e r t i f i c a t i o n would be obviated, and a
reasonable and practical use of the Administrator‘s exemption
authority i s available f o r unusual cases.

       W would i n v i t e your particular attention t o item 4. above.
        e
Although it i s one t h a t has undoubtedly been considered i n the past,
it i s a different approach, and one which could r’aise safety standards
f o r large a i r c r a f t , be simpler t o monitor and enforce, and would
continue the c e r t i f i c a t i o n of “comercia1 operators” who a r e under-
taking operations for compensation or hire.

                                        Sincerely yours,




                                   .
                                  11    John H. Reed
                                        Chairman

								
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