- Avianca Airlines B707 Flight 52 at Long Island, NY
- Accident Overview
- Accident Board Findings
- Accident Board Recommendations
- Relevant Regulations / Policy / Background
- Prevailing Cultural / Organizational Factors
- Key Safety Issue(s)
- Safety Assumptions
- Resulting Safety Initiatives
- Airworthiness Directives (ADs) Issued
- Common Themes
- Related Accidents / Incidents
- Lessons Learned
- Avianca Airlines B707 Flight 52 at Long Island, NY
Photo of an Avianca 707 on the tarmac
Photo copyright Aldo Bidini - used with permission
History of the Flight
AVA052 departed Bogota International Airport at 1310. The flight made a scheduled intermediate stop at Jose Maria Cordova Airport near Medellin, Colombia at 1404 and prepared for departure to JFK. There was no change of flight crew. The crew consisted of a captain, first officer, and flight engineer (second officer). The flight departed Medellin at 1508.
The flight plan was an oceanic route north toward the East Coast of the United States. The route through U.S. airspace included Dixon, North Carolina, then to Norfolk, Virginia, direct to Sea Isle, New Jersey, and on to JFK.
Three Holding Periods
The weather over the East Coast of the U.S. was poor with conditions of overcast and rain over the coastal Mid-Atlantic states and New England. As the flight proceeded northward it was placed in holding three times by air traffic control (ATC). The first period of holding was over Norfolk for 19 minutes, from 1904 to 1923. The flight was placed into holding a second time near Atlantic City for 29 minutes, from 1943 to 2012. The flight was placed into holding a third time, 39 miles south of JFK, for 29 minutes from 2018 to 2047.
Within the third hold period ATC advised AVA052 to expect further clearance at 2105. The first officer responded, "…ah well I think we will need priority we’re passing [unintelligible]." The investigators determined that the first officer was making all calls to ATC.
ATC inquired, "…roger how long can you hold and what is your alternate [airport]?" At 2046:03 the first officer responded, "Yes sir ah we’ll be able to hold about five minutes that's all we can do." The controller replied, "…roger what is your alternate?" The first officer responded, "ah we said Boston but ah it is full of traffic I think." The controller said, "…say again your alternate airport?" The first officer responded, "it was Boston but we can't do it now we, we, don't, we run out of fuel now."
Google Earth images of AVA052 crash site.
ATC responded to the first officer's request for priority by allowing the flight to depart the third holding period at 2047:00 and proceed toward JFK. The flight was given routine ATC service including descents to lower altitudes and heading changes, to place it in sequence with airplanes that were en route to instrument flight rules (IFR) approaches to JFK.
At 2056:16 ATC advised the flight of a windshear. The first officer acknowledged receipt of the windshear advisory. The flight continued to get routine ATC service, including several heading changes, and further descent clearances to 3,000 feet, and finally to 2,000 feet.
The following conversations in Spanish occurred in the flight deck. At 2109:21 the first officer stated, "they accommodate us ahead of an--.” A few seconds later the captain said, "what, " and the first officer replied, "they accommodate us.” The second officer said, "they already know we are in a bad condition.” Then the captain replied, "no they are descending us.” The first officer reported, "one thousand feet.” The captain said, "ah yes." Then the second officer stated, "they are giving us priority."
Windshear and Missed Approach
The crew conducted an ILS approach on JFK runway 22L. The flight was number three to land following a Boeing 727 that was on a 9 mile final approach. Starting at 2117:17 the JFK tower confirmed their airspeed (140 knots) and requested that AV052 increase speed 10 knots. The first officer responded, "okay one zero knots increasing." The captain replied, "tell me things louder because – I'm not – hearing it."
AVA052 ILS missed approach – profile view
They captured the glideslope, lowered the landing gear and flaps, and began the landing checklist. At 2119:58, JFK tower cleared AV052 to land. The captain said, "give me fifty," and shortly thereafter he said, "are we cleared to land no?" The first officer responded, "yes sir we are cleared to land." The first officer said, "localizer to the left slightly below glideslope." Then the second officer said, "stand by flaps fifty landing checklist complete." And the captain said, "flaps fifty now." The second officer said, "fifty green light final set." At 2120:48 the first officer said, "below glideslope."
At 2122:05, AVA052 was about 3.2 miles from the approach end of runway 22L. Fifty two seconds later the first officer said, "this is the windshear." Then the second officer said, "glideslope." A few seconds later the first officer said, "glideslope," "sink rate"; and "five hundred feet."
Between 2123:08 and 2123:23 (CVR), there were 11 "whoop pull up" voice alerts from the airplane's ground proximity warning system (GPWS). Between 2123:25 and 2123:29, there were 4 "glideslope" deviation alerts from the GPWS. At 2123:23, the captain asked, "the runway where is it?" At this time, AVA052 was 1.3 miles from the approach end of runway 22L at an altitude of 200 feet. The first officer said, "I don't see it I don't see it." The captain replied, "give me the landing gear up landing gear up." The AVS052 ILS missed approach figure shows the profile view of the approach path and go around.
AVA052 executed a missed approach, advised the tower, and were directed to call ATC approach. At 2125:07, the New York (NY) TRACON controller replied to the radio call, "Avianca zero five two heavy New York good evening climb and maintain three thousand."
707-300 Flightdeck: Flight engineer's position and fuel panel are on the right.
Photo copyright Europix - used with permission
Flight engineer's fuel system panel – fuel tank gauges are 5 round dials in an inverted "V" arrangement below the light pairs.
Photo copyright AirNikon Collection - PIMA Air & Space Museum - used with permission
At 2125:08, the captain said, "advise him we don't have fuel." The first officer made the radio call, "Climb and maintain three thousand and ah we're running out of fuel sir." The captain asked, "did you already advise that we don't have fuel?" The first officer replied, "Yes sir. I already advise him hundred and eighty on the heading we are going to maintain three thousand feet and he's going to get us back." The captain replied, "okay."
At 2126:35, the NY TRACON controller stated, "and Avianca zero five two heavy ah I'm going to bring you about fifteen miles northeast and then turn you back for the approach. Is that fine with you and your fuel?" The first officer replied, "I guess so thank you very much."
At 2129:11, the first officer asked, "Ah can you give us final now…?" The NY TRACON controller responded, "…affirmative sir turn left heading zero four zero." The controller stated, "Avianca fifty two climb and maintain three thousand." The first officer replied, "ah negative sir we just running out of fuel we okay three thousand now okay." The controller responded, "Okay turn left heading three one zero sir."
The captain called to set flaps 14, and the controller directed AVA052 to heading 360, both of which were confirmed completed. At 2131:01, the controller stated, "okay you're number two for the approach I just have to give you enough room so you make it without ah having to come out again."
At 2131:22, the captain asked, "three sixty no?" The first officer replied, " three sixty." The captain said, "flaps fourteen." About a minute later the flight was instructed to turn left to a heading of 330.
At 2132:14, the first officer said, "three three zero the heading." Twenty five seconds later the second officer said, "flame out flame out on engine number four." The captain replied, "flame out on it." The second officer then said, "flame out on engine number three essential on number two or number one." The captain stated, "show me the runway."
Flight path trace (from radar returns) and key to selected communications
At 2132:49, the first officer radioed, "…we just ah lost two engines and ah we need priority please." The controller then instructed AVA052 to change headings to 250 and advised the flight that it was fifteen miles from the outer marker and cleared for the ILS approach to runway 22L. The first officer replied, "two five zero."
At 2133:04, the captain stated, "select the ILS let's see." A few seconds later the captain stated, "that no – that," and asked, "did you select the ILS?"
At 2133:07, the controller informed the flight, "…you're one five miles from the outer marker maintain two thousand until established on the localizer cleared for ILS two two left." The first officer replied, "it is ready on two." This radio transmission was the last clearance acknowledged by AVA052.
At 2133:24, the Cockpit Voice Recorder ended, due to a loss of electrical power resulting from the failure of the remaining engines.
At 2134:00, the controller asked AVA052, "You have ah you have enough fuel to make it to the airport?" There was no response from the airplane. At about this time, AVA052 impacted on a hillside in a wooded residential area on the north shore of Long Island. The starboard side of the forward fuselage impacted and fractured the wooden deck of a private residence. There was no fire.
Overhead view of accident site
Standard Emergency Phraseology
At the time of the accident, FAA Order 7110.65 provided guidelines to air traffic controllers on assisting aircraft in an emergency. An emergency can be either a "distress" or an "urgency" condition as defined in the pilot/controller glossary. A pilot who encounters a distress condition would declare an emergency by beginning the initial communication with the word "MAYDAY," preferably repeated three times. For an urgency condition the word "PAN-PAN" should be used in the same manner. The word "EMERGENCY" can also be used in place of "MAYDAY."
The first officer requested "priority" from ATC when AVA052 was in the third hold period and it was clear the hold was going to be extended until at least 2105. He did not declare an emergency using standard phraseology so ATC interpreted this as a request to be removed from holding due to low fuel. ATC did arrange to remove AVA052 from holding but proceeded to provide routine ATC service after that without any attempt to move the flight up in the landing sequence or suspend other traffic to allow an emergency landing.
Comparison of Minimum Fuel, Emergency Fuel and Reserve Fuel
FAA Information for Operators (INFO) 08004 provides an overview of these terms and how operators should interact with ATC to communicate their fuel situation. Highlights of the basic definitions and discussion follow. See link below for more details on the definitions.
Illustration of Flight Engineer's Lower Panel Minimum Fuel
The Aeronautical Information Manual (AIM) and the Pilot/Controller Glossary both provide the following definition, which states that, Minimum Fuel:
"Indicates that an aircraft's fuel supply has reached a state where, upon reaching the destination, it can accept little or no delay. This is not an emergency situation but merely indicates an emergency situation is possible should any undue delay occur."
If, at any time, the remaining usable fuel supply suggests the need for traffic priority to ensure a safe landing, the pilot should declare an emergency and report fuel remaining in minutes.
Although not defined in the AIM or Federal Aviation Regulations, the industry-wide connotation typically associated with the term "Fuel Emergency" is:
The point at which, in the judgment of the pilot-in-command, it is necessary to proceed directly to the airport of intended landing due to low fuel. Declaration of a Fuel Emergency is an explicit statement that priority handling (meaning immediate clearance to land with priority over other aircraft) by ATC is both required and expected.
FAA fuel requirements for flight in IFR conditions state that:
"No person may operate a civil aircraft in IFR conditions unless it carries enough fuel (considering weather reports and forecasts and weather conditions) to-"
- Complete the flight to the first airport of intended landing;
- Fly from that airport to the alternate airport [if one is required]; and
- Fly after that for 45 minutes at normal cruising speed or, for helicopters, fly after that for 30 minutes at normal cruising speed.
Minimum Fuel State and Emergency Calls to ATC
The use of a portion of the reserve fuel is not, in itself a cause to declare a minimum fuel state with ATC. Regulations require reserve fuel to enable aircraft to maneuver, due to unforeseen circumstances. Many aircraft safely arrive at their destination having used a portion of the fuel designated as reserve. There is no regulatory definition as to when, specifically, a pilot must declare "Minimum Fuel" or a Fuel Emergency. Air carriers typically develop such guidance for their pilots and include it in their General Operations Manuals; such guidance generally falls along the following lines:
- Declare "Minimum Fuel" when, in your best judgment, any additional delay will cause you to burn into your reserve fuel.
- Declare a Fuel Emergency at the point at which, in your judgment, it is necessary for you to proceed directly to the airport at which you intend to land. Declaration of a Fuel Emergency is an explicit statement that priority handling (meaning immediate clearance to land with priority over other aircraft) by ATC is necessary and expected.
The investigation found that the Avianca Route Manual in use at the time of the accident had a definition of Minimum Fuel similar to that above. The crew did not declare either Minimum Fuel or a Fuel Emergency to ATC using standard phaseology.
Photo of 707 cockpit with pilots and flight engineer
Photo copyright Sam Chui - used with permission
Crew Resource Management (CRM)
Air carrier accident investigation experience over the past 40 years has indicated that most of the accidents were attributable not so much to a lack of individual technical proficiency as to shortcomings in resource management and leadership abilities by captains, and active team support by other flight deck crew members. This experience has led to much greater emphasis on a team approach to training airline flightcrews by most airlines.
This approach, generally known as CRM training, has gained significant support in the airline industry and among regulatory authorities. CRM training is specifically designed to improve communication and teamwork among members of flight crews, and to foster the use of all the resources at their disposal. FAA Advisory Circular (AC) 120-51 issued on December 1, 1989, provides guidance for the development of CRM training. It is linked here: AC 120-51
The first indication that the flightcrew had some concerns about weather, and possibly the fuel state occurred at about 2009. At this time AV052 requested information about delays into Boston after being in holding for 26 minutes. There was no further indication from the flightcrew about AV052's fuel state until after the airplane had been in holding for 1 hour and 6 minutes on three separate occasions.
When ATC issued a message to expect further clearance at 2105 the flightcrew apparently finally realized that they had to commence an approach to JFK and therefore requested priority handling. The Safety Board concluded that the flightcrew had already exhausted its reserve fuel to reach its alternate by the time it asked for priority handling. When asked a second time for its alternate, the first officer responded, "It was Boston, but we can't do it now."
Although the first officer had radioed at 2046:03, "Yes sir, ah, we'll be able to hold about five minutes, that's all we can do," the airplane did not have sufficient fuel to fly to its alternate.
Pilots in a 707 cockpit
The fuel state at the time AVA052 was cleared for approach to JFK was already critical for its destination. To help ensure sufficient fuel to complete a safe landing, an emergency should have been declared in order to receive expedited handling. The airplane exhausted its fuel supply and crashed 47 minutes after the flightcrew stated that there was not sufficient fuel to reach the alternate. This occurred after the flight was vectored for an ILS approach to the destination, missed the first approach, and was unable to complete a second approach.
Because the CVR retained only 40 minutes of flightdeck conversations, the Safety Board could not determine whether the crew discussed the minimum fuel level that they should have onboard when commencing the approach, prior to leaving the last hold period. However it was apparent to the investigators, from communications with ATC while holding (first, the expressed need for "priority" at about 2045 and second, the observations that the flight could hold only 5 minutes, and that they could not reach Boston only minutes later) that the crew was aware of, and concerned about the fuel problem. Whether the captain, or first officer, or both, believed that these transmissions to ATC conveyed the urgency for emergency handling is unknown.
However, at 2054:40, when AVA052 was given a 360 degree turn for sequencing and spacing with other arrival traffic, the flightcrew should have known that they were being treated routinely and that this situation should have prompted them to question the clearance and reiterate the criticality of their fuel situation. At that time, they could have declared an emergency, or at least requested direct routing to the final approach in order to arrive with an acceptable approach minimum fuel level.
After the flight executed a missed approach to JFK at about 2123:28, the captain advised the first officer, "tell them we are in an emergency." However, the first officer acknowledged an ATC altitude and heading instruction to the JFK tower controller, adding, "we're running out of fuel." He did not use the word "emergency," as instructed by the captain, and therefore did not communicate the urgency of the situation. Thus, the tower controller was not alerted to the severity of the problem. When the tower controller advised AVA052 to contact the NY TRACON controller for vectors for a second approach, he did not advise the TRACON controller that AVA052 was running out of fuel. However, when AVA052 contacted the TRACON controller, the first officer again stated, "…we're running out of fuel sir," after acknowledging a clearance to climb to 3,000 feet.
Photo of a 707 cockpit at night
Ivan Koleshov - used with permission
The tower controller did not follow up on the radio calls about running out of fuel. However, the TRACON controller turned the flight back onto a downwind leg and asked the flight if it could accept a base leg 15 miles northeast of JFK. The first officer responded, "I guess so."
Shortly thereafter, at 2124:22, the captain again advised the first officer to, "advise him we have an emergency." Four seconds later, the captain said, "did you tell him?" The first officer replied, " yes sir, I already advised him." Further, at 2125:08, the captain said to the first officer, "advise him we don't have fuel." He asked again, at 2125:28, "Did you advise him that we don't have fuel?" The first officer again said, "yes sir, I already advise him…"
These flightdeck conversations indicate a total breakdown in communications by the flightcrew in its attempts to relay the situation to ATC. The accident may have been inevitable at that point, because the engines began to flame out only about 7 minutes later. However, it is obvious that the first officer failed to convey the message that the captain intended. The evidence strongly suggests that the captain was unaware at times of the content of the first officer's transmissions and that he did not hear or understand the ATC radio calls. The investigators believed it more likely his limited command of the English language prevented him from effectively monitoring the content of the calls. The investigators further believed that this deficiency might have been a factor in the accident, particularly if the captain believed that the first officer had adequately expressed the criticality of the fuel situation upon departure from the third holding period.
In summary, the investigators found that two key factors leading to this accident were:
- The flightcrew's failure to notify ATC of their fuel situation during the third holding period in order to ensure arrival at the approach fix with an adequate approach minimum fuel level.
- The breakdown in communications between the flightcrew and ATC, and among the flight crew members.
The Safety Board recommended that Avianca Airlines incorporate CRM training concepts into the training for all of its flightcrews.
Wreckage and Impact Information
The airplane impacted on a approximately 24 degree upsloping hill. Based on ground scars left by the engines and airframe, the entire fuselage, with the exception of the flightdeck and forward cabin, came to a stop within 21 to 25 feet after impact.
Illustration of AVA052 terrain impact
The fuselage was found partially separated into three sections. The flightdeck and forward cabin had broken away from the rest of the fuselage at the time of terrain impact and continued to move over the crest the slope, coming to rest about 90 feet forward of the main wreckage. This section was significantly damaged, with seats and other cabin components lying on the ground, extending back to the main wreckage.
The main fuselage had come to rest, upright, on the upslope of the hill. The forward end of this section extended over the crest of the slope.
NTSB/FAA wreckage photos of AVA052
Photo of cabin center section. Note separated seat legs still attached to floor. Photo from NTSB/FAA investigation.
Photo of cabin center section. Close view of separated seat leg still attached to floor. Photo from NTSB/FAA investigation.
Forward end of center cabin at the fuselage break. Note there are no seats attached to the floor. Photo from NTSB/FAA investigation.
Cabin Interior and Seat Condition
Interior furnishings, consisting of the galley, seats, seat belts, overhead bins, decorative panels and floor structure from the flightdeck/forward cabin fuselage section were found scattered along the wreckage path between the separated flightdeck/forward fuselage back to and into the fractured opening of the center section the cabin. This fracture was just forward of the point where the leading edge of the wing mates with the fuselage. Interior furnishings were also scattered along the wreckage path forward of the nose of the airplane, up to a point about 100 feet beyond the final resting point of the flightdeck and forward cabin section.
The interior of the flightdeck was found substantially damaged. Four of the five flight deck seats (the three seats occupied by the flightcrew, as well as one of the two observer seats, both of which were unoccupied) were lying outside the flightdeck.There was substantial damage inside the overwing section of the cabin. Interior furnishings, consisting of passenger seat units, overhead bins and decorative panels, were piled up outside the forward break in the fuselage. There was a fracture of the longitudinal floor track, evidenced by a downward disruption of floor panels between two lateral floor beams. The remainder of the cabin floor was generally intact but was displaced downward about 3 inches on the right side. The inboard rear seat legs of 16 seat assemblies remained attached to the floor track in the overwing section (See cabin center section figure). The outboard legs of their assemblies were fractured at the floor track. These seats were found outside the cabin and forward of the overwing section.
Cabin center section with collapsed seats. Photo from NTSB/FAA investigation
According to the lead flight attendant, seated in 2C, who survived with serious injuries, there was no warning to the cabin from the flightdeck regarding the low fuel status, loss of engines, or the impending emergency landing. Therefore, passengers were not briefed on brace positions, other than during the preflight briefing, or on evacuation procedures. However, after the failure of all four engines and generators, the ability of the flightdeck to communicate with cabin of the PA system would have been lost.
Seventy-two of the 74 passengers who survived sustained serious injuries. These injuries consisted of multiple lower leg fractures and dislocations, head injuries, hip fractures, spinal fractures, and multiple lacerations and contusions. The legs of passengers were believed to have impacted the lower seat back frames of seat units in front of them. Simultaneously, passenger seats most likely collapsed and twisted downward and to the left, resulting in hip and spinal fractures. As the impact sequence progressed, separation of the seats from their floor attachments pushed passengers forward into passengers, seats, and other wreckage debris, causing head injuries and lacerations.
AVA052 Cabin seating diagram with injuries noted. Note there are virtually no minor injuries and not all passengers are accounted for per the note above.
It could not be determined where all the passengers were seated at the time of impact, because the airline only assigned seats to a small percentage of passengers. Those passengers who had assigned seats stated that many of them moved freely about the cabin to sit with family and friends. Therefore, passenger seat locations in relation to an individual injury diagram could not be developed with certainty in all cases.
The captain, first officer, and flight engineer died from blunt force head and upper torso trauma. The captain and first officer seats had no shoulder harnesses installed. On March 6, 1980 the FAA required all flightdeck seats to be equipped with combined seatbelts and shoulder harnesses; however, ICAO standards do not address these restraint systems.
Five of the six flight attendants were fatally injured as a result of blunt force injuries to the head, chest, abdomen, and limbs. Three of the five flight attendants' locations could be established based on the statement of the surviving flight attendant. One was seated in the L-1 one attendant seat, the second was in passenger seat 2A, and the third was in passenger seat 3C. Sixty-four adult passengers and one 4 month old infant died as a result of blunt force injuries.
16g Seat Rule History and Avianca AVA052
The seats on AVA052 were known as 9g static load seats which were certified to Civil Aeronautics Regulations (CAR) 4b.260 (equivalent to current requirement 14 CFR 25.561). This was the standard in place at the time the airplane model received FAA type certification in 1959. The accident airplane was put into service in 1967. The more stringent 16g dynamic load seat rule (14 CFR 25.562) was put in place in 1986 after the Avianca Boeing 707 airplane was already in service with the airline. The 16g seat rule did not require existing airplanes in the U.S. fleet to be upgraded to meet the new standard. In addition, airplanes operated by non-U.S. carriers such as Avianca would not have been required to retrofit their airplanes to comply with the 16g rule unless directed by their national airworthiness authorities.
The Avianca accident in 1990 was one of many demonstrating that 9g seats do not assure protection to passengers or crew in a survivable crash. Evidence of poor seat performance during the AVA052 crash sequence includes:
- Large numbers of seats broke loose from the otherwise intact but deformed floor structure and fuselage sections resulting in severe injuries or fatalities for nearly all occupants.
- Seat frames fractured and detached from leg structures still attached to the floor structure. Seat backs fractured and became detached from the seat frames. Seat belts failed. The unrestrained passengers and crew impacted airplane structure or were ejected from the airplane causing severe injuries and fatalities for nearly all occupants.
- Seat tracks and seat attachment fittings fractured allowing seats to break loose from the airplane floor.
- Seat rigidity and deformation led to injuries and impeded the ability of passengers and crew to evacuate the airplane.
- Passengers sustained severe head injuries, lumbar spine, hip and leg fractures while seated in seats still attached to the floor structure.
Collapsed AV052 economy class seat. Note the seat frame is completely fractured in multiple locations and the seat detached from airplane floor due to seat leg failures. Photo from NTSB/FAA investigation.
A great deal of research went into the new 16g seat rule. Poor seat performance such as that seen in AVA052 was studied in a number of accidents. The new rule was tailored to prevent the poor seat performance seen during the AVA052 accident.
A few concepts are fundamental to the 16g seat rule:
- Seats should stay attached up to point of fuselage breakup and have equivalent structural strength to the floor to which they are attached even when the floor is deformed during the accident sequence.
- Seats should deform in a controlled manner such they that they absorb impact energy and minimize injuries to passengers. But the seats should not deform so much that they block evacuation paths out of the airplane or prevent a person from exiting their seat.
- Injury criteria should make for seat designs that provide a high level of protection from head, lumbar spine, and femur leg injuries.
- Seat belt (and belt attachments to the seat) strength and deformation standards should be equivalent to the seats designed to the new dynamic standards.
- The seats should protect occupants for two dynamic pulse load cases. One is an all longitudinal 16g crash loading to simulate running off the end of a runway and impacting ground structure or a berm, for example. The other is a 14g crash loading combining forward longitudinal and down loading to simulate a very hard landing.
This accident reinforced why the 16g dynamic seat standard was appropriate and a substantial benefit to passenger and crew safety in survivable accidents.
Provided is an example test video showing what happens to older 9g static type seats similar to those on AVA052 when subjected to the 16g dynamic requirement. This simulates what happened to the seats during the AV052 accident. Note the seats breaking loose from the floor, and the unrestrained occupants.
Here are videos of similar tests with seats designed to meet the new 16g seat requirement. Note the dramatic improvement in seat performance.
The photo below shows one such success story accident explained in the section.
Photo of Aires Flight 8250 wreckage