National Airlines Flight 193

1978 aviation accident off the coast of Florida

National Airlines Flight 193
Accident
N4744 during recovery
Date	May 8, 1978 (1978-05-08)
Summary	Controlled flight into terrain due to pilot error and lack of crew resource management leading to a loss of situational awareness
Site	Escambia Bay near Pensacola Regional Airport, Pensacola, Florida 30°29′8″N 87°7′3″W / 30.48556°N 87.11750°W / 30.48556; -87.11750
Aircraft
Aircraft type	Boeing 727-235
Aircraft name	Donna
Operator	National Airlines
Registration	N4744
Flight origin	Miami International Airport
Stopover	Melbourne International Airport, Melbourne, Florida
1st stopover	Tampa International Airport, Tampa, Florida
2nd stopover	Louis Armstrong New Orleans International Airport
3rd stopover	Mobile Municipal Airport, Mobile, Alabama
Destination	Pensacola Regional Airport, Pensacola, Florida
Occupants	58
Passengers	52
Crew	6
Fatalities	3
Injuries	11
Survivors	55

National Airlines Flight 193, registration N4744, Donna, was a Boeing 727-235 en route from Miami, Florida to Pensacola on May 8, 1978. It was scheduled with stops at Melbourne, Florida; Tampa; New Orleans, Louisiana and Mobile, Alabama. The accident occurred at night in low visibility from fog. During the descent into Pensacola Regional Airport it impacted Escambia Bay, sinking in 12 feet (3.7 m) of water.

Flight crew

The crew consisted of Captain George T. Kunz (age 55), employed by National Airlines since 1956, who had qualified to fly the Boeing 727 in 1967 and accumulated 18,109 flight hours in his career with 5,358 hours on the Boeing 727; First Officer Leonard G. Sanderson Jr. (31), employed by National Airlines since 1976, with 4,848 flight hours of which 842 hours were on the Boeing 727; and Flight Engineer James K. Stockwell (47), employed by National Airlines since 1969, with 9,486 flight hours of which 7,050 flight hours were on the Boeing 727.

Incident

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The instrument landing system (ILS) for runway 16 had been out of service since January of that year for runway reconstruction. A non-precision approach to runway 25 was available instead. Prior to initiating the approach a twin engine Beechcraft reported breaking out of the overcast at 450 feet (140 m). The minimum descent altitude for this approach was 480 feet (150 m). This concerned the first officer who informed the captain in his opinion that plane had made an illegal approach. An Eastern Air Lines jet ahead of them reported briefly having the runway in sight before losing it in the clouds and going around.

While established on the approach the first officer neglected to make altitude and approach fix call outs. The ground proximity alarm sounded and the first officer checked his altimeter. He read it as 1,500 feet (460 m) and turned off the alarm. The flight data recorder would later show their actual altitude at this point was only 500 feet (150 m). The flight crew may have been distracted by the alarm and failed to realize they passed through the minimum descent altitude. Shortly after this they impacted Escambia Bay. Barge traffic in the area assisted in the evacuation. Three passengers drowned attempting to exit the aircraft. The aircraft was intact after the accident and was removed to a hangar at Naval Air Station Pensacola but written off due to extensive sea water corrosion. The airframe was subsequently disassembled and removed from the air base to a scrapping location.

Accident analysis

Contributing to the crash was poor preparation on the part of the flight crew. While the captain and first officer were aware that runway 16 was closed, they had both forgotten it. A visual approach slope indicator (VASI) light system serving runway 25 was available and operational, but while the information was available to the flight crew, the flight crew was unaware of this alternate approach aid.

An additional contributing factor to the crash was an error on the part of the radar controller. Procedure for runway 25 was to direct flights to intercept the final approach at 8 nmi, with the approach gate at 6 nmi. The controller misjudged the aircraft's distance and turned it to final inside the recommended distance, resulting in the aircraft being on final approach vector at about 4.5 nmi, close to half the distance of a normal approach. The NTSB report concludes the controller "created a situation that would make it impossible for the captain to configure his aircraft in the manner specified in the flight manual".

A reluctance to declare a missed approach pervaded the descent. Radar controller, captain, first officer and flight engineer all had indications of an out of the ordinary approach, producing a rushed and busy environment. An example of this was that the captain failed to lower the landing gear immediately after lowering the flaps to 25 degrees, because he "wanted to avoid placing a simultaneous demand on the hydraulic system while the flaps were in transit". Similarly, the first officer never made the required 1,000-ft callout, because he never got to 1,000 ft mentally, because of his "inner time clock" which was based on a normal descent rate. In addition, each person chose not to ask for or offer additional assistance or warnings, including recommended announcements and acknowledgments. The lack of crew communication and a "no problem here" attitude resulted in false awareness of altitude and descent rate on the part of all involved.

Evacuation

The aircraft was not equipped with, nor was it required to be equipped with, liferafts and approved flotation-type seat cushions. Twenty-four passengers and the crew believed that the seat cushions were flotation devices. Fourteen passengers tried to use them for flotation, and several survivors indicated that the cushions came apart and were not buoyant.

Since, by regulation, (subsequently changed) the Pensacola to Mobile portion of the flight was not an extended overwater flight, the passenger briefing did not include the location and use of water survival equipment. Therefore many passengers were not aware of the location of the life vests, how to don them, how to use them, and the location and use of the life vest's emergency lights. Those passengers who knew or were told that the life vests were stowed in compartments beneath the seats had difficulty extracting them. Rising water in the cabin compounded the problems of locating and removing the vests from the underseat compartments.

References

^ "National Airlines, Inc., Boeing 727-235, N4744NA, Escambia Bay, Pensacola, Florida, May 8, 1978" (PDF). Aircraft Accident Report. National Transportation Safety Board. 1981. NTSB/AAR-78-13. Retrieved May 6, 2010. - Copy at Embry-Riddle Aeronautical University.
Ranter, Harro. "ASN Aircraft accident Boeing 727-235 N4744 Escambia Bay, FL". aviation-safety.net. Retrieved 2020-10-08.
US GPO. "14 CFR §91.519(a)(5)" (PDF). Retrieved 7 June 2010. {{cite journal}}: Cite journal requires |journal= (help)

National Airlines (1934–1980)

History

Accidents & incidents	Flight 16 (1945) Flight 83 (1951) Flight 101 (1952) Flight 470 (1953) Flight 967 (1959) Flight 2511 (1960) Flight 27 (1973) Flight 193 (1978)

Category

v t e Aviation accidents and incidents in 1978 (1978)
Jan 1 Air India Flight 855Feb 11 Pacific Western Airlines Flight 314Feb 17 British Army Gazelle downingMar 1 Continental Airlines Flight 603Mar 3 LAV HS 748 accidentMar 9 China Airlines Flight 831Mar 13 United Airlines Flight 696Mar 16 Balkan Bulgarian Airlines Flight 107Apr 20 Korean Air Lines Flight 902May 8 National Airlines Flight 193May 19 Aeroflot Flight 6709May 23 Yegoryevsk Tu-144 crashJun 21 Iranian Chinook shootdownJun 26 Air Canada Flight 189Jun 26 Helikopter Service Flight 165Aug 9 Olympic Airways Flight 411Aug 30 LOT Polish Airlines Flight 165 hijackingSep 3 Air Rhodesia Flight 825Sep 7 Air Ceylon Avro HS 748 bombingSep 25 Pacific Southwest Airlines Flight 182Sep 26 Air Caribbean Flight 309Sep 30 Finnair Flight 405Oct 3 Finnish Air Force DC-3 crashOct 7 Aeroflot Flight 1080Oct 21 Valentich disappearanceOct 23 Aeroflot Flight 6515Nov 15 Loftleiðir Flight 001Dec 4 Rocky Mountain Airways Flight 217Dec 17 Indian Airlines Flight 403Dec 20 Indian Airlines Flight 410Dec 21 TWA Flight 541Dec 22 Cessna 188 Pacific rescueDec 23 Alitalia Flight 4128Dec 28 United Airlines Flight 173
1977 ◄ ► 1979

Aviation accidents and incidents in 1978 (1978)

Jan 1 Air India Flight 855Feb 11 Pacific Western Airlines Flight 314Feb 17 British Army Gazelle downingMar 1 Continental Airlines Flight 603Mar 3 LAV HS 748 accidentMar 9 China Airlines Flight 831Mar 13 United Airlines Flight 696Mar 16 Balkan Bulgarian Airlines Flight 107Apr 20 Korean Air Lines Flight 902May 8 National Airlines Flight 193May 19 Aeroflot Flight 6709May 23 Yegoryevsk Tu-144 crashJun 21 Iranian Chinook shootdownJun 26 Air Canada Flight 189Jun 26 Helikopter Service Flight 165Aug 9 Olympic Airways Flight 411Aug 30 LOT Polish Airlines Flight 165 hijackingSep 3 Air Rhodesia Flight 825Sep 7 Air Ceylon Avro HS 748 bombingSep 25 Pacific Southwest Airlines Flight 182Sep 26 Air Caribbean Flight 309Sep 30 Finnair Flight 405Oct 3 Finnish Air Force DC-3 crashOct 7 Aeroflot Flight 1080Oct 21 Valentich disappearanceOct 23 Aeroflot Flight 6515Nov 15 Loftleiðir Flight 001Dec 4 Rocky Mountain Airways Flight 217Dec 17 Indian Airlines Flight 403Dec 20 Indian Airlines Flight 410Dec 21 TWA Flight 541Dec 22 Cessna 188 Pacific rescueDec 23 Alitalia Flight 4128Dec 28 United Airlines Flight 173

1977 ◄ ► 1979

v t e Aviation accidents and incidents in the United States and U.S. territories in the 1970s
1970	Cornfield Bomber (February 1970) Eastern Air Lines Shuttle Flight 1320 (March 1970) ALM Flight 980 (May 1970)* Trans International Airlines Flight 863 (September 1970) Wichita State University football team plane crash (October 1970) Southern Airways Flight 932 (November 14 1970) Capitol International Airways Flight C2C3/26 (November 27 1970)
1971	B-52C Lake Michigan crash (January 1971) Colorado Aviation Aero Commander 680 crash (May 1971) Hughes Airwest Flight 706 (June 6 1971) Allegheny Airlines Flight 485 (June 7 1971) Pan Am Flight 845 (July 1971) Alaska Airlines Flight 1866 (September 1971) Northwest Orient Airlines Flight 305 (See D. B. Cooper, November 1971)
1972	Mohawk Airlines Flight 405 (March 1972) Delta Air Lines Flight 9570 (May 1972) American Airlines Flight 96 (June 12 1972) Prinair Flight 191 (June 24 1972)* Lake Winnebago mid-air collision (June 29 1972) Pacific Southwest Airlines Flight 710 (July 5 1972) Delta Air Lines Flight 841 (July 31 1972) Sacramento Canadair Sabre accident (September 1972) Southern Airways Flight 49 (November 1972) United Air Lines Flight 553 (December 10 1972) Chicago–O'Hare runway collision (December 20 1972) Eastern Air Lines Flight 401 (December 29 1972) Puerto Rico DC-7 crash (December 31 1972)*
1973	DeKalb–Peachtree Airport Learjet crash (February 1973) Ozark Air Lines Flight 809 (July 23 1973) Delta Air Lines Flight 723 (July 31 1973) TWA Flight 742 (August 1973) World Airways Flight 802 (September 8 1973) Texas International Airlines Flight 655 (September 27 1973) Pan Am Flight 160 (November 3 1973) National Airlines Flight 27 (November 3 1973) Iberia Flight 933 (December 1973)
1974	Commonwealth Commuter Flight 317 (January 6 1974) Pan Am Flight 806 (January 30 1974)* Delta Air Lines Flight 523 (February 1974) Eastern Air Lines Flight 212 (September 1974) TWA Flight 514 (December 1 1974) Northwest Orient Airlines Flight 6231 (December 1 1974)
1975	Golden West Airlines Flight 261 (Janaury 1975) Eastern Air Lines Flight 66 (June 1975) Wien Air Alaska Flight 99 (August 1975) Overseas National Airways Flight 032 (November 1975)
1976	Alaska Airlines Flight 60 (April 5 1976) American Airlines Flight 625 (April 27 1976)* Air Manila Flight 702 (June 1976) TWA Flight 355 (September 1976)
1977	Japan Air Lines Cargo Flight 1045 (January 1977) Southern Airways Flight 242 (April 4 1977) Delta Air Lines Flight 1080 (April 12 1977) Encino helicopter crash (August 1977) Lynyrd Skynyrd plane crash (October 1977) Air Indiana Flight 216 (December 13 1977) United Airlines Flight 2860 (December 18 1977) Vieques Air Link crash (December 19 1977)*
1978	Continental Airlines Flight 603 (March 1 1978) United Airlines Flight 696 (March 13 1978) National Airlines Flight 193 (May 1978) Pacific Southwest Airlines Flight 182 (September 25 1978) Air Caribbean Flight 309 (September 26 1978)* Rocky Mountain Airways Flight 217 (December 4 1978) TWA Flight 541 (December 21 1978) United Airlines Flight 173 (December 28 1978)
1979	TWA Flight 841 (April 1979) American Airlines Flight 191 (May 25 1979) Downeast Airlines Flight 46 (May 30 1979) Air New England Flight 248 (June 17 1979) American Airlines Flight 293 (June 20 1979) American Airlines Flight 444 (November 1979)
This list is incomplete. An asterisk (*) denotes an incident that took place in a U.S. territory, or in adjacent waters thereof. Flying Tiger Line Flight 45 (July 1970) occurred in the United States Civil Administration of the Ryukyu Islands. 1960–1969 ◄ 1970–1979 ► 1980–1989

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