Page:CAB Accident Report, American Airlines Flight 383.pdf/25

– 24 – With respect to crew coordination it appears significant that the entire flight was conducted in a manner that would expedite the arrival and approach into the Cincinnati Airport. A brief review of the operational phases of the flight shows that; (1) en route clearance changes were obtained which provided direct and shorter routings to Cincinnati, (2) the average ground speed within the terminal area (between 30 miles and 6 miles of the airport) was in excess of 325 knots, a departure from FAR 91.85(c)(1) which restricts terminal area speed to 250 knots IAS within 30 miles of destination below 10,000 feet m.s.l., and (3) despite the forecast for, and observation of approaching adverse weather, the flight elected to conduct a visual approach rather than utilize standard instrument approach procedures.

These phases of the flight do not, nor are they meant to, suggest any hazardous operational practices but they do indicate operational decisions pointed toward arriving at the Cincinnati Airport in the shortest possible time. It is strongly believed that the pilot being observed would normally be more inclined to maintain airway routings, more closely comply with terminal area speed restrictions, and conduct an instrument approach to the field, unless action to the contrary was being suggested or decided upon by the check captain. Further, decisions or suggestions of this nature would tend to indicate to the pilot being observed that all operational aspects of the flight were being closely monitored and would strengthen any possible over reliance situation of one pilot on the other which may have developed in the cockpit. Again, it is realized that this situation alone should not have precluded proper monitoring of aircraft altitude and can only be considered as a possible contributing factor to the apparent inattention to flight instruments.

It was noted that at 1901:14 in response to an inquiry from the tower if they still had the field in sight the flight replied, "just barely we'll pickup the ILS here." Although one of the control heads on the radio frequency selector control panel was found set at the approximate Cincinnati ILS frequency it could not be determined if the ILS had been tuned in throughout the approach or if it had been selected at the time of the above transmission. In either event, a full "fly-up" indication should have been displayed on the glide slope indicator at this point which if observed by the pilots could have alerted them to the low altitude situation or at least could have provided the stimulus for an altimeter cross-check.

It can not be determined to what extend the lightning flashes associated with the storm would have affected cockpit visibility or otherwise distracted the crew or, if the windshield rain repellent had been initially actuated in the light rain showers and had possibly deterred forward visibility. These and other indeterminable factors may or may not have presented additional distractions to the crew but must be considered in the final evaluation. It is clear, however, that a rapidly deteriorating visibility situation and increasingly heavy cockpit workload compounded with all or any combination of the other influencing conditions may have distracted from the full attentiveness of flight instruments and the proper monitoring of the aircraft's altitude.

Review of B-727 Design as Related to Accident Events

The Board would be remiss if it did not take cognizance of the concern that existed in the minds of many elements of the aviation community and traveling public regarding the three Boeing 727 fatal accidents that occurred within a short