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February 19, 1985 · Boeing 747 SP-09 · N4522V

San Francisco, CA

Overview

Report Status
Preliminary report
Event Type
Accident
Date
February 19, 1985
Injury Outcomes
2 injuries (2 serious injuries), 271 uninjured
Location
San Francisco, CA
Aircraft
Boeing 747 SP-09
Tail Number
N4522V
Operator
China Airlines
Injuries
Serious
Aircraft Damage
Substantial
NTSB Number
DCA85AA015

WHILE ABV A CLOUD LAYER (TOP AT FL 370) NR THE JET STREAM, AUTOPLT WAS ENGAGED & WAS IN THE PERFORMANCE MNGMNT SYS (PMS)MODE. THE PMS PROVIDED PITCH GUIDANCE TO HOLD FL 410, ROLL GUIDANCE TO AILERONS & SPOILERS FOR ROLL CTL & AUTOTHROTTLE TO MAINT .85 MACH (254 KIAS). ACFT ENCOUNTERED CLR AIR TURBC & AIRSPEED BGN TO VARY BTN .84 & .88 MACH. PMS BGN MOVING THROTTLES FORE & AFT TO HOLD .85 MACH. DRG AUTOTHROTTLE ADJUSTMENTS, #4 ENG THRUST DECREASED & 'HUNG' AT APRX 1.0 EPR & AIRSPEED BGN DECREASING. FLT ENGINEER ATMTD TO MANUALLY RCVR THE #4 ENG THRUST, BUT DID NOT CLOSE THE BLEED AIR VLV BFR ADJUSTING THE #4 THROTTLE. THE #4 ENG REMAINED AT APRX 1.0 EPR. AS THE ACFT SLOWED, AUTOPLT TRIMMED TO HOLD ALT & HDG TIL THE PLT DISENGAGED IT. AT THAT TIME, ACFT ROLLED/YAWED RGT & ENTERED AN UNCTLD DSCNT INTO THE CLOUDS. AS IT BROKE OUT OF THE CLOUDS AT 11,000', CREW RCVRD & LVLD AT 9500'. DRG DSCNT/RCVRY, ACFT WAS DMGD BY ACCELLERATION FORCES & HI SPEED. THERE WAS EVIDENCE THE PLT WAS PREOCCUPIED WITH ENG PRBLM, DIDN'T MONITOR INSTRUMENTS & OVER-RELIED ON AUTOPLT.

Full Narrative

WHILE ABV A CLOUD LAYER (TOP AT FL 370) NR THE JET STREAM, AUTOPLT WAS ENGAGED & WAS IN THE PERFORMANCE MNGMNT SYS (PMS)MODE. THE PMS PROVIDED PITCH GUIDANCE TO HOLD FL 410, ROLL GUIDANCE TO AILERONS & SPOILERS FOR ROLL CTL & AUTOTHROTTLE TO MAINT .85 MACH (254 KIAS). ACFT ENCOUNTERED CLR AIR TURBC & AIRSPEED BGN TO VARY BTN .84 & .88 MACH. PMS BGN MOVING THROTTLES FORE & AFT TO HOLD .85 MACH. DRG AUTOTHROTTLE ADJUSTMENTS, #4 ENG THRUST DECREASED & 'HUNG' AT APRX 1.0 EPR & AIRSPEED BGN DECREASING. FLT ENGINEER ATMTD TO MANUALLY RCVR THE #4 ENG THRUST, BUT DID NOT CLOSE THE BLEED AIR VLV BFR ADJUSTING THE #4 THROTTLE. THE #4 ENG REMAINED AT APRX 1.0 EPR. AS THE ACFT SLOWED, AUTOPLT TRIMMED TO HOLD ALT & HDG TIL THE PLT DISENGAGED IT. AT THAT TIME, ACFT ROLLED/YAWED RGT & ENTERED AN UNCTLD DSCNT INTO THE CLOUDS. AS IT BROKE OUT OF THE CLOUDS AT 11,000', CREW RCVRD & LVLD AT 9500'. DRG DSCNT/RCVRY, ACFT WAS DMGD BY ACCELLERATION FORCES & HI SPEED. THERE WAS EVIDENCE THE PLT WAS PREOCCUPIED WITH ENG PRBLM, DIDN'T MONITOR INSTRUMENTS & OVER-RELIED ON AUTOPLT.

Flight

Event TypeAccident
Event Time10:16 PST
Nearest Airport0nm N
Runway0
Flight Plan FiledIFR
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftBoeing 747 SP-09
Tail NumberN4522V
Aircraft CategoryAir
DamageSubstantial
OperatorChina Airlines
Operating RulePart 129
Engines4
Engine TypeTurbofan
Engine DetailsP&W · JT9D-7A · Turbofan · 46150
Seats279

People & Injuries

Injury Summary2 injuries (2 serious injuries), 271 uninjured
Fatal0
Serious2
Minor0
Uninjured271
Total273
Crew 1Age 55 · First Class

Conditions

ConditionsIMC
LightDaylight
WindCalm
CeilingUnknown 11000 ft
Temperature / Dew Point0 C / 0 C
Altimeter29.00 inHg
Weather SourcePILO

Appendix: Source Data